Arunan Sivalingam

Infectious and presumed noninfectious endophthalmitis after intravitreal triamcinolone acetonide injection.

Purpose To report potentially distinguishing characteristics between bacterial endophthalmitis and presumed noninfectious endophthalmitis associated with intravitreal triamcinolone acetonide injection. Methods Records of two patients with culture-proven bacterial endophthalmitis and six patients with presumed noninfectious endophthalmitis from intravitreal triamcinolone acetonide injections were analyzed retrospectively. Results Two eyes in two patients with culture-proven bacterial endophthalmitis had decreased vision and hypopyon or vitritis, but no pain or conjunctival injection 2 weeks after intravitreal triamcinolone acetonide injection. Seven eyes in six patients with presumed noninfectious endophthalmitis had blurred vision, hypopyon, and variable pain all within 2 days of intravitreal triamcinolone injection. All seven eyes were followed up closely and had rapid resolution of hypopyon and symptoms. Conclusion Bacterial endophthalmitis after intravitreal triamcinolone acetonide injection may present in an atypical, relatively delayed manner with decreased vision but no pain or redness. Presumed noninfectious endophthalmitis presents within 2 days after the injection, may be accompanied by discomfort, and has a hypopyon that may be the triamcinolone material itself or a sterile inflammatory reaction. In these eyes, the hypopyon and symptoms quickly resolve without treatment.

Visual outcomes following the use of intravitreal steroids in the treatment of postoperative endophthalmitis

OBJECTIVE To compare visual outcomes between cases of acute postoperative endophthalmitis that did or did not receive intravitreal steroids. DESIGN Retrospective nonrandomized comparative trial. PARTICIPANTS Fifty-seven patients with postoperative endophthalmitis. INTERVENTION Thirty-one patients with postoperative endophthalmitis resulting from cataract extraction received both intravitreal antibiotics and steroids, whereas the remaining 26 received only intravitreal antibiotics. MAIN OUTCOME MEASURES Improvement in visual acuity. RESULTS Multivariate logistic regression was used to analyze the variables that potentially influence a three-line visual acuity improvement. The mean baseline visual acuities of both groups were comparable. The use of intravitreal steroids reduced the probability of developing a three-line improvement in visual acuity (odds ratio [OR] = 0.287; 95% confidence interval [CI] [0.072-0.852]). On the basis of logistic regression analysis using our multivariate model, gender, baseline visual acuity, and pars plana vitrectomy were not significantly associated with visual outcome differences between the two groups. CONCLUSIONS Patients who received intravitreal steroids had a significantly reduced likelihood of obtaining a three-line improvement in visual acuity. At a minimum our study provides no support for their use and, therefore, steroids may not be efficacious for acute endophthalmitis related to cataract extraction.

Visual Prognoses Correlated with the Presence of Interna-limiting Membrane in Histopathologic Specimens Obtained from Epiretinal Membrane Surgery

Forty-one patients with a unilateral, macular epiretinal membrane (ERM) underwent pars plana vitrectomy and membrane peeling to improve the visual acuity. The authors retrospectively reviewed the histopathology of the vitrectomy specimen in each instance to determine whether the presence of internal-limiting membrane (ILM) had an adverse effect on visual acuity. Eleven specimens contained long segment of ILM, as determined by light microscopy. With a minimum of 6 months of follow-up, none of these 11 eyes achieved a visual acuity of better than 20/60. Of 30 eyes that did not have ILM present, 41% achieved a visual acuity of 20/60 or better. Overall, 29% of the eyes in the entire series achieved 20/60 or better visual acuity. The difference between the group with ILM versus that without ILM was statistically significant (P = 0.01). The presence of long segments of ILM within the histopathologic specimen after vitreous surgery for removal of a macular ERM appears to indicate a less favorable visual outcome.

Combination intravitreal bevacizumab/panretinal photocoagulation versus panretinal photocoagulation alone in the treatment of neovascular glaucoma.

Purpose: To evaluate same-day combination intravitreal bevacizumab/panretinal photocoagulation (PRP) for the treatment of neovascular glaucoma (NVG) compared with PRP alone. Methods: This was an institutional review board-approved, retrospective, consecutive case-control study of patients receiving same-day combination bevacizumab/PRP or PRP alone as treatment of NVG from September 2004 through June 2007. Visual acuity, intraocular pressure (IOP), presence of anterior segment neovascularization, and required glaucoma interventional procedures were recorded. Results: A total of 23 patients were identified, 11 in the bevacizumab/PRP group and 12 in the PRP alone group. The bevacizumab/PRP group had a significant reduction in IOP compared with the PRP alone group (-11 vs. 0 mmHg, respectively; P = 0.03). There was a significantly higher frequency and rate of neovascular regression in the combination therapy group than in the PRP only group (11 vs 2 eyes [P < 0.001] and 12 vs 127 days [P < 0.0001], respectively). Average follow-up was 143 days for the bevacizumab/PRP group and 118 days for the PRP alone group. Conclusions: Combination treatment resulted in more rapid decrease in IOP. In addition, the combination group had increased frequency and rapidity of regression of neovascularization. This study provides a foundation for further research and suggests consideration for a possible new paradigm for the treatment of NVG.

The ocular ischemic syndrome. III. Visual prognosis and the effect of treatment

SummaryThe records of fifty-two consecutive patients with the ocular ischemic syndrome seen between 1978 and 1985 were reviewed with the purpose of investigating the visual prognosis and effects of treatment. On initial presentation, 43% of affected eyes had a visual acuity of 20/20–20/50, whereas 37% were counting fingers or worse. By the end of one year, only 24% remained in the 20/20–20/50 group, while 58% were counting fingers or worse. The presence of rubeosis iridis was an indicator of poor visual prognosis. Ninety-seven percent of eyes with rubeosis had vision of counting fingers or worse at the end of one year. We were unable to demonstrate convincingly that carotid endarterectomy and superficial temporal artery to middle cerebral artery bypass were of benefit in stabilizing or improving vision in persons with the ocular ischemic syndrome.

Intravitreal bevacizumab (avastin) in central retinal vein occlusion.

Purpose: To describe the effects of intravitreal bevacizumab in eyes with macular edema resulting from central retinal vein occlusions (CRVO). Methods: Retrospective consecutive case series of patients diagnosed with macular edema from CRVO who received intravitreal bevacizumab. Results: Thirty eyes of 29 patients with an average age of 72 years (range, 54–87 years) had intravitreal bevacizumab injections. Mean follow-up was 18.1 weeks. Initial mean visual acuity was 20/394. At the 1- and 2-month follow-up, mean visual acuity improved to 20/237 (n = 26, P = 0.04) and 20/187 (n = 21, P = 0.008), respectively. At the 3- and 4-month follow-up, visual acuity improved from 20/228 to 20/157 (n = 15, P = 0.05) and from 20/313 to 20/213 (n = 11, P = 0.03), respectively. No significant changes in visual acuity were found after 4 months though the number of patients in this group was small. Duration of treatment effect following an injection appears to be limited to 2 months for most patients. No ocular or systemic adverse reactions were noted. Conclusions: The visual benefits of intravitreal bevacizumab for macular edema due to CRVO are apparent early but are not sustained without repeated injections. Larger clinical studies with long-term follow-up will be necessary to better elicit the best regimen for this therapy.

The ocular ischemic syndrome. II. Mortality and systemic morbidity.

The cases of 52 consecutive persons with ocular ischemic syndrome (ocular symptoms and sign attributable to severe carotid artery obstruction) were studied. Folloup disclosed a five year mortality of 40%. In comparison, an age and sex matched control group from the Framingham study had a five year mortality of 11%. The leading cause of death was cardiac diseae (63%), while stroke was second (19%). Other associated diseases included systemic arterial hypertension (73%), diabetes melitus (56%) and peripheral vascular disease (19%).

Aqueous Tube-shunt Implantation and Pars Plana Vitrectomy in Eyes With Refractory Glaucoma

We reviewed the surgical outcome of 20 eyes of 20 consecutive patients who had undergone combined aqueous tube-shunt implantation and vitrectomy for complicated glaucoma associated with vitreoretinal disorders. After a mean follow-up of 10.39 +/- 5.43 months, visual acuity remained stable or improved in 13 patients (65%), and intraocular pressure was controlled (< 22 mm Hg) in 15 (75%). The most common complications were corneal edema (seven eyes) and choroidal effusion (three eyes). Combined tube-shunt implantation and pars plana vitrectomy may successfully control intraocular pressure and maintain preoperative visual acuity in refractory glaucoma associated with vitreoretinal disorders.

Idiopathic Sclerochoroidal Calcification

Idiopathic sclerochoroidal calcification is a disorder that is often overlooked, occurring at the level of the posterior sclera and choroid in older patients. Clinically, it may be confused with choroidal osteoma, choroidal metastasis, amelanotic choroidal nevus, or choroiditis. The authors present seven cases of this unusual entity. The patients ranged in age from 58 to 80 years. In all cases, the yellow lesions were clinically estimated to be at the level of the choroid and sclera, and they were usually located superior to the superotemporal retinal vascular arcade. Systemic investigation of calcium and phosphate metabolism was normal in all patients. The classic clinical manifestations and differentiation of this unusual entity from other similar fundus lesions is discussed.

Management of Thick Submacular Hemorrhage With Subretinal Tissue Plasminogen Activator and Pneumatic Displacement for Age-Related Macular Degeneration

PURPOSE To evaluate the outcome of pars plana vitrectomy, subretinal tissue plasminogen activator (t-PA) infusion and intraocular gas tamponade with and without postsurgical antivascular endothelial growth factor (VEGF) injection for thick submacular hemorrhage due to exudative age-related macular degeneration (AMD). DESIGN Retrospective, comparative, interventional case series. METHODS setting: 2 retina referral centers. The patient population included 101 eyes of 101 patients with neovascular AMD and thick submacular hemorrhage who underwent surgical displacement of the hemorrhage with or without postoperative anti-VEGF injections. Main outcome measures included degree of blood displacement, best and final postoperative visual acuity (VA), and adverse events. Snellen acuity was converted to logMAR for statistical analysis. RESULTS All patients were followed for a minimum of 3 months (mean, 15.3 months, range, 3-70 months). In 83 (82%) of 101 eyes, the procedure resulted in complete hemorrhage displacement from the fovea. Mean preoperative VA was 20/2255 (2.05 logMAR). The acuity significantly improved to 20/893 (1.65 logMAR) at month 1 (P < 0.001) at month 1; 20/678 (1.53 logMAR) at month 3 (P < 0.001), and 20/1150 (1.76 logMAR) at month 12 (P = 0.002). Best postoperative visual acuity improved by at least 1 line in 83 (82%) of 101 eyes, and 19.6% of eyes gained 3 lines or more at month 3. The visual acuity of the group of eyes that received postoperative anti-VEGF injection (n = 39) showed greater visual acuity improvement 6 months postoperatively compared to the group of eyes that did not receive postoperative anti-VEGF. Postoperative complications included vitreous hemorrhage in 2 eyes, rhegmatogenous retinal detachment in 4 eyes, and recurrent thick subretinal hemorrhage in 6 eyes. CONCLUSIONS Vitrectomy with subretinal t-PA injection and gas tamponade was found to be relatively effective for displacement of thick submacular hemorrhage with a significant improvement in visual acuity. There is a loss of acuity over time; the addition of postoperative anti-VEGF therapy may help maintain the visual acuity gains.