Borja Corcóstegui

Comparison of different techniques for purification of triamcinolone acetonide suspension for intravitreal use

Background: Intravitreal triamcinolone has increasingly been used for the treatment of oedematous and neovascular diseases and purification of triamcinolone suspension may be important in order to avoid the potential toxic effects of the vehicle. The aim was to evaluate different techniques used to reduce the solvent agent benzyl alcohol (9.9 mg/ml) from a commercially prepared triamcinolone acetonide suspension. Methods: Different techniques were used to reduce the solvent agent benzyl alcohol: filter techniques using 0.22 μm or 5 μm pore size, and non-filter techniques using sedimentation or centrifugation. Quantification of triamcinolone acetonide and benzyl alcohol was performed by high pressure liquid chromatography (HPLC). Results: Benzyl alcohol concentration was decreased significantly in all the techniques used compared with the original commercial suspension (p<0.05), with no significant differences among them. The reduction was approximately one tenth of its original concentration. However, triamcinolone acetonide concentration differed significantly depending on the method used. Centrifugation method showed no differences versus the original commercial solution; sedimentation technique reduced the expected dose only 25%; the filter technique using a 5 μm pore size membrane reduced the expected dose to one fourth, while the filter technique using a 0.22 μm pore size membrane reduced the expected dose to 45%. Conclusions: All the different techniques employed effectively reduced the concentration of benzyl alcohol. However, the final concentration of triamcinolone was much lower than expected using the filter techniques. The pore size membrane inversely influenced the final concentration, with part of the triamcinolone crystals probably being entrapped in the filter. Centrifugation is recommended as the best way of administering the drug.

Therapeutic options for capillary papillary hemangiomas

PURPOSE To describe the results and therapeutic complications of treatment of papillary capillary hemangiomas over the last 13 years. DESIGN Retrospective, noncomparative, interventional case series. PARTICIPANTS Five cases of unilateral capillary papillary hemangiomas were reviewed. Three patients had von Hippel-Lindau disease, and two had no associated familial or systemic disease. METHODS Two patients were treated with argon green laser, one patient received argon green and diode photocoagulation, and two patients underwent argon green photocoagulation and diode transpupillary thermotherapy (TTT); two eyes also underwent vitreoretinal surgery. Follow-up ranged from 1 to 13 years. MAIN OUTCOME MEASURES The presence of exudative retinal detachment associated with the activity of the hemangioma and the visual acuity were the two main parameters. RESULTS Prompt argon green laser treatment was the most effective therapy; -II was ineffective. Vitreoretinal surgery, transscleral drainage, and argon endolaser photocoagulation in one case resolved bullous retinal detachment secondary to tumor exudation. Pretreatment visual acuity (VA) levels ranged from 20/25 to counting fingers; posttreatment VA levels ranged from 20/25 to light perception. CONCLUSIONS If left untreated, papillary hemangiomas may evolve to exudative retinal detachment and marked VA decreases. Although we have not established an ideal therapy, we recommend appropriate treatment on diagnosis. Close follow-up and multiple treatments with argon laser are likely the best therapeutic course.

Management of macular edema in branch retinal vein occlusion with sheathotomy and recombinant tissue plasminogen activator.

Purpose: The common adventitial sheath that surrounds the retinal venule and arteriole at the crossing site plays a crucial role in branch retinal vein occlusion (BRVO). The purpose of this study was to report the surgical recanalization of the occluded vein using a bimanual technique and recombinant tissue plasminogen activator (tPA) and its effect on final visual acuity. Methods: Arteriovenous sheathotomy was performed, using a bimanual technique, followed by fluid-air exchange and injection of 25 mg of recombinant tPA over the area of the occluded vein. Results: Intraoperative sectioning of the common arteriovenous sheath was achieved in all 40 patients. Thrombus release was observed in 11 cases (27.5%) and was correlated with early surgery (P < 0.001) and better final visual recovery (P < 0.06). Optical coherence tomography showed macular thickness that decreased by greater than 40% in 31 patients (77.5%) compared with preoperatively, and correlated to postoperative visual acuity (P < 0.001). The mean visual acuity increased from 20/100 to 20/40, with 70% of patients gaining three or more lines of visual acuity (Pearson 0.378, P = 0.016). Conclusion: Surgical venous decompression and injection of recombinant tPA may effectively manage macular edema secondary to BRVO, thus improving anatomic and visual outcome. Early surgical intervention may obtain maximum final visual recovery.

Vitreoretinal surgery and endoresection in high posterior choroidal melanomas.

Purpose Eyes with posterior choroidal melanomas more than 9 mm in thickness frequently are enucleated because of the potential complications of radiotherapy. The aim of this study was to evaluate the safety and efficacy of internal resection of these tumors. Methods Twenty-five consecutive patients with high posterior choroidal melanomas with a diameter less than 15 mm and a thickness greater than 9 mm were treated. If the retina was not invaded by the tumor, a vitrectomy was performed, followed by posterior hyaloid dissection, 120° anterior retinotomy, endophotocoagulation 2 mm past the tumor margin, melanoma removal with the vitrectomy probe, retinal reattachment with liquid perfluorocarbon and air, and silicone oil exchange. If the tumor invaded the retina, the laser was applied through the retina, and the retina and tumor were removed together. Results The mean patient age was 46.6 years. The tumor thicknesses ranged from 9.1 to 12.8 mm, and the tumor diameter ranged from 8.9 to 14.8 mm. The mean preoperative visual acuity was 20/60. In 11 patients, the tumor had invaded the retina. We removed the entire tumor from all 25 eyes. The main postoperative complications were cataract (40%), retinal detachment (16%), macular traction (16%), and epiretinal macular proliferation (8%). The mean postoperative visual acuity was 20/100. No tumors recurred, and there was no evidence of metastasis. The follow-up ranged from 12 to 72 months. Conclusions These data suggest that internal resection of high posterior melanomas may conserve ocular and functional vision and does not seem to increase the risk of metastatic disease. Longer follow-up is necessary to establish the safety of the procedure.

LASIK for the Correction of Residual Refractive Errors From Previous Surgical Procedures

BACKGROUND AND OBJECTIVE To evaluate laser assisted in situ keratomileusis (LASIK) efficacy in correcting residual refractive errors after corneal or intraocular surgery (penetrating keratoplasty, radial keratotomy, photorefractive keratectomy, phacoemulsification with intraocular lens (IOL) implantation, penetrating ocular trauma and phakic IOL implantation). MATERIAL AND METHODS We performed LASIK in 87 eyes of 62 patients previously operated by means of other surgical techniques to completely correct the residual refractive error. We report the mean refractive error (in terms of spherical equivalent refraction), uncorrected visual acuity (UCVA) and spectacle corrected visual acuity (SCVA) before and after the surgical procedure. We also analyze safety and stability, in these results with a minimum of 12 months follow-up. RESULTS Mean preoperative spherical equivalent was -5.25 +/- 2.1 diopters (D). Postoperatively, mean spherical equivalent was -0.70 +/- 0.65 D, 76% of eyes were between plano and -1.00 D and 99% were between plano and -2.25 D. At 12 months follow-up the change in the refractive result was equal or less than 0.5 D in 94% of eyes. Preoperatively SCVA was 1.0 or better in 24.13% of cases, and 0.5 or better in 89.65%. Postoperative SCVA was 1.0 or better in 26.43% and 0.5 or better in 95%. Preoperative UCVA was 0.1 in 2 eyes, 0.05 in 4 eyes and count fingers in the rest of the cases. Postoperative UCVA was 1.0 or better in 1.1% and 0.5 or better in 70.1%. We had an extremely low complication rate in this particular group of patients. CONCLUSIONS LASIK can be successfully used to correct residual refractive errors after other surgical procedures.

Surgical Embolus Removal in Retinal Artery Occlusion

Aims: To evaluate the anatomical outcomes, safety and functional effectiveness of surgical embolus removal in retinal artery occlusion (RAO). Methods: Prospective study of seven patients with RAO of <36 h duration. All eyes underwent pars plana vitrectomy and a longitudinal incision of the anterior wall of the occluded arteriole in an attempt to remove the embolus. Outcome measures included visual acuity and arteriolar reperfusion, as evaluated with fluorescein angiography. Results: Surgical removal of the embolus was achieved in six of the seven (87.5%) patients, visual acuity improved from a median of 20/400 (range: hand movements 20/25) to 20/40 (range: hand movements 20/25), and reperfusion of the occluded vessel was angiographically confirmed in four of the six patients in whom the embolus was successfully removed. Conclusion: Surgical removal of retinal arterial emboli seems to be an effective and safe treatment for RAO, but a randomised and controlled clinical trial will be necessary to establish an evidence base for the role, if any, of this intervention.

Vitreoretinal surgery for cystoid macular edema associated with retinitis pigmentosa

PURPOSE To evaluate the anatomic and functional outcome of vitreoretinal surgery in eyes with retinitis pigmentosa (RP) and macular edema. DESIGN Prospective noncomparative case series. PARTICIPANTS Twelve consecutive eyes of eight patients with RP and a documented decrease in visual acuity (VA) to 20/60 or worse caused by macular edema refractory to medical therapy. METHODS Pars plana vitrectomy was performed in the 12 eyes, followed by posterior hyaloid dissection, removal of the posterior inner limiting membrane after staining with indocyanine green, and gas tamponade. Preoperative best-corrected VAs ranged from 20/60 to 20/400 (mean, 20/115). MAIN OUTCOME MEASURES Changes in VA and foveal thickness as determined by optical coherence tomography (OCT). RESULTS The mean preoperative retinal thickness at the fovea was 477 micro m. Optical coherence tomography showed a decrease in macular thickness of >40% in 10 eyes (83.3%), with a mean postoperative foveal thickness of 260 micro m. The mean VA increased from 20/115 to 20/45, with an average of three lines of improvement. CONCLUSIONS Our results suggest that vitreoretinal surgery may effectively manage macular edema in RP.

Histologic findings after amniotic membrane graft in the human cornea

OBJECTIVE To describe the histopathologic findings in the human cornea several months after a stromal amniotic membrane graft. To show the clinicopathologic correlation after the graft in two cases with different follow-up times. DESIGN Two interventional case reports with clinicopathologic correlation. PARTICIPANTS Two patients with neurotrophic corneal ulcer unresponsive to medical treatment (one with stromal vascularization and the other without stromal vascularization). INTERVENTION Amniotic membrane graft was performed in both patients to treat the neurotrophic ulcer. Three and 7 months after amniotic membrane grafting, a penetrating keratoplasty was needed, and the removed corneas were analyzed. MAIN OUTCOME MEASURES Clinical and histopathologic examinations, including routine histopathologic and immunohistochemical studies. RESULTS Complete epithelialization was observed on histologic examination over the basement membrane of the amniotic membrane graft. The amniotic membrane was slowly reabsorbed in the cornea without stromal vascularization with no inflammatory reaction produced. In the cornea that had stromal vascularization the amniotic membrane was rapidly reabsorbed because of the presence of abundant inflammatory cells. Once reabsorbed, the amniotic membrane was replaced by new fibrotic stroma, that was different from that found in the rest of the cornea but that helped to maintain corneal thickness. CONCLUSIONS The amniotic membrane graft allows for correct epithelialization in cases of neurotrophic corneal ulcer. Once the amniotic membrane is reabsorbed, it is replaced by a new fibrotic stroma, which can reduce corneal transparency. In corneas that have no stromal vascularization, the graft may remain in the stroma for many months, compromising corneal transparency during this period.

Macular buckling for eyes with myopic foveoschisis secondary to posterior staphyloma.

Purpose: To determine the effectiveness of macular buckling in eyes with myopic foveoschisis and describe two methods of macular buckling: hard silicone implant and Ando plombe. Methods: Sixteen eyes of 16 consecutive patients with myopic foveoschisis who underwent surgery with the macular buckling procedure were studied. Pars plana vitrectomy combined with macular buckling with hard silicone implant was used in 6 eyes, whereas the other 10 eyes underwent pars plana vitrectomy and macular buckling with the Ando macular plombe. Results: Macular buckling, with both hard silicone implant and macular plombe resulted in reduction of retinal thickness in all patients. Best-corrected visual acuity improved in 14 of 16 eyes (87.5%), whereas it remained stable or decreased in 2 eyes (12.5%). Mean preoperative best-corrected visual acuity was 20/125 (mean logarithm of the minimal angle of resolution 0.8), whereas mean postoperative best-corrected visual acuity improved to 20/50 (mean logarithm of the minimal angle of resolution 0.39). Both methods showed a similar rate of complications, the most frequent being the development of localized areas of retinal pigment epithelium atrophy. Conclusion: Combined pars plana vitrectomy and macular buckling is an effective approach to treat myopic foveoschisis with both anatomical and visual improvement. Despite a similar complication rate with both buckling techniques, macular buckling with the Ando plombe was found to be technically easier with shorter surgical times.

Dexamethasone Intravitreal Implant for Treatment of Patients with Recalcitrant Macular Edema Resulting from Irvine-Gass Syndrome

PURPOSE To evaluate the effectiveness of a single intravitreal injection of dexamethasone implant, over 6 months in patients with recalcitrant CME due to Irvine-Gass syndrome. METHODS Retrospective review of the medical records of nine patients with refractory macular edema (ME) due to Irvine-Gass syndrome, who underwent a single intravitreal injection of dexamethasone implant, Ozurdex, between November 2010 and January 2012, at the Instituto de Microcirurgia Ocular, Barcelona, Spain. All patients underwent a complete ophthalmic evaluation, including best-corrected visual acuity (BCVA) using standardized ETDRS charts, tonometry, fluorescein angiography, and spectral-domain optical coherence tomography with foveal thickness (FT) measurement. RESULTS The mean duration of CME before treatment with Ozurdex was 9.1 months (range, 6-13 months). At baseline, the mean FT was 542.22 ± 134.78 μm. Mean (SD) values of FT did decrease to 350.88 ± 98.71 μm (P = 0.001) at month 1 and 319.22 ± 60.96 μm (P = 0.002) at month 3. Data on the 6-month follow-up showed a mild increase 398.33 ± 127.89 μm (P = 0.031). The mean (SD) change from baseline FT was 191.33 μm (a decrease value of 35%) at month 1, and 223.00 μm (decrease value of 41%) and 143.89 μm (decrease value of 26%) at month 3 and month 6, respectively. The baseline BCVA data were 0.62 ± 0.15 logarithm of the minimum angle of resolution (logMAR). The mean BCVA improved to 0.47 ± 0.21 logMAR (P = 0.008) and 0.37 ± 0.24 logMAR (P = 0.001) after month 1 and month 3, respectively. At the last visit (6-month follow-up), the mean BCVA was 0.37 ± 0.26 logMAR (P = 0.002). CONCLUSIONS In this study, both mean FT and mean BCVA had improved from baseline by 1 month after treatment with a dexamethasone implant, and the improvement remained statistically significant throughout the 6-month study.