Carl H. Park

Intravitreal triamcinolone acetonide in eyes with cystoid macular edema associated with central retinal vein occlusion.

PURPOSE To evaluate treatment of cystoid macular edema associated with central retinal vein occlusion with intravitreal triamcinolone acetonide. METHODS This study included 10 eyes of nine patients with perfused central retinal vein occlusion with visual acuity of 20/50 or worse. Following baseline evaluation, including best-corrected visual acuity, intraocular pressure (IOP), fluorescein angiography, and volumetric optical coherence tomography (VOCT), triamcinolone acetonide (4 mg in 0.1 ml) was injected into the vitreous cavity. RESULTS Mean duration from the time of diagnosis to the intravitreal injection was 15.4 months. All 10 eyes demonstrated biomicroscopic improvement in cystoid macular edema with corresponding improvement in VOCT measurements from a mean of 4.2 mm(3) preinjection to a mean of 2.6 mm(3) at last follow-up (P <.001). Mean best-corrected visual acuity improved from 58 letters (range, 37-72) at baseline to 78 letters (range, 50-100 letters) at last follow-up (average, 4.8 months). The visual acuity improvement was statistically significant (P =.01). Six eyes (60%) were > or =20/50. There were no significant complications. Three eyes (30%) without previous history of glaucoma required initiation of topical aqueous suppressant therapy for IOP elevation at last follow-up. One eye with a previous history of open-angle glaucoma required a trabeculectomy. CONCLUSIONS Intravitreal injection of triamcinolone acetonide appears to be effective in reducing cystoid macular edema associated with central retinal vein occlusion. This reduction often corresponded to an improvement in visual acuity. Further evaluation is warranted to assess its safety and efficacy in these eyes.

Acute Visual Acuity Loss Following Intravitreal Bevacizumab for Diabetic Macular Edema

A 58-year-old woman with non-proliferative diabetic retinopathy presented with decreased visual acuity from chronic macular edema. She had undergone multiple treatments previously, including focal laser treatment and intravitreal triamcinolone acetonide. Within 2 days of treatment with intravitreal bevacizumab, the patient noted a significant decrease in visual acuity. Fluorescein angiogram demonstrated an enlargement of the foveal avascular zone and persistent late leakage following intravitreal bevacizumab; optical coherence tomography performed before and after treatment revealed persistent cystoid macular edema. The use of intravitreal bevacizumab in chronic, refractory diabetic macular edema may cause acute visual acuity loss by disrupting an already fragile vascular perfusion status, leading to macular ischemia.

Macular translocation surgery with 360-degree peripheral retinectomy following ocular photodynamic therapy of choroidal neovascularization

PURPOSE To determine the visual outcomes of eyes that underwent macular translocation surgery with 360 degrees peripheral retinectomy and silicone oil tamponade (MTS360) following ocular photodynamic therapy (OPT) with verteporfin for subfoveal choroidal neovascularization (CNV) associated with age-related macular degeneration (ARMD). DESIGN Observational case series. METHODS A retrospective review of patients who underwent MTS360 with silicone oil tamponade from August 5, 1998 through December 1, 2002. Patients who had at least one episode of OPT with verteporfin before surgery were identified. The number of OPT session, best-corrected Early Treatment Diabetic Retinopathy Study (ETDRS) visual acuity, complications (including postoperative CNV, retinal detachment [RD]), the presence or absence of cystoid macular edema (CME) by optical coherence tomography (OCT) were recorded. RESULTS Eight eyes of eight patients were identified that fulfilled the inclusion criteria. All eyes had at least one episode of OPT (mean, 1.5 treatments). All of these patients at the time of MTS360 demonstrated continued visual loss following the most recent OPT session. The mean preoperative visual acuity was 56 letters. Four of the eight eyes demonstrated CME by OCT on preoperative examination. There were no significant postoperative complications other than one eye that had a successful repair of an RD. At 3 months, the mean visual acuity was 54 letters. At last follow-up (mean, 10 months), the mean visual acuity was 61 letters (P =.5). The final mean visual acuity change for the patients who had only one prior OPT (five eyes) was +10 letters. The mean final visual acuity change for the patients who had multiple OPT sessions (three eyes) was -1 letter. Three of the four eyes that had preoperative CME continued to demonstrate CME at last follow-up. Two eyes that had concurrent cataract extraction surgery with MTS360 did not develop CME. No eyes developed a recurrent CNV during the postoperative period. CONCLUSIONS MTS360 with silicone oil tamponade for CNV associated with ARMD appears to be a viable option for patients who are continuing to lose vision in their better seeing eye following OPT with verteporfin. MTS360 appears to be effective in stabilizing vision, especially in patients who had previously undergone only one OPT session. Further studies are indicated to evaluate the efficacy of MTS360 in this current era of OPT.

Intravitreal bevacizumab for choroidal neovascularization associated with choroidal nevus.

Purpose: To report 10 cases of occult choroidal neovascularization (CNV) associated with choroidal nevus managed with intravitreal bevacizumab. Methods: Interventional case series. Each nevus was examined and imaged with fluorescein angiography, B-scan ultrasonography, and optical coherence tomography. Data were retrospectively analyzed to evaluate outcomes of treatment response and visual acuity. Results: Nine patients presented with CNV overlying a chronic choroidal nevus with a posterior margin within 1.5 mm of the foveola. In the 10th patient, the posterior margin of the nevus was located 10 mm from the foveola with extension of subretinal fluid into the macula. The CNV was subfoveolar in four cases, juxtafoveolar in two cases, and extrafoveolar in four cases. Initial visual acuity was 20/20 to 20/50 in 5, 20/60 to 20/100 in 2, and 20/200 or worse in 3 cases. Clinical features included subfoveolar fluid in nine, exudation in five, and hemorrhage in four cases. Intravitreal bevacizumab (1.25 mg/0.05 cc) was injected with regression of CNV in all 10 cases using 2 to 14 injections (median 3 injections). In 2 eyes, after therapeutic response to bevacizumab later consolidation with photodynamic therapy (juxtafoveolar CNV) (n = 1) or conventional laser (extrafoveolar CNV) (n = 1) was provided. In the remaining 8 eyes, after discontinuation of bevacizumab, there was no recurrence of CNV over mean 10.1 months. At overall mean follow-up of 22.5 months, final visual acuity decreased by 1 line in 4 cases and improved by mean of 3 lines (range, 1–8 lines) in 6 cases. There were no adverse effects from bevacizumab injections. All 10 choroidal nevi remained stable. Conclusion: Intravitreal bevacizumab appears to be an effective treatment option for CNV secondary to choroidal nevus. In some cases, depending on the proximity of the CNV to the foveola, photodynamic therapy or conventional laser may be useful adjunctive therapy.

Microbial spectrum and outcomes of endophthalmitis after intravitreal injection versus pars plana vitrectomy

Purpose: To compare infectious organisms and visual outcomes of endophthalmitis after intravitreal injection (IVI) with endophthalmitis after pars plana vitrectomy (PPV). Methods: Retrospective, comparative, consecutive case series of patients diagnosed with presumed infectious endophthalmitis after IVI of an anti-vascular endothelial growth factor medication or PPV between January 1, 2009, and October 1, 2012, from one center. Main outcome measures were infectious organism and final visual acuity. Results: Forty-four cases of presumed infectious endophthalmitis (17 culture positive) occurred after IVI and 19 cases (9 culture positive) occurred after PPV. Of note, 56.3% of culture-positive IVI cases were due to bacteria associated with oral flora, primarily Streptococcus species, compared with none in the PPV group (P = 0.01). There was a trend approaching significance for IVI patients to have lost ≥3 lines of visual acuity compared with PPV patients at final follow-up (P = 0.07). Within the IVI group, patients were more likely to have lost ≥6 lines of visual acuity at final follow-up when endophthalmitis was due to an organism associated with oral flora (P = 0.007). Conclusion: Endophthalmitis after IVI has a higher likelihood of being due to oral flora compared with endophthalmitis after PPV. Among IVI patients, worse visual outcomes occurred when endophthalmitis was due to oral flora.

MINIMAL ENDOILLUMINATION LEVELS AND DISPLAY LUMINOUS EMITTANCE DURING THREE-DIMENSIONAL HEADS-UP VITREORETINAL SURGERY.

Purpose: To determine minimal endoillumination levels required to perform 3-dimensional heads-up vitreoretinal surgery and to correlate endoillumination levels used for measurements of heads-up display (HUD) luminous emittance. Methods: Prospective, observational surgical case series of 10 patients undergoing vitreoretinal surgery. Endoillumination levels were set to 40% of maximum output and were decreased at set intervals until the illumination level was 0%. Corresponding luminous emittance (lux) of the HUD was measured 40 cm from the display using a luxmeter (Dr. Meter, Model #LX1010BS). Results: In 9 of 10 cases, the surgeon felt that they could operate comfortably at an endoillumination level of 10% of maximum output with corresponding HUD emittance of 14.3 ± 9.5 lux. In the remaining case, the surgeon felt comfortable at a 3% endoillumination level with corresponding HUD emittance of 15 lux. Below this threshold, subjective image dimness and digital noise limited visibility. Endoillumination levels were correlated with luminous emittance from the 3-dimensional HUD (P < 0.01). The average coefficient of variation of HUD luminance was 0.546. There were no intraoperative complications. Conclusion: With real-time digital processing and automated brightness control, 3-dimensional HUD platforms may allow for reduced intraoperative endoillumination levels and a theoretically reduced risk of retinal phototoxicity during vitreoretinal surgery.

Effect of oral pentoxifylline on cystoid macular edema associated with central retinal vein occlusion

Purpose: To determine whether oral pentoxifylline, a xanthine-derived hemorheologic agent, decreases cystoid macular edema (CME) and improves visual acuity in eyes with a perfused central retinal vein occlusion (CRVO). Methods: Retrospective chart review of consecutive patients on pentoxifylline (400 mg po TID) for CRVO was performed. Inclusion criteria included CME, pentoxifylline use for at least 1 month, and a follow-up period of at least 4 months. Exclusion criteria included nonperfused or indeterminate CRVO, the presence of neovascularization, and previous or concurrent laser therapy or any other treatment for CRVO. Statistical analysis of collected data was performed. Results: Eleven patients were identified. All patients had a perfused CRVO. The mean best-corrected Early Treatment Diabetic Retinopathy Study visual acuity was 60 letters (Snellen equivalent 20/128) before the initiation of oral pentoxifylline. The mean time from onset of CRVO to start of pentoxifylline therapy was 5 months (range, 1–12 months). The mean duration of pentoxifylline use was 5.3 months (range, 2.5–10.2 months). The mean follow-up period was 8 months (range, 2.7–16.5 months). Cystoid macular edema had improved in 64% (7/11) of eyes at last follow-up as measured by biomicroscopy and optical coherence tomography. The visual acuity was not significantly changed at 62 letters (20/128+2) (Student t-test, P = 0.7) at last follow-up. There were no significant side effects from pentoxifylline. One patient had mild gastrointestinal disturbance. Conclusion: Pentoxifylline has a favorable adverse effect profile, and can reduce CME in eyes with CRVO. Visual acuity does not appear to change significantly. A larger, randomized, multiarmed clinical trial evaluating the effects of pentoxifylline as an adjunctive treatment modality may be of benefit since even a small positive effect in altering the natural history of CME related to CRVO may be of value for these patients.

Hemi-retinal vein occlusion following LASIK

We report a case of hemi-retinal vein occlusion following laser-assisted in situ keratomileusis (LASIK) in a healthy 46-year-old Caucasian male. A hemi-retinal vein occlusion following LASIK could be coincidental. However, young age, absence of risk factors and negative laboratory testing require consideration of a causal relationship.

Effect of topical aqueous suppression on intraocular gas duration after pure perfluoropropane injection in nonvitrectomized eyes with retinal detachment.

Purpose: To determine whether topical aqueous suppressants affect the duration of pure expansile intraocular gas in nonvitrectomized eyes. Methods: A prospective randomized controlled trial was performed on nonvitrectomized patients undergoing retinal detachment repair with scleral buckle or pneumatic retinopexy using 0.3 mL of 100% perfluoropropane (C3F8) gas tamponade. Eyes were randomly assigned to receive topical dorzolamide 2% and timolol 0.5% twice daily postoperatively until gas dissolution or to observation. Results: Twenty-one patients met all inclusion and exclusion criteria. Twelve were randomized to the control group and nine to the dorzolamide–timolol group. In the dorzolamide–timolol group, mean intraocular pressure was 17.4 on postoperative Day 1 and 12.5 on postoperative Week 1 (P = 0.03). In the control group, mean intraocular pressure was 14.5 on postoperative Day 1 and 15.1 on postoperative Week 1 (P = 0.73). The mean duration of C3F8 was 37.8 days in the dorzolamide–timolol group and 40.4 days in the control group (P = 0.70). Conclusion: Topical aqueous suppression does not seem to have a significant effect on the duration of pure expansile intraocular C3F8 in nonvitrectomized eyes after pneumatic retinopexy or scleral buckling.

Intravitreal Triamcinolone Acetonide Injection for Macular Edema Due to Central Retinal Vein Occlusion Persisting Despite Multiple Intravitreal Bevacizumab Injections

PURPOSE To evaluate the response to intravitreal triamcinolone acetonide for macular edema persisting or recurring despite multiple intravitreal bevacizumab (IVB) treatments for central retinal vein occlusion (CRVO). METHODS Retrospective interventional case series of 21 eyes with CRVO from 21 patients who were diagnosed with persistent or recurrent macular edema secondary to CRVO and treated with 0.1mL (4mg) intravitreal triamcinolone acetonide (IVTA) after initial treatment with 3 or more IVB injections. Anatomic and visual responses were the study primary outcomes. RESULTS Mean logarithm of the minimum angle of resolution visual acuity was 1.19 (20/316) immediately before IVTA injection, and improved to 1.04 (20/219) 1 month after IVTA administration (P=0.003). The mean central macular thickness on optical coherence tomography decreased from 533.4 μm immediately before IVTA to 327.9 μm after IVTA injection (P<0.001). No cases of endophthalmitis, retinal detachment, or neovascularization were noted. CONCLUSIONS Intravitreal triamcinolone acetonide appears to improve vision and reduce persistent or recurrent macular edema secondary to CRVO despite multiple bevacizumab injections.