Christine R. Gonzales

Endophthalmitis after Pars Plana Vitrectomy: A 20- and 25-Gauge Comparison

OBJECTIVE Recent retrospective analyses have suggested that postoperative endophthalmitis may be more frequent with 25- than 20-gauge pars plana vitrectomy (PPV). Because the infection risk may depend on the suturing status of the sclerotomy, and the perioperative anti-infection protocol, we compared the incidence rate of endophthalmitis after sutureless 25-gauge versus sutured 20-gauge PPV on a large cohort of patients operated with a standardized perioperative anti-infection protocol. DESIGN Retrospective comparative case series. PARTICIPANTS Consecutive patients who underwent 20- or 25-gauge PPVs at a single center over a multi-year period. METHODS We analyzed 3597 consecutive PPVs. Patients with a pre-PPV diagnosis of endophthalmitis, PPVs performed for implantation of drug delivery devices, or 25-gauge PPVs with all sclerotomies sutured closed were excluded. Patients with > or =1 week of follow-up were divided into 2 study groups by sclerotomy status at the end of surgery: the 20-gauge group had 3 sutured 20-gauge sclerotomies, and the 25-gauge group had > or =1 unsutured 25-gauge sclerotomy. Endophthalmitis was defined by clinical criteria independent of microbiological results. MAIN OUTCOME MEASURES The incidence of endophthalmitis was compared between 25- versus 20-gauge groups. RESULTS Of 3372 PPV surgeries meeting inclusion and exclusion criteria, 1948 and 1424 surgeries were 20- and 25-gauge PPVs, respectively. Average age (+/- standard deviation) of patients was 54.6 (+/- 22.6) and 64.4 (+/- 16.5) years in the 20- and 25-gauge PPV groups, respectively (P<0.0001). Median post-PPV follow-up time was not significantly different between the 2 groups (12.5 vs 13.0 months; P = 0.69). Endophthalmitis was observed in 1 patient (0.07%; 95% confidence interval, 0%-0.21%) from the 25-gauge group and none in the 20-gauge group (P = 0.42; Fisher exact test, 2-tailed). The use of air/gas endotamponade (P<0.0001) and intravitreal triamcinolone (P<0.001) was more common in 25- versus 20-gauge PPV. CONCLUSIONS The incidence of endophthalmitis was low in both groups. We were unable to show a significant difference in the incidence of endophthalmitis between sutureless 25-gauge and sutured 20-gauge PPV, and conclude that a careful perioperative anti-infection protocol may reduce 25-gauge PPV endophthalmitis risk to that of 20-gauge PPV.

Birdshot retinochoroidopathy: immunopathogenesis, evaluation, and treatment

Birdshot retinochoroidopathy (BSR) is a bilateral posterior uveitis. A putative organ-specific autoimmune disease, it is strongly associated with the HLA-A29 allele, and understanding the immunopathogenesis of BSR is of great interest. The clinical features include minimal anterior uveitis, vitritis, retinal vasculitis, cystoid macular edema, and distinctive hypopigmented choroidal lesions. Findings on electrophysiology studies and angiography have implications for understanding the pathophysiology of the disease, and may be useful for following the course of BSR and the response to therapy in individual patients. The decision to initiate therapy can be difficult, but corticosteroids and immunosuppressive agents are often used.

Pediatric rhegmatogenous retinal detachment: clinical features and surgical outcomes.

Objective: To describe the characteristics of and surgical outcomes for primary pediatric rhegmatogenous retinal detachment (RRD) and to evaluate whether specific characteristics impact anatomical outcomes after surgical intervention. Methods: Data for consecutive patients (18 years of age or younger) with RRD who required surgery over a 5-year period were studied retrospectively. Patients with recurrent retinal detachment or active retinopathy of prematurity were excluded. Results: Forty-six eyes of 45 patients (median age, 9 years) were included. Ninety-eight percent of the patients had at least 1 predisposing factor, including prior surgery (61%), trauma (43%), developmental abnormality (35%), and myopia (17%). Retinal reattachment was attained in 78% of eyes. Younger age (P = 0.019), worse initial vision (P = 0.008), greater extent of retinal detachment (P = 0.007), and presence of proliferative vitreoretinopathy (grade C or worse) (P = 0.008) were associated with worse anatomical outcomes. Vision improved after surgery in 56% of patients, but overall visual results were modest. Thirty-seven percent of patients had vision-threatening lesions in the other eye, and 18% had a history of retinal detachment in the fellow eye. Conclusions: Pediatric RRD is often associated with a predisposing factor. Favorable anatomical and visual outcomes are possible, and lesions in the fellow eye are common.

Association of systemic risk factors with the progression of laser-treated retinopathy of prematurity to retinal detachment.

Purpose: To identify systemic risk factors associated with treatment failure of diode laser photocoagulation for threshold or prethreshold retinopathy of prematurity (ROP). Methods: Consecutive infants treated with laser at our institution and infants referred from outside centers with progression to stage 4 or 5 ROP after laser treatment were included in this retrospective study. Two groups were identified: those with regression of ROP after laser (LT group; 196 eyes of 98 infants) and those with progression to stage 4 or 5 ROP after laser (ST group; 134 eyes of 80 infants). Results: Using a multiple logistic regression model, there was a statistically significant association for progression of treated ROP to retinal detachment (RD) with history of sepsis (P < 0.001), oxygen therapy (P = 0.003), mechanical ventilation (P = 0.003), respiratory distress syndrome (RDS; P = 0.005), and patent ductus arteriosus (PDA; P = 0.042). On the other hand, jaundice (P = 0.563), anemia (P = 0.599), thrombocytopenia (P = 0.689), and blood transfusion (P = 0.878) did not show a statistically significant association with failure of laser treatment and progression of ROP to stage 4 or 5 disease. Conclusions: Premature infants with a history sepsis, oxygen therapy, mechanical ventilation, RDS, and PDA may be at a higher risk for progression of ROP despite diode laser treatment.

25-Gauge vitrectomy for paediatric vitreoretinal conditions.

Summary: This is a retrospective study of 56 eyes of 49 children undergoing vitrectomy with 25-gauge instrumentation. There were no cases of endophthalmitis, wound leaks or hypotony requiring treatment. A modified approach in which the conjunctiva and sclera is sutured was used for young babies requiring a pars plicata approach. Objective: To evaluate the feasibility and safety of 25-gauge vitrectomy for various vitreoretinal indications in the paediatric population. Methods: Consecutive patients aged 18 years or less undergoing vitrectomy for various vitreoretinal indications over a 5-year period were studied retrospectively. Two different surgical techniques were used: a modified 25-gauge approach in which the sclerotomies and conjunctiva were sutured as described previously for most children under the age of 1 year, and a transconjunctival 25-gauge approach for older children Results: 56 eyes in 49 children (16 girls and 33 boys) were included. Intraoperative unplanned events or complications included: conversion to 20-gauge vitrectomy (four), conversion of one port to a 20-gauge sclerotomy (two), suspected lens damage (one) and intraoperative bleeding from a vascular ridge (one). Postoperative complications included cataract (five), rhegmatogenous retinal detachment (four) and vitreous haemorrhage (three). The four retinal detachments were either recurrent or occurred in eyes with complex ocular pathology and were not felt to be related to the surgical technique. There were no cases of postoperative hypotony requiring intervention, choroidal detachment, endophthalmitis or sclerotomy-related retinal breaks. Conclusions: 25-gauge vitreoretinal techniques can be used in various paediatric vitreoretinal conditions and facilitate easy access to small spaces in the paediatric eye. To avoid postoperative hypotony, a modified technique is recommended for younger babies in which the conjunctiva and sclera is sutured.

Intravitreous Vascular Endothelial Growth Factor (VEGF) Inhibitor Therapy for Tamoxifen Induced Macular Edema

A 59-year-old male patient with tamoxifen induced macular edema in both eyes was treated with intravitreous sodium pegaptanib. Follow-up clinical examination, OCT, and FA demonstrated reduced edema and leakage with improvement in visual acuity.

Suprachoroidal Hemorrhage as an Intraoperative Complication of 25-Gauge Pars Plana Vitrectomy

Purpose: To describe a case of suprachoroidal hemorrhage occurring during 25-gauge vitrectomy. Methods: Retrospective case review. Results: An 80-year old pseudophakic man developed intraoperative suprachoroidal hemorrhage during a vitreous biopsy procedure for chronic intraocular inflammation. Despite drainage of the choroidals, visual outcome was poor. Conclusions: 25-gauge vitrectomy is often referred to as a “less-invasive” procedure than 20-gauge vitrectomy, but it is not necessarily less risky and probably carries a similar risk profile.

Traumatic macular hole in shaken baby syndrome successfully treated with pars plicata vitrectomy and gas tamponade.

PURPOSE To describe an infant with shaken baby syndrome and a traumatic macular hole treated with pars plana vitrectomy and gas tamponade. DESIGN Case report. METHODS A 4-month-old infant with suspected shaken baby syndrome presented with intraretinal and premacular hemorrhages. To prevent amblyopia, these hemorrhages were removed by pars plana vitrectomy, during which a full-thickness macular hole was discovered. Completion of a posterior vitreous detachment was not attempted at the time. Six months later, the macular hole remained open and was treated with pars plana vitrectomy, internal limiting membrane peeling, and perfluoropropane tamponade. RESULTS The procedure was well tolerated, and the macular hole closed without postoperative positioning. The hole remained closed 6 months after surgical repair. CONCLUSIONS Traumatic macular hole may be a complication of shaken baby syndrome. This case demonstrates that pars plana vitrectomy with gas tamponade can be used to successfully treat traumatic macular hole in infants.

Macular infarction secondary to Staphylococcus epidermidis infection.

PURPOSE To describe a patient with macular infarction caused by Staphylococcus epidermidis-induced endophthalmitis. METHODS Case report. RESULTS An 88-year-old woman was referred to our clinic for endophthalmitis after cataract extraction. She was diagnosed to have an S. epidermidis infection. Her vision dropped from 20/50 to hand motions. During the course of her infection, she developed multiple multifocal branch retinal artery occlusions associated with absolute capillary nonperfusion centrally and was diagnosed with macular infarction. CONCLUSION Although most commonly associated with aminoglycoside toxicity, macular infarction can occur after endophthalmitis treatment without the use of aminoglycosides.

Syphilitic scleritis and choroidal malignant melanoma of the same eye.

A 42-year-old Italian homosexual presented with a red painful eye associated with exudative retinal detachment that was subsequently attributed to syphilitic posterior scleritis. These findings all resolved with intravenous penicillin therapy. However, choroidal mass lesion persisted and subsequent ancillary imaging including B scan and ultrasonography confirmed the presence of a choroidal melanoma, which was treated with radioactive plaque therapy. This case report will describe the interesting findings of this unique presentation.