David L. Yarian

Pneumatic retinopexy : a two-year follow-up study of the multicenter clinical trial comparing pneumatic retinopexy with scleral buckling

The authors report 2-year follow-up information on 179 of 198 eyes (90%) enrolled in a previously published multicenter, randomized, controlled clinical trial comparing pneumatic retinopexy (PR) with scleral buckling (SB) for the management of selected retinal detachments. Scleral buckling was compared with PR with regard to redetachment after the initial 6-month follow-up period (1% versus 1%), overall attachment (98% versus 99%), subsequent cataract surgery (18% versus 4%; P less than 0.05), preoperative visual acuity (no significant difference), and final visual acuity of 20/50 or better in eyes with macular detachment for a period of 14 days or less (67% versus 89%; P less than or equal to 0.05). Reoperations after a failed PR attempt did not adversely affect visual outcome. After 2 years, PR continues to compare favorably with SB.

ACUTE TEAR OF THE RETINAL PIGMENT EPITHELIUM

Tears of the retinal pigment epithelium are a recently recognized complication of senile macular degeneration. A retinal pigment epithelial tear associated with an extramacular pigment epithelial detachment is described in which the patient recovered excellent vision. The clinical features of this condition are discussed, and evidence is presented which localizes the cleavage plane in retinal pigment epithelial detachments to be between retinal pigment epithelial basement membrane and the remainder of Bruchs membrane.

Short-term complications of intravitreal injection of triamcinolone acetonide

Purpose: To describe the short-term complications associated with intravitreal triamcinolone acetonide (IVTA) injection in the treatment of posterior segment disorders. Methods: The medical records of 784 patients (929 consecutive eyes) were retrospectively reviewed at a single institution. One or more IVTA injections for treatment of a variety of steroid-responsive posterior segment disorders (predominantly diabetic macular edema, choroidal neovascularization, and retinal venous occlusions) were administered. Adverse events occurring within 3 months of the initial injection were identified. Results: The most common adverse event occurring within 3 months after the initial injection was steroid-related ocular hypertension, with intraocular pressure spikes of >21 mm Hg in 21% of eyes and >25 mm Hg in 11% of eyes. Ocular inflammation occurred in six eyes (0.6%): four eyes with sterile hypopyon and two eyes without hypopyon. Three eyes (0.3%) had corneal epithelial defects thought to be related to pretreatment with povidone–iodine solution. No eyes had culture-positive infectious endophthalmitis. Cataract progression was not assessed in this analysis. Conclusion: IVTA injection for the treatment of steroid-responsive disorders of the posterior segment, when administered under sterile conditions, is associated with a low incidence of serious vision-threatening adverse events within the first 3 months after injection.

Retinal hemangioma-like lesions in eyes with retinitis pigmentosa.

The authors report two patients with bilateral vascular masses of the peripheral retina associated with primary pigmentary dystrophy of the retina (retinitis pigmentosa). Although they are most similar to the retinal capillary hemangiomas of von Hippel, the affected patients had no clinical history or clinical findings suggestive of that syndrome. They differ from the calcified retinal hamartomas that have been associated with retinitis pigmentosa because they do not show the extensive telangiectasia and exudation seen with the exudative retinopathy that has been described with retinitis pigmentosa. They do not show the fluorescein angiographic pattern that characterizes peripheral choroidal neovascularization. Their main complication seems to be vitreous hemorrhage rather than exudative retinopathy. The authors discuss the possible relationship of these acquired retinal vascular masses to the retinitis pigmentosa.

An Investigation of the Hospital Charges Related to the Treatment of Endophthalmitis in the Endophthalmitis Vitrectomy Study

PURPOSE The purpose of the study is to assess the hospital charges associated with the treatment of endophthalmitis using a sample of patients from the Endophthalmitis Vitrectomy Study (EVS). METHODS The Endophthalmitis Vitrectomy Study was a multicenter, randomized clinical trial with a two-by-two factorial design to compare immediate pars plana vitrectomy to tap-biopsy and to compare the use of systemic antibiotics (intravenous) to no intravenous antibiotics in the management of postoperative endophthalmitis. Hospital charge data were collected retrospectively from 129 patients from the 4 clinical centers participating in this ancillary study. This represents 31% of the total Endophthalmitis Vitrectomy Study population. An analysis of variance was used to compare hospital charges across center and treatment. A charge-effectiveness analysis compared measures the effectiveness across treatment groups. The annual savings of hospital charges in the United States was estimated for a range of annual incidence rates of endophthalmitis. RESULTS The use of intravenous antibiotics significantly increased hospital charges. Patients undergoing vitrectomy had significantly higher hospital charges than did patients undergoing tap-biopsy. The most charge-effective treatment for patients presenting with light perception only vision was immediate vitrectomy, whereas the most charge-effective treatment for patients presenting with better vision was tap-biopsy. Factors other than treatment independently associated with hospital charges were female sex, history of diabetes, symptom of red eye, and baseline vision of light perception only. CONCLUSIONS Assuming the results of the Endophthalmitis Vitrectomy Study were used as a guide for the treatment of endophthalmitis, the estimated annual nationwide reduction of hospital charges would be between

Micropulsed laser photocoagulation and intravitreal triamcinolone acetonide injection for the treatment of retinal angiomatous proliferation.

7.6 million and

Tumor-associated retinal pigment epithelial proliferation simulating retinal pigment epithelial tear.

40.0 million.

Noninfectious Endophthalmitis Associated With Intravitreal Triamcinolone Injection

Purpose: To investigate visual acuity and fluorescein angiographic outcomes, as well as adverse events, associated with treatment of retinal angiomatous proliferation (RAP) with micropulsed laser photocoagulation and intravitreal triamcinolone acetonide injection. Methods: In this retrospective, noncomparative, interventional, consecutive case series, the medical records of all patients treated for RAP with micropulsed laser photocoagulation (yellow or green dye; duration, 0.02–0.05 second; power adjusted to achieve a white burn of moderate intensity at the level of the RAP lesion in the retina) and intravitreal triamcinolone acetonide (4 mg/0.1 mL) injection between January 2003 and November 2004 were reviewed by one of four retina specialists at a single retina practice. Main outcome measures were visual acuity, leakage shown by fluorescein angiography, and adverse events. Results: The study included 14 eyes of 13 patients (8 women and 5 men; median age, 83 years [range, 70–90 years]). Triamcinolone acetonide injection preceded laser treatment by a median duration of 7 days (range, 5–16 days) in 8 eyes, was performed on the same day as laser treatment in 2 eyes, and followed laser treatment by a median duration of 7 days (range, 7–28 days) in 4 eyes. Eyes were followed a median of 18 months (range, 12–27 months) after treatment with both laser and intravitreal triamcinolone injection. Compared with pretreatment visual acuity, vision at 12 months and the last follow-up examination was stable in 5 eyes (36%), improved by ≥2 lines in 6 eyes (43%), and worsened by ≥2 lines in 3 eyes (21%). The median visual acuity before treatment was 20/200 compared with 20/80 at 3 months after treatment (P = 0.02), 20/100 at 6 months after treatment (P = 0.16), 20/200 at 12 months after treatment (P = 0.73), and 20/100 (P = 0.63) at the last follow-up examination. For 13 eyes (93%), fluorescein angiography performed 6 months after administration of both laser and intravitreal triamcinolone injection demonstrated resolution of all leakage; one eye was treated with photodynamic therapy with verteporfin 6 months after treatment for persistent low-grade leakage. Elevated intraocular pressure (>25 mm Hg) occurred in 2 eyes at 2.5 months and 2 months after intravitreal triamcinolone acetonide injection; both eyes were treated with transient use of antiglaucoma eyedrops. Seven (78%) of 9 phakic eyes had cataract progression, and 5 of these 7 eyes underwent cataract extraction during the follow-up period. No other adverse events occurred. Conclusions: Micropulsed laser photocoagulation and intravitreal triamcinolone acetonide injection may be effective and safe treatment for RAP lesions.

Retinal Pigment Epithelial Tears Through the Fovea With Preservation of Good Visual Acuity

A lesion with both the clinical and fluorescein angiographic appearance of the classical retinal pigment epithelial (RPE) tear was discovered over the dome of an actively growing metastatic choroidal tumor in a patient with a previous history of breast carcinoma. However, our patient exhibited no evidence of pigment epithelial detachment or age-related macular degeneration, the underlying cause of the RPE tear. Although we cannot be sure that a true RPE tear did not exist over our patients tumor, more likely, we are observing a tumor induced zone of RPE dehiscence accompanied by RPE proliferation at its border, giving a very similar fundus appearance. Possible pathogenic mechanisms for the finding in our patient, and a comparison to those mechanisms responsible for the classical RPE tear, are discussed.