Donald S. Fong

Surgical management of macular holes: a report by the American Academy of Ophthalmology.

OBJECTIVE The document describes macular hole surgery and examines the available evidence to address questions about the efficacy of the procedure for different stages of macular hole, complications during and after surgery, and modifications to the technique. METHODS A literature search conducted for the years 1968 to 2000 retrieved over 400 citations that matched the search criteria. This information was reviewed by panel members and a methodologist, and it was evaluated for the quality of the evidence presented. RESULTS There are three multicenter, controlled, randomized trials that constitute Level I evidence and compare the value of surgery versus observation for macular hole. There are three multicenter, controlled, randomized trials studying the use of adjuvant therapy in macular hole repair. Postoperative vision of 20/40 or better has been reported in 22% to 49% of patients in randomized trials. The risks of surgical complications include retinal detachment (3%), endophthalmitis (<1%), cataract (>75%), and late reopening the hole (2% to 10%). CONCLUSIONS The evidence does not support surgery for patients with stage 1 holes. Level I evidence supports surgery for stage 2 holes to prevent progression to later stages of the disease and further visual loss. Level I evidence shows that surgery improves the vision in a majority of patients with stage 3 and stage 4 holes. There is no strong evidence that adjuvant therapy used at the time of surgery results in improved surgical outcomes. Patient inconvenience, patient preference, and quality of life issues have not been studied.

Visual Side Effects Of Successful Scatter Laser Photocoagulation Surgery For Proliferative Diabetic Retinopathy: A Literature Review

Purpose: To review the literature on limitations and adverse effects associated with scatter or panretinal laser photocoagulation (PRP) for diabetic retinopathy (DR). Design: Literature review. Results: Scatter laser photocoagulation is associated with moderate visual loss, some diminished visual field, reduced color vision, and reduced contrast sensitivity. Conclusions: Scatter laser photocoagulation has been shown to reduce the risk of severe visual loss from proliferative DR. However, scatter treatment is associated with some decline in visual function. These effects should be studied more extensively and should be considered when comparing pharmacologic treatments for proliferative DR.

Corticosteroids in posterior segment disease: an update on new delivery systems and new indications.

Purpose of review Corticosteroids are traditionally used for inflammatory disorders because of their ability to diminish neutrophil transmigration, limit access to sites of inflammation, and decrease cytokine production. More recently, however, investigators have focused on the angiostatic and antipermeability properties of corticosteroids for posterior segment diseases such as age-related macular degeneration (AMD), diabetic retinopathy, and macular edema. Both new angiostatic and traditional corticosteroids are currently undergoing evaluation as new delivery techniques such as intravitreal injection and intraocular sustained-release devices facilitate high local angiostatic and antipermeability concentrations while minimizing extraocular toxicity. The purpose of this review is to discuss recent work concerning both the mechanism and effectiveness of these newer treatments. Recent findings Steroids may exert a beneficial effect in AMD–related choroidal neovascular membranes (CNVM) through inhibition of CNVM-promoting macrophages and direct inhibition of angiogenic growth factors. They may also alter extracellular matrix turnover and inhibit matrix metalloproteinases involved in CNVM formation. Intravitreal steroid injections potently inhibit experimental CNVM in primates and rats and have shown promise in some early human pilot trials. In proliferative diabetic retinopathy, steroids may directly inhibit growth factors such as vascular endothelial derived growth factor and inhibit leukocytes that play an important role in early microvascular alterations. Intravitreal steroid injections inhibit experimental preretinal neovascularization in pigs and rats, and rubeosis in some early human studies. In addition, the effect of steroids on vascular permeability has led to their use for macular edema from many causes such as diabetes and venous occlusive disease. Summary The use of steroids to treat a number of retinal diseases is gaining wide spread acceptance. The apparent short-term success must be balanced by the fact that the long-term safety and efficacy have yet to be determined for any of these approaches. A number of large randomized prospective clinical trials of steroid compounds and new delivery systems are currently under way for AMD, diabetic retinopathy, uveitis, and other retinovascular diseases, and hopefully these studies will provide guidance about the use of these new modalities.

Intravitreal Bevacizumab and Ranibizumab for Age-Related Macular Degeneration: A Multicenter, Retrospective Study

OBJECTIVE To compare visual acuity (VA) outcomes after bevacizumab or ranibizumab treatment for AMD. DESIGN Comparative, retrospective case series. PARTICIPANTS We followed 452 patients in a retrospective study of exudative AMD treated with anti-vascular endothelial growth factor drugs; 324 patients were treated with bevacizumab and 128 patients with ranibizumab. METHODS All treatment-naïve patients who received either bevacizumab or ranibizumab were followed for 1 year. Baseline characteristics and VA were recorded using standard descriptive statistics. MAIN OUTCOME MEASURES Visual acuity. RESULTS At 12 months, the distribution of VA improved in both groups with 22.9% of bevacizumab and 25.0% of ranibizumab attaining >or=20/40. Improvement in vision was observed in 27.3% of the bevacizumab group and 20.2% of the ranibizumab group. The mean number of injections at 12 months was 4.4 for bevacizumab and 6.2 for ranibizumab. There were 8 (2%) deaths in the bevacizumab group and 4 (3%) in the ranibizumab group. Two patients developed endophthalmitis in the bevacizumab group and the ranibizumab group. The bevacizumab group had slightly worse acuity at baseline, but both groups showed improvement and stability of vision over time. CONCLUSIONS Both treatments seem to be effective in stabilizing VA loss. There was no difference in VA outcome between the 2 treatment groups. Because the study is a nonrandomized comparison, selection bias could mask a true treatment difference. Results from the Comparison of the Age-related Macular Degeneration Treatment Trials will provide more definitive information about the comparative effectiveness of these drugs.

Glitazone Use Associated with Diabetic Macular Edema

PURPOSE To determine the ocular safety of glitazones in patients with diabetes, we investigated the association of diabetic macular edema (DME) in a large population of glitazone users. DESIGN Prospective cohort study. METHODS The study was conducted at Kaiser Permanente Southern California. About 170,000 persons with diabetes were identified using the Diabetes Case Identification Database. Glitazone drug use was obtained from the pharmacy database. The main outcome measure was the development of macular edema (ME). The chi2 test was used to compare proportions and t tests were used for means. Logistic regression analysis was used to adjust for potential confounding variables. RESULTS In 2006, there were 996 new cases of ME. Glitazone users were more likely to develop ME in 2006 (odds ratio [OR], 2.6; 95% confidence interval [CI], 2.4 to 3.0). After excluding patients who did not have the drug benefit, did not have an eye exam, and had a HgA1c <7.0, glitazone use was still associated with an increased risk of developing ME (OR, 1.6; 95% CI, 1.4 to 1.8). CONCLUSION The current study appears to show that the glitazone class of drug is associated with DME. After adjusting for confounding factors of age, glycemic control, and insulin use, glitazones are still modestly associated with DME. A more in-depth study will need to be done to evaluate the role of other confounding factors. When treating patients with DME, ophthalmologists should consider the role of the glitazones.

Comparison of time-domain OCT and fundus photographic assessments of retinal thickening in eyes with diabetic macular edema.

PURPOSE To explore the correlation between optical coherence tomography (OCT) and stereoscopic fundus photographs (FP) for the assessment of retinal thickening (RT) in diabetic macular edema (DME) within a clinical trial. METHODS OCT, FP, and best corrected visual acuity (VA) measurements were obtained in both eyes of 263 participants in a trial comparing two photocoagulation techniques for DME. Correlation coefficients (r) were calculated comparing RT measured by OCT, RT estimated from FP, and VA. Principal variables were central subfield retinal thickness (CSRT) obtained from the OCT fast macular map and DME severity assessed by a reading center using a seven-step photographic scale combining the area of thickened retina within 1 disc diameter of the foveal center and thickening at the center. RESULTS Medians (quartiles) for retinal thickness within the center subfield by OCT at baseline increased from 236 (214, 264) microm in the lowest level of the photographic scale to 517 (455, 598) microm in the highest level (r = 0.67). However, CSRT interquartile ranges were broad and overlapping between FP scale levels, and there were many outliers. Correlations between either modality and VA were weaker (r = 0.57 for CSRT, and r = 0.47 for the FP scale). OCT appeared to be more reproducible and more sensitive to change in RT between baseline and 1 year than was FP. CONCLUSIONS There was a moderate correlation between OCT and FP assessments of RT in patients with DME and slightly less correlation of either measure with VA. OCT and FP provide complementary information but neither is a reliable surrogate for VA.

Comparative Effectiveness of Antibiotic Prophylaxis in Cataract Surgery.

PURPOSE Intracameral injection is an effective method for preventing infection, but no controlled study has been published in the United States. DESIGN We conducted an observational, longitudinal cohort study to examine the effect of topical and injected antibiotics on risk of endophthalmitis. PARTICIPANTS We identified 315 246 eligible cataract procedures in 204 515 members of Kaiser Permanente, California, 2005-2012. METHODS The study used information from the membership, medical, pharmacy, and surgical records from the electronic health record. MAIN OUTCOME MEASURES The adjusted odds ratio (OR) and 95% confidence interval (CI) for the association of antibiotic prophylaxis (route and agent) with risk of endophthalmitis was estimated using logistic regression analysis. RESULTS We confirmed 215 cases of endophthalmitis (0.07% or 0.7/1000). Posterior capsular rupture was associated with a 3.68-fold increased risk of endophthalmitis (CI, 1.89-7.20). Intracameral antibiotic was more effective than topical agent alone (OR, 0.58; CI, 0.38-0.91). Combining topical gatifloxacin or ofloxacin with intracameral agent was not more effective than using an intracameral agent alone (compared with intracameral only: intracameral plus topical, OR, 1.63; CI, 0.48-5.47). Compared with topical gatifloxacin, prophylaxis using topical aminoglycoside was ineffective (OR, 1.97; CI, 1.17-3.31). CONCLUSIONS Surgical complication remains a key risk factor for endophthalmitis. Intracameral antibiotic was more effective for preventing post-cataract extraction endophthalmitis than topical antibiotic alone. Topical antibiotic was not shown to add to the effectiveness of an intracameral regimen.

Mucosa-associated lymphoid tissue lymphoma with intraocular involvement.

Purpose: To report the clinicopathologic features of a patient with mucosa-associated lymphoid tissue (MALT) lymphoma of the conjunctiva and associated intraocular involvement. Methods: This study is a retrospective clinicopathologic correlative case report summarizing the clinical, radiologic, and histopathologic findings of a patient with conjunctival MALT lymphoma and associated intraocular involvement. Results: Ophthalmic examination and fluorescein angiography demonstrated progressive conjunctival infiltration bilaterally, marked uveal effusions in the left eye, and cellular white infiltrates of the choroid in the right eye. MRI of the orbit revealed a diffusely infiltrating intra- and extraocular lesion extending around the globe and optic nerve in the left eye without evidence of intracranial extension. Conjunctival biopsy showed low-grade tumor cells, consistent with the diagnosis of MALT lymphoma. The patient was successfully treated with external beam radiation with marked clinical improvement. Conclusion: Conjunctival MALT lymphomas, typically indolent and localized tumors, may extend into the orbit and invade local tissues such as the choroid with devastating consequences. A conjunctival biopsy can provide an easy diagnosis of this treatable entity.

Factors associated with follow-up eye examinations among persons with diabetes.

Objective: The authors investigated the process of diabetes eye care by assessing follow-up eye examinations in patients with diagnosed diabetes in a managed care organization. Methods: The authors randomly identified 5000 diabetic patients from the Kaiser Permanente Southern California diabetes case identification database. A total of 2412 patients received an eye examination during the enrollment period. The medical records of these patients then were reviewed to determine the interval of the next eye examination. The authors investigated characteristics of patients who had a follow-up examination within 1 year and >1 year. Results: Although every diabetic patient is sent an annual reminder to get an eye examination, only 27.6% of patients were re-examined within 1 year. One third of patients with diabetes did not see an ophthalmologist or optometrist in the next 2 years even though a substantial number had already been diagnosed with retinopathy. Patients who were older, had a longer duration of diabetes, and used insulin were more likely to have a follow-up examination within 1 year. Neither levels of glycosylated hemoglobin or serum cholesterol nor race/ethnicity were associated with likelihood of getting a repeat examination. Patients who had slightly worse visual acuity and retinopathy level were more likely to have an examination within 1 year. Conclusion: The current report assesses the process of eye care by investigating the frequency of follow-up examination in patients with diabetes mellitus. Patients who were older, with longer duration of diabetes, with poorer vision and more severe retinopathy were more likely to have a follow-up examination within 1 year. Glycemic control and race/ethnicity were not associated with follow-up within 1 year. Additional studies are needed to further understand the barriers to receiving a follow-up eye examination among people with diabetes.

Recent Statin Use and Cataract Surgery

PURPOSE To investigate whether the statin class of drugs reduces the risk of cataract extraction. DESIGN Case-control study. METHOD setting: Kaiser Permanente Southern California, which provides prepaid healthcare for 3.2 million residents by 6000 physicians. patient population: Eligible patients were those who had 5+ years of continuous enrollment in 2009. Cases were 13 982 patients who underwent cataract surgery in their first eye in 2009. Controls were the 34 049 patients who had an eye examination, but did not undergo cataract surgery or have a diagnosis of cataract in their medical record. observation procedure: The primary source of data to assess cataract surgery, treatment with statins, and other risk factors is the electronic database of Kaiser Permanente. main outcome measure: Use of the statin class of drug. RESULTS Patients who had cataract surgery were older, were more likely to be white, and appeared to have more coronary artery disease but less diabetes. The proportion of statin users appeared to be greater among those with cataract surgery (64.3%) compared to those without a diagnosis of cataract or cataract surgery (55.5%). After adjustment for age, sex, race, smoking status, diabetes, and coronary artery disease, longer-term statin use was found to be protective against cataract extraction (OR: 0.93, P = .02), while shorter-term use was associated with cataract surgery (OR: 1.11, P < .0001). Age-stratified logistic regression analysis showed that statin use of 5 years or more was protective against cataract surgery in the younger age group (50-64 years), while shorter-term use (<5 years) was associated with an increased risk of surgery in both the younger and older age groups (60+ years). CONCLUSION The current study finds that recent longer-tem statin use was protective against cataract surgery in younger patients (50-64 years of age), while shorter-term use was associated with an increased risk of surgery. One strength of the current study is information on the large number of incident cases of cataract extraction and the electronic database on drug use. Additional studies will be needed to understand the difference in effect between longer- and shorter-term users of statins.