Dong Heun Nam

Changes in aqueous concentrations of various cytokines after intravitreal triamcinolone versus bevacizumab for diabetic macular edema.

PURPOSE To investigate the changes in aqueous inflammatory and angiogenic cytokine levels after intravitreal injection of triamcinolone or bevacizumab for reducing foveal thickness in diabetic macular edema (DME). DESIGN Prospective, interventional case series. METHODS Twenty-two eyes of 11 patients with bilateral DME and 6 eyes of 6 patients undergoing cataract surgery participated in this study. In each DME patient, 1 eye received an intravitreal injection of 4 mg triamcinolone acetonide and the other eye received 1.25 mg bevacizumab. Aqueous humor samples were obtained before and 4 weeks after the intravitreal injection in the DME group and before the surgery in the control group. Aqueous concentrations of interleukin (IL)-6, IL-8, interferon-induced protein (IP)-10, monocyte chemotactic protein (MCP)-1, platelet-derived growth factor (PDGF)-AA, and vascular endothelial growth factor (VEGF) were measured by multiplex bead assay. RESULTS Before the administration of the drugs, aqueous levels of IL-8, IP-10, MCP-1, and VEGF were significantly higher in the DME group than in the control group. After intravitreal injection, foveal thickness was more decreased in the triamcinolone acetonide (IVTA) group compared with the bevacizumab (IVBe) group. IL-6, IP-10, MCP-1, PDGF-AA, and VEGF were significantly decreased in the IVTA group, but only VEGF in the IVBe group. Aqueous levels of VEGF were more decreased in the IVBe group than in the IVTA group. CONCLUSIONS These findings suggest that the pathogenesis of DME is not only related to VEGF dependency, but also to other mechanisms suppressed by corticosteroids. We suppose that these cytokines would have an important role in both the pathogenesis of DME and the underlying mechanism of intravitreal injections.

Minimal fluid-air exchange in combined 23-gauge sutureless vitrectomy, phacoemulsification, and intraocular lens implantation.

Purpose: The purpose of this study was to compare rates of postoperative hypotony and intraocular lens-related complications between minimal fluid–air exchange and partial fluid–air exchange in combined 23-gauge vitrectomy and cataract surgery. Methods: A prospective, consecutive, interventional case series of 48 eyes that underwent 23-gauge vitrectomy with a minimal fluid–air exchange (minimal F–A group) was compared with a retrospective, consecutive case series of 38 eyes that underwent 23-gauge vitrectomy with a partial fluid–air exchange (partial F–A group). The main outcome measures were postoperative hypotony (<6 mmHg) and intraocular lens-related complications, such as posterior capsule opacification or pupillary capture. Results: Two (5.3%) of 38 eyes in the partial F–A group had hypotony, and only 1 (2.1%) of 48 eyes in the minimal F–A group had hypotony (P > 0.05). Posterior capsule opacification was identified in 11 (28.9%) of 38 eyes in the partial F–A group but only in 4 (8.3%) of 48 eyes in the minimal F–A group (P = 0.013). Pupillary capture was observed in 3 (7.9%) of 38 eyes in the partial F–A group, but it was absent in the minimal F–A group (P = 0.049). No retinal detachment or endophthalmitis was developed in both groups during follow-up. Conclusion: Minimal fluid–air exchange in combined 23-gauge sutureless vitrectomy and cataract surgery may reduce postoperative hypotony and intraocular lens–related complications.

Combined 23-gauge sutureless vitrectomy and clear corneal phacoemulsification in patients with proliferative diabetic retinopathy.

Purpose: To evaluate the results and complications of combined 23-gauge sutureless vitrectomy, clear corneal phacoemulsification, and intraocular lens implantation in patients with proliferative diabetic retinopathy. Methods: This was a retrospective, consecutive, noncomparative, interventional case series of 136 eyes of 108 patients who underwent combined sutureless vitrectomy and clear corneal cataract surgery for the complications of proliferative diabetic retinopathy. The main outcome measures were visual outcomes and surgical complications. Results: Main indications for the combined surgery were vitreous hemorrhage (78 eyes, 57.4%) and tractional retinal detachment (36 eyes, 28.7%). The logarithm of the minimum angle of resolution visual acuity (mean ± SD) improved from 0.86 ± 0.59 preoperatively to 0.39 ± 0.52 six months postoperatively (P < 0.0001). Intraoperative retinal tear occurred in 7 eyes (5.1%) and postoperative vitreous hemorrhage in 10 eyes (7.5%). Even in the absence of suturing of sclerotomy sites, only 1 eye (0.7%) had postoperative hypotony (<6 mmHg). During the 6 months after surgery, only 1 eye (0.7%) developed neovascular glaucoma and 6 eyes (4.4%) required a repeat vitrectomy (3 for retinal detachment and 3 for vitreous hemorrhage). Conclusion: Combined 23-gauge sutureless vitrectomy and clear corneal phacoemulsification in patients with proliferative diabetic retinopathy was safe and effective. It may have not only the known advantages of conventional combined surgery but also additionally those such as faster visual rehabilitation and less conjunctival fibrosis.

Comparison of intraoperative complications of phacoemulsification between sequential and combined procedures of pars plana vitrectomy and cataract surgery.

Purpose: To compare intraoperative complications during phacoemulsification between sequential and combined procedures of vitrectomy and cataract surgery. Methods: We retrospectively reviewed the medical records of 54 patients who underwent cataract surgery in a previously vitrectomized eye (sequential group) and 311 patients who underwent combined vitrectomy and cataract surgery (combined group). Primary outcome measures were intraoperative complications during phacoemulsification. Secondary measures were preoperative and intraoperative cataract gradings. Results: The most common complication during phacoemulsification was posterior capsule rupture. The rate of posterior capsule rupture was higher in the sequential group (6 eyes, 11.4%) than in the combined group (14 eyes 4.5%, P = 0.049). Preoperative lens density (nuclear color and posterior subcapsular scores) was higher in the sequential group (P < 0.001). Intraoperative nuclear grading was higher compared with the preoperative one in the sequential group, but the two gradings did not differ in the combined group. Conclusion: Phacoemulsification in a vitrectomized eye is associated with a higher rate of posterior capsule rupture than the one in combined vitrectomy. These results may have been caused by hard nucleus cataract in a vitrectomized eye.

Effect of Volume Used in Sub-Tenon’s Anesthesia on Efficacy and Intraocular Pressure in Vitreoretinal Surgery

Purpose: To compare the effect of volumes used in sub- Tenon’s anesthesia on efficacy and intraocular pressure (IOP) in vitreoretinal surgery. Methods: A prospective clinical trial was conducted on patients undergoing sub-Tenon’s anesthesia for vitreoretinal surgery. Patients were randomized to receive either 3-, 5- or 7-ml volumes of anesthetic solution. IOP were measured immediately prior to injection, immediately after injection and at 2, 5 and 10 min after injection. Pain scores were assigned using a numerical visual analogue scale immediately after surgery, and again on postoperative day 1. Results: A total of 108 patients (119 eyes) were studied, including 35 eyes in the 3-ml group, 48 eyes in the 5-ml group, and 36 eyes in the 7-ml group. There were significant elevations in mean IOP following injection in all groups, and a trend for larger rises in IOP with larger volumes of anesthesia (p < 0.01). Mean IOP were elevated after injection, and reduced at all time intervals. However, the reduction in the 3-ml group took levels to preinjection amounts. There were no significant differences in patient-reported pain scores among the groups when assessed immediately after surgery or on postoperative day 1. The incidence of chemosis and high IOP elevations (≥40 mm Hg) were more frequent in the 7-ml group (p < 0.05). Conclusions: Sub-Tenon’s anesthesia is effective in vitreoretinal surgery. It would appear that a 3–5-ml volume of anesthetic is safe, when considering the associated complications.

Pars plana Ahmed implantation combined with 23-gauge vitrectomy for refractory neovascular glaucoma in diabetic retinopathy.

Purpose To evaluate the efficacy and safety of a pars plana Ahmed valve implantation combined with 23-gauge sutureless vitrectomy in the treatment of patients with medically uncontrolled neovascular glaucoma (NVG) in proliferative diabetic retinopathy (PDR). Methods The authors retrospectively reviewed the records of 11 consecutive patients with refractory NVG in PDR who underwent a 23-gauge sutureless vitrectomy combined with pars plana placement of an Ahmed valve implant. Control of intraocular pressure (IOP), pre- and postoperative best-corrected visual acuity and the development of intra- and postoperative complications were evaluated during the follow-up. Results The mean follow-up was 12.2 months (range, 8 to 25 months). Mean preoperative IOP was 35.9 ± 6.3 mmHg and mean postoperative IOP at the last visit was 13.3 ± 3.2 mmHg. Control of IOP (8 to 18 mmHg) was achieved in all patients, but 91% (10 of 11 patients) needed antiglaucoma medication (mean number of medications, 1.2 ± 0.6). Postoperative visual acuity improved in 11 eyes, and the logarithmically to the minimum angle of resolution mean visual acuity in these eyes improved from 1.67 ± 0.61 to 0.96 ± 0.67. The complications that occurred were transient hypotony in one case, transitory hypertension in two cases, and postoperative vitreous hemorrhage which spontaneously cleared in two cases. Conclusions We suggest the combination of 23-gauge pars plana vitrectomy and Ahmed valve implantation is safe and effective in PDR patients with refractory NVG.

Changes in aqueous cytokines after intravitreal triamcinolone versus bevacizumab for macular oedema in branch retinal vein occlusion

Purpose:  To investigate the changes in the aqueous levels of various cytokines after intravitreal triamcinolone or bevacizumab for branch retinal vein occlusion (BRVO).

Endogenous Aeromonas Hydrophila Endophthalmitis in an Immunocompromised Patient

Purpose To report a case of endogenous endophthalmitis due to Aeromonas hydrophila in a patient with distal common bile duct carcinoma and biliary sepsis. Methods A 72-year-old woman with distal common bile duct carcinoma, obstructive jaundice, diabetes mellitus, and hypertension had a 1-day history of blurred vision, redness, and eye discharges in the right eye. An ophthalmic examination showed no light perception vision, increased intraocular pressure, severe corneal edema, severe anterior chamber reaction, exudative membranes on the anterior lens surface, and severe vitreal reaction. There was no ocular history of trauma, infection, or surgery in either eye. Results Under the impression of endogenous bacterial endophthalmitis, immediate intraocular cultures and intravitreal antibiotic injections were performed, but the anterior chamber reaction, and the ultrasonogram findings were deteriorated. Evisceration was undertakened because of extrusion of the intraocular contents, and Aeromonas hydrophila was isolated by intraocular culture. Conclusions Endogenous endophthalmitis due to Aeromonas hydrophila is rare, but has a rapid clinical course and a poor prognosis, despite of prompt diagnosis and management.

Different Expression of Vascular Endothelial Growth Factor and Pigment Epithelium-Derived Factor between Diabetic and Non-Diabetic Epiretinal Membranes

Purpose: To determine whether there is a difference in protein levels of expression of vascular endothelial growth factor (VEGF), pigment epithelium-derived factor (PEDF), platelet-derived growth factor (PDGF) and transforming growth factor β1 (TGF-β1) between diabetic and non-diabetic epiretinal membranes (ERMs). Methods: ERMs and vitreous were surgically removed from the eyes of 8 patients with proliferative diabetic retinopathy and from 6 patients with proliferative vitreoretinopathy. Concentrations of VEGF, PEDF, PDGF and TGF-β1 were investigated by an enzyme-linked immunosorbent assay. Results: The concentrations of VEGF were higher in ERMs from patients with diabetes (9.2 ± 8.0 pg/μg protein) compared to those without diabetes (1.2 ± 3.0 pg/μg protein; p = 0.026), while the concentrations of PEDF were higher in ERMs from patients without diabetes (7.5 ± 1.5 ng/μg protein) compared to those with diabetes (3.5 ± 1.5 ng/μg protein; p = 0.002). In addition, the VEGF-to-PEDF ratio was higher in diabetic ERMs (2.80 ± 1.83) than in non-diabetic ones (0.17 ± 0.09; p = 0.019). However, the concentrations of PDGF and TGF-β1 in membranes were not different between patients with diabetes and those without diabetes. Conclusion: This study found the difference in protein levels of expression of VEGF and PEDF between diabetic and non-diabetic ERMs. These results suggest that a disturbance in the balance between angiogenic and anti-angiogenic factors may play an important role in angiogenesis in diabetic ERMs.

Surgeon-controlled–endoillumination-guided irrigation and aspiration during combined 23-gauge sutureless vitrectomy and cataract surgery in eyes with poor fundus reflex

&NA; We describe a surgeon‐controlled−endoillumination‐guided irrigation and aspiration (I/A) technique that can be used to polish the posterior capsule during combined 23‐gauge sutureless vitrectomy and cataract surgery in eyes with a poor red fundus reflex. In a dark room with the microscope light turned off, the surgeon holds and controls a 23‐gauge endoilluminator with the left hand to achieve better retroillumination during I/A. Using surgeon‐controlled endoillumination, it is possible to follow and guide the posterior capsule area undergoing I/A. The excellent visibility of the posterior capsule facilitates posterior capsule polishing with no intraoperative complications. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.