Elad Moisseiev

Long-term evaluation of patients treated with dexamethasone intravitreal implant for macular edema due to retinal vein occlusion

PurposeTo evaluate the long-term visual prognosis and complications of patients who received intravitreal Ozurdex injections for the treatment of macular edema (ME) due to retinal vein occlusion (RVO).MethodsA total of 17 patients who received Ozurdex injections in our institution as part of the GENEVA study were recalled for examination. Recorded parameters included final visual acuity (VA), final retinal thickness by optical coherence tomography, persistence of ME, and the occurrence of any complications.ResultsMean follow-up time was 50.5 months. Patients with branch RVO (BRVO) had a more favorable prognosis than central RVO (CRVO), and their mean VA had improved significantly, whereas the mean VA for the patients with CRVO did not improve significantly. Retinal thickness had reduced significantly in the whole group and in each subgroup separately. Complications included 10 patients with cataract progression, 1 with elevated intraocular pressure, and 1 with neovascularization and vitreous hemorrhage.ConclusionsThis is the first reported long-term evaluation of patients treated with Ozurdex. Our results indicate that it has favorable long-term safety profile, and may have a beneficial effect on the visual prognosis in BRVO even in the absence of continuous treatment. Further research is required to establish the optimal retreatment schedule for Ozurdex.

Comparison of Pars Plana Vitrectomy With and Without Scleral Buckle for the Repair of Primary Rhegmatogenous Retinal Detachment

PURPOSE To compare pars plana vitrectomy (PPV) with combined PPV and scleral buckle (SB) for the repair of noncomplex primary rhegmatogenous retinal detachment (RRD). DESIGN Retrospective, nonrandomized, interventional case series. METHODS We reviewed 181 consecutive cases of vitrectomy for primary RRD at 2 major medical centers in Israel. The follow-up was at least 3 months. There were 96 eyes in the PPV group and 85 eyes in the PPV plus SB group. Main outcome measures were single-surgery anatomic success (SSAS) and final visual acuity (VA). RESULTS SSAS was achieved in 81.3% and 87.1% in the PPV and PPV plus SB groups, respectively (P=.29). Final anatomic success rate was 98.9% and 98.8%, respectively (P=.61). Final VA was 0.41 (20/51) in the PPV group and 0.53 (20/68) in the PPV plus SB group (P=.13). The final VA was significantly better than the preoperative VA in both groups (P<.0001). In detachments caused by inferior tears, SSAS rates were 80.9% and 81.5% in the PPV and PPV plus SB groups, respectively (P=.74). In phakic eyes, SSAS rates were 92% and 87.5%, respectively, and in pseudophakic eyes, SSAS rates were 77.5% and 86.7%, respectively, in the PPV and PPV plus SB groups (P=.29). CONCLUSIONS The reattachment rate and the final VA were similar in both groups. The addition of SB did not improve the results and was associated with slightly lower VA than with PPV alone. Tear location or lens status had no significant effect on success rates. It is likely that in eyes undergoing PPV for primary RRD, addition of a SB is not warranted.

Retreatment with Ozurdex for macular edema secondary to retinal vein occlusion

Purpose To review the current practice of retreatment with Ozurdex injections in patients with macular edema (ME) secondary to retinal vein occlusion (RVO), and to recommend simple guidelines for Ozurdex reinjection in management of RVO. Methods This was a multicenter retrospective study of patients who received more than 2 Ozurdex injections for the treatment of ME in RVO. Recorded parameters included percent of patients with a 15-letter gain, visual acuity (VA) improvement from baseline, change in central macular thickness (CMT), time to reinjection, and occurrence of any complications. Results A total of 128 patients were included, 58 (45.3%) with central RVO (CRVO) and 70 (54.7%) with branch RVO (BRVO). Mean interval for Ozurdex reinjection was 5.9 months following the first injection and 8.7 months following the second. A >15-letter gain in VA was observed in 34 (48.8%) patients with CRVO and 16 (28%) patients with BRVO. Mean overall VA improvement at month 6 did not show significance (p>0.05); however, a significantly better mean VA improvement was seen in treatment-naïve eyes (p<0.03). The CMT was significantly reduced compared to baseline. The mean CMT decreased by 214.6 μm in eyes with BRVO (n = 53) and by 355.1 μm in eyes with CRVO (n = 63) (p = 0.002). Complication rates were very low. Conclusions Repeated injections of Ozurdex are effective and have a favorable safety profile. In current practice, the retreatment interval with Ozurdex injections might be too long, precluding the full therapeutic potential of this treatment modality. A strategy for managing RVO patients treated with Ozurdex on an as-needed basis is provided.

Enhanced Depth Imaging Optical Coherence Tomography: Choroidal Thickness and Correlations With Age, Refractive Error, and Axial Length

BACKGROUND AND OBJECTIVE To evaluate choroidal thickness at five macular locations and assess the correlations between choroidal thickness at these locations with age, refractive error, and axial length. PATIENTS AND METHODS Eighty-four eyes from 42 healthy adult volunteers were included. Enhanced depth imaging by spectral-domain optical coherence tomography was performed, and choroidal thickness was measured at five macular locations: subfoveal and 3 mm nasal, temporal, superior, and inferior. Correlations of choroidal thickness at each location with age, refractive error, and axial length were analyzed. RESULTS Mean choroidal thicknesses at the subfoveal, superior, inferior, temporal, and nasal locations were 293, 308, 264, 263, and 174 μm, respectively. A correlation was found between choroidal thickness, age, refractive error, and axial length at all locations. CONCLUSION Mean subfoveal choroidal thickness in healthy adults is approximately 300 μm. A correlation was found between choroidal thickness and all parameters studied.

Anaphylactic reaction following intracameral cefuroxime injection during cataract surgery

We report a patient who developed an anaphylactic reaction several minutes after intracameral injection of cefuroxime at the end of uneventful phacoemulsification and intraocular lens implantation surgery. The patient had a known allergy to penicillin but not to cefuroxime. This rare life-threatening complication was recognized and immediately treated by the surgeon. The literature on the use of intracameral cefuroxime for endophthalmitis prophylaxis and its risk for anaphylaxis is reviewed. Cataract surgeons should be aware of this potentially fatal complication and be prepared to handle it.

Macular hole after vitrectomy for primary rhegmatogenous retinal detachment.

Purpose: To report a series of full-thickness macular holes (MH) that developed after pars plana vitrectomy for rhegmatogenous retinal detachment (RRD). Methods: A retrospective review of the demographic and medical data, including optical coherence tomography studies of 6 patients (7 eyes) who underwent pars plana vitrectomy for RRD and subsequently developed MH. Results: There were 4 women and 2 men with a mean age of 60 ± 10 years (range, 50–79 years). The mean interval between RRD repair and MH formation was 20 ± 18 months (range, 1–48 years). Five eyes underwent surgery to repair the MHs, four of which were closed at the last follow-up. Two eyes were not operated, one because of unfavorable prognosis, and in the other, which presented with an epiretinal membrane before the development of the MH, the hole closed spontaneously. In all operated cases, the inner limiting membrane was peeled during MH surgery. The mean logarithm of the minimal angle of resolution was 0.73, 0.53, 0.77, and 0.57 at RRD presentation, after surgical repair of RRD and before MH diagnosis, at MH presentation, and at last follow-up, respectively. The study subjects accounted for 1.1% of our 609 patients who underwent pars plana vitrectomy for primary RRD during the study period. Conclusion: Macular hole may develop after pars plana vitrectomy for RRD, and these cases can be surgically repaired. The pathogenesis of the formation of these holes remains unclear.

Evaluation of Pain in Intravitreal Bevacizumab Injections

Purpose: To evaluate the correlation between pain associated with intravitreal bevacizumab injection and the location of the injection. Methods: The study included 218 eyes of 218 patients, who received an intravitreal bevacizumab injection at our institution. Pain was measured by the Visual Analog Scale (VAS). Additional parameters recorded included age, sex, indication for the injection, injection site by quadrant, number injections in the study eye, presence of diabetes mellitus, and lens status. Results: Indications for injection included age-related macular degeneration (69.7%), diabetic macular edema (13.3%), neovascularization due to proliferative diabetic retinopathy (6.9%), and cystoid macular edema secondary to retinal vascular occlusions (10.1%). Pain scores on the VAS ranged from 0 to 84, with a mean of 17.4 ± 17.1. Pain did not correlate significantly with any of the recorded parameters, but a trend was found toward less pain associated with injection in the lower-left quadrant (p = 0.067). Conclusions: This is the largest series studying the pain associated with intravitreal injections and provides a thorough description of the pain associated with this procedure. Since there is no anatomical difference between quadrants, we assume the demonstrated trend indicates that less pain is associated with the location in which it is most convenient for the ophthalmologist to perform the injection.

Vitrectomy for Idiopathic Epiretinal Membrane in Elderly Patients: Surgical Outcomes and Visual Prognosis

Purpose: To evaluate the clinical course and visual prognosis of elderly patients over 75 years of age who underwent PPV and peeling of idiopathic ERM. Design: Retrospective case series. Methods: A retrospective chart review of patients that underwent vitrectomy for idiopathic ERM in two public hospitals. Twenty nine eyes of 29 patients 75 years and older who underwent PPV and ERM peeling were included in the study series. Patients with additional ocular vision-limiting conditions other than cataract were excluded. Main outcome measures included VA improvement, OCT changes and complications. Results: Mean patient age was 79.6 years, the highest in published literature. Mean change in VA was 0.23 logMAR units, and 65.5% patients gained 2 or more lines of vision. Eight of the 10 patients aged 80 years or older gained 2 lines or more. Fourteen patients (48.3%) achieved final VA of 20/40 or better, and only 2 (6.9%) had final VA of 20/200 or worse. Concurrent cataract extraction was performed in 73% of the phakic eyes, and at the end of the follow up 93% were pseudophakic. Complication rates were similar to those reported in the literature. Conclusions: Pars plana vitrectomy with ERM peeling is safe and effective in restoring VA in elderly patients, and the results are comparable to those previously reported for younger patients with idiopathic ERM. Old age should not hinder surgery in patients with idiopathic ERM who seek to improve their vision and quality of life.

Advances in bone marrow stem cell therapy for retinal dysfunction

ABSTRACT The most common cause of untreatable vision loss is dysfunction of the retina. Conditions, such as age‐related macular degeneration, diabetic retinopathy and glaucoma remain leading causes of untreatable blindness worldwide. Various stem cell approaches are being explored for treatment of retinal regeneration. The rationale for using bone marrow stem cells to treat retinal dysfunction is based on preclinical evidence showing that bone marrow stem cells can rescue degenerating and ischemic retina. These stem cells have primarily paracrine trophic effects although some cells can directly incorporate into damaged tissue. Since the paracrine trophic effects can have regenerative effects on multiple cells in the retina, the use of this cell therapy is not limited to a particular retinal condition. Autologous bone marrow‐derived stem cells are being explored in early clinical trials as therapy for various retinal conditions. These bone marrow stem cells include mesenchymal stem cells, mononuclear cells and CD34+ cells. Autologous therapy requires no systemic immunosuppression or donor matching. Intravitreal delivery of CD34+ cells and mononuclear cells appears to be tolerated and is being explored since some of these cells can home into the damaged retina after intravitreal administration. The safety of intravitreal delivery of mesenchymal stem cells has not been well established. This review provides an update of the current evidence in support of the use of bone marrow stem cells as treatment for retinal dysfunction. The potential limitations and complications of using certain forms of bone marrow stem cells as therapy are discussed. Future directions of research include methods to optimize the therapeutic potential of these stem cells, non‐cellular alternatives using extracellular vesicles, and in vivo high‐resolution retinal imaging to detect cellular changes in the retina following cell therapy. HIGHLIGHTSThere are various types of bone marrow stem cells.These stem cells have paracrine trophic effects on damaged tissue.The stem cells are useful for a variety of retinal conditions.This investigational therapy is being explored in clinical trials.

Macular Hole following Intravitreal Bevacizumab Injection in Choroidal Neovascularization Caused by Age-Related Macular Degeneration.

This report describes formation of a full-thickness macular hole subsequent to an injection of bevacizumab for the treatment of neovascular AMD. This complication may be caused by focal tractional forces on the retinal surface due to either vitreous incarceration at the injection site or contraction of the choroidal neovascularization membrane. Alternatively, it may be due to a toxic effect of bevacizumab on a previously compromised retina.