Eric R. Holz

Intravitreal triamcinolone does not alter basal vascular endothelial growth factor mRNA expression in rat retina

Intravitreal triamcinolone inhibits choroidal neovascularization. To investigate if vascular endothelial growth factor (VEGF) is affected, we examined VEGF expression after intravitreal triamcinolone administration in rat retina. Using in situ hybridization, we have found dense clustered VEGF mRNA signals in the retinal pigment epithelium, moderate patchy signals in the inner nuclear layer, and positive labeling in a sub-population of ganglion cells. Densitometry and northern blot analysis revealed no significant alteration of VEGF mRNA expression pattern and level 3-21 days after triamcinolone injection. Our data indicate that intravitreal triamcinolone does not affect basal VEGF mRNA expression in normal adult rat retina.

Laser treatment in fellow eyes with large drusen: Updated findings from a pilot randomized clinical trial

PURPOSE To update the findings from the Choroidal Neovascularization Prevention Trial (CNVPT) with respect to resolution of drusen, incidence of choroidal neovascularization, and visual function. DESIGN A multicenter, randomized, controlled, pilot clinical trial. PARTICIPANTS The 120 patients enrolled in the CNVPT. Patients had signs of choroidal neovascularization or retinal pigment epithelial detachment in 1 eye and had >/=10 large (>63- micro m) drusen in the contralateral, or fellow, eye. INTERVENTION The fellow eye of 59 patients was assigned randomly to argon green laser treatment consisting of multiple 100- micro m spots at least 750 micro m from the center of the fovea. The fellow eye of the remaining 61 patients was assigned randomly to observation. MAIN OUTCOME MEASURES Change in visual acuity was the primary outcome measure. Incidence of choroidal neovascularization, resolution of drusen, change in contrast threshold, change in critical print size for reading, and incidence of geographic atrophy were secondary outcome measures. RESULTS Throughout 4 years of follow-up, there were no statistically significant differences in change in visual acuity, contrast threshold, critical print size, or incidence of geographic atrophy. With additional follow-up, the large increase in the incidence of choroidal neovascularization observed within 18 months of treatment was maintained; however, by 30 months, the incidence in the two treatment groups was the same. Most drusen resolution in treated eyes occurred within 24 months of the initial treatment. Treated eyes that received higher-intensity laser burns had an increased risk of choroidal neovascularization. Among eyes developing choroidal neovascularization in each treatment group, most lesions (two thirds or more) were composed of occult neovascularization only. CONCLUSIONS Laser treatment as applied in the CNVPT caused an excess risk of choroidal neovascularization in the first year or so after treatment. The increased early incidence of choroidal neovascularization was not associated with either a harmful or beneficial effect in this pilot study.

25-gauge vitrectomy using sulfur hexafluoride and no prone positioning for repair of macular holes.

Purpose: To report on the outcomes of 25-gauge pars plana vitrectomy using sulfur hexafluoride and no prone positioning for repair of macular holes. Methods: Retrospective case series of 44 consecutive patients who underwent pars plana vitrectomy with internal limiting membrane peeling for repair of stages 2 to 4 idiopathic macular holes using 20% to 30% sulfur hexafluoride. No postoperative prone positioning or gas augmentation was used. Results: The macular hole closure rate was 88.6%. There were no differences in the macular hole closure rates between phakic and pseudophakic patients (21 of 23 vs. 17 of 21, respectively) or among stages 2, 3, and 4 macular holes (12 of 13, 20 of 23, and 7 of 8, respectively). In eyes successfully operated on, visual acuity improved from 0.61 logarithm of the minimal angle of resolution (logMAR) (20 of 82) preoperatively to 0.483 logMAR (20 of 61) at 1 month and 0.396 logMAR (20 of 50) at a mean final follow-up of 10.8 months. Adverse effects were elevation of intraocular pressure to >30 mmHg in 7 (13.6%) of 44 patients on the first postoperative day, postoperative retinal detachments in 2 (4.5%) of 44 patients, and progression of cataract requiring cataract surgery in 7 (30.4%) of 23 phakic patients during follow-up. Conclusions: Macular hole closure rates similar to those achieved using pars plana vitrectomy with perfluoropropane and prone positioning can be achieved using sutureless 25-gauge vitrectomy with sulfur hexafluoride tamponade and no prone positioning for both phakic and pseudophakic patients.

Optical coherence tomography of idiopathic juxtafoveolar telangiectasia.

BACKGROUND AND OBJECTIVE To document optical coherence tomography (OCT) findings in a series of eyes with group 2A idiopathic juxtafoveal telangiectasia. PATIENTS AND METHODS This study is a retrospective review of patient charts, OCT, fundus photography, and fluorescein angiography involving 23 eyes (12 patients). Mean retinal thickness in 9 macular areas was calculated and compared to previously published measurements from normal eyes. RESULTS OCT in 8 of 13 stage 3 eyes revealed foveal cysts without evidence of cystoid macular edema on fluorescein angiography or biomicroscopy, and 1 lamellar hole. In stage 3 eyes, mild retinal thickening was found in 7 of 9 macular areas (P < .05). CONCLUSIONS OCT commonly reveals foveal cysts in stage 3 idiopathic juxtafoveal telangiectasia. Consistent findings of associated mild macular thickening and lack of late petaloid hyperfluorescence on fluorescein angiography suggest that these cysts differ in pathophysiology from cystoid macular

Lensectomy and vitrectomy with and without intravitreal triamcinolone acetonide for vascularly active stage 5 retinal detachments in retinopathy of prematurity.

Purpose: To determine the anatomical success rate of lensectomy and vitrectomy with and without intravitreal triamcinolone acetonide (TA) for vascularly active stage 5 tractional retinal detachments due to retinopathy of prematurity (ROP). Methods: In a retrospective, interventional, single-surgeon, consecutive case series, the records of 21 eyes of 21 patients presenting with stage 5 retinal detachment secondary to ROP who underwent primary pars plicata vitrectomy with lensectomy from February 1998 to January 2004 were evaluated. All eyes were vascularly active at the time of surgery. Eleven eyes underwent the surgical procedure without TA (group 1), and 10 eyes received TA at the end of the procedure (group 2). The main outcome measure, retinal reattachment, was reviewed at the final follow-up visit, which ranged from 6 months to 42 months (mean, 28 months) after surgery. Results: None (0/11) of the eyes in group 1 maintained attachment, while 6 (60%) of 10 eyes in group 2 maintained at least posterior pole reattachment at the final visit. None of the group 2 eyes exhibited plus disease during follow-up. None of the eyes in either group exhibited signs of increased intraocular pressure after surgery. All six eyes that maintained posterior pole reattachment were able to fix and follow light at the last follow-up visit. Conclusions: Vascularly active stage 5 ROP detachments portend a poor progress. The use of TA as a postoperative adjunct may improve the likelihood of retinal reattachment in select cases.

Anatomical success rate after primary three-port lens-sparing vitrectomy in stage 5 retinopathy of prematurity.

Purpose: To assess the anatomical success rate after three-port lens-sparing vitrectomy (LSV) in stage 5 (total) retinal detachments secondary to retinopathy of prematurity. Methods: In a retrospective, interventional, single-surgeon, consecutive case series, the records of 33 eyes of 21 patients presenting with stage 5 retinal detachment secondary to retinopathy of prematurity who underwent primary three-port LSV from February 1998 to January 2004 were evaluated. Twenty-one eyes (63.6%) had open anteriorly–open posteriorly and 12 (36.4%) had open anteriorly–narrow posteriorly in terms of anatomical configuration. The main outcome measure, retinal reattachment, was reviewed at final follow-up visits, which ranged from 6 months to 48 months (mean, 32 months) after LSV. Results: Fifteen eyes (45.5%) maintained attachment and 18 eyes (54.5%) remained detached at the final visit. Open anteriorly–open posteriorly configuration eyes had a statistically significant higher anatomical success rate than eyes with an open anteriorly–narrow posteriorly configuration (P < 0.001). Conclusions: Three-port LSV may achieve anatomical success in stage 5 retinopathy of prematurity–related detachments. The open anteriorly–open posteriorly configuration portends a better prognosis; thus, surgery should be performed before closure of the posterior retina into a funnel configuration, if possible.

Iris-sutured intraocular lenses for ectopia lentis in children

PURPOSE: To compare outcomes and complications of pars plana lensectomy–vitrectomy (PPL–PPV) for the management of ectopia lentis in children with and without a foldable iris‐sutured intraocular lens (IOL). SETTING: Department of Ophthalmology, Baylor College of Medicine, Houston, Texas, USA. METHODS: This study comprised 22 eyes of 12 consecutive pediatric patients with ectopia lentis who had PPL–PPV by the same vitreoretinal surgeon with (12 eyes; Group L) or without (10 eyes; Group A) insertion of a foldable iris‐sutured IOL between June 1998 and October 2006. Outcome measures included the proportion of eyes achieving visual acuity of 20/40 or better, mean logMAR visual acuity, and complications. RESULTS: There was no statistically significant difference between the 2 groups in the proportion of eyes achieving a visual acuity of 20/40 or better (Group A: 5/10; Group L: 10/12) (P = .17) or the mean postoperative best corrected logMAR visual acuity (Group A: 0.41 [20/52]; Group L: 0.24 [20/35]) (P = .18). Complications included IOL dislocation in 4 (33%) of 12 eyes in Group L (95% confidence interval, 11%‐65%). Eyes with dislocated IOLs had retrieval with resuturing of the IOL to the iris and had a mean visual acuity of 20/27 at the last follow‐up. No retinal detachment was observed. CONCLUSION: Pars plana lensectomy–vitrectomy with iris‐fixation of a foldable IOL for the management of ectopia lentis yielded visual outcomes as least as good as those of optically corrected aphakia with a significant risk for dislocation.

Alcaligenes xylosoxidans and Propionibacterium acnes postoperative endophthalmitis in a pseudophakic eye

PURPOSE To report a case of persistent polymicrobial postoperative endophthalmitis caused by Alcaligenes xylosoxidans and Propionibacterium acnes in a pseudophakic eye. A. xylosoxidans is a gram-negative bacteria resistant to most antibiotics. METHODS Case report. RESULTS A 72-year-old man presented with clinical signs of endophthalmitis on the first postoperative day after a phacoemulsification procedure with posterior chamber intraocular lens, left eye. Initial treatment included topical, subconjunctival, and oral antibiotics. After initial clearing, there was recrudescence of infection on postoperative day 37 that prompted referral of the patient to the Cullen Eye Institute. Treatment at that time included anterior chamber and vitreous taps with intravitreal antibiotic injections. Complete pars plana vitrectomy and intraocular lens explantation were eventually required because of persistent infection with a resistant organism. Cultures from the first procedure grew A. xylosoxidans and P. acnes. Cultures from the vitrectomy grew only A. xylosoxidans. At the final follow-up visit 6 months after the initial procedure. The eye was without inflammation with best-corrected visual acuity of 20/40. CONCLUSION Both A. xylosoxidans and P. acnes can cause chronic progressive endophthalmitis after cataract extraction often resistant to corrective antibiotic therapy. Successful intervention may require complete vitrectomy with intraocular lens and capsule removal.

Long-term visual outcomes following lens-sparing vitrectomy for retinopathy of prematurity

Aim To describe the long-term outcomes of lens-sparing vitrectomy (LSV) for retinopathy of prematurity (ROP). Methods Single-centre retrospective case series of eyes that underwent LSV for ROP between 1998 and 2005 and had a follow-up of at least 5 years. The primary outcome was the mean visual acuity, and secondary outcomes were the proportion of eyes without functional vision, proportion of eyes with anatomic success, proportion of Stage 4A eyes with vision better than 20/400, proportion of Stage 4B eyes with vision better than 20/800. Results Thirty-seven eyes of 30 patients (mean age at last follow-up: 7.1 years) were included in the study, while an additional 23 patients had been lost to follow-up and were not included in the study. Of eyes that underwent LSV for Stage 4A or 4B: 63% had measurable visual acuity (mean logMAR 0.92 for Stage 4A, 1.63 for Stage 4B), 19% had form vision, but neurological comorbidities precluded visual acuity measurement, and the remaining 18% had light perception or no light perception. Conclusions While most eyes that underwent LSV for Stage 4A or 4B ROP maintain useful vision with long-term follow-up, approximately one-fifth of eyes had no functional vision, and in a further fifth, vision could not be measured due to severe neurological impairment.

Familial exudative vitreoretinopathy mimicking persistent hyperplastic primary vitreous

PURPOSE To report an unusual case of familial exudative vitreoretinopathy in an infant. METHODS Case report. A 6-day-old girl had unilateral microphthalmia in the right eye, with a retrolental plaque initially diagnosed as persistent hyperplastic primary vitreous. Three months later, peripheral retinal vascular changes and a fibrovascular ridge were noted in the left eye, suggesting familial exudative vitreoretinopathy as the cause in both eyes. RESULTS The microphthalmic right eye was unsalvageable. The left eye developed an exudative retinal detachment despite photocoagulation of the peripheral avascular retina. Additional cryotherapy resulted in resolution of the detachment and regression of the vascular changes. CONCLUSIONS With highly asymmetric involvement, neonatal familial exudative vitreoretinopathy can mimic persistent hyperplastic primary vitreous. Fellow eye involvement can progress rapidly.