Eric W. Schneider

A Comparative Study of Rebound Tonometry With Tonopen and Goldmann Applanation Tonometry Following Vitreoretinal Surgery.

PURPOSE To investigate agreement in intraocular pressure (IOP) measurements among Icare rebound tonometry, Tonopen tonometry, and Goldmann applanation tonometry following vitreoretinal surgery. DESIGN Reliability analysis of tonometers. METHODS Fifty-eyes of 50 adults undergoing vitreoretinal surgery were enrolled. IOP was measured on first postoperative day using Icare (Tiolat, Helsinki, Finland), followed by Tonopen (Reichert, Depew, New York, USA) and Goldmann (Haag-Streit USA, Mason, Ohio, USA) in randomized order. Intraclass correlation coefficients (ICC) and Bland-Altman plots were calculated for all subcategories. RESULTS Icare successfully measured IOP in all eyes, while Goldmann was unmeasurable in 6 eyes (12%) and Tonopen in 1 eye (2%). Mean IOP by Icare, Tonopen, and Goldmann was 15.9 ± 8.9, 16.9 ± 6.2, and 16.0 ± 7.3 mm Hg, respectively (P = .76). Type of intraocular tamponade, status of lens, status of cornea, gauge of instrumentation, and history of prior vitrectomy did not result in significant differences among the 3 tonometers. ICC was excellent (>0.75) in all subgroups, except at IOP <10 and ≥ 23 mm Hg (based on Icare). In eyes with IOP <10 mm Hg, Icare underestimated IOP (mm Hg; P = .01) compared to Goldmann (2.0 ± 2.1) and Tonopen (3.5 ± 2.4), whereas at IOP ≥ 23 mm Hg Icare was overestimated (P = .01) compared to Goldmann (3.77 ± 3.49) and Tonopen (4.97 ± 3.33). Overall, differences in IOP were ≤ 3 mm Hg in 58% of eyes for Icare-Tonopen, 72% for Tonopen-Goldmann, and 62% for Icare-Goldmann. CONCLUSION IOP measurements using Icare rebound tonometry, Tonopen, and Goldmann tonometry are in excellent agreement following vitreoretinal surgery. However, Icare overestimates at IOP ≥ 23 and underestimates at IOP <10 mm Hg.

Combination therapy for macular edema secondary to retinal vein occlusion.

In the nearly two decades following the publication of the Branch Retinal Vein Occlusion Study (BVOS) and Central Retinal Vein Occlusion Study (CVOS), pharmacologic therapy for retinal vein occlusion (RVO) was almost nonexistent. However, the introduction of intravitreal therapy — namely corticosteroids and anti-VEGF agents — has provided a host of new pharmacologic options to clinicians. As evidenced by several large-scale clinical trials,1-4 intravitreal monotherapy is effective for the vast majority of patients with RVO and has thus become the predominant therapeutic approach.5 Unfortunately, a small minority of patients display recalcitrant macular edema despite frequent intravitreal monotherapy dosing. In the SCORE trials, 11.6% to 12.0% of patients treated with repeated intravitreal triamcinolone lost at least 15 letters, and more than 20% had central point thicknesses greater than 500 μm at 12-month follow-up.1,2 Although the rate of refractory edema was lower in the BRAVO/CRUISE trial (0.7% to 3.8% lost at least 15 letters, and 6.7% to 15.9% had central foveal thickness greater than 400 μm at 12 months), frequent ranibizumab monotherapy was not universally successful.3,4 Such recalcitrant cases have prompted the search for therapeutic alternatives, most notably combination pharmacologic and pharmaco-laser treatments.

Reported Complications Following Laser Vitreolysis

Importance Use of laser vitreolysis for symptomatic floaters has increased in recent years, but prospective studies are not available and the complication profile is poorly understood. Objective To analyze cases of complications following laser vitreolysis as voluntarily reported to the American Society of Retina Specialists Research and Safety in Therapeutics (ASRS ReST) Committee, an independent task force formed to monitor device-related and drug-related safety events. Design, Setting, and Participants A retrospective assessment was performed of all cases of complications following laser vitreolysis that were voluntarily reported by practitioners throughout the United States to the ASRS ReST Committee from the first report on September 19, 2016, through March 16, 2017, the date of data analysis and manuscript writing. Main Outcomes and Measures Complications reported to the ASRS ReST Committee following laser vitreolysis were analyzed by type to gain an understanding of the spectrum of potential complications. Results A total of 16 complications following laser vitreolysis were reported in 15 patients by 7 US vitreoretinal specialists during the study period. Complications included elevated intraocular pressure leading to glaucoma; cataracts, including posterior capsule defects requiring cataract surgery; retinal tear; retinal detachment; retinal hemorrhages; scotomas; and an increased number of floaters. Conclusions and Relevance This report presents a spectrum of complications reported to the ASRS ReST Committee across 6 months. The rate of complications cannot be determined because the denominator of total cases is unknown. Also, these findings cannot determine whether there is a causal association between these complications and laser vitreolysis. Prospective studies are warranted to better understand the efficacy of this procedure and the frequency of attendant complications. Until then, practitioners should be aware of the profile of potential complications to properly inform patients during the consent process. The ASRS ReST Committee will continue to monitor device-related and drug-related adverse events and encourages active surveillance and reporting by all physicians.

Retained Intraocular Perfluoro-n-octane After Valved Cannula Pars Plana Vitrectomy for Retinal Detachment

BACKGROUND AND OBJECTIVE To investigate cases of retained intraocular perfluoro-n-octane (PFO) after pars plana vitrectomy (PPV) for retinal detachment (RD). PATIENTS AND METHODS Retrospective, noncomparative case series of six eyes with retained intraocular PFO after RD repair. Clinical data were supplemented with an experimental silicone eye model. RESULTS A cluster of six cases of retained intraocular PFO after PPV for RD repair were noted shortly after transitioning to valved cannulas. PFO was noted in the anterior chamber (AC) and/or vitreous and removed with AC paracentesis, AC wash-out, and/or PPV. A silicone eye model demonstrated that PFO levels are maintained anterior to cannula insertion with valved cannulas only. CONCLUSION The authors hypothesize that anterior PFO fill using valved cannulas can lead to sequestration within the AC, zonules, ciliary sulcus, ciliary teeth, and/or capsular bag. They suggest vigilance in not overfilling PFO, particularly when transitioning to use of valved cannulas, to minimize the risk of intraocular retention.

Development of Bilateral Acquired Toxoplasmic Retinochoroiditis During Erlotinib Therapy

Author Contributions: Dr Engelbert had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: All authors. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: All authors. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Pang, Engelbert. Administrative, technical, or material support: Pang. Study supervision: Freund, Engelbert.

'Hypopyon' in the anterior chamber: unilateral ocular relapse of acute myeloid leukaemia in a 2-year-old girl.

A 2-year-old girl with acute myeloid leukaemia (AML M5a) with t(8;16)(p11 2;p13 3) who had been in remission since induction chemotherapy presented with lethargy and right eye pain 5 months later. The right eye intraocular pressure was elevated at 45–50 mm/Hg (reference, 10–20 mm/Hg). Anterior segment examination revealed corneal oedema and predominantly circumcorneal injection. The pupil was irregular and reacted to light poorly owing to posterior synechiae; the iris was undulated with overlying fibrinous exudate and a large ‘hypopyon’ in the aqueous (upper left; image taken while the patient was in a supine position). The left eye appeared normal. Cytology of the right anterior chamber fluid showed leukaemic blasts (upper right) with vacuolated cytoplasm and haemophagocytosis (lower left), the features similar to those seen in patient’s initial diagnostic bone marrow examination (lower right). A repeat bone marrow examination demonstrated no evidence of leukaemia, suggesting an isolated ocular relapse. The patient then received an umbilical cord stem cell transplant, but subsequently suffered from graft-versus-host disease and other complications. She expired 2 months after ocular relapse. While isolated ocular relapse of leukaemia has been reported previously, the vast majority of cases are acute lymphoblastic leukaemia rather than myeloid leukaemia. Interestingly, the leukaemic blasts in our case harboured t(8;16)(p11 2;p13 3) that has been associated with monocytic differentiation, haemophagocytosis by leukaemic cells and extramedullary involvement. It remains to be determined if the ocular relapse in this patient was related to the particular cytogenetic change and the leukaemic cells’ unique behaviour (haemophagocytosis). This case emphasizes an inclusion of leukaemic involvement in differential diagnoses for ‘hypopyon’ in the anterior chamber, particularly in a paediatric patient with a clinical history of acute leukaemia, and advocates a cytological examination of the aqueous fluid for a definitive diagnosis.