Florentina J. Freiberg

Comparison of phacotrabeculectomy versus phacocanaloplasty in the treatment of patients with concomitant cataract and glaucoma

BackgroundCataract and glaucoma are both common comorbidities among older patients. Combining glaucoma surgery with minimal invasive phacoemulsification (phaco) is a considerable option to treat both conditions at the same time, although the combination with filtration surgery can produce a strong inflammatory response. Combined non-penetrating procedures like canaloplasty have shown to reduce intraocular pressure (IOP) comparable to trabeculectomy without the risk of serious bleb-related complications. The purpose of this retrospective study was to compare the outcomes of phacotrabeculectomy and phacocanaloplasty.MethodsThirty-nine eyes with concomitant cataract and glaucoma who underwent phacotrabeculectomy (n = 20; 51.3%) or phacocanaloplasty (n = 19; 48.7%) were included into this trial on reduction of IOP, use of medication, success rate, incidence of complications and postsurgical interventions. Complete success was defined as IOP reduction by 30% or more and to 21 mmHg or less (definition 1a) or IOP to less than 18 mmHg (definition 2a) without glaucoma medication.ResultsOver a 12-month follow-up, baseline IOP significantly decreased from 30.0 ± 5.3 mmHg with a mean of 2.5 ± 1.2 glaucoma medications to 11.7 ± 3.5 mmHg with a mean of 0.2 ± 0.4 medications in eyes with phacotrabeculectomy (P < .0001). Eyes with phacocanaloplasty had a preoperative IOP of 28.3 ± 4.1 mmHg and were on 2.8 ± 1.1 IOP-lowering drugs. At 12 months, IOP significantly decreased to 12.6 ± 2.1 mmHg and less glaucoma medications were necessary (mean 1.0 ± 1.5 topical medications; P < .05). 15 patients (78.9%) with phacotrabeculectomy and 9 patients (60.0%) in the phacocanaloplasty group showed complete success according to definition 1 and 2 after 1 year (P = .276). Postsurgical complications were seen in 7 patients (36.8%) of the phacocanaloplasty group which included intraoperative macroperforation of the trabeculo-Descemet membrane (5.3%), hyphema (21.1%) and bleb formation (10.5%). Although more complications were observed in the phacotrabeculectomy group, no statistically significant difference was found.ConclusionsPhacocanaloplasty offers a new alternative to phacotrabeculectomy for treatment of concomitant glaucoma and cataract, although phacotrabeculectomy yielded in better results in terms of IOP maintained without glaucoma medications.

Corneal thickness after overnight wear of an intraocular pressure fluctuation contact lens sensor.

Purpose:  To assess the effect of overnight wear of a contact lens‐based sensor (CLS) for monitoring of 24‐hr intraocular pressure (IOP) fluctuations on central corneal thickness (CCT).

Optical Coherence Tomography Angiography of the Foveal Avascular Zone in Retinal Vein Occlusion

Purpose: The aim of the study was to visualize and to quantify pathological foveal avascular zone (FAZ) alterations through optical coherence tomography angiography (OCT-A) in eyes with retinal vein occlusion (RVO) in comparison to the unaffected fellow eyes. Procedures: OCT-A was conducted with the Avanti® RTVue 100 XR system (Optovue Inc., Fremont, Calif., USA). The borders of the superficial vascular layer (SVL) were defined as 3 μm below the internal limiting membrane and 15 μm below the inner plexiform layer, and for the deep vascular layer (DVL) as 15 and 70 μm below the inner plexiform layer, respectively. The length of the horizontal, vertical and maximum FAZ was manually measured for the SVL and DVL in each eye. Additionally, the angle between the maximum FAZ diameter and the papillomacular plane was measured. Results: OCT-A depicted defects within the perifoveal vasculature in eyes with branch retinal vein occlusion (BRVO; n = 11) and central retinal vein occlusion (CRVO; n = 8). These resulted in an enlargement of the maximum FAZ diameter in eyes with RVO (n = 19) in comparison to the healthy fellow eyes (n = 19; 921 ± 213 vs. 724 ± 145 µm; p = 0.008). Furthermore, a significant correlation was found between best-corrected visual acuity (BCVA) and the maximum FAZ diameter in the DVL (Spearmans ρ = -0.423, p < 0.01). Lastly, in the eyes with RVO, the angle between the papillomacular plane and the maximum FAZ diameter was only in 21.05% (SVL) and 15.79% (DVL) of the cases at 0 ± 15 or 90 ± 15°, respectively. In healthy eyes, these angles (which putatively represent a regular FAZ configuration) were more prevalent (SVL 68.42 vs. 21.05%, p = 0.003; DVL 73.68 vs. 15.79%, p < 0.001). Conclusion: OCT-A shows morphological alterations of the FAZ in eyes with CRVO and BRVO. The correlation of the maximum FAZ diameter with BCVA suggests that these alterations are functionally relevant.

Postoperative subconjunctival bevacizumab injection as an adjunct to 5-fluorouracil in the management of scarring after trabeculectomy.

Purpose Scarring after glaucoma filtering surgery remains the most frequent cause for bleb failure. The aim of this study was to assess if the postoperative injection of bevacizumab reduces the number of postoperative subconjunctival 5-fluorouracil (5-FU) injections. Further, the effect of bevacizumab as an adjunct to 5-FU on the intraocular pressure (IOP) outcome, bleb morphology, postoperative medications, and complications was evaluated. Methods Glaucoma patients (N = 61) who underwent trabeculectomy with mitomycin C were analyzed retrospectively (follow-up period of 25 ± 19 months). Surgery was performed exclusively by one experienced glaucoma specialist using a standardized technique. Patients in group 1 received subconjunctival applications of 5-FU postoperatively. Patients in group 2 received 5-FU and subconjunctival injection of bevacizumab. Results Group 1 had 6.4 ± 3.3 (0–15) (mean ± standard deviation and range, respectively) 5-FU injections. Group 2 had 4.0 ± 2.8 (0–12) (mean ± standard deviation and range, respectively) 5-FU injections. The added injection of bevacizumab significantly reduced the mean number of 5-FU injections by 2.4 ± 3.08 (P ≤ 0.005). There was no significantly lower IOP in group 2 when compared to group 1. A significant reduction in vascularization and in cork screw vessels could be found in both groups (P < 0.0001, 7 days to last 5-FU), yet there was no difference between the two groups at the last follow-up. Postoperative complications were significantly higher for both groups when more 5-FU injections were applied. (P = 0.008). No significant difference in best corrected visual acuity (P = 0.852) and visual field testing (P = 0.610) between preoperative to last follow-up could be found between the two groups. Conclusion The postoperative injection of bevacizumab reduced the number of subconjunctival 5-FU injections significantly by 2.4 injections. A significant difference in postoperative IOP reduction, bleb morphology, and postoperative medication was not detected.

Intracorneal hematoma after canaloplasty and clear cornea phacoemulsification: surgical management.

Purpose This is a case report of intracorneal hematoma after canaloplasty and clear cornea phacoemulsification. Methods A 75-year-old woman presented with primary open angle glaucoma and visually significant cataract. Canaloplasty and clear corneal phacoemulsification were performed. Postoperatively she had an intracorneal hematoma, which was removed through a clear corneal tunnel. Results Preoperative best-corrected visual acuity (BCVA) was 20/40 in the right eye and mean intraocular pressure (IOP) was 20 mmHg. Uneventful canaloplasty, clear corneal phacoemulsification, and implantation of a posterior chamber intraocular lens were performed. One day after the operation, BCVA was 20/400 in the right eye. The IOP was 8 mmHg. Anterior segment examination revealed a nasally located intrastromal hematoma between corneal stroma and Descemet membrane. The intracorneal hematoma was removed through a clear corneal tunnel. Six months postoperatively, BCVA was 20/25 in the right eye. The IOP with one medication was 17 mmHg. Conclusions This operation was a minimally invasive technique to remove intrastromal hematocornea after viscocanaloplasty.

Response of Postoperative and Chronic Uveitic Cystoid Macular Edema to a Dexamethasone-Based Intravitreal Implant (Ozurdex)

PURPOSE To survey the clinical responses to treatment of chronic postoperative and uveitic cystoid macular edema (CME) with a dexamethasone-based intravitreal implant (Ozurdex(®)). METHODS This retrospective, interventional case series reports on patients with chronic CME after uncomplicated vitrectomy for epiretinal gliosis or phacoemulsification (group 1: 12 eyes) or secondary to noninfectious endogenous uveitis (group 2: 36 eyes). Central retinal thickness (CRT), best-corrected visual acuity (BCVA, logMAR), and intraocular pressure (IOP) throughout follow-up were gleaned from the medical records. RESULTS In group 1, CRT decreased, compared with baseline, from 519 ± 43 to 297 ± 23 and 356 ± 49 μm by the 1- and 3-month visit (P = 0.02) and to 429 ± 57 μm before reimplantation. In group 2, CRT decreased from 460 ± 31 to 300 ± 21 and 312 ± 26 μm by the 1- and 3-month follow-up, respectively (P = 0.001), and to 373 ± 32 μm before reimplantation. Complete resolution of CME was achieved in 67% and 94% (groups 1 and 2, respectively) by 1 month and in 42% and 80% by 3 months after injection. In group 1, BCVA improved from 0.46 ± 0.08 to 0.27 ± 0.09 and 0.20 ± 0.06 (P = 0.01) by the 1- and 3-month follow-up, respectively, and to 0.32 ± 0.08 before reimplantation. In group 2, BCVA improved from 0.47 ± 0.06 to 0.34 ± 0.09, 0.26 ± 0.07, and 0.29 ± 0.08 (P < 0.05) at 1 and 3 months of follow-up and before reimplantation, respectively. A significant IOP increase was not observed in either group. Mean time to reimplantation of Ozurdex was 6.4 ± 5.7 and 6.6 ± 3.4 months for postoperative and uveitic CME, respectively. CONCLUSION Ozurdex seems to achieve a sustained effect over up to 6 months in postsurgical and uveitic CME.

LOW ENDOPHTHALMITIS RATES AFTER INTRAVITREAL ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR INJECTIONS IN AN OPERATION ROOM: A Retrospective Multicenter Study.

Purpose: To evaluate the rate of presumed endophthalmitis (EO) after intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections in three European hospitals performed in an operation room (OR) under sterile conditions. Methods: A retrospective multicenter study between 2003 and 2016 at three European sites, City Hospital Triemli Zurich, Switzerland (CHT), Zealand University Hospital Roskilde, Denmark (ZUH) and University Clinic Bern, Switzerland (UCB). Intravitreal injection (IVI) database of each department was reviewed. All anti-vascular endothelial growth factor injections were performed using a standardized sterile technique in an operation room. Injection protocols were similar between the three sites. No preinjection antibiotics were given. Postoperative antibiotics varied among sites. Results: A total of 134,701 intravitreal injections were performed at the 3 sites between 2003 and 2016. Ten cases of presumed endophthalmitis were documented: 4 in 50,721 at CHT (95% CI: 0.0071–0.0087%), 2 in 44,666 at ZUH (95% CI: 0.0039–0.0051%), and 4 in 39,314 at UCB (95% CI: 0.0092–0.011%). This results in one case in 13,470 intravitreal injections and a combined incidence of 0.0074% per injection (95% CI: 0.0070–0.0078%). Positive cultures were found in 4 out of 10 presumed endophthalmitis cases. Conclusion: The standardized sterile technique in an operation room with laminar airflow showed very low rates of endophthalmitis at three European sites.

Vasculitis-like hemorrhagic retinal angiopathy in Wegener's granulomatosis

BackgroundGranulomatosis with polyangiitis, also known as Wegener’s granulomatosis, is a chronic systemic inflammatory disease that can also involve the eyes. We report a case of massive retinal and preretinal hemorrhages with perivascular changes as the initial signs in granulomatosis with polyangiitis (Wegener’s granulomatosis).Case presentationA 39-year-old Caucasian male presented with blurred vision in his right eye, myalgia and arthralgia, recurrent nose bleeds and anosmia. Fundus image of his right eye showed massive retinal hemorrhages and vasculitis-like angiopathy, although no fluorescein extravasation was present in fluorescein angiography. Laboratory investigations revealed an inflammation with increased C-reactive protein, elevated erythrocyte sedimentation rate and neutrophil count. Tests for antineutrophil cytoplasmic antibodies (ANCA) were positive for c-ANCA (cytoplasmatic ANCA) and PR3-ANCA (proteinase 3-ANCA). Renal biopsy demonstrated a focal segmental necrotizing glomerulonephritis. Granulomatosis with polyangiitis (Wegener’s granulomatosis) was diagnosed and a combined systemic therapy of cyclophosphamide and corticosteroids was initiated. During 3 months of follow-up, complete resorption of retinal hemorrhages was seen and general complaints as well as visual acuity improved during therapy.ConclusionVasculitis-like retinal changes can occur in Wegener’s granulomatosis. Despite massive retinal and preretinal hemorrhages that cause visual impairment, immunosuppressive therapy can improve ocular symptoms.

Optical coherence tomography angiography in age-related macular degeneration: persistence of vascular network in quiescent choroidal neovascularization

T his retrospective study was designed to evaluate the characteristics of quiescent type 2 choroidal neovascular (CNV) lesions, as well as differences between active CNV [under current anti-vascular endothelial growth factor (anti-VEGF) treatment] and inactive CNV. Therefore, we analysed split-spectrum amplitude-decorrelation angiography (SSDA)-based optical coherence tomography (OCT) (Optovue RTVue XR Avanti) images of 12 eyes (n = 12, 6 versus 6) with age-related macular degeneration (AMD). Quiescent CNVs were defined by the absence of any activity sign, such as subretinal or intraretinal fluid, choroidal or retinal haemorrhage or an increasing size of pigment epithelial detachments after anti-VEGF treatment cessation in formerly treated CNV. Eyes with currently quiescentCNVhad receiveda totalmean of 14.4 (SD 8.56) anti-VEGF injections (ranibizumab or aflibercept) according to a treat and extend dosing regimen (Freund et al. 2015). No injections for at least 15 months prior study enrolment were administered. Agematched control eyes were chosen randomly from our database of patients under anti-VEGF therapy for AMD. The persistence of a pathologic vascular network was seen in all quiescent CNV lesions (Figs. 1,2). Inactive lesions were characterized by a main vessel trunk (mean diameter 20.4 1.8 lm) and an intralesional rarefication of capillaries.Nouniformpattern of persistent lesions was seen. The average dimensions of inactive lesions amounted to 262.5 9 246.1 lm ( 48.5 9 51.6) as measured in two perpendicular orientations. Active lesions measured 178.6 9 139.3 lm ( 65.3 9 60.6). Five of six active lesions were characterized by a peripheral halo (mean gap to normally vascularized tissue 14.3 5.3 lm) (Fig. 3). The majority of active lesions (five of six) were localized in the choroidal capillary layer [defined as 30 lm and 60 lm below the retinal pigment epithelium (RPE)] and the outer retina (defined as 70 lm below the inner plexiform layer (IPL) and 30 lmbelow theRPE) (Fig. 4), whereas inactive lesions were found only in choroidal capillary layers. In contrast to the frequent misperception that neovascular lesions regress after long-term anti-VEGF treatment (Do et al. 2012; Wang et al. 2016), our findings appear to imply the persistence of neovascular lesions in quiescent CNV. This observation may indicate that inactivity of CNV lesions, as observed by structural SD-OCT, is not necessarily accompanied by a regression and reduction in size of former active CNV. Regular anti-VEGF treatment over a certain period of time may lead to a higher level of vascular maturity resulting in quiescent, non-leaking lesions. Mature vessels are adequately covered by pericytes, less fenestrated and consequently not dependent on external VEGF. Mature pericytes supply their ‘own’ neighbouring vascular endothelial cells with VEGF (Furuya et al. 2005). The regression of mature vessels due to VEGF blockage is therefore no expectable corollary. This raises the question, whether exudative AMD requires a lifelong treatment? As a potential counterargument, it may be mentioned that an increasing atrophic area and/or the formation of a subretinal scar (occurring in advanced stages of all AMD forms) is accompanied by less VEGFproducing tissue. This may result in a natural cessation of leakage. Recently, R. Spaide described an abnormalization of vessels after long-term exposure to anti-VEGF agents. This abnormalization was characterized by larger vessel diameters and a reduced number of ‘fresh’ capillaries. Iatrogenic ‘pruning’ of sprouting vessels by anti-VEGF agents resulted in higher blood flow levels in the remaining vascular network, in turn giving rise to a higher risk of arteriogenesis (Spaide 2015). In

Photodynamic therapy in combination with intravitreal ziv-aflibercept and aflibercept injection in patients with chronic or repeatedly recurrent acute central serous chorioretinopathy: a single-center retrospective study

Purpose The objective of the study was to assess the effect of off-label photodynamic therapy (PDT) in combination with intravitreal off-label ziv-aflibercept or off-label aflibercept injection in patients with chronic or repeatedly recurrent acute central serous chorioretinopathy (CSC). Patients and methods Changes in best corrected visual acuity (BCVA) and subfoveal subretinal fluid (sSRF) and maximum subretinal fluid (mSRF) were retrospectively analyzed in a single-center cohort study of 17 patients (18 eyes) with persistent subretinal fluid for more than 3 months of duration of CSC. Treatment efficacy was measured between injection and PDT at 30±15 days, 90±15 days and 180±30 days after PDT. Results Significant reduction of sSRF and mSRF was shown after therapy with ziv-aflibercept and aflibercept combined with PDT (p<0.001). Course of BCVA showed non-significant improvement within 6 months (p=0.065). One case of allergic reaction after fluorescein angiography and one case of ophthalmic migraine after ziv-aflibercept injection were documented. One case of reversible vision loss occurred during 6 months after combination therapy. No other adverse events or side effects were reported. Conclusion Combination therapy of ziv-aflibercept and aflibercept with PDT seems to be beneficial, even in cases of chronic or repeatedly recurrent acute CSC. This includes cases of CSC resistant to or recurrent after medical treatment, PDT alone or therapy with anti-vascular endothelial growth factor alone.