G. Baker Hubbard

Intraoperative Microscope-Mounted Spectral Domain Optical Coherence Tomography for Evaluation of Retinal Anatomy during Macular Surgery

OBJECTIVE To evaluate the use of microscope mounted spectral domain optical coherence tomography (SD-OCT) to detect changes in retinal anatomy during macular surgery. DESIGN Retrospective, observational case series. PARTICIPANTS We included 25 eyes of 24 consecutive patients who underwent SD-OCT during macular surgery. METHODS A retrospective review of operative techniques, outcomes, and imaging for all patients who underwent intraoperative microscope mounted SD-OCT during surgery for macular hole or epiretinal membrane (ERM) from April 2009 to April 2010 was performed. Qualitative and quantitative characteristics of intraoperative and postoperative changes in retinal anatomy were studied. MAIN OUTCOME MEASURES Intraoperative change in macular hole dimensions and retinal thickness in patients with ERM owing to surgical manipulation measured using SD-OCT. RESULTS Intraoperative SD-OCT from 13 eyes of 13 patients undergoing surgery for macular hole was reviewed. Two cases had images of suboptimal quality and were excluded. The remaining 11 eyes were subjected to quantitative analysis, which revealed stability of macular hole height and central hole diameter after internal limiting membrane (ILM) peeling, but an increase in the diameter of subretinal fluid under the macula in ten of 11 eyes (average 87% wider). Intraoperative imaging from 12 eyes of 11 patients undergoing surgery for ERM was analyzed. Quantitative analysis revealed an average increase of retinal thickness after ILM peel of <2%. Ten of 12 eyes developed a new subretinal hyporeflectance, which likely represents shallow detachment of the macula, after uncomplicated membrane peel. CONCLUSIONS Use of intraoperative SD-OCT has provided new insight into the changes to retinal anatomy during macular surgery and may prove to be a useful tool for vitreoretinal surgery. Further study is warranted to determine whether intraoperative changes such as the creation of shallow retinal detachments during uncomplicated macular surgery affects visual recovery. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.

Outcomes after Intravitreal Bevacizumab versus Laser Photocoagulation for Retinopathy of Prematurity: A 5-Year Retrospective Analysis.

PURPOSE To determine the relative effectiveness, major complications, and refractive errors associated with intravitreal bevacizumab (IVB) versus panretinal photocoagulation (PRP) to treat type 1 retinopathy of prematurity (ROP). DESIGN Retrospective case series. PARTICIPANTS Consecutive infants with type 1 ROP who received either IVB or PRP and had at least 6 months of follow-up. METHODS The data from infants treated with either IVB or PRP for type 1 ROP between 2008 and 2012 were recorded from 2 medical centers in Atlanta, Georgia. MAIN OUTCOME MEASURES Recurrence rate, complication rate, and refractive error. RESULTS A total of 54 eyes (28 patients) with type 1 ROP were evaluated: 22 eyes (11 patients) received IVB, and 32 eyes (17 patients) received PRP. Among the 22 eyes treated with IVB, 16 eyes had zone I ROP and 6 eyes had posterior zone II ROP. The number of zone I and II ROP eyes treated with PRP were 5 and 27, respectively. Mean gestational age, birth weight, postmenstrual age at initial treatment, and follow-up period for the infants receiving IVB were 24.2 weeks, 668.1 g, 35.1 weeks, and 21.7 weeks, respectively, and for the infants receiving PRP, these were 24.8 weeks, 701.4 g, 36.1 weeks, and 34.5 weeks, respectively. Retinopathy of prematurity recurred in 3 (14%) of 22 IVB-treated eyes and in 1 (3%) of 32 PRP-treated eyes. Neither retinal detachment nor macular ectopia developed in any of the IVB-treated eyes. In PRP-treated eyes, retinal detachment developed in only 1 eye and macular ectopia developed in 5 eyes. Mean spherical equivalent and postgestational age at the last refraction for IVB-treated eyes were -2.4 diopters (D) and 22.4 months, respectively, and for PRP-treated eyes, these were -5.3 D and 37.1 months, respectively. Mean spherical equivalent for zone I ROP eyes treated with IVB and PRP were -3.7 D and -10.1 D, respectively, and for zone II ROP eyes, these were 0.6 D and -4.7 D, respectively. CONCLUSIONS Both IVB and PRP are effective treatment options for type 1 ROP with low complication rates. IVB was associated with less myopia than PRP, although longer follow-up was available for PRP.

Uveal Metastasis from Lung Cancer : Clinical Features, Treatment, and Outcome in 194 Patients

PURPOSE To evaluate the clinical features, treatment, and prognosis of patients with uveal metastasis from lung cancer. DESIGN Retrospective chart review. PARTICIPANTS There were 194 patients with a diagnosis of uveal metastasis from lung cancer. INTERVENTION Radiotherapy, chemotherapy, enucleation, or observation. MAIN OUTCOME MEASURES Ocular tumor control, final visual acuity, and tumor-related death. RESULTS There were 374 uveal metastatic tumors originating from primary lung cancer in 229 eyes of 194 patients. Tumor location included choroid (88%), ciliary body (2%), and iris (10%), with bilateral involvement in 18%. Diagnosis of uveal metastasis preceded the diagnosis of primary lung cancer in 44% of patients. The choroidal metastatic focus had a mean basal diameter of 8 mm and mean thickness of 3 mm, and were mostly located posterior to the equator (91%). The choroidal metastasis commonly had yellow or orange color (98%), had plateau (61%) or dome (38%) configuration, and displayed associated subretinal fluid (85%). Choroidal tumors were multifocal in 49 cases (23%). Ciliary body tumors were commonly dome shaped (75%) with an episcleral sentinel vessel (75%). Iris tumors were multifocal in 2 cases (13%), had visible intrinsic vessels (97%), and were associated with tumor seeding in the angle (38%) or on the iris stroma (25%). The uveal metastases were treated with teletherapy (31%), chemotherapy (18%), brachytherapy (9%), chemotherapy combined with teletherapy or brachytherapy (14%), enucleation (3%), or observation (21%). At last visit, eyes with follow-up showed tumor regression (66%), stability (12%), growth (14%), recurrence (3%), or new metastasis (5%). Visual acuity improved or remained stable in 59% eyes. One-year mortality from the time of detection of uveal metastasis was 54%. CONCLUSIONS Of 194 patients with uveal metastasis from lung cancer, 44% did not have a history of known lung cancer. Current methods of ocular treatment allow globe salvage in 92% of patients and improved/stable vision in 59% of patients. Systemic prognosis remains poor with tumor-related death in 54% of patients at 1 year.

Visual outcomes and incidence of recurrent vitreous hemorrhage after vitrectomy in diabetic eyes pretreated with bevacizumab (avastin).

Purpose: To evaluate the safety and effect of bevacizumab pretreatment on the incidence of recurrent vitreous hemorrhage and visual acuity after vitrectomy for proliferative diabetic retinopathy. Methods: This was a consecutive, retrospective, and comparative cohort study. Patients undergoing vitrectomy from September 2006 through November 2007 at the Emory Eye Center for complications of proliferative diabetic retinopathy were identified and reviewed. A total of 33 eyes pretreated with bevacizumab and 104 untreated eyes were observed for postoperative vitreous hemorrhage and final visual acuity. Results: Patients in the bevacizumab group were significantly younger than those in the untreated group (average age, 46.4 vs. 58.4 years) and were more likely to have 20-gauge instrumentation (58% vs. 36%). An average of 9.6 days passed between injection and surgery. Early (4-6 weeks) rebleed rates were 15% versus 13% in the bevacizumab and untreated groups, respectively, and not statistically different. Preoperative (7/200 vs. count finger at 4′), 1-month postoperative (20/200−3 vs. 20/150), and 3-month postoperative visual acuity (20/100−3 vs. 20/100+2) were not statistically different between groups. No statistical difference was found in rebleed rates regarding the gauge of vitrectomy. Conclusion: Bevacizumab pretreatment for diabetic vitrectomy was not associated with any observed complications but did not influence rates of postoperative vitreous hemorrhage or final visual acuity in this retrospective series. The overall incidence of postoperative early vitreous hemorrhage in this series was 13% and seems lower than historically reported rates.

Treatment of Coats’ disease with intravitreal bevacizumab

Objective To compare the efficacy of intravitreal bevacizumab plus ablative therapy with ablative therapy alone for Coats’ disease. Methods A retrospective review of all paediatric patients who received treatment for Coats’ disease from a single surgeon (GBH) from 1 January 2001 to 31 March 2010 was performed. Ten consecutive patients who received intravitreal bevacizumab as part of their treatment were matched to 10 patients treated with ablative therapy alone by macular appearance, quadrants of subretinal fluid, and quadrants of telangiectasias. Outcomes evaluated were number of treatment sessions, time to full treatment, and resolution of disease. Results There was no statistical difference between baseline characteristics when comparing the bevacizumab and control groups. Eyes treated with bevacizumab required more treatments over a longer time period compared to the control group. All patients in the bevacizumab group were successfully treated while two of the patients in the control group failed ablative techniques. Conclusions Intravitreal bevacizumab may play a role as adjuvant therapy in select cases of Coats’ disease, but its use does not reduce the time to full treatment. Resolution of disease was seen in the most severe cases treated with bevacizumab plus thermal ablation whereas their matched controls failed therapy with laser and cryotherapy alone.

Topical Ketorolac in Vitreoretinal Surgery: A Prospective, Randomized, Placebo-Controlled, Double-Masked Trial

OBJECTIVE To evaluate the effects of topical ketorolac in patients undergoing vitreoretinal surgery. METHODS One hundred nine patients undergoing vitrectomies were randomized to receive either topical ketorolac tromethamine, 0.4%, or placebo. Patients were instructed to begin taking the study medication 3 days preoperatively (4 times daily) and to continue taking it 4 weeks postoperatively. MAIN OUTCOME MEASURES Intraoperative pupil diameter, postoperative day 1 pain and inflammation, 1-month postoperative retinal thickness, and preoperative and 1-month postoperative best-corrected visual acuities. RESULTS The difference in mean pupil diameters between patients using ketorolac and those taking placebo was 0.06 mm (P = .39). Patients taking ketorolac and those taking placebo had mean pain scores (scale, 1-10) of 0.24 (SD, 0.6) and 1.06 (SD, 2) (P = .03) and mean inflammation grades (grade, 0-4) of 0.59 (SD, 0.7) and 1.16 (SD, 0.9) (P < .001), respectively. Ketorolac reduced central subfield thickness by 8%, but this was not statistically significant. At 1 month, mean visual acuities improved to 0.40 logMAR units (mean Snellen, 20/50; SD, 0.28 logMAR units) in the ketorolac group from 0.83 logMAR units (20/150(+2); SD, 0.60 logMAR units) at baseline and to 0.67 logMAR units (20/100(+1); SD, 0.46 logMAR units) in the placebo group from 0.92 logMAR units (20/150(-2); SD, 0.62 logMAR units) at baseline (P = .001). CONCLUSIONS Topical ketorolac was well tolerated and safe, reduced postoperative pain and inflammation, and improved visual recovery in this prospective, double-masked trial. APPLICATION TO CLINICAL PRACTICE Topical ketorolac may benefit patients undergoing vitreoretinal surgery. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00576329.

Combination intravitreal triamcinolone injection and cryotherapy for exudative retinal detachments in severe Coats disease.

Intravitreal triamcinolone injection effectively reduces subretinal fluid in pediatric patients with exudative retinal detachments in severe Coats disease. However, when combined with cryotherapy, a large percentage of patients develop rhegmatogenous retinal detachments with proliferative vitreoretinopathy.

Incidence of Postvitrectomy Macular Edema Using Optical Coherence Tomography

OBJECTIVE To evaluate the incidence, effect on visual recovery, and predisposing risk factors of postvitrectomy macular edema (ME). DESIGN Prospective cohort study. PARTICIPANTS One-hundred nine eyes undergoing nonemergent vitrectomy surgery. METHODS Eyes were evaluated for postoperative day 1 inflammation, 1-month retinal thickness using optical coherence tomography, and preoperative and 1-month postoperative best-corrected visual acuity (BCVA). Macular edema was defined as central subfield thickness > or =272 microm. MAIN OUTCOME MEASURES Retinal thickness, inflammation, and BCVA. RESULTS Incidence of ME on optical coherence tomography was 47% (95% confidence interval [CI], 37%-56%). Mean 1-month visual acuity improved 3.3 lines (0.33 logarithm of minimum angle of resolution [logMAR] units) to 20/80(+1) (0.58+/-0.46 logMAR units) from 20/150(-2) (0.91+/-0.63 logMAR units) before surgery (P<0.001). Mean 1-month center point thickness (CPT), central subfield (CSF), and total macular volume were 265+/-107 microm, 288+/-94 microm, and 7.8+/-1.2 mm(3), respectively. Severity of postoperative inflammation predicted retinal thickness at 1 month (P<0.05). Intraoperative epinephrine use was associated with increased postoperative inflammation (P = 0.02). Eyes with greater reduction in CSF (or CPT) from baseline experienced more rapid visual recovery (r = -0.36; 95% CI, -0.61 to -0.06; P = 0.02). CONCLUSIONS Postvitrectomy ME is common and delays visual recovery. Degree of postoperative inflammation is an important risk factor for ME and, in this series, was increased in the setting of intraocular epinephrine. Efforts to reduce or prevent inflammation after vitrectomy should be beneficial and therefore are encouraged.

Clinical characteristics of hydroxychloroquine retinopathy

Aims To assess the characteristics and outcomes of patients with hydroxychloroquine retinopathy and to review the current screening guidelines. Methods Retrospective chart review of patients diagnosed as having hydroxychloroquine retinopathy at our institution between 2004 and 2008. Results All seven patients were women. While every patient received 400 mg of hydroxychloroquine per day, every patient exceeded the recommended daily dosage allowance (6.5 mg/kg/day). The mean daily dose of hydroxychloroquine was 8.2 mg/kg/day (range: 6.8–13.6 mg/kg/day). The mean duration of usage was 16.3 years (range: 8.5–30 years), and the mean cumulative dose was 2377 g (range: 1241–4380 g). The mean visual acuity at presentation was 20/30, but all patients exhibited significant visual-field defects. Colour vision was impaired in six patients. Four patients exhibited granular hyperpigmentation in the central macula, and three had a bulls eye appearance. The mean follow-up time was 21 months. The visual outcomes remained stable for every patient except for one patient who experienced an improvement in visual function after drug cessation. Conclusions Hydroxychloroquine retinopathy, although rare, still exists despite current screening guidelines. The authors recommend that physicians dose hydroxychloroquine according to lean body weight and that they use risk stratification to guide their screening regimens.

Anterior Diffuse Retinoblastoma Mutational Analysis and Immunofluorescence Staining

Retinoblastoma is the most common primary intraocular tumor of childhood and may be heritable or occur sporadically. Anterior diffuse retinoblastoma is an uncommon variant that is thought to be sporadic. We describe a child with anterior diffuse retinoblastoma who presented with a pseudohypopyon. Genetic analysis showed a germline mutation of the RB1 allele that is potentially heritable. Immunofluorescence staining was positive for transforming growth factor beta and for vascular endothelial growth factor and negative for inducible nitric oxide synthase and for hypoxia inducible factor alpha in the tumor seeds, indicating acquisition of nonischemia-mediated survival factors of the tumor seeds in the aqueous humor.