Hadi Zambarakji

Vitreoretinal complications of osteoodontokeratoprosthesis surgery.

Purpose: To describe the vitreoretinal complications in a cohort of patients with osteoodontokeratoprosthesis (OOKP) and discuss surgical management. Methods: Review of notes of 35 OOKP cases performed at the Sussex Eye Hospital (Brighton, United Kingdom) between January 1999 and December 2005 was performed. Results: The overall incidence of vitreoretinal complications was 22.8%, which included vitreous hemorrhage (3 patients), rhegmatogenous retinal detachment (3 patients), endophthalmitis with retinal detachment complicating lamina resorption and optic extrusion (2 patients), and intraoperative choroidal hemorrhage (1 patient). Preexisting aphakia was associated with rhegmatogenous retinal detachment (P < 0.05, &khgr;2 = 4.36). Five patients required pars plana vitrectomy, which was performed either endoscopically (two cases) or using a binocular indirect viewing system (three cases) with one case requiring removal of the OOKP and insertion of a temporary keratoprosthesis. Retinal detachment repair was attempted on four of five patients but was successful for only one. Vitreous hemorrhage without retinal detachment required vitrectomy in one case, while two cases cleared spontaneously. Conclusions: Eyes receiving OOKP are prone to vitreoretinal complications, with retinal detachment associated with a poor prognosis. Thicker OOKP laminae and lamina bulk screening will hopefully reduce the risk of endophthalmitis due to unexpected resorption.

CMVR diagnoses and progression of CD4 cell counts and HIV viral load measurements in HIV patients on HAART

AIM To assess the impact of highly active antiretroviral therapy (HAART) on the prevalence and progression of CMV retinitis (CMVR) among AIDS patients with baseline CD4 cell counts <100 cells × 106/l. METHODS A longitudinal cohort study of 1292 patients. CD4 cell counts and HIV viral load measurements were obtained before commencing therapy, at 3 months, 1 year, 2 years, and at last follow up. The CMVR prevalence rate was measured for the subgroup with baseline CD4 cell counts <100 cells × 106/l. CMVR adverse event (AE) rates per 100 person days at risk were calculated for the subgroup with CMVR and baseline CD4 cell counts <100 cells × 106/l. RESULTS 1292 patients were started on HAART. 8% of patients had CD4 counts <50 cells × 106/l and 40% had detectable HIV viral load at last follow up. The prevalence of CMVR for the subgroup with baseline CD4 <100 cells × 106/l was 10%. For those with baseline CD4 <100 cells × 106/l, the mean CMVR AE rate was greatest during the first 6 months of follow up after HAART commencement (p <0.003). The mean AE rate per 100 person days at risk was 0.36 (95% CI 0.167 to 0.551) before starting HAART, and 0.14 (95% CI 0.085 to 0.199) after starting HAART (p = 0.03). CONCLUSIONS HAART significantly prolongs the disease-free intervals in patients with pre-existing disease but recurrences persist within the first 6 months of starting therapy. AE were absent beyond 18 months of follow up in all patients including those with persistently low CD4 counts and detectable HIV viral load indicating clinical immunorestoration. New methods for monitoring the response to therapy are needed to identify those at risk.

An unusual cause of oscillopsia

Editor,—Chronic maxillary atelectasis (CMA),1 also known as silent sinus syndrome (SSS)2 describes the same condition. Typically, the patient presents with acute enophthalmos and hypoglobus in the absence of previous trauma or surgery. Past sinus disease may be present and computed tomograph (CT) scans demonstrate ipsilateral sinus contraction, orbital floor resorption, and thinning with inferior prolapse into the maxillary sinus. We present a patient who noted oscillopsia while jogging 1 year after being diagnosed with SSS. ### CASE REPORT A 26 year …

OBSERVATION: FLUOCINOLONE ACETONIDE (ILUVIEN) IMPLANT MIGRATION INTO THE ANTERIOR CHAMBER.

Purpose: To describe the anterior chamber migration of a fluocinolone acetonide (Iluvien) implant in the context of previous vitrectomy and complicated cataract surgery. Methods: Retrospective observational case series. Two patients with a history of vitrectomy and complicated phacoemulsification surgery, one of whom had pseudoexfoliation. Results: The implant migrated to the anterior chamber shortly after implantation. One patient had the implant removed after one recurrence; the other used pilocarpine 2% eye drops to reduce the risk of further migration. Conclusion: Complicated cataract surgery and vitrectomy can be associated with migration of fluocinolone acetonide implants into the anterior chamber.

Spectral domain ocular coherence tomography findings pre- and post vitrectomy with fibrovascular membrane delamination for proliferative diabetic retinopathy

PurposeTo describe the intraretinal microstructure using serial spectral domain optical coherence tomography (SD-OCT) preceding and following pars plana vitrectomy and delamination of fibrovascular membranes in patients with proliferative diabetic retinopathy (PDR).MethodsThis retrospective, interventional case series includes 28 eyes. Outcome measures included LogMAR distance best-corrected visual acuity (BCVA), SD-OCT integrity of photoreceptor inner and outer segments junction (IS/OS), and integrity of external limiting membrane (ELM).ResultsPre-operative central macular thickness (CMT) was significantly correlated with the final post-operative LogMAR BCVA (Pearson’s coefficient r=0.89; P=0.001). The eyes were categorised into three groups based on post-operative IS/OS integrity (group 0: IS/OS intact; group 1: IS/OS irregular but not completely disrupted; group 2: IS/OS completely disrupted). Mean BCVA improved significantly in group 0 (n=9) from 1.13±0.75 preoperatively to 0.34±0.21 (Student’s t-test: P=0.06), in group 1 (n=10) the BCVA improved from 0.88±0.56 to 0.58±0.31 (Student’s t-test: P=0.053) and in group 2 (n=9) the BCVA improved from 1.64±0.53 to 1.53±0.75 (Student’s t-test: P=0.652).IS/OS integrity and ELM integrity at 3 months post operatively, were significantly and positively correlated with final BCVA (Pearson’s coefficient: r=0.83, P<0.001 and r=0.72, P<0.001, respectively).ConclusionsPre-operative CMT and post-operative disruption of the IS/OS and ELM are useful prognostic indicators in fibrovascular delamination surgery for patients with PDR.

The management of macular hole retinal detachment and macular retinoschisis in pathological myopia; a UK collaborative study

PurposeTo study UK practice patterns for the management of retinal detachment secondary to macular hole (MHRD) and macular retinoschisis (MRS) in pathological myopia (PM). To review the anatomical and visual outcomes of the surgically managed cases.MethodsA prospective observational case series for the management of MHRD was undertaken in association with the British Ophthalmological Surveillance Unit (BOSU). The results were combined with retrospective data, collected by the COllaboration of British RetinAl Surgeons (COBRA), on the management of both MHRD and MRS in PM in the UK. A total of 20 cases of MHRD and 53 cases of MRS (27 surgical cases and 26 cases managed conservatively) are reported in this combined study.ResultsMHRD: Mean baseline best corrected visual acuity (BCVA) was 1.60 logMAR. All cases underwent pars plana vitrectomy (PPV). Mean post-operative BCVA was 1.49 logMAR (p = 0.674). The macular hole was closed in 5/20 (25%) cases, open/flat in 10/20 (50%) cases and open/elevated in 4/20 cases (20%). MRS: Mean baseline BCVA was 0.87 logMAR in the surgical group and 0.45 logMAR in the conservatively managed group (p = 0.002). All eyes that had surgical intervention underwent PPV. Mean post-operative BCVA was 0.68 logMAR (p = 0.183). Anatomical outcomes demonstrated a persistent MRS in 2/27 (7.4%) cases, partial resolution in 7/27 (25.9%) cases and complete resolution in 16/27 (59.2%) cases.ConclusionsPPV is the only surgical procedure performed for the management of MHRD and MRS amongst the study participants. Success rates and visual outcomes are limited for MHRD and consistent with the current literature for MRS.

Management of macular edema in vitrectomized patients with diabetes

ABSTRACT Introduction: Diabetic macular edema is the result of a complex interlay of ocular and systemic factors. In diabetic eyes undergoing pars plana vitrectomy surgery (PPV) indications are variable and add to the complexity of the management of persistent or recurring macular edema. Area of research covered: This review focuses on the management of macular edema in eyes of diabetic patients with previous PPV surgery. Additional data are presented for the development of macular edema in relation to non-diabetic etiologies and associated intraoperative factors. The risk/benefit profile of current treatment options was also evaluated. Expert commentary: Vitrectomy plays an important role in the management of vitreoretinal disorders in diabetic patients. Its role in the management of diabetic macular edema (DME) in the absence of vitreous traction remains controversial. There is a paucity of evidence relating to the treatment outcomes for DME in vitrectomized eyes. Pharmakokinetic studies in experimental models have indicated the reduced half-life of anti-VEGF or steroids in vitrectomised eyes though similar studies in humans are lacking. In clinical studies, DME treatment with ranibizumab or bevacizumab has been demonstrated to have favourable visual and anatomic outcomes in vitrectomized eyes in post hoc or retrospective studies. These results are still less favourable in comparison to non vitrectomized eyes. Intravitreal triamcinolone has demonstrated minimal improvement however dexamethasone and fluocinolone implants had encouraging outcomes. For both anti-VEGF agents or steroids well-conducted prospective, randomized controlled trials are needed to substantiate these outcomes.

Availability of anti-VEGF agents for the management of advanced diabetic retinopathy in the NHS

The anti-vascular endothelial growth factor (anti-VEGF) drug Bevacizumab (Avastin Genentech Inc. (Roche Group), San Francisco, California, USA) has been in circulation for several years within the ophthalmic community. Numerous studies have reported clinical outcomes of Bevacizumab in the context of proliferative diabetic retinopathy (PDR)1–4 and neovascular glaucoma. These, including a comprehensive review5 and a meta-analysis,6 have all reported favourable clinical outcomes. Studies therefore confirm that Bevacizumab reduces the risk of haemorrhage, reduces the need for endodiathermy, facilitates surgery and reduces surgical time if administered days prior to vitrectomy surgery for PDR. Bevacizumab also reduces retinal neovascularisation and/or iris neovascularisation in patients with rubeotic glaucoma secondary to advanced PDR when used …