James C. Lai

VISUAL IMPROVEMENT FOLLOWING INTRAVITREAL BEVACIZUMAB (AVASTIN) IN EXUDATIVE AGE-RELATED MACULAR DEGENERATION

Purpose: To study the visual and anatomic outcome of intravitreal bevacizumab injection in the treatment of exudative age-related macular degeneration (AMD). Methods: Retrospective review of patients who received one or more intravitreal bevacizumab injections for exudative AMD. Outcome measures include standardized visual acuity, optical coherence tomography (OCT), macular thickness and volume, intraocular pressure, and blood pressure at 24 or more weeks follow-up. Results: Fifty eyes of 48 patients were identified. Patients were observed for a median length of follow-up of 34 weeks (range, 24–50 weeks). Thirty-six eyes (72%) had prior treatment with pegaptanib (Macugen) and/or photodynamic therapy (PDT) and 14 eyes (28%) were treatment-naive. Mean visual acuity increased by 6.5 letters (P < 0.01) at 4 weeks and 5.3 letters (P < 0.01) at 24 weeks after initial bevacizumab injection. At 24 weeks, naive eyes had a mean increase of 14.2 letters (P < 0.001) and previously treated eyes had a mean increase of 2.8 letters (P = 0.06). Overall, mean OCT macular thickness and volume decreased by 73 &mgr;m (P < 0.001) and 1.0 mm3 (P < 0.001) respectively at last follow-up. At last follow-up, all eyes received an average of 3.5 injections and experienced an average of 1.08 recurrences. There was no incidence of severe vision loss or adverse effect. Conclusion: Intravitreal bevacizumab has the potential for improvement in vision in both naive and previously treated eyes for at least 6 months. The benefit is more pronounced in eyes without prior pegaptanib and/or PDT.

Visual Outcome and Bacterial Sensitivity After Methicillin-Resistant Staphylococcus aureus–Associated Acute Endophthalmitis

PURPOSE To determine the frequency, visual outcome, and bacterial sensitivity in cases of methicillin-resistant Staphylococcus aureus (MRSA)-associated acute postoperative endophthalmitis occurring after cataract surgery. DESIGN Retrospective, consecutive, observational case series. METHODS Sixty-four cases of acute endophthalmitis occurring within six weeks after cataract surgery were identified over a three-year interval at a single vitreoretinal practice. Cases related to MRSA were studied and visual outcomes and bacterial sensitivities were recorded. RESULTS Thirty-three of the 64 eyes were culture positive, and six of the 33 cases (18.2%) demonstrated MRSA infection. All six eyes were started on fluoroquinolone antibiotics two or three days before surgery. Corneal abnormalities were noted in five of the six cases (83.3%), ranging from wound infection to diffuse corneal opacification. Visual acuity at last follow-up was no light perception (NLP) in two eyes, hand movements in two eyes, and 20/30 or better in two eyes. One eye with NLP vision underwent enucleation within three days of presentation because of panophthalmitis and impending sepsis. All six organisms were sensitive in vitro to both gentamicin and vancomycin. No organism was sensitive to any fluoroquinolone antibiotic, although not all organisms were tested against all fluoroquinolones. CONCLUSIONS MRSA infection accounts for 18% of culture-positive cases of endophthalmitis in this study and was associated with a poor visual outcome in two-thirds of our patients. MRSA organisms may be resistant in vitro to all generations of fluoroquinolone antibiotics, but do seem to be sensitive to gentamicin and vancomycin. The incidence of MRSA endophthalmitis seems to have increased significantly since the Endophthalmitis Vitrectomy Study was published in 1996.

Comparison of silicone oil versus gas tamponade in the treatment of idiopathic full-thickness macular hole

PURPOSE To compare anatomic and functional outcomes of macular hole surgery with either silicone oil or C(3)F(8) gas tamponade. DESIGN Retrospective comparative interventional study. PARTICIPANTS Fifty-four eyes of 51 patients underwent pars plana vitrectomy for macular holes. Thirty-one eyes were treated with silicone oil tamponade, and 23 eyes were treated with C(3)F(8) tamponade. METHODS Demographics, preoperative and postoperative characteristics, and complications were analyzed. MAIN OUTCOME MEASURES Preoperative and postoperative visual acuity, initial hole closure, number of persistent or recurrent holes, number of reoperations, and final hole closure. RESULTS The silicone oil and gas tamponade groups were demographically similar. The rate of hole closure after one operation with oil tamponade was significantly lower than that with gas tamponade (65% vs. 91%; P = 0.022). The percentage of patients undergoing a second operation was significantly higher in the oil group (35% vs. 4%; P = 0.006). However, with reoperations, the final rate of hole closure was similar between the oil and gas groups (90% vs. 96%; P = 0.628). The final median visual acuity for the gas group was significantly better than for the oil group (20/50 vs. 20/70; P = 0.047). CONCLUSIONS C(3)F(8) gas proved to be a more effective tamponade than silicone oil with respect to achieving initial closure of macular holes. Eyes receiving an oil tamponade required significantly more reoperations to achieve a similar rate of hole closure compared with eyes undergoing a gas tamponade. Final visual acuity was better for gas-operated eyes than for silicone-operated eyes.

Bioadhesives for intraocular use.

Background/Purpose: A safe, effective adhesive could be useful in the management of retinal holes or tears and selected complicated retinal detachments, as well as for attaching a small electronic device (retinal prosthesis) to the retina. In this study, we examined nine commercially available compounds for their suitability as intraocular adhesives. Methods: The following materials were studied: commercial fibrin sealant, autologous fibrin. Cell‐Tak, three photocurable glues, and three different polyethylene glycol hydro‐ gels. An electronic strain gauge measured the adherence forces between different glues and the retina. The stability of hydrogels at body temperature and the impermeability of the hydrogel adhesive to dextran blue were examined. Long‐term biocompatibility testing of the most promising glues in terms of adhesive force, consistency, and short‐term safety (hydrogels) were done in rabbits. Funduscopy, electroretinogram, and histology of the retina were performed. Results: Hydrogels had 2 to 39 times more adhesive force (measured in mN) than the other glues tested. They liquefied at body temperature after 3 days to a few months. Hydrogels were impermeable to dextran blue. One type of hydrogel proved to be nontoxic to the retina. Conclusions: Hydrogels proved to be superior for intraocular use in terms of consis‐tency, adhesiveness, stability, impermeability, and safety.

Recovery of visual function after removal of chronic subfoveal perfluorocarbon liquid.

These symptoms can include weakness, fatigue, spontaneous bleeding, and increased infection.3 As the disease progresses, hypercalcemia due to increased bone resorption is often seen.3 Commonly, patients can develop kidney involvement, resulting in renal failure.3 In this case, the patient had none of these signs and symptoms when she initially presented with visual complaints. In the literature, there is a report of known systemic multiple myeloma with choroidal involvement,1 and there is a case of an extramedullary plasmacytoma in the choroid without development of multiple myeloma.2 This case demonstrates that systemic multiple myeloma can present initially as an amelanotic choroidal mass that simulates a choroidal melanoma. The diagnosis of choroidal plasmacytoma in this case is strongly supported by the rapid and complete response of the lesion to radiotherapy. In addition, the finding of multiple systemic plasmacytomas further supports the diagnosis. References 1. Sandberg HO, Westby RK, Arnesen K. Plasmacytoma of the uvea in a case of multiple myeloma. Acta Ophthalmol 1989; 67:329–332. 2. Honavar SG, Shields CL, Shields JA, Demirci H, Ehya H. Extramedullary plasmacytoma confined to the choroid. Am J Ophthalmol 2001;131:277–278. 3. Munshi NC, Tricot G, Barlogie B. Plasma cell neoplasms. In: DeVita VT, Hellman S, Rosenberg SA, eds. Cancer: Principles and Practice of Oncology. 6th ed. Vol 2. Philadelphia: Lippincott Williams & Wilkins, 2001:2465–2491.

Bilateral ocular ischemic syndrome secondary to giant cell arteritis progressing despite corticosteroid treatment

PURPOSE To report the development of a bilateral ocular ischemic syndrome despite corticosteroid treatment in a patient with giant cell arteritis. METHOD Case report. RESULTS Despite receiving high-dose intravenous methylprednisolone and oral prednisone for biopsy-proven giant cell arteritis that presented as a severe anterior ischemic optic neuropathy in the right eye, a patient developed progressive ocular ischemia in that eye as well as an ocular ischemic syndrome in the fellow eye. CONCLUSIONS Some patients with giant cell arteritis, possibly patients with other underlying systemic vasculopathies, are refractory to what should be adequate treatment with systemic corticosteroids and may develop a bilateral ocular ischemic syndrome.

Central retinal vein occlusion in patients treated with long-term warfarin sodium (Coumadin) for anticoagulation.

Purpose: To describe the clinical features of persons who developed central retinal vein occlusion (CVO) while being treated with Coumadin for chronic anticoagulation. Methods: In a retrospective, comparative, noninterventional case series of patients diagnosed with CVO while being treated with Coumadin as a systemic anticoagulant, visual and anatomical outcomes were compared with those for a cohort of patients diagnosed with CVO who were not treated with any systemic anticoagulation. Results: Fourteen eyes of 14 patients treated with Coumadin were identified. At presentation, the median international normalization ratio (INR) was 2.20 (range, 1.3–5.0). Eight patients (57%) had a therapeutic INR at the time of CVO. Their visual acuity and perfusion status were similar to those of patients with subtherapeutic INR. At the last follow-up (median, 16 months), visual acuity and perfusion status of the group of 14 eyes were similar to baseline findings (P = 0.62). Clinical features and outcomes were similar to those for a cohort of patients with CVO who were not being treated with systemic anticoagulation. Conclusion: CVO can occur in patients being treated with Coumadin for systemic anticoagulation. Final visual acuity and perfusion status were similar to those in a cohort of patients with CVO who were not treated with Coumadin. Although visual acuity is unaffected, ensuring that the INR for these patients remains in the therapeutic range may be important to help prevent secondary systemic thrombotic and embolic disease.

Prevalence and Etiology of Hearing Loss in Rural Nicaraguan Children

Objective/Hypothesis: The prevalence and causes of pediatric hearing loss (HL) in the developing world are largely unknown. Infectious sequelae, ototoxic medications, and genetic causes may play a larger role in developing countries. In addition, the significance of GJB2 mutation gene in poorly developed areas remains unclear. The intent of this study is to investigate the prevalence and etiology of HL in children living in a remote, impoverished region of northern Nicaragua.

Polypoidal Choroidal Vasculopathy Exudation and Hemorrhage: Results of Monthly Ranibizumab Therapy at One Year

Purpose: To evaluate the efficacy and safety of monthly intravitreal injections of ranibizumab in patients with polypoidal choroidal vasculopathy (PCV) and active exudation or hemorrhage. Methods: A prospective, single practice, open label trial of monthly intravitreal ranibizumab (0.5 mg) injections for PCV in 13 eyes of 13 patients who completed the 1-year study. The primary outcome measure was stabilization of vision (loss of <15 ETDRS letters). Secondary outcome measures included incidence of ocular and systemic adverse events, changes in subretinal hemorrhage, central foveal thickness, and polypoidal complexes on indocyanine green angiography at 1 year. Results: No patient lost ≥15 letters in visual acuity at 1 year. Three patients (23%) gained ≥15 letters at 12 months. Subretinal hemorrhage resolved in 9/9 eyes (100%). Macular edema improved in 5/5 eyes (100%). Subretinal fluid completely resolved in 4/9 eyes (44%), decreased in 2/9 eyes (22%), and increased in 3/9 eyes (33%). Polypoidal complexes decreased in 5/13 eyes (38%). Conclusion: Continuous monthly intravitreal ranibizumab decreases leakage and hemorrhage in eyes with exudative and hemorrhagic complications of PCV. Branching vascular networks persisted, and polypoidal complexes decreased in only 5/13 (38%) eyes with continuous antiangiogenic therapy at 1 year.

Complement-induced retinal arteriolar occlusions in the cat.

Purpose: To develop an animal model of complement‐induced retinal vasculopathy and determine whether it resembles Purtschers retinopathy. Methods: Intravenous cobra venom factor was used to achieve intravascular activation of the complement system in cats. After a single bolus of cobra venom factor (75 units/kg), retinal blood flow was monitored at regular intervals by fluorescein angioscopy and angiography. Results: Multiple small retinal arteriolar occlusions were present during the initial fluorescein transit of the immediate postinjection fluorescein study in 12 of 12 animals. Small, rapidly moving gaps in the fluorescein column were seen in two thirds of the animals observed continuously by fluorescein angioscopy. Angiographically, the obstructions were transient, and filling of the associated patches of capillary nonperfusion occurred within 3 minutes. Purtschers‐like ischemic retinal infarcts did not develop in any eye. Histopathologic analysis failed to demonstrate the nature of the transient vascular obstructive lesions, but indirect evidence suggested the possibility of granulocyte aggregates. Conclusion: Intravascular activation of the complement system produces transient microembolic retinal arteriolar occlusions in the cat. Although this model may represent a mild form of Purtschers retinopathy, factors in addition to complement activation appear necessary to induce ischemic retinal infarcts.