Jang Won Heo

Serratia marcescens endophthalmitis associated with intravitreal injections of bevacizumab.

PurposeTo report two cases of Serratia marcescens endophthalmitis related to presumed aliquot drug contamination, and to determine the incidence of acute endophthalmitis after intravitreal injection of bevacizumab.MethodsA retrospective chart review of 2020 consecutive intravitreal bevacizumab injection (IVBI) cases at the three affiliated hospitals of Seoul National University (A, B, and C) was carried out between 12 October 2006, and 31 January 2008. Bevacizumab was retrieved multiple times from a single original vial as needed and then discarded on the same day at hospital A and C, or prepared as a single dose aliquot vial at a compounding pharmacy in the hospital B.ResultsThe incidence of endophthalmitis after IVBI was 2/2020 (0.099%). Two patients receiving IVBI on the same day, but by different surgeons in different sites in hospital B, developed acute endophthalmitis. S. marcescens was isolated from the vitreous sample of the two patients. Molecular typing with pulsed field gel electrophoresis showed that the organisms were of the same strain, which suggested that the drug was contaminated at the pharmacy.ConclusionsEndophthalmitis is a rare complication after IVBI and can be caused by contaminated aliquot drug. Serratia is one of the causative organisms of acute endophthalmitis, which can have devastating consequences, despite the treatment. A compounding pharmacy in a hospital might not be able to guarantee that aliquoted drug is free of contamination for the IVBI.

Clinical features and course of ocular toxocariasis in adults.

Purpose To investigate the clinical features, clinical course of granuloma, serologic findings, treatment outcome, and probable infection sources in adult patients with ocular toxocariasis (OT). Methods In this retrospective cohort study, we examined 101 adult patients diagnosed clinically and serologically with OT. Serial fundus photographs and spectral domain optical coherence tomography images of all the patients were reviewed. A clinic-based case-control study on pet ownership, occupation, and raw meat ingestion history was performed to investigate the possible infection sources. Results Among the patients diagnosed clinically and serologically with OT, 69.6% showed elevated immunoglobulin E (IgE) levels. Granuloma in OT involved all retinal layers and several vitreoretinal comorbidities were noted depending on the location of granuloma: posterior pole granuloma was associated with epiretinal membrane and retinal nerve fiber layer defects, whereas peripheral granuloma was associated with vitreous opacity. Intraocular migration of granuloma was observed in 15 of 93 patients (16.1%). Treatment with albendazole (400 mg twice a day for 2 weeks) and corticosteroids (oral prednisolone; 0.5–1 mg/kg/day) resulted in comparable outcomes to patients on corticosteroid monotherapy; however, the 6-month recurrence rate in patients treated with combined therapy (17.4%) was significantly lower than that in patients treated with corticosteroid monotherapy (54.5%, Pu200a=u200a0.045). Ingestion of raw cow liver (80.8%) or meat (71.2%) was significantly more common in OT patients than healthy controls. Conclusions Our study discusses the diagnosis, treatment, and prevention strategies for OT. Evaluation of total IgE, in addition to anti-toxocara antibody, can assist in the serologic diagnosis of OT. Combined albendazole and corticosteroid therapy may reduce intraocular inflammation and recurrence. Migrating feature of granuloma is clinically important and may further suggest the diagnosis of OT. Clinicians need to carefully examine comorbid conditions for OT. OT may be associated with ingestion of uncooked meat, especially raw cow liver, in adult patients.

Secondary macular hole formation after vitrectomy.

Purpose: The purpose of this study was to report the incidence and the underlying ocular pathology of a macular hole (MH) that develops in vitrectomized eyes and to evaluate its prognosis. Methods: A retrospective chart review was performed in patients who underwent vitrectomy between March 2004 and June 2009. Cases that developed an MH in vitrectomized eyes were identified, and the data from all ophthalmology examinations were collected. Patients with recurrent MHs after the initial MH surgery were excluded. Results: We identified 10 cases of secondary MH during a period of 64 months (incidence, 8 of 3,279 [0.24%]). Two cases of secondary MHs were not included in the calculations because the initial vitrectomies were performed before March 2004. The initial vitrectomy was performed on four eyes with vitreous hemorrhage caused by proliferative diabetic retinopathy, three eyes with retinal detachment from high myopia, one eye with combined retinal detachment with uveitis, one eye with rhegmatogenous retinal detachment, and one eye with an epiretinal membrane. The macular pathology identified before MH formation included cystoid macular edema in two eyes, epiretinal membrane in four eyes, and no specific lesion in another four eyes. The secondary MHs were managed by additional vitrectomy, peeling of the internal limiting membrane, and intravitreal gas tamponade. Nine of 10 eyes achieved hole closure after the secondary surgery, and 8 eyes recovered their previous visual acuity; the other 2 eyes had visual loss within 2 Snellen chart lines, and none of the 9 patients had a recurrence during a mean follow-up of 20.7 months (range, 4-31 months). Conclusion: The development of secondary MHs after vitrectomy is rare. Pathogenic mechanisms other than idiopathic MH may be involved in these cases. The anatomical and functional outcome of the secondary MHs that developed after vitrectomy was good, although the final visual acuity was dependent on the underlying ocular pathology.

Early versus late intravitreal triamcinolone acetonide for macular edema associated with branch retinal vein occlusion.

Purpose To compare the effect of early versus late intravitreal injection of triamcinolone in patients with macular edema due to branch retinal vein occlusion (BRVO). Methods Twenty eyes of 20 patients with macular edema from BRVO, including 10 with duration after onset of ≤3 months and 10 with duration of >3 months, were treated using a single intravitreal triamcinolone injection (4 mg/0.1 ml). Best-corrected visual acuity and foveal thickness by optical coherence tomography were measured 1, 3, and 6 months post-injection. Results In patients that received treatment after a disease duration of ≤3 months, visual acuity and foveal thickness significantly improved from baseline over 6 months of follow-up. However, in those with a duration of > 3 months, improvements in visual acuity and foveal thickness, though apparent at 1 month, were not maintained at 3 and 6 months post-triamcinolone. Conclusions Intravitreal triamcinolone is more effective in patients with BRVO who are treated earlier.

Lens-sparing Vitrectomy for Stage 4 and Stage 5 Retinopathy of Prematurity

Purpose To describe the results of lens-sparing vitrectomy for the correction of retinal detachment associated with retinopathy of prematurity (ROP) and its associated complications. Methods Seventeen patients who underwent a lens-sparing vitrectomy for stage 4 and stage 5 ROP with plus disease at Seoul National University Childrens Hospital between 1999 and 2003 were enrolled in this study. The patients who had bilateral retinal detachment of ROP underwent a lens-sparing vitrectomy in one eye and a scleral buckling surgery or lensectomy-vitrectomy in the other eye. The patients who had a retinal detachment in one eye and a regressed ROP in the other eye underwent unilateral lens-sparing vitrectomies. A review of their preoperative clinical findings (including the status of retinal detachment and plus disease), post-operative results, and any complications encountered was performed. Results In 17 patients, the postoperative success rate of lens-sparing vitrectomy was 58.8%. However, lens-sparing vitrectomy as a treatment for stage 5 ROP (25.0%) produced more negative post-operative results than it did when used to treat either those for stage 4a (75,0%) or 4b (66.7%) ROP. Among the 10 eyes in which the retina was attached, form vision was shown in six eyes, light could be followed by three eyes, and no light perception was present in one eye. Intra- and post-operative complications included retinal break formation, cataracts, vitreous hemorrhages, and glaucoma in patients with stages 4b and stage 5 ROP. Conclusions Lens-sparing vitrectomy resulted in encouraging surgical outcomes in the correction of retinal detachment of ROP, especially in stage 4 patients. Therefore, a lens-sparing vitrectomy for stage 4 ROP patient may be beneficial, although it is still associated with some intra- and post-operative complications.

BILATERAL SAME-DAY INTRAVITREAL INJECTIONS USING A SINGLE VIAL AND MOLECULAR BACTERIAL SCREENING FOR SAFETY SURVEILLANCE

Purpose: To evaluate the safety of bilateral same-day intravitreal injections using a single vial and to introduce a molecular surveillance system to screen bacterial drug contamination using eubacterial polymerase chain reaction (PCR). Methods: Retrospective review of the medical records of 135 patients who received 574 bilateral same-day intravitreal injections for various retinal diseases in 2 tertiary referral hospitals between January 2008 and March 2010 was performed. Data were obtained regarding the diagnosis, kinds of drugs injected, postinjection complications, and the result of molecular bacterial screening of the injected drugs. Drugs for bilateral intravitreal injections were drawn from a single vial and injected using separate syringes or needles. Molecular bacterial screening was performed using the remaining drug in the syringe by 16S ribosomal DNA real-time PCR. Results: A total of 574 injections (384 bevacizumab, 154 ranibizumab, and 36 triamcinolone) were administered on bilateral eyes of 135 patients. There were no complications, including endophthalmitis, uveitis, retinal tear, or retinal detachment. Of the 278 injections screened for bacterial contamination using eubacterial PCR, no cases (0%) showed drug contamination by bacteria. The sensitivity of eubacterial PCR for molecular bacterial screening was 10 colony-forming units (CFUs)/mL or lower. Conclusion: Bilateral same-day intravitreal injections drawn from a single vial using separate syringes or needles are well tolerated by patients, and its safety profile may be equivalent to unilateral injections. The bacterial molecular surveillance system using eubacterial PCR demonstrated the safety of bilateral same-day intravitreal injections and may be used for safety surveillance and for timely intervention of possible drug-related endophthalmitis.

Intraperitoneal Infusion of Mesenchymal Stem/Stromal Cells Prevents Experimental Autoimmune Uveitis in Mice

Autoimmune uveitis is one of the leading causes of blindness. We here investigated whether intraperitoneal administration of human mesenchymal stem/stromal cells (hMSCs) might prevent development of experimental autoimmune uveitis (EAU) in mice. Time course study showed that the number of IFN-γ- or IL-17-expressing CD4+ T cells was increased in draining lymph nodes (DLNs) on the postimmunization day 7 and decreased thereafter. The retinal structure was severely disrupted on day 21. An intraperitoneal injection of hMSCs at the time of immunization protected the retina from damage and suppressed the levels of proinflammatory cytokines in the eye. Analysis of DLNs on day 7 showed that hMSCs decreased the number of Th1 and Th17 cells. The hMSCs did not reduce the levels of IL-1β, IL-6, IL-12, and IL-23 which are the cytokines that drive Th1/Th17 differentiation. Also, hMSCs did not induce CD4+CD25+Foxp3+ cells. However, hMSCs increased the level of an immunoregulatory cytokine IL-10 and the population of IL-10-expressing B220+CD19+ cells. Together, data demonstrate that hMSCs attenuate EAU by suppressing Th1/Th17 cells and induce IL-10-expressing B220+CD19+ cells. Our results support suggestions that hMSCs may offer a therapy for autoimmune diseases mediated by Th1/Th17 responses.

Modified transscleral fixation using combined temporary haptic externalization and injector intraocular lens implantation

&NA; Several transscleral suturing techniques require intricate surgical maneuvers and are associated with an increased risk for surgical trauma. We describe a new scleral fixation method that combines the advantages of temporary haptic externalization and injector implantation of an intraocular lens (IOL). After IOL insertion with the injector, each haptic is externalized through 2 adjacent corneal incisions. A 10‐0 polypropylene suture loop is made at each exposed haptic and transscleral IOL fixation performed. This modified technique is a safe and effective way to fixate the IOL in eyes with insufficient capsule support. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Visual and anatomic outcomes of golf ball-related ocular injuries

AimsTo investigate the characteristics and prognoses of golf ball-related ocular injuries (GROIs) using standardized terminology, classification, and scoring systems.MethodsTwenty-two GROI patients were assessed using the Birmingham Eye Trauma Terminology, Ocular Trauma Classification Group (OTCG) classification, and Ocular Trauma Score. Globe preservation and final visual acuity (FVA) were assessed according to the injury severity categorical designation.ResultsFourteen patients were injured on golf courses and eight on driving ranges. Nine patients (40.9%) had open-globe injuries (five ruptures (22.7%), four penetrating injuries (18.2%)). All rupture cases required enucleation, whereas penetrating injury cases did not (the FVA ranged from 20/100 to no light perception). In open-globe injuries, wearing glasses protected against rupture (P=0.008). Thirteen patients sustained closed-globe injuries that were accompanied by lens subluxation (38.5%), choroidal rupture (30.8%), macular commotio retinae (38.5%), and traumatic optic neuropathy (7.7%). Twelve (54.5%) patients had orbital wall fractures. The mean number of related surgeries required was 1.5±1.7 across all patients.ConclusionEyes with GROIs had devastating FVA and globe preservation status, especially those with open-globe injuries. Observing golf rules and improving driving-range facilities are essential for preventing GROIs. Protective eyewear may reduce ocular damage from GROIs, especially globe rupture.

Cytomegalovirus retinitis after intravitreal bevacizumab injection in an immunocompetent patient.

We report a case of cytomegalovirus (CMV) retinitis after intravitreal bevacizumab injection. A 61-year-old woman with diabetic macular edema developed dense vitritis and necrotizing retinitis 3 weeks after intravitreal bevacizumab injection. A diagnostic vitrectomy was performed. The undiluted vitreous sample acquired by vitrectomy was analyzed by polymerase chain reaction and culture. Polymerase chain reaction of the vitreous was positive for CMV DNA. Other laboratory results did not show evidence of other infectious retinitis and systemic immune dysfunction. Human immunodeficiency virus antibodies were also negative. After systemic administration of ganciclovir, retinitis has resolved and there has been no recurrence of retinitis during the follow-up period of 12 months. Ophthalmologists should be aware of potential risk for CMV retinitis after intravitreal bevacizumab injection.