Jeffrey Gale

Anatomical and visual outcomes of macular hole surgery with short-duration 3-day face-down positioning.

Purpose: The role of face-down posturing after macular hole (MH) surgery remains unclear and controversial. We evaluated the anatomical and visual outcomes of MH repair using a short duration (3 days) of prone positioning. Methods: Prospective series of 50 consecutive eyes in 50 patients with Stage 2 or Stage 3 idiopathic MHs. All eyes underwent vitrectomy MH surgery with internal limiting membrane peeling and 20% sulfur hexafluoride (SF6) gas tamponade. The procedure was combined with phacoemulsification cataract surgery in phakic eyes. Surgical outcomes, MH closure rates, complications, and postoperative visual acuity were investigated. Results: Anatomical closure of MHs was achieved in 49 (98%) of 50 eyes by 1 surgery. Postoperative logarithm of the minimum angle of resolution visual acuity decreased (i.e., improved) by 0.271 (95% confidence interval, 0.101–0.441 [P = 0.0024]). One complication of intraocular lens pupillary capture and one case of chronic cystoid macular edema were observed. There were no complications attributed to intraocular pressure fluctuations. Conclusion: Vitrectomy with internal limiting membrane peeling and gas tamponade with SF6 followed by short-duration 3-day face-down positioning is a successful surgical intervention for Stage 2 and Stage 3 idiopathic MHs. This method possessed minimal complications and offered significant improvement in visual acuity.

Survey of intravitreal injection techniques and treatment protocols among retina specialists in Canada

OBJECTIVE To describe intravitreal injection (IVI) techniques and treatment protocols by retina specialists in Canada from August 1, 2012, to October 1, 2012. DESIGN Cross-sectional survey. PARTICIPANTS All fellowship-trained retina specialists across Canada, as identified from the Canadian Ophthalmological Society directory and the Canadian Retina and Vitreous Society directory. METHODS An anonymous 28-question survey was sent to 125 retina specialists across Canada by email. Reminder letters were sent by email, mail, and fax as necessary. RESULTS A total of 75 (63%) retina specialists responded to the survey. Most IVIs were performed in the office. Most surgeons did not use gloves (61%), sterile draping (91%), or surgical mask (71%). Antisepsis was used on conjunctiva by 100% and on periocular skin by 48%. Nearly all specialists used a sterile lid speculum (91%). Common anaesthetics included topical proparacaine or lidocaine drops (90%), topical lidocaine gel (25%), topical pledget (23%), and subconjunctival lidocaine injections (23%). Most (83%) dilate the pupil before IVI. Prophylactic topical antibiotics were used by 43%; 50% of these were started immediately after IVI. Injection location was estimated by visualization by 45%. A majority (63%) inject inferotemporally. Anterior chamber paracentesis was performed routinely by 5%. Optic nerve perfusion was formally assessed by 48%. The most common treatment protocol for age-related macular degeneration was treat and extend. For both diabetic and retinal vein occlusion-related macular edema, the most common protocol was 3 initial monthly injections with PRN follow-up. CONCLUSIONS A wide variety of IVI practice patterns exist in terms of aseptic technique, anaesthetics, prophylactic antibiotics, postinjection monitoring, and treatment protocol.

A trial of topical prednisolone acetate before intravitreal triamcinolone acetonide decreases intraocular pressure spikes

OBJECTIVE To compare adverse intraocular pressure (IOP) spikes in patients receiving intravitreal triamcinolone acetonide (IVTA) in 2 cohorts: (i) patients who underwent a topical prednisolone acetate trial (PAT) without incurring a short-term IOP rise, and (ii) control patients who did not undergo a PAT. DESIGN Retrospective cohort study. PARTICIPANTS Charts of all patients who underwent any intravitreal injection during the study period were reviewed (n = 1150). METHODS Patients in the PAT group received a 6-week course of prednisolone acetate 1% 4 times per day and had an IOP that did not rise above 25 mm Hg or above 8 mm Hg over the IOP in the contralateral eye. Patients undergoing a PAT and having a short-term IOP rise were not studied. Control patients did not receive a PAT. All patients received 12-20 mg of IVTA. Patients were followed for a minimum of 6 weeks and follow-up lasted for 1 year or until intraocular surgery or another IVTA injection was performed. RESULTS There were 97 patients in the PAT cohort and 75 control patients. Patients in the PAT cohort had a lower proportional rise between maximum IOP and baseline (43%) compared with controls (64%) (p = 0.035). Patients in the PAT group also had a lower risk of incurring a 40% (p = 0.05), 60% (p = 0.018), and 100% (p = 0.045) increase in maximum IOP (vs baseline) compared with controls and were less likely to require glaucoma filtration surgery (p = 0.035). CONCLUSIONS Patients undergoing a PAT who did not have a subsequent short-term IOP rise had a lower risk of severe IOP spikes after IVTA compared with those patients receiving IVTA but not having undergone a PAT.

Resistance of ocular flora to gatifloxacin in patients undergoing intravitreal injections

OBJECTIVE To compare gatifloxacin resistance in a population of ophthalmology patients who had received intravitreal injections (IVIs) with prophylactic topical gatifloxacin use to resistance in a similar population of patients who had not received IVI. DESIGN Nested case-control study. PARTICIPANTS Fifty eyes of 50 patients who received prior IVI were enrolled, as were 50 control eyes. METHODS Each patient had a conjunctival swab performed on the study eye, which underwent microbial identification and testing for gatifloxacin resistance using the ellipsoid test to determine a minimum inhibitory concentration (MIC) value for each isolate. The primary outcome was susceptibility to gatifloxacin, as measured by the MIC of each isolate. RESULTS A total of 111 bacterial isolates were obtained from 60 eyes; the remainder was culture negative. There were no significant differences in bacterial species or culture positivity rate between case and control eyes (50% in cases vs. 66% in controls, p = 0.16). The most common organism was coagulase-negative staphylococcus, comprising 64% of all isolates. Resistance to gatifloxacin was observed in 76% of the bacterial isolates and 38% of patients in the case group, as compared with 3% of bacterial isolates and 4% of patients in the control group, a result that was statistically significant (p = 0.0002 and 0.0008, respectively). The mean gatifloxacin MIC was also significantly higher in the case group. CONCLUSIONS Topical gatifloxacin prophylaxis in those who receive IVI is associated with an increased rate of gatifloxacin resistance among conjunctival isolates.

Practice patterns of Canadian vitreoretinal specialists in diabetic macular edema treatment

OBJECTIVE To establish the practice patterns of Canadian vitreoretinal (VR) specialists in the treatment of diabetic macular edema (DME). DESIGN A survey was mailed, faxed, e-mailed, and published online for access by all Canadian VR specialists. PARTICIPANTS All VR specialists identified from the Canadian Ophthalmology Society directory and the Canadian Retina and Vitreous Society directory. METHODS A 19-item survey investigating treatment of DME was mailed to all VR specialists. A reminder fax and e-mail was sent with the survey attached. In all correspondence, physicians were given information regarding an available online version of the survey. The survey data was descriptively analyzed with the Statistical Package for the Social Sciences. RESULTS With clinically significant macular edema (CSME) that is either away from the foveal avascular zone (FAZ) or diffuse, the most common first-line treatment option was macular photocoagulation 48 (78.8%) and 33 (54.1%), respectively. For microaneurysms within the FAZ, 33 (54.1%) of respondents chose intravitreal antivascular endothelial growth factor agents as their first-line treatment. In all, 51 respondents (83.6%) felt that vitrectomy played a role in the management of treatment-resistant CSME. Before utilizing intravitreal triamcinolone acetonide (IVT) injections, 34 (55.7%) of respondents did use a topical steroid trial to look for raised intraocular pressure whereas 16 (26.2%) of respondents did not use IVT injections at all. CONCLUSIONS This survey provides valuable practical information on how DME is currently being treated in Canada and may serve as a baseline to assess how these patterns evolve over time.

Histoplasma capsulatum endophthalmitis in southeastern Ontario

A 62-year-old male living in the St. Lawrence River basin presented with a 4-month history of decreased vision, photophobia, floaters, and conjunctival erythema of the right eye, in addition to a 40-pound weight loss over the previous year. Five years earlier, he had uncomplicated cataract surgery with postoperative vision of 6/7.5 in the same eye. On examination, the patient’s vision was counting fingers at 0.3 m (OD) and 6/7.5 (OS). Examination of the right eye revealed severe anterior chamber inflammation with numerous Koeppe and Busacca nodules on the iris. The posterior segment was poorly visualized because of dense vitreous cells, and a B-scan was negative for retinal detachment and intraocular mass. The left eye was normal. Ancillary testing ruled out tuberculosis, syphilis, toxoplasmosis, sarcoidosis, and HIV. Initial management with intensive topical administration of corticosteroids and homatropine quickly resolved the anterior segment inflammation; however, the posterior segment inflammation slowly progressed despite an injection of triamcinolone acetonide 40 mg into the subTenon’s space. The patient then underwent a diagnostic

Macular choroidal osteoma with progressive widespread outer-retinal dysfunction

Typically, choroidal osteoma is a unilateral, juxtapapillary tumour found in women in their second or third decades. Patients can present with metamorphopsia, blurred vision, and visual field defects, butmost are asymptomatic. Gradual visual loss is typically associated with degeneration of the overlying retinal pigment epithelium (RPE). Acute visual loss and (or) metamorphopsia is typically associated with hemorrhagic subretinal fluid accumulation from an associated choroidal neovascular membrane. A 49-year-old male was referred to a tertiary care centre with decreased visual acuity OS and enlargement of an abnormal area of RPE that had been diagnosed as central serous retinopathy 17 years earlier. Best-corrected visual acuity was 6/6 OD and 6/9-2 OS. A slightly elevated, depigmented area was observed superior to the macula (Fig. 1). A subretinal mass extending from the optic nerve head to the foveal avascular zone was identified on optical coherence tomography. CT scan (Fig. 2) revealed a small focal area of calcification involving the submacular choroid, which was corroborated by B-scan. A fluorescein angiogram demonstrated early hyperfluorescence with late staining (Fig. 1). On Goldmann visual field examination, there was a relative scotoma in the right nasal hemifield of the left eye. Microperimetry demonstrated a larger lesion than seen with fundus photography and intravenous fluorescein angiography (Fig. 3). The patient was evaluated at an ocular oncology centre, and the diagnosis of choroidal osteoma was confirmed. The recent decrease in OS visual acuity was presumed to be a result of the mass impinging upon the fovea, and various treatment options were considered. Radiation therapy might have resulted in significant radiation retinopathy and, similarly, transpupillary thermotherapy might have caused further central vision loss. Multifocal electroretinography was performed (Fig. 3). Regional retinal responses within the area overlying the lesion were found to be of similar amplitude when compared with responses within an area of equal eccentricity but without underlying pathology. This was in contrast with the decline in visual acuity and deficits on perimetry testing. Choroidal osteoma is a rare ocular tumour of unknown etiology. Cases of choroidal osteoma in males and children are very rare. Several theories of the pathogenesis have been proposed, including inflammatory, hereditary, and congenital theories. This patient’s history of serous chorioretinopathy may represent a precursor or an early manifestation of the osteoma lesion. This report is the first to illustrate multifocal electroretinography responses overlying a choroidal osteoma. The normal responses suggest that the reduction in visual acuity may be due to the distortion of the retina as opposed to damage of the retina nerve fibre layer. Choroidal osteomas commonly become bilateral, highlighting the need for frequent fluorescein angiography in order to detect any new lesions in the perifoveal region bilaterally. Early detection may allow for the use of a prophylactic barrier line of laser treatment to the advancing edge, which may preserve vision. We continue to follow

Silicone oil sequestration under epiretinal membrane.

Silicone Oil Sequestration Under Epiretinal Membrane A 61-year old woman presented with a history of slow deterioration and fluctuating vision in her right eye 14 years after undergoing combined scleral buckle and pars plana vitrectomy with silicone oil for repair of a macular-off retinal detachment. The silicone oil had been removed 6 months after the initial vitrectomy. Visual acuity was 6/24 in the right eye with significant metamorphopsia. Clinical examination revealed the epiretinal membrane with sequestration of preretinal silicone oil bubbles under the membrane (Figure 1). These bubbles were overlying much of the central macula and were mobile in a positiondependent manner, similar to the inverse hypopyon appearance that may be seen with anterior chamber silicone oil emulsification. Of note, the distribution of silicone oil bubbles spared the fovea likely because of a stronger adherence of the epiretinal membrane to the fovea than to the surrounding macula. Spectral domain optical coherence tomography imaging confirmed the presence of mobile silicone oil bubbles trapped under the epiretinal membrane (Figure 2A). This was treated with pars plana vitrectomy and membrane peeling (see Video, Supplemental Digital Content 1, http://links.lww.com/IAE/A167). As the membrane was retracted with forceps, many of the trapped silicone oil bubbles were liberated and dispersed (Figure 3). Postoperative optical coherence tomography revealed complete removal of the epiretinal membrane and the oil (Figure 2B). Histopathologic analysis of the epiretinal membrane revealed the presence of multiple multinucleated giant cells, as well as internal limiting

Anatomic Distribution of Gadolinium Contrast Medium by High-Resolution Magnetic Resonance Imaging After Peribulbar and Retrobulbar Injections

OBJECTIVE To examine the anatomic distribution of gadolinium contrast medium by high-resolution surface-coil magnetic resonance imaging after peribulbar and retrobulbar injection. METHODS Comparative case series in which 4 healthy volunteers were randomized to peribulbar (n = 2) or retrobulbar (n = 2) injection of gadolinium and lidocaine hydrochloride, 2%, without epinephrine. Magnetic resonance imaging was performed before injection and at 5 minutes and 90 minutes after injection. RESULTS The peribulbar injection technique resulted in contrast medium primarily in the extraconal space, with no gadolinium observed at the orbital apex; surprisingly, a small amount of contrast medium was observed in the pterygopalatine fossa immediately after peribulbar injection. The retrobulbar injection technique resulted in gadolinium signal diffusely enhancing the intraconal space, orbital apex, optic nerve sheath, and optic canal. The signal intensity was clearly observed in the cavernous sinus surrounding the cavernous portion of the internal carotid artery. A small amount of contrast medium was detected in the pterygopalatine fossa. CONCLUSIONS The retrobulbar injection technique localizes to the intraconal space, with access to intracranial and central nervous system structures via the optic canal, superior orbital fissure, and cavernous sinus. In contrast, the peribulbar injection technique produces a mostly extraconal distribution; however, intraconal solution may communicate with the central nervous system via the inferior orbital fissure and pterygopalatine fossa. This novel finding suggests that peribulbar anesthesia has a readily accessible route for central nervous system toxic effects. Magnetic resonance imaging with gadolinium contrast medium administration provides an important methodological advantage over previously described techniques and is a safe, reproducible, and superior method of orbital imaging.

Resolution of subretinal fluid associated with a spontaneous retinal pigment epithelial tear after intravitreal ranibizumab injection.

Rips or tears in the retinal pigment epithelium (RPE) can occur spontaneously in neovascular age-related macular degeneration (AMD), usually in the setting of pigment epithelium detachment (PED). RPE tears have been reported after photodynamic therapy and after intravitreal injection of anti–vascular endothelial growth factor (antiVEGF) agents such as ranibizumab. We report a case of a patient with neovascular AMD-related PED who had developed a spontaneous RPE tear prior to any treatment. The subretinal fluid resolved and the visual acuity improved 4 Snellen lines after 3 intravitreal injections of ranibizumab. An 82-year-old woman with a history of AMD and bilateral pseudophakia presented with a 3-week history of sudden onset of metamorphopsia and decreased visual acuity in the right eye. At presentation, her visual acuity was 6/60 and fundus examination revealed an RPE tear with serous retinal detachment, which was confirmed by intravenous fluorescein angiogram (IVFA) and optical coherence tomography (Figs. 1 and 2). The patient consented to receive treatment with 3 monthly intravitreal injections of ranibizumab, which began 2 days later. She reported a subjective improvement in her visual acuity approximately 1 week after her first injection. Her visual acuity improved to 6/21 and 6/15 after the first and second injections, respectively. IVFA and optical coherence tomography done 1 month after her last treatment showed resolution of her subretinal fluid and a decrease in her macular thickness (Figs. 1 and 2). Overall, her visual acuity improved from 6/60 pretreatment to 6/15 posttreatment. No other interventions were performed and there was no history of prior treatment for AMD. The prevalence of spontaneous RPE tear following PED was conservatively estimated to be 10% in a retrospective study of 64 patients. All of these tears occurred within a few months of initial presentation for PED. Patients commonly complain of sudden vision loss and distortion. RPE tears involving the fovea have a poor visual prognosis, with most patients having visual acuity of 20/200 or less. Currently, there are few treatment options for RPE tears. One prospective study followed 6 patients who underwent RPE-choroid translocation surgery for spontaneous or intravitreal injection–related RPE tears. Mean visual acuity improved from 6/48 to 6/24, with follow-up ranging from 6 months to 2 years. One case report showed improvement of visual acuity from 6/60 to 6/12 with continued anti-VEGF treatment even after an injectioninduced tear. Studies have shown the benefits of treating neovascular AMD with intravitreal ranibizumab, but many