Jeffrey L. Marx

Homocysteine: A Risk Factor for Retinal Venous Occlusive Disease

PURPOSE Recent studies have shown a relationship between elevated levels of homocysteine and vascular disease including cerebrovascular accidents and myocardial infarctions. We evaluated patients with a recent retinal vein occlusion to determine if there was an associated elevation of homocysteine. DESIGN Age and gender matched case-controlled study. PARTICIPANTS Twenty patients with retinal venous occlusive disease within the previous 6-month period and 40 control patients without retinal venous occlusive disease were enrolled in the study. METHODS Twenty patients with a history of retinal vein occlusion underwent laboratory testing to determine serum homocysteine levels. In addition, a health survey was completed and several laboratory tests relating to vascular disease including cholesterol were checked. Two control groups were selected. The first group included patients with diabetes and no history of retinal vascular occlusive disease. The second control group included nondiabetic patients who also had no prior history of retinal vascular occlusive disease. MAIN OUTCOME MEASURES The main parameter measured in this study is fasting homocysteine. RESULTS Fifteen of 20 patients (75%) with retinal vein occlusion disease had an elevated fasting serum homocysteine level, whereas only 5 of 40 control patients (13%) had an abnormal homocysteine level (P < 0.0005). CONCLUSIONS Patients with retinal venous occlusive disease have higher levels of homocysteine, which may serve as a modifiable risk factor.

Ocular injuries from paintball pellets.

OBJECTIVE To evaluate the ocular effects of blunt trauma due to injury from a paintball pellet. DESIGN Noncomparative case series. PARTICIPANTS Thirteen patients who suffered ocular injury from paintballs are described. The patients presented to six different civilian and military emergency departments in tertiary care medical centers. INTERVENTION Patients were treated for the ocular injury. MAIN OUTCOME MEASURES Patients were evaluated for initial and final visual acuity. The reason for persistent loss of vision was delineated. RESULTS There were 12 males and 1 female with an average age of 21 years (range, 12-33 years). Eleven of the 13 had no ocular protection at the time of the ocular injury. On initial examination, nine patients had a hyphema, nine had a vitreous hemorrhage, six had a retinal tear or detachment, three had corneal or corneal-scleral ruptures, and one had traumatic optic neuropathy. The final visual acuity was 20/40 or better in two patients, 20/50 to 20/150 in three patients, and 20/200 or worse in eight patients. CONCLUSION Injuries due to paintball pellets can result in severe ocular damage and significant loss of vision. Eyecare professionals should be aware of the risks of this sport and must strongly advise participants to wear adequate protection when involved in this activity.

Randomized trial of anesthetic methods for intravitreal injections.

Purpose: To compare the effectiveness of four different anesthetic methods for intravitreal injection. Methods: Twenty-four patients each received four intravitreal injections using each of four types of anesthesia (proparacaine, tetracaine, lidocaine pledget, and subconjunctival injection of lidocaine) in a prospective, masked, randomized block design. Pain was graded by the patient on a 0 to 10 scale for both the anesthesia and the injection. Results: The average combined pain scores for both the anesthesia and the intravitreal injection were 4.4 for the lidocaine pledget, 3.5 for topical proparacaine, 3.8 for the subconjunctival lidocaine injection, and 4.1 for topical tetracaine. The differences were not significant (P = 0.65). There were also no statistical differences in the individual anesthesia or injection pain scores. Subconjunctival lidocaine injection had the most side effects. Conclusion: Topical anesthesia is an effective method for limiting pain associated with intravitreal injections.

Humphrey visual field findings in hydroxychloroquine toxicity

PurposeTo analyze Humphrey visual field (HVF) findings in hydroxychloroquine (HCQ) retinal toxicity.MethodsHVF tests were interpreted retrospectively in this observational case series of 15 patients with HCQ toxicity. Patients seen at Lahey Clinic were identified by diagnosis coding search. Patients with age-related macular degeneration or glaucoma with visual field loss were excluded. HVFs done before the diagnosis were analyzed to see if earlier diagnosis could have been possible.ResultsA total of 66 HVFs were reviewed and categorized. Some abnormalities were subtle. Paracentral defects were seen on 10-2 tests whereas 24-2 tests, due to their compressed scale, showed central changes. The abnormalities were often more obvious on pattern deviation rather than the gray scale. Of those patients with prior HVFs available for review, 50% showed HVF abnormalities typical of HCQ toxicity present several months or years before diagnosis. HVF changes preceded fundus changes in nine patients.ConclusionHVF abnormalities indicating HCQ toxicity vary depending on the specific HVF test performed. Clinicians need to be aware of the subtle nature of HVF changes in early toxicity.

Intravascular Lymphoma Masquerading as Vogt-Koyanagi-Harada Syndrome

Purpose: To describe the clinical course of a case of intravascular lymphoma. Design: Case report. Methods: Retrospective chart review. Results: A 56-year-old man presented with blurry vision associated with fever and decreased hearing. Ocular exam including fluorescein angiography and OCT was consistent with Vogt-Koyanagi-Harada syndrome and the patient initially improved with corticosteroids. Clinical deterioration led to further systemic workup and revealed intravascular lymphoma. The patient was started on chemotherapy with resolution of visual complaints. Conclusions: Intravascular lymphoma can present as a masquerade of VKH syndrome. Diagnosis can be aided with measurement of LDH and skin biopsy.

Anatomic and Visual Outcomes of Noninfectious Endophthalmitis after Intravitreal Triamcinolone

PURPOSE To describe the anatomic and visual outcomes of patients in whom noninfectious endophthalmitis developed after injection of intravitreal triamcinolone acetonide. DESIGN Retrospective case series. METHODS Ophthalmologic evaluations of patients in whom noninfectious endophthalmitis developed after intravitreal triamcinolone took place on the day of injection, at the time of presentation of noninfectious endophthalmitis, at the time of clearance of inflammation, and on follow-up examination. Seventeen eyes of 17 patients were identified from 2 institutions. Noninfectious endophthalmitis was identified based on history of visual loss immediately or soon after injection, lack of ocular pain, hypopyon, anterior or vitreous inflammation, and triamcinolone crystals present in the anterior or posterior chambers. Main outcome measures were Snellen visual acuity (VA) and mean foveal thickness by optical coherence tomography. RESULTS Mean VA and mean foveal thickness on the day of injection of intravitreal triamcinolone were 20/132 (logarithm of the minimum angle of resolution [logMAR], 0.82 +/- 0.45) and 432 +/- 118 microm, respectively. Mean VA at time of noninfectious endophthalmitis (mean, 1.9 days after injection) was 20/4444 (logMAR, 2.35 +/- 0.98). At last follow-up (mean, 57.6 days), VA and mean foveal thickness were 20/56 (logMAR, 0.44 +/- 0.30) and 301 +/- 71 microm, respectively. CONCLUSIONS VA and mean foveal thickness in all patients with noninfectious endophthalmitis after intravitreal triamcinolone improved to better than preinjection levels in this series. At last follow-up, no patient had sustained visual loss from noninfectious endophthalmitis. Noninfectious endophthalmitis after intravitreal triamcinolone may not exclude good visual and anatomic prognoses.

Preferential Hyperacuity Perimetry to detect hydroxychloroquine retinal toxicity.

Purpose: To determine if Preferential Hyperacuity Perimetry (PHP) testing can detect the presence of retinal toxicity due to hydroxychloroquine (HCQ) or chloroquine administration. Methods: Fifteen patients were divided into three groups. Five patients had confirmed HCQ or chloroquine toxicity, five patients had suspected HCQ toxicity, and five patients had history of long-term use of HCQ or chloroquine but no evidence of toxicity. All patients underwent PHP testing. Results: All patients with either known or suspected toxicity based upon standardized visual field testing and/or fluorescein angiography demonstrated significant hyperacuity defects on PHP testing. None of the patients on long-term HCQ therapy, without clinical suspicion of toxicity, demonstrated a PHP hyperacuity defect. Conclusion: Results of this pilot study with patients with known or suspected HCQ or chloroquine toxicity suggest that PHP may be a useful adjunct for testing of patients suspicious for toxicity due to these medications. Further testing is warranted.

Ergonomics: Back to the Future

m u fi p p p m w w t The frequency of musculoskeletal disorders (MSD) has been reported in the ophthalmic literature over the last decade. Based upon different criteria, survey instruments, and populations studied, the prevalence of MSD symptoms in ophthalmologists varies. Kitzmann et al report the first study that compares MSD symptoms in ophthalmologists to family medicine doctors at 2 institutions using the same survey instrument. Ophthalmologists reported a statistically significant increased prevalence of neck, hand/wrist, and lower back pain in comparison to their family medicine doctor colleagues. Although the number of ophthalmologists surveyed was relatively low, and findings in practice settings as opposed to these 2 academic institutions may differ, the rates of symptoms among ophthalmologists were comparable to a survey done almost a decade ago in a larger cohort of subjects. In response to published reports and data from the recent American Academy of Ophthalmology (AAO) membership survey (private communication, AAO Membership Secretariat, April 2010), the AAO Board of Trustees has commissioned a task force composed of 6 ophthalmologists, a group of ergonomics specialists headed by Dr. Sandra Woolley from the Mayo Clinic, and representatives from AAO leadership. Our goals are: (1) to inform academy members about common occupational musculoskeletal disorders and how to prevent them, and (2) to develop ergonomic guidelines/standards for ophthalmic equipment and encourage their adoption by the device industry. The National Institute of Occupational Safety and Health (NIOSH) have identified 4 factors influencing the development of musculoskeletal disorders: (1) environmental hazards, (2) human biologic factors, (3) behavioral factors or unhealthy lifestyles, and (4) inadequacies in existing health care. As work-related MSDs are the result of multiple causes, only some of which may be modifiable, ergonomic intervention alone may not eliminate the risk or decrease the symptoms. However, to effectively manage these problems, it is important to understand all of the factors including age, presence of systemic disease, physiologic predisposition, work behaviors, type of job, and ergonomic design of equipment. Musculoskeletal disorders in health professionals have been extensively documented. By far the largest body of work related to MSDs and health care professionals is in the dental and laparoscopic surgery fields. While we undertake efforts in ophthalmology to identify risk factors, educate membership, and work with industry to adapt equipment, we can use the other medical specialties’ experiences to glean several relevant take home lessons for ophthalmologists and our task force. Exposure to risks for MSDs starts early and attention to ergonomic recommendations need to occur during training. Several studies have shown that dental and dental hygiene r

Effect of adjunctive diclofenac with verteporfin therapy to treat choroidal neovascularization due to age-related macular degeneration: Phase II study

Background: To determine short-term effects of topical diclofenac administered in conjunction with verteporfin therapy for predominantly classic subfoveal choroidal neovascularization (CNV) due to age-related macular degeneration (AMD). Methods: Randomized, multicenter (14), prospective, placebo-controlled, double-masked clinical trial. Patients (n = 61) were randomly assigned to treatment with diclofenac sodium ophthalmic solution 0.1% or placebo and followed for 12 weeks. Patients instilled diclofenac or placebo two drops four times daily, 2–4 days before verteporfin treatment until 2 weeks after treatment, then two drops twice daily for 10 weeks. This exploratory study was not powered to detect differences between treatment groups. Statistical analyses were conducted solely to aid interpretation of results. Results: In diclofenac-treated eyes, mean changes in visual acuity letter score from baseline in the diclofenac and placebo groups were +1.8 letters and –1.0 at week 1 (P = 0.505 between groups). Mean visual acuity letter scores decreased in both groups at all subsequent visits, with a mean change at 12 weeks of –7.4 with diclofenac and –2.6 with placebo (P = 0.213). Percentages of eyes with stable or improved vision (change ≤4 or increase ≥5 letters) were similar in the diclofenac and placebo groups at all study visits. No significant between-group differences in changes from baseline in lesion area, greatest linear dimension (GLD), fluorescein leakage, or retinal thickness were detected. Conclusion: In patients with predominantly classic subfoveal CNV due to AMD, administration of topical diclofenac with verteporfin therapy was associated with similar vision outcomes to placebo plus verteporfin therapy.

Changes in flare after intravitreal injection of three different anti-vascular endothelial growth factor medications.

Purpose: To compare the change in anterior chamber flare after intravitreal injection of the anti-vascular endothelial growth factor agents bevacizumab, aflibercept, and ranibizumab. Methods: Sixty-one eyes of 53 patients underwent intravitreal injection with anti-vascular endothelial growth factor medications for exudative age-related macular degeneration, diabetic macular edema, or retinal vein occlusion. There were a total of 26 eyes injected with bevacizumab, 14 eyes injected with aflibercept, and 21 eyes injected with ranibizumab. Anterior segment flare was measured with a laser flare meter (Kowa) before intravitreal injection and 1 day after injection. The change in flare was analyzed. Results: The mean change in flare after 1 day was +2.5 photons per millisecond in patients who received bevacizumab, 0.0 photons per millisecond for aflibercept, and −0.2 photons per millisecond for ranibizumab. There was a statistically significant difference between the 3 medications (P = 0.006). Pairwise analysis of the change in flare showed a statistically significant difference between bevacizumab and ranibizumab (P = 0.002). The change in flare in patients who received aflibercept was not different from that in those who received bevacizumab (P = 0.08) or ranibizumab (P = 0.99). Conclusion: There was a statistically significant increase in flare after bevacizumab injection compared with ranibizumab. This difference was small and is not believed to be clinically significant. There was no statistical difference in the change in flare between aflibercept and the other medications, although the number of eyes in the aflibercept group was small.