Jochen Hayler

Intravitreal injection of crystalline cortisone as adjunctive treatment of proliferative vitreoretinopathy

AIM To report on clinical outcome and complications of intravitreal injection of crystalline cortisone in patients undergoing pars plana vitrectomy for treatment of proliferative vitreoretinopathy. METHODS The study included all 16 patients who underwent pars plana vitrectomy for treatment of proliferative vitreoretinopathy, who received an intravitreal injection of 10–20 mg crystalline triamcinolone acetonide at the end of surgery, and who were operated on by the same surgeon. Most of the vehicle of the solution containing the cortisone crystals was removed before performing the injection. Mean follow up time was 1.64 (SD 2.15) months (median 1.23 months; range 0.20–9.20 months). The study group was compared with a control group which consisted of 144 patients undergoing pars plana vitrectomy for proliferative vitreoretinopathy performed by the same surgeon. RESULTS In the study group compared with the control group, intraocular inflammation, as estimated clinically by slit lamp biomicroscopy, was lower, appearance of the fundus upon ophthalmoscopy in the first postoperative week was clearer, and postoperative pain in the first two postoperative days was reduced. Intraocular pressure measured at the end of the first postoperative week did not vary significantly between the groups. A pseudohypopyon consisting of cortisone crystals in the inferior anterior chamber angle was detected in one patient. Postoperative infectious endophthalmitis was not encountered. CONCLUSIONS This pilot study suggests that intravitreal injection of crystalline cortisone with most of the vehicle removed is not toxic to intraocular structures, reduces postoperative intraocular inflammation, and may be a potentially useful additional tool in the treatment of proliferative vitreoretinopathy.

Intravitreal injection of crystalline cortisone as adjunctive treatment of proliferative diabetic retinopathy.

PURPOSE To report the clinical outcome and complications of intravitreal injections of crystalline cortisone in patients undergoing pars plana vitrectomy for treatment of proliferative diabetic retinopathy. METHODS The prospective, interventional case series study included 29 consecutive patients (29 eyes) who underwent pars plana vitrectomy for treatment of complicated proliferative diabetic retinopathy associated with central retinal traction detachment. All patients received an intravitreal injection of 15 to 20 mg of crystalline triamcinolone acetonide at the end of surgery, and were operated on by the same surgeon. Mean follow-up time was 1.4 +/- 1.1 months (median, 1 month; range, 0.30 to 4.9 months). RESULTS At the end of the follow-up period, the retina was attached in 26 of the 29 patients (89.7%). In three of the 29 patients (10.3%), a retinal redetachment had occurred. None of the patients developed iris neovascularization, and the iris neovascularization, present preoperatively in 12 patients, slightly to markedly regressed in all 12 patients. Preoperative and postoperative intraocular pressure values (P =.72) and blood glucose measurements did not vary significantly. A pseudohypopyon consisting of cortisone crystals in the inferior anterior chamber angle was detected in one patient and resolved spontaneously within 4 days. CONCLUSIONS The present clinical study suggests that intravitreal injection of crystalline cortisone with most of the vehicle removed seems to be well tolerated by eyes undergoing pars plana vitrectomy for treatment of complicated diabetic proliferative retinopathy. In view of the antiphlogistic and antiproliferative effect of cortisone, future randomized clinical trials may be indicated to investigate further the role of intravitreal injection of crystalline cortisone in the treatment of proliferative diabetic retinopathy.

Regression of neovascular iris vessels by intravitreal injection of crystalline cortisone.

PurposeTo report the clinical outcome of patients who received an intravitreal injection of crystalline triamcinolone acetonide as treatment of neovascular glaucoma. Patients and MethodsThe study included 14 eyes of 14 patients with secondary neovascular glaucoma attributable to proliferative diabetic retinopathy (n = 9) or ischemic central retinal vein occlusion (n = 5). All patients received an intravitreal injection of 20 mg of crystalline triamcinolone acetonide as the only procedure (n = 4) or in combination with additional procedures, such as goniosynechiolysis (n = 1), phacoemulsification and intraocular lens implantation (n = 2), or transscleral peripheral retinal cryocoagulation (n = 7). Mean follow-up time was 3.10 ± 2.40 months (median, 3.5 months; range, 0.50–5.7 months). A goniosynechiolysis was carried out in those patients in whom the anterior chamber was circumferentially closed. ResultsAfter surgery, including the first days after surgery, the patients were nearly pain-free. Intraocular pressure was significantly (P <0.01) reduced from 33.4 ± 14.5 mm Hg before surgery to 20.7 ± 8.2 mm Hg at the end of the follow-up period. Postoperative visual acuity (mean, 0.09 ± 0.07; median, 0.10; range, finger counting to 0.25) was slightly but not significantly (P = 0.31) better than the preoperative values. Degree of rubeosis iridis decreased significantly (P = 0.02) from 2.6 ± 1.3 relative units to 1.3 ± 1.2 relative units. When considering only the four patients for whom the intraocular cortisone injection was the only procedure performed, mean intraocular pressure decreased from 26.5 ± 12.1 mm Hg to 21.75 ± 11.3 mm Hg. ConclusionsIntravitreal injection of crystalline cortisone with most of the vehicle removed may be a potentially useful additional tool in the treatment of neovascular glaucoma.

Central retinal vessel trunk exit and location of glaucomatous parapapillary atrophy in glaucoma1

OBJECTIVE To evaluate whether the position of the central retinal vessel trunk exit on the lamina cribrosa spatially correlates with the location of parapapillary atrophy in glaucoma. DESIGN Clinic-based, observational, cross-sectional study. PATIENTS Color stereo optic disc photographs of 95 patients with primary or secondary open-angle glaucoma and 65 healthy persons were morphometrically evaluated. The intrapapillary and parapapillary region was divided into four quadrants. We determined the position of the central retinal vessel trunk exit on the lamina cribrosa surface and measured the area of parapapillary atrophy and neuroretinal rim in the four quadrants. MAIN OUTCOME MEASURES The area of neuroretinal rim and parapapillary atrophy and the position of the central retinal vessel trunk exit. RESULTS Comparing measurements between opposite disc quadrants showed that beta zone of parapapillary atrophy was significantly (P < 0.05) larger and that the neuroretinal rim was significantly smaller when beta zone and neuroretinal rim were measured in the disc quadrant most distant to the central retinal vessel trunk exit, than if the beta zone and neuroretinal rim were measured in the quadrant containing the vessel trunk exit. Comparing measurements in the disc quadrants between eyes with different positions of the central retinal vessel trunk exit revealed that, in the respective disc quadrant, the beta zone was significantly larger and the neuroretinal rim was smaller in eyes with the vessel trunk exiting in the opposite disc quadrant than in eyes with the vessel trunk exit located in the respective disc quadrant where the measurements were obtained. CONCLUSIONS Position of the central retinal vessel trunk exit on the lamina cribrosa influences the location of parapapillary atrophy in glaucoma. The longer the distance to the central retinal vessel trunk exit, the more enlarged is parapapillary atrophy and the smaller is the neuroretinal rim. This relationship agrees with the spatial relationship between glaucomatous neuroretinal rim loss and enlarged parapapillary atrophy in glaucoma. Diagnostically, it may indicate that, in eyes with an abnormal configuration of parapapillary atrophy or with an abnormal position of the central retinal vessel trunk exit, early glaucomatous rim changes should be looked for in the disc sector that is most distant to the central retinal vessel trunk exit and where parapapillary atrophy may be relatively large.

Discriminant analysis formulas of optic nerve head parameters measured by confocal scanning laser tomography.

PurposeTo evaluate whether discriminant analysis formulas of optic disc variables measured by confocal laser scanning tomography can detect glaucomatous visual field defects, to compare the diagnostic precision of these formulas to detect glaucomatous visual field defects in different types of chronic open-angle glaucoma, and to assess whether gender or refractive error influence the results obtained by the formulas. MethodsOne hundred and sixty-one patients with perimetrically defined glaucomatous optic nerve damage and 194 healthy subjects were recruited. All patients underwent confocal laser scanning tomography of the optic disc. The data were analyzed with three linear discriminant analysis formulas (sectorial, Bathija, and Mikelberg) obtained in sets of data different from those used in the present study. ResultsThe areas under the receiver-operating characteristic curves of the three formulas and of the cup shape measure as a single parameter ranged from 0.649 to 0.81 in the entire group, and the results did not change when age-matched eyes were considered (0.618–0.812). In each of the glaucoma subgroups with primary open-angle, pseudoexfoliative, and normal-pressure glaucoma, and additionally in the hyperopic, myopic, female, and male subgroups, the sectorial formula had the highest diagnostic precision and the highest correlation coefficients with the visual field indices, followed by the Bathija and Mikelberg formulas, without major differences between the subgroups. All three formulas were more effective than the cup shape measure as a single parameter. ConclusionIn the various chronic open-angle glaucomas, the sectorial and Bathija formulas tended to have higher diagnostic precision than the Mikelberg formula and the cup shape measure. Gender and refractive error do not markedly influence the diagnostic precision of the formulas tested. The scores of the formulas are mild indicators of the amount of glaucomatous visual field loss. All three formulas are superior to the single cup shape measure in the detection of glaucomatous optic nerve damage.

Intraocular pressure after homologous penetrating keratoplasty.

PurposeTo evaluate intraocular pressure (IOP) changes after homologous central penetrating keratoplasty in a noncomparative interventional case series. MethodsThe study included 245 patients undergoing homologous central penetrating keratoplasty for keratoconus (n = 77), herpetic corneal scars (n = 29), nonherpetic corneal scars (n = 46), Fuchs endothelial dystrophy (n = 24), and secondary corneal endothelial decompensation caused by preceding intraocular operations (n = 69). Mean follow-up time was 30.4 ± 18.7 months (range, 12.1–111.6 months). The same surgeon operated on all patients, and a peripheral iridotomy was routinely performed. ResultsOn the first postoperative day, IOP was significantly (P = 0.02) higher than that before keratoplasty. Taking the whole study group and taking the study groups separately, IOP measurements determined on the third postoperative day (P = 0.57), 1 week after surgery (P = 0.55), or later (P > 0.50) were not significantly different from the preoperative values. Eyes undergoing keratoplasty with cataract surgery and eyes undergoing keratoplasty without additional intraocular procedures did not vary significantly (P > 0.10) in IOP measurements. IOP did not differ significantly (P > 0.50) between eyes with an immunologic graft reaction (n = 29) and eyes without a reaction (n = 216). Acute angle-closure glaucoma was not detected in any of the patients. IOP measurements were statistically independent of suture type (P > 0.10), age (P > 0.05), preoperative and postoperative refractive error (P > 0.05), preoperative and postoperative corneal astigmatism (P > 0.10), preoperative and postoperative visual acuity (P > 0.10), diameter of graft and trephine (P > 0.15), and oversize of the graft (P > 0.50). Postoperative IOP measurements were significantly (P < 0.01) correlated with preoperative IOP values. ConclusionsIn eyes with a peripheral iridotomy performed during surgery, homologous central penetrating keratoplasty usually does not markedly change IOP. The main risk factor for postoperatively increased IOP is increased IOP before surgery.