Jonathan L. Prenner

Congenital X-linked retinoschisis classification system.

Purpose: To establish a classification system for congenital X-linked retinoschisis (CXLRS) using clinical examination and optical coherence tomography (OCT). Methods: Thirty-eight eyes of 19 patients who carried a clinical diagnosis of CXLRS were examined with OCT and clinical examination. Eyes were classified into one of four types based on a combination of clinical examination and OCT. Results: All patients had bilateral OCT scanning performed at an average age of 8.64 years (range 2.24–17.4 years). Review of OCT scans revealed that 37 of 38 eyes had foveal schisis (97%) while 31 of 38 (82%) eyes had macular schisis deeper than the nerve fiber layer in areas of ophthalmoscopically normal macular retina. The authors termed this flat schisis phenomenon lamellar schisis. Thirty of 38 (79%) had peripheral bullous schisis cavities present. Conclusions: OCT examinations of patients with CXLRS reveal lamellar schisis in areas of ophthalmoscopically normal macular retina in 82% of eyes with the clinical diagnosis of CXLRS. Using both clinical examination and OCT, the authors were able to identify foveal, lamellar, and peripheral schisis, lamellar schisis only identifiable by OCT. These findings allow the authors to propose a classification system. The authors hope this classification system will allow a better understanding of the natural history of CXLRS disease and allow testing of therapeutic options.

Long-term incidence and timing of intraocular hypertension after intravitreal triamcinolone acetonide injection.

PURPOSE To describe the long-term incidence and timing of steroid-induced ocular hypertension after intravitreal triamcinolone acetonide (IVTA) therapy. DESIGN Retrospective case series of 929 eyes of 841 patients. PARTICIPANTS Patients with a variety of posterior segment disorders in a single group practice. INTERVENTION Pars plana injection of IVTA. MAIN OUTCOME MEASURES Intraocular pressure (IOP) and requirement for glaucoma surgery. RESULTS Overall, 929 eyes received >or=1 injections (mean, 1.6) of 4 mg of IVTA. During a mean follow-up period of 14+/-6.9 months, the Kaplan-Meier cumulative incidences of IOP elevations >21 mmHg at 6, 12, 18, and 24 months post-injection were 28.2%, 34.6%, 41.2%, and 44.6%, respectively; similarly, the incidences of eyes with IOP measurements >25 mmHg were 14.6%, 19.1%, 24.1%, and 28.2%, respectively. At the same time points, IOP-lowering medications were required by 13.0%, 16.9%, 20.7%, and 24.2% of eyes, respectively. Only 3 eyes (0.3%) required IOP-lowering surgery. Preexisting glaucoma, younger age, and a history of an IOP elevation after a previous IVTA injection were risk factors for IOP elevations after IVTA injection. The minimum and maximum follow-up were 3 weeks and 37 months. The mean rate of attrition in this study was 3% per month. CONCLUSIONS Elevations in IOP after IVTA injection are common. Younger patients and eyes with preexisting glaucoma or a history of a steroid response should be monitored more closely for IOP elevations after IVTA therapy.

Postinjection Endophthalmitis in the Comparison of Age-Related Macular Degeneration Treatments Trials (CATT)

OBJECTIVE To describe the incidence and outcomes of endophthalmitis after intravitreal injections of anti-vascular endothelial growth factor agents in the Comparison of Age-Related Macular Degeneration Treatments Trials (CATT) and to assess the effect of prophylactic topical antimicrobials on incidence. DESIGN Cohort study within a randomized clinical trial. PARTICIPANTS Patients enrolled in CATT. METHODS Patients with neovascular age-related macular degeneration received intravitreal injections of ranibizumab or bevacizumab under 1 of 3 dosing regimens. The study protocol specified preinjection preparation to include use of a sterile lid speculum and povidone iodine (5%). Use of preinjection and postinjection antibiotics was at the discretion of the treating ophthalmologist. Patients were followed up monthly for 2 years. MAIN OUTCOME MEASURES Development of endophthalmitis and visual acuity. RESULTS Endophthalmitis developed after 11 of 18 509 injections (1 per 1700 [0.06%]; 95% confidence interval, 0.03%-0.11%), and in 11 of 1185 patients (0.93%; 95% confidence interval, 0.52-1.66). Incidence of endophthalmitis was 0.15% among injections with no antibiotic use, 0.08% among injections with preinjection antibiotics only, 0.06% among injections with postinjection antibiotics only, and 0.04% among injections with preinjection and postinjection antibiotics (P = 0.20). All eyes were treated with intravitreal antibiotics and 4 underwent vitrectomy. Among the 11 affected eyes, the final study visual acuity was 20/40 or better in 4 eyes (36%), 20/50 to 20/80 in 2 eyes (18%), 20/100 to 20/160 in 3 eyes (27%), and worse than 20/800 in 2 eyes (18%). The final visual acuity was within 2 lines of the visual acuity before endophthalmitis in 5 eyes (45%). CONCLUSIONS Rates of endophthalmitis were low and similar to those in other large-scale studies. Use of topical antibiotics either before or after injection does not seem to reduce the risk for endophthalmitis.

A novel approach for posterior chamber intraocular lens placement or rescue via a sutureless scleral fixation technique.

The approach to intraocular lens (IOL) implantation in an eye with insufficient capsular support continues to present a unique surgical challenge. A report from the American Academy of Ophthalmology Ophthalmic Technology Assessment group reviewed the standard approaches to this surgical problem (anterior chamber IOL, scleral sutured posterior chamber IOL [PCIOL], and iris fixated PCIOL) and did not identify compelling data to recommend one technique over another. However, each approach has well-known liabilities. Anterior chamber IOL placement may increase the risk of developing glaucoma, intraocular inflammation, and corneal decompensation. Suture degradation and breakage with subsequent IOL dislocation may occur in cases of suture fixation to both the iris and the sclera. In an effort to create a minimally invasive approach that could improve surgical outcomes, we developed a technique that allows for ciliary sulcus–based scleral fixation of a PCIOL without the use of sutures scleral flaps or fibrin glue. This approach may modify the incidence of complications secondary to anterior chamber IOL placement and the risk of IOL malposition secondary to suture rupture. We significantly modified an anterior segment technique in a manner that takes advantage of the surgical instrumentation and skill set of the posterior segment surgeon. Through these modifications, we have been able to achieve a reliable and reproducible surgical procedure that can be performed both for the rescue of a dislocated IOL and for the implantation of a secondary IOL. The technique allows for permanent scleral fixation of the polypropylene haptics of a three-piece IOL directly into the sclera, thus obviating the need for suturing and achieving a position in the ciliary sulcus.

Risk factors for choroidal neovascularization and vision loss in the fellow eye study of CNVPT.

Purpose: To identify risk factors for the development of choroidal neovascularization (CNV) and vision loss in the Fellow Eye Study of the Choroidal Neovascularization Prevention Trial. Methods: Retrospective review of 121 patients enrolled in a multicentered, randomized, controlled trial. Patients had neovascular age‐related macular degeneration in one eye and more than 10 large drusen in the other eye. Records of patients randomly assigned to laser treatment or observation were reviewed through 4 years of follow‐up. Three candidate risk factors for the development of CNV and vision loss were evaluated. Results: Eyes with hyperfluorescent drusen on fluorescein angiography at 3 minutes appeared to have a decreased risk of CNV. Patchy choroidal filling was seen in 14% of patients. Eyes with patchy choroidal perfusion showed a higher risk of developing CNV that was not statistically significant, and the increased risk was present only in treated eyes. Reticular pseudodrusen were present in only three eyes. Conclusions: Reticular pseudodrusen were rare. Late drusen fluorescence may protect against the development of CNV.

Current visual and anatomic outcomes of pneumatic retinopexy.

Purpose: To assess current visual and anatomic outcomes of pneumatic retinopexy (PR) for the repair of rhegmatogenous retinal detachment (RD). Methods: Retrospective chart review of 150 patients who underwent PR for RD between January 2000 and February 2005. Patients with a history of scleral buckling, Lincoff balloon, or proliferative diabetic retinopathy in the same eye were excluded. Results: Successful reattachment was achieved in 76.7% with a single procedure and 98.7% after additional procedures. A total of 17.3% underwent a subsequent procedure for a new or persistent tear. The success rate remained consistent in pseudophakic and aphakic eyes, and eyes with traumatic detachments, macular detachment, multiple breaks, poor preoperative visual acuity (VA) (<20/50), superior and inferior lattice degeneration, ≥6 clock hours of detachment, and prior pars plana vitrectomy. A total of 2.7% of eyes underwent a second additional procedure for RD. A total of 32% of males versus 15.3% of females underwent an additional procedure for RD (P = 0.07). Final VA ≥20/50 was achieved in 80.8% of macula-on and 73.6% of macula-off RDs. Of eyes that underwent an additional procedure, final VA ≥20/50 was achieved in 63.2% of macula-on and 43.8% of macula-off RDs, and those with macula-on RD lost a mean of 1.79 (±4.9) lines of Snellen VA, while those with macula-off RD gained a mean of 5.6 (±4.6) lines (P = 0.00006). Conclusions: PR had a high anatomic success rate in eyes with a wide variety of complicated RDs. Male sex may be a risk factor for failed PR. Careful monitoring and treatment of postoperative tears is important in preventing redetachment.

Short-term effectiveness of intravitreal bevacizumab versus ranibizumab injections for patients with neovascular age-related macular degeneration.

Purpose: To compare the effectiveness of three consecutive intravitreal injections of bevacizumab (Avastin) and ranibizumab (Lucentis) in patients with treatment-naïve neovascular age-related macular degeneration. Methods: This is a retrospective comparative study of qualifying consecutively treated patients (n = 176) with new-onset subfoveal choroidal neovascularization presenting at 6 retina referral centers. Patients were treated with 3 consecutive monthly injections of ranibizumab (0.5 mg) or 3 injections of bevacizumab every 6 weeks (1.25 mg) as determined by physician and patient preference. Ophthalmologic evaluations included monthly visual acuity measurements, ocular examinations, and optical coherence tomography imaging at each visit. Results: A 29.2% reduction in the mean central foveal thickness measurement through optical coherence tomography was found in the ranibizumab-treated patients versus a 20.9% reduction in the bevacizumab-treated patients (P ≤ 0.02). Fifty-three percent of ranibizumab-treated patients had returned to a central foveal thickness of <200 μm by the completion of 3 injections compared with 35% of patients treated with bevacizumab (P ≤ 0.07). No ocular or systemic adverse events were reported in either group. Conclusion: Short-term effectiveness of ranibizumab treatment, as measured by incremental improvement in optical coherence tomography parameters, was significantly greater than bevacizumab treatment, suggesting that there is a difference in the biologic activities of ranibizumab and bevacizumab.

Intravitreal Triamcinolone Acetonide Injections in the Treatment of Retinal Vein Occlusions

BACKGROUND AND OBJECTIVE To report the visual acuity response after intravitreal triamcinolone injection in patients with macular edema due to retinal vein occlusions. PATIENTS AND METHODS Retrospective nonrandomized interventional series of 172 consecutive patients with macular edema due to retinal vein occlusions who were treated with intravitreal triamcinolone acetonide injection. Patients underwent Snellen visual acuity testing and ophthalmoscopic examination at baseline and 1, 3, 6, and 12 months after intravitreal triamcinolone acetonide injection. RESULTS All subtypes of retinal vein occlusions showed significant improvements in mean visual acuity 1 month after injection. This improvement in visual acuity was maintained over the 12-month period for all but the central retinal vein occlusion group. Seventy-one (41.3%) of the 172 patients received more than one intravitreal triamcinolone injection for unresolved or recurrent macular edema. CONCLUSION This study demonstrates a benefit associated with intravitreal triamcinolone acetonide injection for retinal vein occlusions that was maintained by patients with branch retinal vein occlusions and hemiretinal vein occlusions over a 12-month period. Visual acuity improvement was not maintained in patients with central retinal vein occlusions with this course of treatment.

One-year outcomes of eyes treated with a sutureless scleral fixation technique for intraocular lens placement or rescue.

Purpose: To report the 1 year results of a novel surgical technique for sutureless scleral fixation of a 3-piece intraocular lens. Methods: Retrospective consecutive series of patients who underwent sutureless scleral fixation of a three-piece intraocular lens. All patients were required to have at least 1 year of follow-up to be included in the series. Outcomes data were obtained and treated with simple statistical analyses. Results: A total of 24 patients were included in the study population. The average age was 75 years (range, 44–87). Short-term complications were few and included vitreous hemorrhage (n = 2), elevated intraocular pressure (n = 1), and hypotony (n = 1). Long-term complications included intraocular lens dislocation (n = 3) and cystoid macular edema (n = 1). Mean visual acuity improved from logMAR 1.30 (Snellen 20/399) to 0.52 (Snellen 20/66) at 1 year. Conclusion: This novel technique for sutureless scleral fixation of a three-piece intraocular lens was well-tolerated 1 year after surgery.

The Microsurgical Safety Task Force: Evolving Guidelines for Minimizing the Risk of Endophthalmitis Associated With Microincisional Vitrectomy Surgery

The Microsurgical Safety Task Force: Evolving Guidelines for Minimizing the Risk of Endophthalmitis Associated With Microincisional Vitrectomy Surgery V itrectomy surgery is performed 250,000 times per year in the United States and 500,000 times per year world-wide for a variety of vitreoretinal pathologic conditions. Traditionally, vitrectomy surgery has been performed with 20-gauge (20-G) instrumentation, first by creating conjunctival peritomies and then constructing 3 20-G scleral incisions through the pars plana to allow access to the vitreous cavity. The conjunctival peritomies and three sclerotomy sites are closed with sutures at the conclusion of the surgery. In contrast to 20-G surgery, 25-gauge (25-G) or 23-gauge (23-G) vitrectomy is initiated by placing 3 cannulae through the conjunctiva, sclera, and pars plana. At the conclusion of the procedure, the cannulae are removed, and because of the smaller incision size, the wounds may self-seal without sutures. The development of a 20-G microincisional cannulae system also is now being evaluated. Overall, 25-G and 23-G surgery avoids the need for conjunctival peritomies and their subsequent closure with sutures, avoids the need for sclerotomy sutures, and permits the use of smaller wounds. This, in turn, has the potential to shorten operative times, improve early postoperative visual outcomes, decrease postoperative discomfort, and hasten postoperative recovery. As with most evolutionary routes, the transition to minimally invasive vitrectomy surgery has not been an entirely smooth one. With the new techniques, a collection of new instruments and refinements in the surgical technique have arrived. Today, the popularity of 23-G and 25-G vitrectomy surgery is at its highest level yet and is still rising. During the past 5 years, there has been a rapid adaptation of microincisional vitrectomy and its usage continues to rise.1,2 In 2008, 50% of vitreous surgery incorporated the microincisional technique. According to a survey conducted by the American Society of Retina Specialists, 70% of U.S. surgeons used 25-G technology in 2007.1 In contrast, just 3 years earlier, 70% of surgeons had claimed to have never used the technique.2 The trend of increased usage and expanding indications for small-gauge vitrectomy has been associated with reports of an increased rate of postvitrectomy complications, including early postoperative hypotony, choroidal hemorrhage, and endophthalmitis.3–11 Although all postoperative complications are potentially vision threatening, endophthalmitis is the most dreaded and severe complication of any intraocular procedure and may result in severe vision loss or blindness. Because of several reports of an increased incidence of endophthalmitis with microincisional vitrectomy compared with sutured vitrectomy,7–9 a Microsurgery Safety Task Force was convened; consensus was sought among a panel of vitreoretinal surgeons experienced with both 20-G and small-gauge pars plana vitrectomy (PPV). Objective evidence was sought for all guidelines, but consensus was accepted when evidence remains incomplete. In the absence of either evidence or consensus, this study identifies the outstanding issues in need of further investigation.