Jorge A. Fortun

Initial outcomes following intravitreal ocriplasmin for treatment of symptomatic vitreomacular adhesion

BACKGROUND AND OBJECTIVE When delivered via a single intravitreal injection, ocriplasmin can effect proteolytic resolution of symptomatic vitreomacular adhesion (VMA). The authors describe their initial clinical experience with ocriplasmin at a large academic center. PATIENTS AND METHODS Retrospective review of all patients with symptomatic VMA treated with ocriplasmin from January 2013 through May 2013 at a single center. RESULTS Nineteen patients with symptomatic VMA received intravitreal ocriplasmin. Eight patients (42%) exhibited resolution of VMA. Macular holes in three of six patients (50%) closed after injection. A higher proportion of VMA resolution was observed in patients with the following baseline characteristics: age less than 65 years, focal adhesions less than or equal to 1,500 μm, presence of macular hole, phakic status, and absence of epiretinal membrane. CONCLUSION Initial clinical outcomes using ocriplasmin in this study are consistent with those reported in the phase 3 clinical trials. Improved clinical results can be achieved with careful case selection based on specific baseline characteristics.

Current Infectious Endophthalmitis Rates After Intravitreal Injections of Anti-Vascular Endothelial Growth Factor Agents and Outcomes of Treatment.

BACKGROUND AND OBJECTIVE To assess the incidence and outcomes of infectious endophthalmitis after intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) agents. PATIENTS AND METHODS Patient records at the Bascom Palmer Eye Institute (BPEI) from January 1, 2005, through December 31, 2014, were reviewed. The largest commercial claims and encounters database in the U.S. (MarketScan) was utilized to calculate the population-based endophthalmitis rate for 2011 to 2013. RESULTS The population-based rate of endophthalmitis after anti-VEGF injections for 2011 to 2013 was 391/740,757 (0.053%). BPEIs rate was 20/121,285 (0.016%) during the study period: eight after bevacizumab (0.012%), six after ranibizumab (0.018%), and six after aflibercept (0.031%) injection. Nine BPEI cases (45%) were culture-positive: Streptococcus species (5), coagulase-negative Staphylococcus (3), and non-anthracis Bacillus (1). Final visual acuity varied from 20/25 to no light perception. CONCLUSION Endophthalmitis after anti-VEGF injection was uncommon in our institution and in the population-based database. Treatment outcomes were variable but generally fared better in the culture-negative cases.

Pseudocystic Foveal Cavitation in Tamoxifen Retinopathy

PURPOSE To present 3 cases of tamoxifen-induced foveal cavitation and review previous prospective and cross-sectional studies. DESIGN Observational case series. METHODS Retrospective analysis of patients presenting to a single institution with evidence of tamoxifen-induced maculopathy. RESULTS Three patients presented with pseudocystic foveal cavitation similar in appearance to macular telangiectasia type 2 on spectral-domain optical coherence tomography (SD OCT) imaging. CONCLUSIONS Tamoxifen maculopathy is characterized by cavitation in the central macula with or without typical cystoid macular edema. Pathogenesis involves toxicity to retinal Müller cells. It can occur with low daily and cumulative doses of the drug, and in the absence of subjective visual complaints or crystalline retinopathy. Prospective research with SD OCT imaging will be required to gain a more accurate estimate of the incidence of tamoxifen retinopathy.

Optic disc pit maculopathy: A review and update on imaging and treatment

Wiethe first described optic disc pits (ODP) as part of a spectrum of congenital cavitary optic disc anomalies. They are considered by some to be a colobomatous defect of the optic nerve head. They occur in <1/ 10,000 patients and are bilateral in 10% to 15% of cases. The main complication associated with visual deterioration is optic disc pit maculopathy consisting of neurosensory macular detachments and intraretinal fluid accumulation resulting in schisis-like changes in the macula. The literature suggests that macular detachments occur in 30% to 45% of patients with congenital pit of the optic nerve. Although spontaneous reattachment has been reported, most eyes with ODPassociated macular detachment have poor visual prognosis if left to the natural course. The origin of the fluid and the exact pathophysiology remains unclear. Despite the unknown source of the fluid, imaging has allowed closer inspection and evaluation of ODP maculopathy. Given that the pathology and mechanism of ODP maculopathy is not completely understood, there have been many proposed treatments that have all varied in anatomic success and visual outcome. This article is an up-todate literature review on the (1) clinical signs and symptoms of optic disc pit maculopathy; (2) current imaging modalities and findings; (3) hypothesized source and mechanism of subretinal and intraretinal fluid accumulation; and (5) a summary of reported treatments.

Incidence of postoperative suprachoroidal hemorrhage after glaucoma filtration surgeries in the United States.

Purpose To report the 3-month incidence rates of postoperative suprachoroidal hemorrhage after glaucoma filtration surgeries and to examine the subsequent surgical treatments in these eyes. Methods This is a retrospective study using the nationally pooled, insurance claim-based MarketScan databases from the years 2007–2011. Patients with records of trabeculectomy and/or tube shunt procedures were identified, and all cases of “definite” (ie, properly coded) and “suspected” (possibly miscoded) postoperative suprachoroidal hemorrhage occurring within 3 months of their glaucoma filtration procedures were captured along with the surgical interventions used for this condition. Kaplan–Meier survival analysis was used to evaluate the 3-month incidence rates of suprachoroidal hemorrhage, and regression analysis was applied to calculate the odds ratios, confidence intervals, and P-values. Results There were 17,843 trabeculectomies and 9,597 tube shunt surgeries identified. Among these, there were 107 cases (247 including “suspected” cases) of postoperative suprachoroidal hemorrhage within 3 months of trabeculectomy and 113 cases (255 including “suspected” cases) within 3 months of tube shunt procedures. The 3-month cumulative incidence rate of postoperative suprachoroidal hemorrhage ranged from 0.6%±0.06% to 1.4%±0.09% after trabeculectomy and 1.2%±0.11% to 2.7%±0.16% after tube shunt surgery. Postoperative suprachoroidal hemorrhage was almost twice as likely to occur after tube shunt surgeries than after trabeculectomies for both “definite” and “definite” plus “suspected” cases (odds ratio, 1.98; 95% confidence interval, 1.51–2.58; P<0.001; and odds ratio, 1.95; 95% confidence interval, 1.63–2.32; P<0.001, respectively). Among the 502 “definite” and “suspected” cases of postoperative suprachoroidal hemorrhage, 32.9% (165 cases) had a treatment record of choroidal tap and 8.8% (44 cases) had a treatment record of pars plana vitrectomy. Conclusion In this sample, the 3-month cumulative incidence rate of postoperative suprachoroidal hemorrhage was 0.6%–1.4% after trabeculectomy and 1.2%–2.7% after tube shunt procedures, and the majority of the cases appeared to be managed without further surgery. Postoperative suprachoroidal hemorrhage was almost twice as likely to occur after tube shunt surgeries as after trabeculectomies.

Progression Rate From Intermediate to Advanced Age-Related Macular Degeneration Is Correlated With the Number of Risk Alleles at the CFH Locus.

Purpose Progression rate of age-related macular degeneration (AMD) varies substantially, yet its association with genetic variation has not been widely examined. Methods We tested whether progression rate from intermediate AMD to geographic atrophy (GA) or choroidal neovascularization (CNV) was correlated with genotype at seven single nucleotide polymorphisms (SNPs) in the four genes most strongly associated with risk of advanced AMD. Cox proportional hazards survival models examined the association between progression time and SNP genotype while adjusting for age and sex and accounting for variable follow-up time, right censored data, and repeated measures (left and right eyes). Results Progression rate varied with the number of risk alleles at the CFH:rs10737680 but not the CFH:rs1061170 (Y402H) SNP; individuals with two risk alleles progressed faster than those with one allele (hazard ratio [HR] = 1.61, 95% confidence interval [CI] = 1.08–2.40, P < 0.02, n = 547 eyes), although this was not significant after Bonferroni correction. This signal was likely driven by an association at the correlated protective variant, CFH:rs6677604, which tags the CFHR1-3 deletion; individuals with at least one protective allele progressed more slowly. Considering GA and CNV separately showed that the effect of CFH:rs10737680 was stronger for progression to CNV. Conclusions Results support previous findings that AMD progression rate is influenced by CFH, and suggest that variants within CFH may have different effects on risk versus progression. However, since CFH:rs10737680 was not significant after Bonferroni correction and explained only a relatively small portion of variation in progression rate beyond that explained by age, we suggest that additional factors contribute to progression.

Cataracts induced by neodymium–yttrium-aluminium-garnet laser lysis of vitreous floaters

Background Neodymium–yttrium-aluminium-garnet (Nd:YAG) laser vitreolysis has been proposed as a treatment modality for symptomatic vitreous floaters. The purpose of this paper is to report two cases of cataracts associated with posterior capsular compromise, induced by Nd:YAG laser vitreolysis for symptomatic vitreous floaters. Method Case series. Results Two patients who underwent ND:YAG laser vitreolysis for symptomatic floaters, presented with decline in visual acuity in the treated eye after the laser procedure. At the slit-lamp biomicroscope, each patient was found to have a posterior subcapsular cataract in the treated eye, with obvious loss of integrity of the posterior capsule. These two patients underwent cataract extraction by the same surgeon via phacoemulsification. Both eyes were found to have a defect in the posterior capsule intraoperatively. In both cases, a three-piece acrylic intraocular lens implant was placed in the sulcus, achieving optic capture. The best-corrected visual acuity (BCVA) was 20/20 in both patients, at 1 month following the surgery. At 2 months, one patient had a BCVA of 20/15. The second patient maintained a BCVA of 20/20 at 3 months. Conclusions Secondary cataract formation accompanied by loss of integrity of the posterior capsule is a potential complication of Nd:YAG laser vitreolysis for symptomatic floaters.

The effect of air tamponade on the ingress of ocular surface pathogens in sutureless transconjunctival microincisional vitrectomy

Purpose: To assess the effect of air versus fluid tamponade on the intraocular migration of india ink particles through nonsutured transconjunctival 23-gauge sclerotomies in living porcine eyes. Methods: Both eyes (n = 20) underwent 3-port, transconjunctival, 23-gauge vitrectomy. An angled trocar insertion technique was used in all cases. In each animal, one eye underwent a partial fluid–air exchange at the conclusion of the vitrectomy, yielding an air fill of approximately 80% (n = 10), whereas the other was left fluid filled (n = 10). After removal of the instruments and trocar cannulae, india ink was applied to the ocular surface. Animals were allowed to partially recover from anesthesia and resume normal blinking behavior. Animals were then reanesthetized, euthanized, and enucleated. Histopathologic examination was performed in a masked fashion. The presence and location of ink was noted for each identified sclerotomy. Results: Ink was identified on the ocular surface in 18 of 20 eyes. Sclerotomy wounds were identified in 16 of 20 eyes. Ink penetration was seen in 2 of 16 sclerotomy wounds, 1 in an air-filled globe and 1 in a fluid-filled globe. In both eyes, the ink was identified along the outer one third of the wound. There was no penetration of ink along the inner two thirds of the sclerotomy wound or in the posterior segment of any eyes. Conclusion: In an experimental, in vivo, porcine model, india ink migration into angled transconjunctival sclerotomy incisions was minimal, regardless of the use of an 80% fluid–air exchange at the conclusion of the case.

Ocriplasmin and its role in the management of vitreoretinal interface disorders.

The vitreous gel has an outer cortex consisting primarily of type II collagen that is attached to the internal limiting membrane (ILM) consisting primarily of type IV collagen. The vitreous plays a central role in many common and potentially blinding diseases such as diabetic retinopathy, proliferative vitreoretinopathy, and vitreomacular interface disorders; the latter will be the focus here. The development of a posterior vitreous detachment is a natural process that occurs typically after the age of 50 years. However, sometimes the posterior hyaloid face does not detach completely and there are focal areas that remain attached to the macula. This is a condition known as vitreomacular adhesion (VMA). In a recent noncomparative case series of 106 eyes with symptomatic idiopathic VMA, spontaneous release of VMA occurred in 34% of eyes during the mean study follow-up period of 23 months. In the cases where VMA does not resolve on its own, traction on the retina may develop, leading to subsequent anatomic distortion; although the terminology is not universally accepted, this anatomic distortion on OCT in the setting of VMA is referred to as vitreomacular traction (VMT). If left untreated, VMT can sometimes progress into a sight-threatening condition where patients can experience decreased visual acuity, metamorphopsia, and scotomas; full-thickness macular holes can also form as a result of VMT. In a retrospective analysis of 53 consecutive symptomatic eyes with untreated VMT, Hikichi et al found that 64% of eyes experienced a decrease in visual acuity of Z2 Snellen lines after a

Visually Significant Cystoid Macula Edema after Glaucoma Drainage Implant Surgery

Purpose: This study examines the incidence of visually significant cystoid macular edema (CME) after glaucoma drainage implant (GDI) surgery and analyses risk factors associated with developing CME and prognosis with treatment. Materials and Methods: In total, 185 eyes from 185 glaucoma patients (mean age, 72.46±13.94 y) who underwent GDI surgery at a tertiary eye institute were recruited. Patients were classified based on the presence (CME) or absence (No-CME) of CME. Pre-GDI and post-GDI best-corrected visual acuity, number of intraocular pressure (IOP)-lowering medications, IOP, standard automated perimetry and post-GDI complications, were recorded and compared between the 2 groups. Optical coherence tomography (OCT) was used to quantify retinal thickness and monitor CME. Results: In total, 41 (22.2%) eyes developed visually significant CME after GDI surgery. Patients with CME had a higher incidence of pre-GDI nonsteroidal anti-inflammatory drug (P<0.01) use and higher number of prior glaucoma surgeries (P<0.01). CME patients had a higher (P<0.01) incidence of iritis, epiretinal membrane, and hypotony. CME eyes responded well to steroids, with resolving macular edema (458.4±151.9 vs. 322.0±92.0 µm, P<0.01) and improving visual acuity (0.73±0.48 vs. 0.56±0.56 logarithm of minimum angle of resolution, P<0.01). Both CME and non-CME groups had equivalent lowering of IOP and post-GDI glaucoma medications; with no significant elevation in IOP in the steroid-treated CME group. Conclusions: Post-GDI surgery visually significant CME rates are potentially higher in a real hospital scenario compared with controlled clinical trials. With diligent treatment, CME resolves effectively restoring visual acuity and central macular thickness.