Kapil G. Kapoor

Mineralocorticoid Antagonists in the Treatment of Central Serous Chorioretinopathy: A Comparative Analysis.

Background and Objective: Overaction of mineralocorticoid receptor (MR) pathways has been implicated in the pathophysiology of central serous chorioretinopathy (CSCR). The purpose of this study was to evaluate MR antagonists in the treatment of CSCR. Study Design and Methods: A retrospective chart review was conducted of all CSCR patients at one center treated with spironolactone or eplerenone (50 mg p.o. b.i.d.) or observation. Patients were followed at monthly intervals with examination and optical coherence tomography. Results: 32 patients (12 eplerenone, 12 spironolactone, 8 observation) were enrolled in the study. Both MR antagonists demonstrated statistically significant visual acuity improvement and subretinal fluid reduction at 1, 2, and 3 months compared to baseline (p < 0.05). 58.3% of patients had complete resolution of subretinal fluid at 2 months on MR antagonists, compared to 12.5% under observation (p < 0.05). Photodynamic therapy was used to treat refractory subretinal fluid past 6 months in 1/24 (4.2%) on MR antagonists and 2/8 (25%) patients under observation. There was no difference in efficacy between eplerenone and spironolactone. Spironolactone exhibited increased side effects (8/12, 75%) compared to eplerenone (3/12, 25%; p < 0.05). Conclusions: This data supports the use of MR antagonists in CSCR and suggests an accelerated improvement compared to observation. Prospective randomized trials are needed to better elucidate the precise role of MR antagonists in the management of CSCR.

The Sustained-Release Dexamethasone Implant: Expanding Indications in Vitreoretinal Disease

Abstract Corticosteroids play an important role in the therapeutic approach to vitreoretinal disease. The Ozurdex® implant (DEX Implant 0.7 mg, Ozurdex®, Allergan Inc., Irvine, CA, USA) offers sustained release of dexamethasone in the vitreous cavity, and this novel drug delivery system has proven useful both in improving clinical outcomes and in reducing injection burden. While the Food and Drug Administration approves the use of the DEX implant in retinal vein occlusions and non-infectious posterior uveitis, its utilization continues to expand in its breadth of diversity across myriad vitreoretinal conditions. Additionally, modified injection techniques are evolving to improve the safety profile of the DEX implant in eyes that are often considered to have relative contraindications to its use, further extending its application. This review aims to evaluate the evidence supporting the expanding indications and injection techniques of the DEX sustained-release implant in vitreoretinal disease, and explores potential future indications for its use. Arenas for future research are also identified to further elucidate the precise role of the DEX implant in our current treatment model. Increased awareness of effective and safe uses of the DEX implant can refine our therapeutic approach to vitreoretinal disease and ultimately improve patient outcomes.

Access to ophthalmologists in states where optometrists have expanded scope of practice

Importance As the United States considers how to best structure its health care services, specialty care availability is receiving increased focus. This study assesses whether patients lack reasonable access to ophthalmologists in states where optometrists have been granted expanded scope of practice. Objective To determine the estimated travel time (ETT) to the nearest ophthalmologist office for persons residing in states that have expanded scope of practice for optometrists, and to quantify ETT to the nearest ophthalmologist for Medicare beneficiaries who received surgical care from optometrists in those states between 2008 and 2014. Design, Setting, and Participants This study used data from the 2010 US census, a 2016 American Academy of Ophthalmology member database, and a data set of claims data for a random sample of 20% of beneficiaries enrolled in Medicare nationwide from 2008 to 2014 (n=14 063 725). Combining these sources with geographic information systems analysis, the ETT to the nearest ophthalmologist office was calculated for every resident of Kentucky, Oklahoma, and New Mexico. This study also assessed ETT to the nearest ophthalmologist for Medicare beneficiaries in those states who had received surgery from an optometrist from 2008 to 2014. Data analyses were conducted from July 2016 to July 2017. Main Outcomes and Measures The proportion of residents of Kentucky, Oklahoma, and New Mexico who live within an ETT of 10, 30, 45, 60, or 90 minutes of the nearest ophthalmologist office. Results The study included 4 339 367 Kentucky residents, 3 751 351 Oklahoma residents, and 2 059 179 New Mexico residents. Of these, 5 140 547 (50.6%) were female. Racial/ethnic composition included 7 154 847 people (70.5%) who were white, 640 608 (6.3%) who were black, and 1 418 246 (14.0%) who were Hispanic. The mean (SD) age was 37.8 (22.8) years. More than 75% of residents in the 3 states lived within an ETT of 30 minutes to the nearest ophthalmology office, and 94% to 99% of residents lived within an ETT of 60 minutes to the nearest ophthalmology office. Among Medicare beneficiaries who received surgery by optometrists, 58.3%, 51.1%, and 46.9% in Kentucky, Oklahoma, and New Mexico, respectively, lived within an ETT of 30 minutes from the nearest ophthalmologist office. Conclusions and Relevance In the states where optometrists have expanded scope of practice, most residents lived within an ETT of 30 minutes of the nearest ophthalmologist office, as do half of Medicare beneficiaries who received surgical care from optometrists. These results can help inform policy makers when weighing the pros and cons of scope of practice expansion for optometrists.

Intravitreal Daptomycin for Recalcitrant Postoperative Endophthalmitis

Purpose: To report the first case to our knowledge of intravitreal daptomycin used to successfully treat culture-negative vancomycin resistant to exogenous endophthalmitis. Methods: Case report with preoperative, intraoperative, and postoperative findings. Results: A 63-year-old Caucasian male underwent routine pars plana vitrectomy with epiretinal membrane peeling. He developed acute postoperative endophthalmitis, and underwent vitreous tap and injection of intravitreal vancomycin/ceftazidime/dexamethasone. Gram stain showed Gram-positive cocci, but cultures were negative. His infection subsequently proved very recalcitrant and his treatment course involved pars plana vitrectomy with anterior chamber washout and repeat injection of antibiotics, followed by repeat intravitreal vancomycin and ceftazidime. Ultimately, a second vitrectomy with intravitreal daptomycin controlled his intraocular infection. On each occasion, cultures were negative. Conclusion: This case suggests that vancomycin resistance should be considered in culture-negative postoperative endophthalmitis, and intravitreal daptomycin should be considered as an important treatment alternative. Although vancomycin resistance is fairly rare in endophthalmitis, acknowledgment of its increasing occurrence rate is critical for optimal management.

Spironolactone as an Adjunctive Treatment in Neovascular Age-Related Macular Degeneration

Neovascular age-related macular degeneration (AMD) is a potentially sight-threatening condition. The current standard-of-care treatment regimen is serial intravitreal antivascular endothelial growth factor injections. While these typically have great success, they do carry exceptional treatment burden on the patient, cost burden due to their required frequency of use, and the risk of endophthalmitis, which can be devastating. This case report explores an alternative potential option as a treatment adjunct for neovascular AMD (nAMD), and identifies some of the overlap between nAMD and central serous chorioretionpathy. Future research is needed to better understand the role of mineralocorticoid receptor antagonist treatment in this disease spectrum.

Spironolactone for Secondary Central Serous Chorioretinopathy: A Challenge-Rechallenge Case

Central serous chorioretinopathy (CSCR) is potentially sight-threatening and has been associated with corticosteroid use. CSCR secondary to steroid use can sometimes be challenging to treat, especially if continuing steroid use is medically necessary. In this case report we demonstrate the efficacy of spironolactone as an effective agent in countering CSCR secondary to steroid use. This challenge-rechallenge case may be helpful to clinicians in delineating a treatment paradigm for these patients.

Love really is in the eye of the beholder

A patient is presented with a branch retinal vein occlusion, associated with an arcuate pattern of superotemporal intraretinal hemorrhages and macular edema. A SD-OCT raster through the intraretinal hemorrhages revealed this heart-shaped hyperreflective focus. Intraretinal hemorrhages on SD-OCT have been described previously [1], typically with oval-shaped medium to hyperreflective echoes. This fortuitous image likely represents the confluence of two ovalshaped hyperreflective echoes consistent with intraretinal hemorrhages, as noted on exam (Fig. 1). Other considerations in this differential include cotton wool spots, which are more nodular and elongated and in the nerve fiber layer, and none were noted on exam [1, 2]. Exudates are significantly more hyperreflective, and none were noted on exam. Microaneurysms appear similarly hyperreflective, but are typically smaller. Finally, hyperreflective foci have been described in BRVO, but are more pinpoint with brighter hyperreflectivity [3]. Ultimately, this heartwarming image shows that sometimes you may find love where least expected!