Kevin M. Colleaux

Effect of prophylactic antibiotics and incision type on the incidence of endophthalmitis after cataract surgery.

BACKGROUND There is controversy as to the efficacy of various measures in the prophylaxis of endophthalmitis after cataract surgery. In addition, it has been suggested that clear-corneal incisions may convey an increased risk of postoperative infection. We performed a retrospective review to assess the effect of prophylactic antibiotics and incision type on the incidence of endophthalmitis after cataract surgery. METHODS A retrospective chart review and surgeon survey were used to collect data for the 13,886 consecutive cataract operations performed between Sept. 1, 1994, and Jan. 31, 1998 by nine surgeons at a hospital-based surgical unit in Saskatoon. All cataract extractions were by phacoemulsification. All cases of endophthalmitis arising from the unit are managed at the hospital except in extenuating circumstances. We assessed the effect of preoperative administration of antibiotic drops, subconjunctival antibiotic injections at the conclusion of surgery and clear-corneal versus scleral tunnel incisions on the incidence of endophthalmitis by means of univariate and multivariate Poisson regression analysis. RESULTS The incidence of postoperative endophthalmitis was significantly lower with subconjunctival antibiotic injections than without such injections (0.011% vs. 0.179%) (p = 0.009, odds ratio 16.23 [95% confidence interval 1.92 to 137.14]). The difference in the incidence of endophthalmitis with preoperative use of antibiotic drops (0.066%) and with no antibiotic drops preoperatively (0.115%) was not significant. Similarly, the difference in the incidence of endophthalmitis with clear-corneal (0.129%) and scleral tunnel (0.050%) incisions was not significant. INTERPRETATION Our results suggest that prophylactic subconjunctival antibiotic injections at the conclusion of cataract surgery decrease the incidence of postoperative endophthalmitis.

Canadian expert consensus: optimal treatment of neovascular age-related macular degeneration.

BACKGROUND New therapeutic approaches, particularly anti-vascular endothelial growth factor (anti-VEGF) therapies, prevent, and in some cases reverse, vision damage caused by age-related macular degeneration (AMD). Unequal access to care across Canada remains a problem for many retina specialists and their patients. OBJECTIVE To develop a consensus concerning the management of patients with exudative age-related macular degeneration (AMD). DESIGN Consensus document. PARTICIPANTS Ten Canadian retina specialists. METHODS The development of a consensus among Canadian experts concerning optimal treatment of AMD began with a review of the clinical evidence, daily practices, existing guidelines, and current national and international approvals and policies. The experts met on June 29, 2010, in Quebec City to discuss their findings and to propose strategies for consensus. RESULTS The result of this expert panel is a consensus proposal for Canadian ophthalmologists and retina specialists who are treating patients with or at risk for developing neovascular AMD. CONCLUSIONS The consensus provides guidelines to aid retina specialists in managing exudative AMD. Currently, ranibizumab is the only agent with sufficient Level I evidence and a Health Canada-approved indication for the treatment of wet AMD. Bevacizumab has been shown to be noninferior in preserving and improving visual acuity when compared to ranibizumab. Potential safety differences between the 2 drugs remain to be elucidated. The positioning of ranibizumab in this therapeutic area will be further defined as additional data for existing and emerging therapies become available. Until then, this agent remains the therapy of choice for individuals with neovascular AMD.

West Nile chorioretinitis.

CASE REPORT The clinical course of 2 Canadian cases of West Nile chorioretinitis is described. The patients developed visual-field disturbances shortly after flu-like illnesses and were referred for retinal evaluation. Full ophthalmologic examination included Snellen visual acuity testing, applanation tonometry, slit-lamp examination, dilated fundus examination, fundus photography, and fluorescein angiography. Both patients developed self-limited cases of chorioretinitis exhibiting characteristic fundus and fluorescein angiographic findings. COMMENTS Since the introduction of West Nile virus to Canada and its progressive spread across the country, more patients will present to their eye specialists with chorioretinitis. In cases of chorioretinal inflammation, West Nile virus infection should be included in the differential diagnosis.

Optimal Treatment of Retinal Vein Occlusion: Canadian Expert Consensus.

Background: The availability of new therapeutic approaches, particularly intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapies, has prompted significant changes to the established treatment paradigms for retinal vein occlusion (RVO). Better visual outcomes and significantly lower rates of adverse events have been noted in multiple large randomized clinical trials and have led to a new standard of care for this sight-threatening condition. Objective: To develop an expert consensus for the management of RVO and associated complications in the context of recent clinical evidence. Methods: The development of a Canadian expert consensus for optimal treatment began with a review of clinical evidence, daily practice, and existing treatment guidelines and algorithms. The expert clinicians (11 Canadian retina specialists) met on February 1, 2014, in Toronto to discuss their findings and to propose strategies for consensus. Results: The result of this expert panel is a consensus proposal for Canadian ophthalmologists and retina specialists treating patients presenting with RVO. Treatment algorithms specific to branch and central RVO (BRVO and CRVO) were also developed. Conclusions: The consensus provides guidelines to aid clinicians in managing RVO and associated complications in their daily practice. In summary, laser remains the therapy of choice when neovascularization secondary to RVO is detected. Adjunctive anti-VEGF could be considered in managing neovascularization secondary to RVO in cases of vitreous hemorrhage. Intravitreal anti-VEGF should be considered for symptomatic visual loss associated with center-involving macular edema on optical coherence tomography. Patients with BRVO and a suboptimal response to anti-VEGF could be treated with grid laser, and those with CRVO and an inadequate response to anti-VEGF may be candidates for intravitreal steroids.

Contemporary Management of Diabetic Retinopathy in Canada: From Guidelines to Algorithm Guidance

Recent advances in the therapeutic options and approaches for diabetic retinopathy (DR) and diabetic macular edema (DME) have resulted in improved visual outcomes for many patients with diabetes. Yet, they have also created many clinical dilemmas for treating ophthalmologists and retina specialists, including treatment selection, initiation, frequency and duration. With this in mind, a panel of Canadian retina specialists met and discussed the current clinical evidence as well as specific situations and scenarios commonly encountered in daily practice. They also shared their experiences and therapeutic approaches. This document, containing a consensus on treatment algorithms for various clinical scenarios, is the result of their lengthy and in-depth discussions and considerations. The intent is to provide a step-by-step approach to the treatment of DR and DME. Although clinicians are encouraged to use and refer to these algorithms as a guide for various situations, they are not meant to be a replacement for sound clinical judgment.

Interferon beta retinopathy in a patient with multiple sclerosis

Retinopathy is a very rare complication in multiple sclerosis patients treated with interferon beta-1a.1–3 In fact, after an extensive literature search, we found only 3 reports of this complication in the English literature.1–3 It is well known that interferon alpha as treatment for various diseases, including hepatitis C, may induce retinopathy, but interferon beta-1a is not identified as a cause of retinopathy.1 A 42-year-old otherwise healthy female was referred to our clinic in 2005 with reduced central and peripheral vision in the right eye for 5 days. Her past ocular history included 2 assessments in our clinic in 1987 and 1996 with complaints of blurry vision in the right eye. Examination was unremarkable, and the blurry vision resolved in both instances spontaneously. Vision was 20/50 in the right eye and 20/20 in the left. There was no afferent pupillary defect and no colour desaturation. Slit-lamp examination was unremarkable. Dilated fundus examination demonstrated healthy discs, vessels, and peripheries in both eyes. There was no optic nerve edema. There were minimal pigmentary changes in the macular area of the right eye with no edema. Optic neuritis was suspected. A Humphrey 24-2 visual field test demonstrated a mild reduction of the mean defect in the right eye. Further questioning revealed an episode of right-sided numbness a month earlier that had resolved in weeks. Subsequently, an MRI demonstrated several hyperintense lesions, and the diagnosis of multiple sclerosis was highly suspected. The patient was referred to a neurologist for assessment with follow-up planned if the vision did not improve. The patient was not seen in our clinic for 3 years. During that time, her neurologist confirmed relapsing-remitting multiple sclerosis, and the patient was started on an interferon beta-1a medication in May 2007. The patient was referred to our clinic in 2008 with some visual field loss in the right eye for the preceding 5 months. She had been taking interferon beta-1a at that time at a dose of 44 g 3 times per week for the previous 11 months to control her multiple sclerosis. On examination, her vision was 20/30 bilaterally with J1 near vision. Her ocular pressures were normal, and anterior segment examination was unremarkable. Fundus examination revealed healthy optic nerves. An old cotton wool spot was noted along the inferotemporal arcade of the right eye with a few cotton wool spots noted in the inferior posterior pole of the left eye. Fluorescein angiography confirmed microvascular occlusions with some vascular remodeling changes particularly in the right eye (Fig. 1). Angiography of the left eye was unremarkable despite the cotton wool spots. Her blood pressure, electrolytes, and coagulation profile were normal. A diagnosis of interferon beta-1a retinopathy was suspected, and the patient was instructed to discontinue the medication. The patient was seen in follow-up 4 months later. The retinopathy had improved significantly with complete regression of the cotton wool spots. Although retinopathy is often reported with interferon alpha, it is a very uncommon occurrence with interferon beta-1a. Our patient developed retinopathy bilaterally after being treated with interferon beta-1a for multiple sclerosis. There are, to our knowledge, only 3 reported cases of this occurrence in the English literature. The previously reported cases presented in a similar way to ours, the retinopathy involving a temporal relation with interferon beta treatment of multiple sclerosis and no other risk factors for retinopathy.1–3 In those cases the retinopathy resolved upon cessation of the drug. Our case illustrates the potential need for an eye examination for any patient treated with interferon beta and complaining of eye-related symptoms.

Retinal degeneration in autoimmune polyglandular syndrome type 1: a case series

Background Autoimmune polyglandular syndrome type 1 (APS1) is a rare autosomal recessive disorder due to mutations in the AIRE gene. Aim To report the ocular features and characterise the retinal phenotype in molecularly confirmed APS1. Method This retrospective case series reviewed five molecularly confirmed cases with APS1 known to have ocular involvement (age range: 19 months–44 years; mean follow-up of 8 years). The medical history, ocular history and evaluation, visual field testing, full-field electroretinogram (ERG) and antiretinal antibody results were reviewed. Results All but one case had decreased vision at first presentation. All cases had peripheral pigmentary retinal changes; macular atrophy was noted in 80% of cases. The most common feature on spectral-domain optical coherence tomography was a disruption of the external limiting membrane and inner segment ellipsoid band (n=3). Fundus autofluorescence imaging demonstrated a parafoveal ring of hyper-autofluorescence (n=1) or a stippled and patchy autofluorescence pattern in the macula (n=1). The visual fields were constricted in all tested patients (n=3). The rod ERG was abnormal in all cases; the relative involvement of rods and cones differed. Four patients who were tested for antiretinal antibodies were found positive by immunohistochemistry (n=3) and/or western blot (n=2). Conclusions Photoreceptor degeneration is part of APS1 phenotype and the presence of antiretinal antibodies strongly supports an aetiology similar to that of non-paraneoplastic autoimmune retinopathy. Periodic retinal evaluation and imaging, visual field testing and ERG would assist in monitoring the retinopathy in APS1-related disease.

Bilateral retinal arteriolar occlusion secondary to OKT3 therapy

0 KT3, a murine monoclonal antibody, is a potent immunosuppressive agent used for the treatment and prophylaxis of solid-organ allograft rejection. It selectively binds the CD3 molecule in the T -cell antigen receptor complex, inhibiting T -cell function. 1 Common side effects include the first-dose syndrome of transient fever, chills and headache related to the release of cytokines, including tumour necrosis factor. 1•2 Other side effects include pulmonary edema, diarrhea, hypotension, aseptic meningitis, encephalopathy and seizures.U Ocular side effects have been reported, including conjunctivitis in about 75% of patients.4 There has been a single case report of diffuse anterior scleritis related to OKT3 therapy.4 Neuro-ophthalmic manifestations have been reported as sequelae of aseptic meningitis, encephalopathy and cerebral infarction. 3•5 We report a case of severe bilateral visual loss due to occlusion of multiple retinal arterioles secondary to OKT3 therapy ultimately complicated by retinal proliferative vasculopathy.