Kyle Kovacs

Morphologic differences in epiretinal membranes on ocular coherence tomography as a predictive factor for surgical outcome.

Purpose: To evaluate whether morphologic differences in idiopathic epiretinal membranes seen on optical coherence tomography may help predict surgical outcomes. Methods: Seventy-five eyes of 74 patients who underwent primary pars plana vitrectomy with membrane peeling were retrospectively reviewed. Outcome measures included visual acuity, macular contour on optical coherence tomography, central macular thickness, and reoperation rate. Results: According to the preoperative macular contour, 75 eyes were categorized into 4 types: 42 eyes were included in the diffuse (DIF) type, 12 in the cystoid macular edema (CME) type, 14 in the pseudolamellar hole (PLH) type, and 7 in the vitreomacular traction (VMT) type. Surgical procedure significantly improved vision in all types except for the PLH type (DIF, P < 0.0001; CME, P = 0.0378; PLH, P = 0.838; and VMT, P = 0.0273). There was a significant relationship between pre- and postoperative macular contour. All preoperative VMT showed normal contour on postoperative optical coherence tomography but had the highest reoperation rate. Conclusion: Surgical intervention for the PLH-type epiretinal membrane was not associated with the visual improvement seen in other epiretinal membrane types, and the VMT type had the highest reoperation rate. Future studies should evaluate the potential benefit of internal limiting membrane peeling with or without short-term gas tamponade in these cases.

Minocycline Inhibition of Photoreceptor Degeneration

OBJECTIVE To determine whether systemic minocycline can protect photoreceptors in experimental retinal detachment (RD). METHODS Retinal detachment was induced in mice by subretinal injection of sodium hyaluronate, 1.4%. In 1 experiment, mice received daily injections of minocycline (group 1) or saline (group 2). In a second experiment, mice were treated with minocycline or saline beginning 24 hours prior, immediately after, or 24 hours after experimental RD. In both experiments, photoreceptor cell survival and apoptosis were assessed by immunohistochemistry with primary antibodies against photoreceptor cell markers, rod rhodopsin, and cone opsin, and by terminal deoxynucleotidyl transferase-mediated dUTP-biotin end labeling. RESULTS Photoreceptor cell apoptosis was detected at day 1 after experimental RD, with apoptotic cells peaking in number at day 3 and dropping by day 7. Treatment with minocycline significantly reduced the number of apoptotic photoreceptor cells associated with RD when given 24 hours before or even 24 hours after RD. CONCLUSIONS Our data suggest that minocycline may be useful in the treatment of photoreceptor degeneration associated with RD, even when given up to 24 hours after RD. CLINICAL RELEVANCE Use of minocycline in patients with macula-off RD may prevent photoreceptor apoptosis and glial cell proliferation, improving final visual outcomes.

Angiogenic and Inflammatory Vitreous Biomarkers Associated With Increasing Levels of Retinal Ischemia.

PURPOSE To characterize the angiogenic and inflammatory vitreous biomarker profiles in a spectrum of ischemic retinopathies, including neovascular glaucoma. METHODS This institutional review board-approved study retrospectively analyzed 80 undiluted vitreous samples obtained during pars vitrectomy. The specimens were frozen (-80°C) and sent for concentration analysis of 34 proteins by Bio-Plex Pro assays. Specimens were divided into four groups: patients undergoing epiretinal membrane (ERM) peeling and/or macular hole (MH) surgery with no history of diabetes (non-DM group), patients undergoing ERM peeling, and/or MH surgery with a history of diabetes (DM group), patients with proliferative diabetic retinopathy (PDR group), and patients with neovascular glaucoma (NVG group). Parametric and nonparametric analyses of demographics and cytokine levels were performed using SPSS. RESULTS There were no significant differences in demographics among cohorts. Numerous proteins were significantly elevated between non-DM and DM (G-CSF, sCD40L, Endoglin, IL-6, placental growth factor [PlGF], VEGF-D), DM and PDR (leptin, IL-8, PlGF, VEGF-A), and PDR and NVG (G-CSF, leptin, TIE-2, sCD40L, EGF, HB-EGF, IL-6, IL-8, PlGF, TNF-α). Only PlGF was significantly elevated between each successive cohort. The most potent drivers of NVG were PlGF, VEGF-A, IL-6, and IL-8. CONCLUSIONS While the role of angioproliferative growth factors is well documented in ischemic retinopathy, our study delineates the importance of inflammatory and previously underreported angiogenic proteins. It also demonstrates a significant incremental increase in certain factors with increasing levels of ischemia. Both of these findings may guide the development of future therapies for ischemic retinopathies.

Surgical outcomes after epiretinal membrane peeling combined with cataract surgery

Objective To compare functional and anatomical outcomes after idiopathic epiretinal membrane (ERM) peeling combined with phacoemulsification and intraocular lens implantation versus ERM peeling alone. Methods A retrospective, non-randomised comparative case series study was conducted of 81 eyes from 79 patients who underwent ERM peeling at the Beth Israel Deaconess Medical Center between 2001 and 2010. Eyes that underwent combined surgery for ERM and cataracts (group 1) were compared with those that had ERM peeling alone (group 2) with respect to best-corrected visual acuity at 6 months and 1 year after surgery, postoperative central macular thickness (CMT) as measured on optical coherence tomography, and rates of complications, including elevated intraocular pressure (IOP), ERM recurrence and need for reoperation. Results Mean logMAR visual acuity improved significantly in both groups at 6 months (p<0.001) and 1 year (p<0.001) after surgery. There was no statistical difference between the two groups in visual acuity improvement at 6 months (p=0.108) or 1 year (p=0.094). Mean CMT of both groups also significantly decreased after surgery (p=0.002), with no statistical difference in CMT reduction between the two groups, but a trend toward less CMT reduction in group 1 (p=0.061). The rates of complications, including IOP elevation, ERM recurrence and frequency of reoperation, were similar in the two groups, with non-statistical trends toward greater ERM recurrence (p=0.084) and need for reoperation (p=0.096) in those that had combined surgery. Conclusions Combined surgery for ERMs and cataracts may potentially be as effective as membrane peeling alone with respect to visual and anatomical outcomes. Further studies are necessary to determine if there may be greater ERM recurrence or need for reoperation after combined surgery.

A RETROSPECTIVE ANALYSIS OF TRIPLE COMBINATION THERAPY WITH INTRAVITREAL BEVACIZUMAB, POSTERIOR SUB-TENONʼS TRIAMCINOLONE ACETONIDE, AND LOW-FLUENCE VERTEPORFIN PHOTODYNAMIC THERAPY IN PATIENTS WITH NEOVASCULAR AGE-RELATED MACULAR DEGENERATION

Purpose: To assess the efficacy of triple combination therapy (TCT) including bevacizumab (BEV), low-fluence photodynamic therapy, and posterior sub-Tenons triamcinolone acetonide in patients with wet age-related macular degeneration. Methods: This institutional review board-approved retrospective consecutive case series included 31 eyes treated for wet age-related macular degeneration with TCT at the Beth Israel Deaconess Medical Center between June 2004 and November 2008. Outcome measures included visual acuity, retinal thickness as measured by optical coherence tomography, time to retreatment, and complications. Results: Triple combination therapy eyes showed significant 3-month and 6-month improvement in visual acuity of 0.140 ± 0.273 logarithm of the minimum angle of resolution and 0.182 ± 0.383 logarithm of the minimum angle of resolution after treatment, respectively (P = 0.0219 and 0.0470, respectively). Central retinal thickness significantly improved at 3 months (−123.8 ± 102.7 μm), 6 months (−87.7 ± 99.8 μm), and 12 months (−101.6 ± 103.3 μm) on optical coherence tomography. Half of eyes that underwent TCT required retreatment by the conclusion of their follow-up, and eyes that underwent TCT had a 1-year Kaplan-Meier survival rate of 62.1 ± 10.8%. Conclusion: Triple combination therapy (TCT) appears to effectively improve visual acuity and decrease retinal thickness often without need for subsequent retreatment within the first year of follow-up. Further investigation of TCT in prospective trials is warranted.

Apoptosis in Diabetic Fibrovascular Membranes After Panretinal Photocoagulation

A more complete understanding of the role of apoptosis in the regression of diabetic neovasculature following laser panretinal photocoagulation (PRP) will both elucidate the treatments therapeutic mechanism and potentially lead to novel treatments for neovascularization associated with proliferative diabetic retinopathy that target apoptotic pathways. Pars plana vitrectomy with fibrovascular membrane delamination was performed on five patients with proliferative diabetic retinopathy, with four having received previous PRP treatment and one no previous laser treatment. Using in situ terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling, propidium iodide and hematoxylin-eosin staining, apoptotic cells were identified in the excised membranes. The authors found evidence of cells undergoing apoptosis in all of the excised membranes, with increasing amounts of preoperative PRP associated with an increased number of apoptotic cells per millimeter of membrane. The preliminary data suggest that the decrease in ambient mitogen, initiated by PRP treatment, activates apoptosis in diabetic fibrovascular membranes.

Corneal hysteresis and anterior segment optical coherence tomography anatomical parameters in primary angle closure suspects: Anatomic corneal hysteresis associations

Corneal hysteresis (CH) is a dynamic marker of structural and functional changes in the cornea associated with intraocular pressure (IOP) and central corneal thickness, but its utility in assessing primary angle closure suspects (PACS) has not been fully elucidated.

Pneumocephalus and Sixth Nerve Palsy after Epidural Steroid Injection: Case Report and Review of the Literature

BACKGROUND Pneumocephalus has been described as an unintended outcome after epidural injections. However, oculomotor palsy from pneumocephalus after epidural injection is very rare. CASE REPORT We report a case of pneumocephalus-induced sixth nerve palsies and diplopia in an 87-year-old woman after epidural steroid injection. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Pneumocephalus-induced oculomotor palsy is a rare complication after epidural injection, a commonly performed medical procedure. Knowledge of this presentation will help emergency physicians distinguish between this entity and other causes of neurologic deficits.

Delayed bilateral fibrinous anterior chamber reaction following autologous bone marrow transplant and cataract surgery

Purpose Immune reconstitution uveitis (IRU) is a well-described phenomenon that by definition occurs in patients with AIDS who undergo highly active antiretroviral therapy resulting in a rebound inflammatory response to the presence of clinically latent cytomegalovirus (CMV). We hypothesize that similar phenomena may exist in other cohorts who undergo transient immunosuppression with rapid white blood cell count recovery. Observations A patient developed rebound inflammation a few months after cataract surgery with intraocular lens placement characterized by photophobia, significant anterior chamber cell and fibrinous deposits. She had a history of multiple myeloma treated with chemotherapy and a recovery of white blood cell counts following autologous bone marrow transplant. She underwent a thorough work-up for infectious etiologies, as well as the presence of intraocular CMV, which were negative. Her vision and symptoms improved to baseline with the use of topical steroids and at one year her exam remained stable. Conclusions and Importance With a negative work-up for infectious etiologies, and the timing and clinical presentation, the patients inflammation was likely the result of rapid white blood cell count recovery following iatrogenic immunosuppression similar to the mechanism described for IRU.