Levent Akduman

Macular translocation with retinotomy and retinal rotation for exudative age-related macular degeneration.

PURPOSE To determine the effectiveness of macular translocation with retinotomy and retinal rotation in exudative age-related macular degeneration. METHODS After written informed consent was obtained, 20 patients underwent macular translocation. We created a 180-degree retinotomy superior, inferior, and temporal to the macula near the equator. The hinged retinal flap was rotated superiorly or inferiorly to place the center of the fovea over an area of healthy retinal pigment epithelium. The retina was flattened under silicone oil and laser photocoagulation was placed. RESULTS The fovea was moved 425 to 1,700 microm (965+/-262 microm) superiorly or inferiorly. Follow-up time was 2 to 12 months (median 8 months). Complications included macular pucker (3 eyes), subfoveal hemorrhage (2 eyes), macular hole (1 eye), and progression of cataract in phakic eyes (3 eyes). Thirteen of 20 eyes showed various degrees of proliferative vitreoretinopathy with epiretinal membrane formation over the inferior peripheral retina with the inferior retinal detachment stabilized by the silicone oil. One eye progressed to phthisis bulbi. Initial visual acuity ranged from 20/80 to 20/800 (median 20/150) and final visual acuity ranged from light perception to 20/200 (median 20/1000). CONCLUSION The fovea can be moved up to 1,700 microm with retinotomy and retinal rotation; however, there is a high rate of complications. Proliferative vitreoretinopathy is the major complication of this technique and is probably related to the extensive retinotomy and subretinal irrigation inherent in the technique. Other techniques such as scleral shortening may have fewer complications.

Treatment of cystoid macular edema with the new-generation NSAID nepafenac 0.1%.

Purpose: To describe the use of nepafenac 0.1% for cystoid macular edema (CME). Methods: This was a multicenter retrospective review of 22 CME cases (20 patients) treated with nepafenac 0.1% (six with concomitant prednisolone acetate 1%) from December 2005 to April 2008: three acute pseudophakic CME cases, 13 chronic/recalcitrant pseudophakic CME cases, and six cases of uveitic CME. Pre- and post-treatment retinal thickness and visual acuity were reported. Results: Following treatment for six weeks to six months, six eyes with uveitic CME showed a mean retinal thickness improvement of 227 ± 168.1 μm; mean best-corrected visual acuity (BCVA) improvement was 0.36 ± 0.20 logMAR. All three cases of acute pseudophakic CME improved after four to 10 weeks of nepafenac, with a mean improvement in retinal thickness of 134 ± 111.0 μm. BCVA improved in two patients (0.16 and 0.22 logMAR) but not in the third due to underlying retinal pigment epithelium changes. Thirteen eyes with chronic/recalcitrant pseudophakic CME demonstrated a mean improvement in retinal thickness of 178 ± 128.7 μm after nepafenac and mean BCVA improvement of 0.33 ± 0.19 logMAR. Conclusion: The positive outcomes of these 22 eyes strongly suggest that nepafenac 0.1% is a promising drug for the treatment of CME. Additional study under randomized controlled conditions is warranted.

Incidence of Complications in 25-Gauge Transconjunctival Sutureless Vitrectomy Based on the Surgical Indications

BACKGROUND AND OBJECTIVE To determine which skills are most important to clinicians and how they correlate with Accreditation Council for Graduate Medical Education (ACGME) competencies. PATIENTS AND METHODS A descriptive analysis to test four hypotheses: specific skill sets are likely to be important/mandatory for residents to obtain during training; comprehensive and subspecialist ophthalmologists would likely value skills similarly; year of training would likely affect the ranking of skills; and surveying practicing ophthalmologist could help to modify the educational curriculum. RESULTS Highest-ranked skill sets included interpersonal and communication skills (mean, 1.17 +/- 0.08), ocular trauma (mean, 1.28 +/- 0.26), and practice-based learning (mean, 1.37). Comprehensive ophthalmologists and subspecialists did not significantly differ in the ranking of skill sets. Year of graduation did not affect the ranking of skill sets. CONCLUSION The ACGME core competencies of interpersonal and communication skills and practice-based learning were ranked as highly important to both comprehensive and subspecialty ophthalmologists. These are included in ACGME core competency requirements. These findings support ACGME core competencies and the need for continued evaluation of ophthalmology residents in all areas of medical training.

Minimal intensity diode laser (810 nanometer) photocoagulation (MIP) for diffuse diabetic macular edema (DDME)

Background and objective. To determine the effectiveness of minimal intensity diode laser (810 nm) photocoagulation (MIP) for diffuse diabetic macular edema (DDME). Methods. Patients demonstrating diffuse diabetic macular edema (DDME) were treated with minimal intensity diode 810 laser photocoagulation or modified grid photocoagulation consecutively. Patients were seen and reevaluated at regular follow up visits every 3 to 4 months and retreated if residual diffuse diabetic macular edema was still present. Selected patients were tested with Goldmann visual field, pre and post-treatment. Visual improvement, visual loss, visual field, reduction/elimination of macular edema, and a number of treatments were studied. Results. Reduction/elimination of DDME was observed in approximately 74% of eyes with 24 months follow up. The number of treatments per eye ranged from 1 to 5. The presence of cystoid macular edema, initial poor visual acuity, the presence of coexisting macular ischemia, or a history of systemic hypertension did not effect the outcome. Patients without a history of systemic vascular disease had a better chance of visual stabilization or improvement compared to those patients with a history of systemic vascular disease. Eighty-eight percent of patients had at least stable visual acuity at the last follow up visit. No post-treatment subjective complaints of increased pericentral scotomas were encountered in this group of patients and post-treatment atrophic scarring was substantially reduced, by using minimal intensity diode laser 810 photocoagulation, compared to eyes previously treated with shorter wavelengths and more visible burns. Conclusion. Minimal intensity diode laser 810 nm modified grid laser photocoagulation for diffuse diabetic macular edema (DDME) is effective in reducing/eliminating DDME, although resolution of edema may be slightly prolonged and may require 1 or 2 additional treatments compared to eyes previously treated with shorter wavelengths and more visible burns. However, this method appears to be advantageous in that it appears to reduce the objective and subjective effect on the pericentral visual field, as well as substantially reducing the post-treatment atrophic scarring seen in patients treated with shorter wavelength lasers and move visible burns.

Spontaneous Dissociation and Dislocation of Retisert Pellet

Purpose: To report 4 cases of spontaneous Retisert pellet dislocation. Design: Retrospective case series. Methods: Description of cases. Results: In all 4 cases, the time of Retisert implantation was 3–6 years prior to presentation. One case was complicated by retinal commotio and a retinal tear; another was complicated by corneal endothelial failure, due to dislocation of the pellet into the anterior chamber. Conclusion: Spontaneous pellet separation may occur with Retisert as a late complication. It is unclear whether these dislocations are from a manufacturing fault or are related to extended intraocular exposure.

Bilateral idiopathic multifocal retinal pigment epithelium detachments in otherwise healthy middle-aged adults: a clinicopathologic study.

Purpose: To present the results of a clinicopathologic study of patients with bilateral idiopathic multifocal serous retinal pigment epithelial detachments (RPEDs). Method: Retrospective review of the medical records of three middle-aged patients with innumerable RPEDs. The eye of one patient was available for histopathologic examination. Results: The presence of multiple serous RPEDs was verified with fluorescein angiography and optical coherence tomography in two patients and by histopathologic examination of one eye of a third patient, who developed a submacular hematoma and vitreous hemorrhage caused by a focal area of choroidal neovascularization. Conclusions: No cause for the multifocal serous RPEDs was found.

Resistant fusarium keratitis progressing to endophthalmitis

Objective: To report a case of multidrug-resistant Fusarium sp keratitis that progressed to endophthalmitis and that eventually required enucleation. Methods: Case report and literature review. Isolate identification and susceptibility testing were performed by the Fungus Testing Laboratory at San Antonio, TX. Results: A 52-year-old soft contact lens wearer had a corneal abrasion and developed a corneal infiltrate. Examination of corneal scrapings revealed filamentous hyphae with septation and conidia. Despite aggressive antifungal therapy with topical natamycin, amphotericin B, and systemic fluconazole, the keratitis progressed, and a penetrating keratoplasty was performed. Histopathologic analysis of the corneal button showed disruption of Descemets membrane with periodic acid-Schiff-positive fungal hyphae on both sides. Recurrent infection of the graft and progression to endophthalmitis was treated with repeated intravitreal amphotericin B injections, repeat penetrating keratoplasties, and pars plana vitrectomies. Even after systemic use of itraconazole, voriconazole, and posaconazole and topical use of voriconazole, the infection progressed and an enucleation was required. Isolate identification and susceptibility testing found a multidrug-resistant Fusarium solani species complex, partially sensitive to natamycin only. Conclusions: Multidrug-resistant Fusarium sp is rare and may have devastating consequences in patients with advanced keratitis progressing to endophthalmitis. Such an extensive multidrug resistance is surprising in that resistance to antifungal treatment is supposedly rare. Empirical antifungal therapy is usually instituted using one or more antifungal agents, without checking antifungal sensitivities. In light of the growing concern for increased emergence of resistant strains, we propose a lower threshold to check for sensitivities in the face of unresponsive fungal infections.

Efficacy of patterned scan laser in treatment of macular edema and retinal neovascularization.

Purpose: To analyze the benefits, efficacy, and complications of the PASCAL® photocoagulation laser system (OptiMedica, Santa Clara, CA, USA) in patients treated at our institution. Methods: We conducted a retrospective chart review of 19 patients (28 eyes) who underwent laser treatment using the PASCAL® photocoagulation system from November 2006 to November 2007. These 28 eyes were divided into two groups; group 1 eyes underwent macular grid laser and group 2 eyes underwent panretinal photocoagulation. Treatment was performed for macular edema or for iris or retinal neovascularization. Outcomes measured included best-corrected visual acuity (BCVA), efficacy of laser treatment, complications, duration of the procedure, and pain perception, which were noted in the charts for panretinal treatments. Results: Follow-up was 5.9 ± 2.6 months for group 1 and 5.9 ± 4.0 months for group 2. In group 1, 9/28 eyes required a second treatment for remaining edema. BCVA was stable or better in 66% (14/21) and average central foveal thickness on ocular coherence tomography improved in 71% (15/21). Time to completion for a number of laser patterns for grid photocoagulation was felt to be too long for completing the total pattern safely, although we have not noted any related complications. In group 2, the neovascularization regressed at least partially in 3/7 patients. Patient-reported pain perception was 3.6 on a scale of 1 to 10 for group 2. Occasional hemorrhages occurred secondary to irregular laser uptake at different spots in the patterns. We observed no visual outcome consequences because of these hemorrhages during follow-up. Conclusions: Retinal photocoagulation by the PASCAL® laser has comparable efficacy to historical results with conventional retinal photocoagulation in short-term follow-up. PASCAL® photocoagulation can be performed quicker with less discomfort for patients.

A case of infected scleral buckle with Mycobacterium chelonae associated with chronic intraocular inflammation

Purpose: To describe a unique case of chronic intraocular inflammation secondary to scleral buckle infection with Mycobacterium chelonae that was successfully treated with buckle explantation. Methods: Case report. Results: A 59-year-old male with a history of retinal detachment repair at the age of 41 presented with chronic, recurrent intraocular inflammation responsive to topical corticosteroids. Conjunctival erosion with exposure of the scleral buckle occurred five months after initial presentation. The scleral buckle was removed and cultured. After three weeks of postoperative topical tobramycin and dexamethasone treatment, the patient has remained symptom-free without medications. The explanted material grew acid-fast bacilli later identified as M. chelonae. Conclusions: This case describes a new finding of chronic intraocular inflammation associated with a scleral buckle infected with M. chelonae and the successful resolution of extraocular infection and intraocular inflammation after buckle removal.

Comparison of silicone oil removal with passive drainage alone versus passive drainage combined with air-fluid exchange.

Purpose To compare silicone oil removal with passive drainage alone versus passive drainage combined with air–fluid exchange in regard to floaters. Methods Twenty-five consecutive patients who were seen at the Retina Center in St. Louis, Missouri between May 1996 and May 1999 and underwent silicone oil removal were requested to complete a mailed questionnaire regarding the presence of floaters. The medical records of the 21 patients (22 eyes) who returned the questionnaire were also reviewed retrospectively for clinical evidence of floaters if they were identified in the postoperative fundus examination. Results Fifteen patients (16 eyes) (73%) reported floaters after silicone oil removal. Three (14%) of these eyes also had clinical evidence of floaters on postoperative fundus examination. Univariate analyses of primary eye disease other than proliferative diabetic retinopathy, duration of silicone oil retention in the eye, and final visual acuity were not associated with the patients’ reported incidence of floaters. No patients with proliferative diabetic retinopathy reported floaters after silicone oil removal. Silicone oil removal procedure (i.e., removal with passive drainage alone or passive drainage combined with air–fluid exchange) did not influence the reported occurrence of floaters (P = 0.65). Conclusion Silicone oil removal is often associated with floaters from residual oil droplets. There is no difference in the incidence of floaters seen after silicone oil removal with passive drainage alone versus passive drainage combined with air–fluid exchange.