Linda M. Meyer

Secondary Glaucoma After Intravitreal Dexamethasone 0.7 mg Implant in Patients with Retinal Vein Occlusion: A One-Year Follow-Up

PURPOSE To investigate the rate of secondary glaucoma after intravitreal dexamethasone 0.7 mg (Ozurdex(®)) implantation over a clinical treatment period of 1 year. METHODS A prospective study of a series of 16 patients (9 males, 7 females; mean age 76 years) suffering from central- or branch retinal vein occlusion treated with dexamethasone 0.7 mg were followed up for 12 months. Main outcome measures were intraocular pressure (IOP) determined with Goldmann applanation tonometry (GAT) and Pascal dynamic contour tonometry (DCT), as well as best-corrected visual acuity (BCVA) and central retinal thickness measured with optical coherence tomography (OCT). RESULTS BCVA (logMAR) improved in treated patients from mean 0.81 at baseline to a peak of 0.47 after 2 months but declined irrespective of reinjections to 0.87 at 12 months. Central retinal thickness measured with OCT initially decreased but increased again with recurring macular edema. 69% of patients treated with dexamethasone 0.7 mg had an IOP increase of at least 5 mmHg. In total, 50% of patients had an increase of ≥10 mmHg during the studied period. The IOP increase in treated eyes was significant 1, 2, 3, and 8 months after dexamethasone 0.7 mg implantation. CONCLUSION Secondary glaucoma after intravitreal injection of dexamethasone 0.7 mg might be underestimated in the GENEVA studies. The clinical safety profile reported here calls for thorough identification of suitable patients and frequent IOP control if dexamethasone 0.7 mg (Ozurdex) is applied as a long-term treatment.

Cystoid Macular Edema after Complicated Cataract Surgery Resolved by an Intravitreal Dexamethasone 0.7-mg Implant.

Purpose: To report the effective treatment of cystoid macular edema (CME) following complicated cataract surgery (resulting in Irvine-Gass syndrome) with a dexamethasone 0.7-mg (Ozurdex®) intravitreal implant. Methods: An interventional case report with optical coherence tomography (OCT) scans. Results: An 83-year-old Caucasian woman was suffering from CME following complicated cataract surgery on her left eye. She had undergone 3 intravitreal injections of dexamethasone 0.4 mg in the 3 months following the surgery without any improvement of visual function. Seven months after the cataract surgery, she received a single intravitreal injection of dexamethasone 0.7 mg (Ozurdex). Four weeks following the injection, her best-corrected visual acuity improved from 0.3 to 0.8. CME resolved with a reduction of central retinal thickness from 393 µm pre-Ozurdex injection to 212 µm post-Ozurdex injection, as measured by OCT scan. Conclusion: Dexamethasone 0.7 mg (Ozurdex) has proven to be an effective treatment option in retinal vein occlusion and non-infectious uveitis. It can also be considered as off-label treatment in Irvine-Gass syndrome.

Two-year outcome of repeat trabeculectomy with mitomycin C in primary open-angle and PEX glaucoma.

Purpose To evaluate the effectiveness of repeat trabeculectomy with risk factor–adjusted mitomycin C (MMC) application in primary open-angle glaucoma (POAG) and pseudoexfoliation glaucoma (PEXG) over 2 years. Methods A total of 58 patients (43 with POAG, 15 with PEXG) who had undergone repeat trabeculectomy with MMC were included in this retrospective study. Exposure time of MMC 0.3 mg/mL was adjusted according to a standardized protocol. Main outcome measures were best-corrected visual acuity (BCVA), intraocular pressure (IOP) reduction, surgical success rate (criteria were defined as A: IOP ≤21 mm Hg and a reduction of IOP ≥20%; B: IOP ≤18 mm Hg and a reduction of IOP of ≥30%; C: IOP ≤15 mm Hg and a reduction of IOP of ≥40% from baseline), and number of medications at baseline, 3 months, and 2 years postoperatively. Results The BCVA remained stable for 2 years after surgery (0.47 ± 0.47 at baseline, 0.49 ± 0.64 logMAR units after 2 years, respectively). Mean IOP decreased from 22.2 ± 7.0 mm Hg at baseline to 12.7 ± 3.1 mm Hg at 3 months and 12.9 ± 4.3 mm Hg 2 years after surgery. The qualified success rate for criterion A was 75.4%, for criterion B 66.6%, and for criterion C45.6%. Complete success rates were 42.9%, 37.5%, and 32.1%, respectively. Two years after repeat trabeculectomy, the mean IOP was reduced by 38.8%, and the number of medications was reduced significantly. Conclusions Repeat trabeculectomy with MMC is successful at lowering IOP in POAG and PEXG and permits a significant and safe reduction of antiglaucomatous medication for at least 2 years after surgery.

Recovery of Visual Function after Administration of Dabigatran Etexilate

A 46-year-old Caucasian female underwent pars plana vitrectomy (ppv) for retinal detachment. After the procedure, the patient could only distinguish hand movements; the condition was tentatively diagnosed as nonarteritic anterior ischemic optic neuropathy. Conventional treatment with systemic corticosteroids and acetylsalicylic acid was ineffective and yielded substantial steroid-related side effects. Additional administration of 2 × 110 mg dabigatran etexilate (Pradaxa®), a novel direct thrombin inhibitor, resulted in a prompt and marked improvement of visual acuity, which indicated improved blood flow in the central vessels of the optic nerve. Dabigatran etexilate may provide a promising alternative for the treatment of postprocedural vision loss after ppv.

Incidence of cystoid macular edema following secondary posterior chamber intraocular lens implantation.

Purpose To investigate the incidence and risk factors for the occurrence of cystoid macular edema (CME) after secondary posterior chamber intraocular lens (PC IOL) fixation. Setting Eye Clinic Herzog Carl Theodor, Munich, Germany. Design Retrospective case series. Methods Eyes with secondary PC IOL implantation were included. Eyes in Group 1 were treated because of preexisting aphakia; eyes in Group 2 had reimplantation or refixation of a failed primary PC IOL (Group 2). Patients were followed for at least 12 months with measurement of corrected distance visual acuity (CDVA) and central retinal thickness with optical coherence tomography (OCT). Risk factors for CME occurrence were evaluated with standard statistical procedures. Cutoff points of sensitivity and specificity were calculated for the prediction of CME with the receiver operating characteristic (ROC) method. Results Forty‐two eyes of 40 patients (16 men, 24 women; mean age 75.4 years ± 13.7 [SD]) were included. There were 28 eyes in Group 1 and 14 eyes in Group 2. Seven eyes (16.7%) developed CME with significant impairment of CDVA and an increase in central retinal thickness on OCT. Five eyes in Group 1 and 2 eyes in Group 2 were affected, without a significant difference between groups. The CDVA after surgery had a significant influence, and there was a trend toward patient age as a risk factor. The ROC analysis yielded 83.9 years of age and a CDVA of 0.35 logMAR, respectively, as meaningful cutoff points. Conclusions Secondary PC IOL fixation was performed with good results despite the inherent CME risk from the procedure. Advanced age and poor CDVA after surgery might predict CME occurrence. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Schleimpflug photography detects alterations in corneal density and thickness in patients with dry eye disease

BACKGROUND Dry eye disease is a common ocular surface disease that significantly affects the quality of life. Little is known about a potential impact of the disease on corneal morphology. This study was carried out to investigate for the first time if dry eye disease induces changes in corneal density and thickness. METHODS In total 97 patients suffering from dry eye disease and 33 healthy age-matched individuals were included in this prospective, randomized study. Corneal morphology was documented with Scheimpflug photography and analyzed for central corneal thickness and corneal density in five anatomical layers (i.e. epithelium, Bowman membrane, corneal stroma, Descemet membrane and endothelium). RESULTS Corneal density was significantly reduced in the epithelium (p = 0.0053), Bowman membrane (p = 0.0049) and Descemets membrane (p = 0.0385) in patients with dry eye syndrome compared to healthy controls. This decrease was age-dependant. Furthermore, central corneal thickness was significantly reduced in patients with dry eye syndrome compared to the control group (p = 0.0495). The change was again dependent on age with lower values at higher age. Central corneal thickness increased with age in the control group. CONCLUSION The results of this study indicate that corneal morphology is subject to significant alterations in patients with dry eye disease. Scheimpflug photography provides not only unique information in lens trials but is also able to detect changes of corneal anatomy. However, further investigations with other anterior segment imaging techniques, such spectral domain optical coherence tomography (SD OCT/Pentacam®) are necessary to further evaluate the clinical consequences of these findings.

Ultraviolet radiation exposure triggers neurokinin-1 receptor upregulation in ocular tissues in vivo

ABSTRACT The purpose of this study was to investigate the neurokinin receptor‐1 (NKR‐1) protein expression in ocular tissues before and after supra‐cataract threshold ultraviolet radiation (UVR‐B peak at 312nm) exposure in vivo in a mouse model. Six‐week‐old C57Bl/6 mice were unilaterally exposed to a single (2.9kJ/m2) and an above 3‐fold UVR‐B cataract threshold dose (9.4kJ/m2) of UVR. UVR‐exposure (&lgr;peak=312nm) was performed in mydriasis using a Bio‐Spectra exposure system. After latency periods of 3 and 7 days, eyes were fixed in 4% paraformaldehyde, embedded in paraffin, sectioned and stained with fluorescence coupled antibody for NKR‐1 and DAPI for cell nuclei staining. Control animals received only anesthesia but no UVR‐exposure. Cataract development was documented with a Leica dark‐field microscope and quantified as integrated optical density (IOD). NKR‐1 is ubiquitously present in ocular tissues. An above 3‐fold cataract threshold dose of UV‐radiation induced NKR‐1 upregulation after days 3 and 7 in the epithelium and endothelium of the cornea, the endothelial cells of the iris vessels, the pigmented epithelium/stroma of the ciliary body, the lens epithelium, pronounced in the nuclear bow region and the inner plexiform layer of the retina. A significant upregulation of NKR‐1 could not be provoked with a single cataract threshold dose (2.9kJ/m2 UVR‐B) ultraviolet irradiation. All exposed eyes developed anterior subcapsular cataracts. Neurokinin‐1 receptor is present ubiquitously in ocular tissues including the lens epithelium and the nuclear bow region of the lens. UV‐radiation exposure to an above 3‐fold UVR‐B cataract threshold dose triggers NKR‐1 upregulation in the eye in vivo. The involvement of inflammation in ultraviolet radiation induced cataract and the role of neuroinflammatory peptides such as substance P and its receptor, NKR‐1, might have been underestimated to date. HIGHLIGHTSWe investigate neurokinin‐1 receptor expression in ocular tissues after in vivo unilateral ultraviolet radiation exposure.We demonstrate for the first time that the neurokinin‐1 receptor is present in the lens.UVR triggers an upregulation of neurokinin‐1 receptor in vivo in different ocular tissues including the lens.The role of inflammation in UVR cataract has been underestimated so far.

Delayed Macular Hole Closure

Purpose: The presented case raises questions regarding the favorable scheduling of planned postoperative care and the ideal observation interval to decide for reoperations in macular hole surgery. Furthermore a discussion about the use of short- and long-acting gas tamponades in macular hole surgery is encouraged. Methods: We present an interventional case report and a short review of the pertinent literature. Results: We report a case of spontaneous delayed macular hole closure after vitreoretinal surgery had been performed initially without the expected success. A 73-year-old male Caucasian patient presented at our clinic with a stage 2 macular hole in his left eye. He underwent 23-gauge pars plana vitrectomy and internal limiting membrane peeling with a 20% C2F6-gas tamponade. Sixteen days after the procedure, an OCT scan revealed a persistent stage 2 macular hole, and the patient was scheduled for reoperation. Surprisingly, at the date of planned surgery, which was another 11 days later, the macular hole had resolved spontaneously without any further intervention. Conclusions: So far no common opinion exists regarding the use of short- or long-acting gas in macular hole surgery. Our case of delayed macular hole closure after complete resorption of the gas tamponade raises questions about the need and duration of strict prone positioning after surgery. Furthermore short-acting gas might be as efficient as long-acting gas. We suggest to wait with a second intervention at least 4 weeks after the initial surgery, since a delayed macular hole closure is possible.

Fast Resolution of Recurrent Pronounced Macular Edema following Intravitreal Injection of Dexamethasone 0.7 mg.

Purpose: To report the fast resolution of recurrent pronounced macular edema due to central retinal vein occlusion (CRVO) within 72 h following intravitreal injection of dexamethasone 0.7 mg (Ozurdex®). Methods: An interventional case report with optical coherence tomography scans and fluorescein angiographic pictures. Results: A 69-year-old Caucasian man underwent intravitreal injection of dexamethasone 0.7 mg due to incomplete CRVO. He had previously undergone 6 intravitreal injections of bevacizumab 1.25 mg (Avastin®) and a C-grid laser photocoagulation over an interval of 16 months. After repeated recurrences of macular edema, the injection of dexamethasone reduced the macular edema from 570 µm preoperatively to 246 µm postoperatively within 72 h following the injection. Best-corrected visual acuity improved from 0.1 to 0.6 within the same interval. Conclusion: Dexamethasone can lead to a very fast reduction of macular edema in patients with vision loss due to CRVO and may facilitate an immediate visual rehabilitation. Retinal anatomy and visual acuity may be restored even in long-standing, recurrent cases.