Michael A. Albert

Incidence Of Acute Onset Endophthalmitis Following Intravitreal Bevacizumab (avastin) Injection

Purpose: To report the incidence of acute endophthalmitis as a complication of intravitreal bevacizumab (Avastin) (IVB) injection in a tertiary vitreoretinal group practice. Methods: A retrospective chart review of 5,233 consecutive eyes that underwent IVB injection at Retina Consultants of Alabama (RCA) from October 1, 2005, to August 31, 2007, was performed to identify cases of acute endophthalmitis. Results: During the 23-month study interval, the overall incidence rate of postinjection endophthalmitis was 0.019% (1/5,233). In the single case of acute endophthalmitis, bacterial cultures revealed coagulase-negative Staphylococcus (CNS) species. Visual acuity after treatment for endophthalmitis was improved (baseline 4/400) to 20/400 at two months after the initial IVB injection. Conclusions: Acute endophthalmitis is a rare potential complication of IVB. Prophylaxis with topical povidone-iodine and adherence to aseptic technique minimizes the risk of postinjection infection. Summary Statement: A retrospective review of 5,233 consecutive intravitreal injections of bevacizumab (Avastin) revealed only a single case of acute endophthalmitis. Adherence to aseptic technique and the use of povidone-iodine prophylaxis minimizes the risk of postinjection intraocular infection.

Intravitreal bevacizumab treatment for radiation macular edema after plaque radiotherapy for choroidal melanoma.

Purpose: To evaluate the effect of intravitreal bevacizumab treatment on patients with macular edema (ME) due to radiation retinopathy after plaque radiotherapy for choroidal melanoma. Methods: In this retrospective case series, 10 consecutive patients with ME due to radiation retinopathy after plaque radiotherapy for choroidal melanoma were treated with a single intravitreal injection of bevacizumab. Postinjection best-corrected visual acuity (BCVA) and mean foveal thickness measured by ocular coherence tomography were the primary outcome measures. Results: The mean BCVA at the time of the diagnosis of choroidal melanoma was 20/25 (range, 20/20 to 20/40). The mean radiation dose to the foveola was 4,323 cGy (range, 1,908–7,975 cGy). Radiation ME developed at a mean of 26 months (range, 17–44 months) after plaque radiotherapy. Choroidal melanoma regressed in all patients, and there were no neovascular sequelae. At the time of radiation ME diagnosis, the mean BCVA was 20/100 (range, 20/40 to 20/200). After bevacizumab injection, the mean BCVA was 20/86 at 6 weeks and 20/95 at 4 months. Mean foveal thickness measured by ocular coherence tomography was 482 &mgr;m before injection, 284 &mgr;m 6 weeks after injection, and 449 &mgr;m 4 months after injection. Conclusions: Intravitreal bevacizumab injection decreases mean foveal thickness while only modestly improving BCVA on a short-term basis in patients with radiation-induced ME.

Incidence of hemorrhagic complications after intravitreal bevacizumab (avastin) or ranibizumab (lucentis) injections on systemically anticoagulated patients.

Purpose: To assess the risk of hemorrhagic complications when performing intravitreal injections on systemically anticoagulated patients. Methods: A single-center retrospective case series of 520 consecutive patients (675 eyes) receiving 3,106 antivascular endothelial growth factor injections. Patients on the systemic anticoagulants Coumadin (warfarin sodium) or Plavix (clopidogrel bisulfate) were identified, as well as patients on aspirin. Demographic parameters were recorded, as well as relevant anticoagulant medications, preoperative/postoperative best-corrected visual acuities and intraocular pressures, previous ocular surgery, relative ocular diagnoses, and injection complications. Results: Of all patients, 104 were on Coumadin (134 eyes; 548 injections), 90 were on Plavix (123 eyes; 523 injections), 7 were on both Coumadin and Plavix (8 eyes; 33 injections), and 319 were not anticoagulated (400 eyes; 2002 injections). Also, 1,254 injections were on patients taking aspirin. There were no hemorrhagic complications (choroidal hemorrhage, vitreous hemorrhage, or increased submacular hemorrhage) noted in the Plavix (P = 1.0000; 95% confidence interval = 0.0000-0.0088), Coumadin (P = 1.0000; 95% confidence interval = 0.0000-0.0084), or aspirin (P = 1.0000; 95% confidence interval = 0.0000-0.0037) groups. Conclusion: The risk of hemorrhagic complications in systemically anticoagulated patients receiving intravitreal injections is extremely low. Because of the demonstrated thromboembolic risk of stopping anticoagulant therapy, we recommend that patients continue their current regiment without cessation.

Incidence of endophthalmitis following 20-gauge and 25-gauge vitrectomy.

Incidence of Endophthalmitis Following 20-Gauge and 25-Gauge Vitrectomy The 25-gauge transconjunctival sutureless pars plana vitrectomy (PPV) system enables sutureless three-port PPV without the need for conjunctival peritomies, decreases mean operative times, decreases surgically-induced trauma at sclerotomy sites, and reduces postsurgical patient discomfort.1 Decreased traumatic conjunctival and scleral manipulation with less postoperative inflammation, as well as less induced corneal astigmatism, allows for more rapid postoperative visual recovery. The self-sealing nature of the incisions in sutureless transconjunctival vitrectomy surgery, however, does pose theoretical concerns for possible increased risk of hypotony, vitreous incarceration, and postoperative intraocular infection.2–4 Postoperative endophthalmitis following ophthalmic surgery remains rare with an incidence of approximately 0.1%.5–7 Endophthalmitis following 20-gauge PPV has been reported as 0.07% by Cohen et al7 in their 10-year survey published in 1995. Although cases of endophthalmitis have been reported after 25-gauge transconjunctival sutureless PPV,2–4 the exact incidence was unknown until two very recent series were published.8,9 Scott et al8 and Kunimoto and Kaiser9 both reported an increased rate of endophthalmitis following 25-gauge PPV compared with 20gauge PPV. The purpose of the current study was to examine the incidence of endophthalmitis following 25-gauge transconjunctival sutureless PPV in a large, single institution, single surgical location, consecutive case series. Methods

Safety, Efficacy, And Quality Of Life Following Sutureless Vitrectomy For Symptomatic Vitreous Floaters

Purpose: To determine the safety, efficacy, and quality of life improvement following sutureless 25-gauge pars plana vitrectomy for symptomatic floaters. Methods: Patients with symptomatic vitreous floaters who underwent sutureless vitrectomy between January 2008 and January 2011 were included. Data were collected regarding baseline preoperative characteristics, postoperative outcomes, complications, and a nine-item quality-of-life survey completed by each patient. Results: One hundred and sixty-eight eyes (143 patients) underwent sutureless 25-gauge pars plana vitrectomy for symptomatic vitreous floaters. Mean Snellen visual acuity was 20/40 preoperatively and improved to 20/25 postoperatively (P < 0.0001). Iatrogenic retinal breaks occurred in 12 of 168 eyes (7.1%). Intraoperative posterior vitreous detachment induction was not found to increase the risk of retinal breaks (P = 1.000). Postoperative complications occurred in three eyes, of which one had transient cystoid macular edema and two had transient vitreous hemorrhage. Approximately 88.8% of patients completed a quality-of-life survey, which revealed that 96% were “satisfied” with the results of the operation, and 94% rated the experience as a “complete success.” Conclusion: Sutureless 25-gauge pars plana vitrectomy for symptomatic vitreous floaters improved visual acuity, resulted in a high patient satisfaction quality-of-life survey, and had a low rate of postoperative complications. Sutureless pars plana vitrectomy should be considered as a viable means of managing patients with symptomatic vitreous floaters.

Trans-luminal Nd: YAG laser embolysis for branch retinal artery occlusion

Purpose: To evaluate the clinical efficacy of transluminal YAG laser embolysis (TYE) for patients with severe vision loss secondary to a newly diagnosed branch retinal artery occlusion (BRAO) with visible emboli. Methods: Five eyes of five patients with acute, severe vision loss secondary to a branch retinal artery occlusion with visible emboli and retinal whitening were prospectively examined, enrolled, and underwent visual acuity testing, ophthalmic examination, color photography, and fluorescein angiography. Each patient was offered TYE and the potential risks of the treatment were explained. Follow-up examinations were undertaken postprocedure day 1 and subsequent follow-up depended on the clinical course. Results: In our five patients baseline best-corrected visual acuity (BCVA) was found to be 5/400, count fingers at 3 feet, count fingers at 5 feet, 20/800, and 20/200. All five of our patients showed improvement in BCVA 1 day after TYE. Fluorescein angiography showed immediate and dramatic restoration in flow past the obstructed arteriole in all patients. Patient 2 developed subretinal hemorrhage, which after vitrectomy and associated procedures the acuity improved to 20/25 at 22 days after the TYE. Final BCVA was 20/30, 20/25, 20/40, 20/30, and 20/40. Conclusion: TYE is a treatment modality to be considered in patients with BRAO who present acutely with severe vision loss and a visible embolus. The risks of TYE must be weighed against the possibility of severe and permanent loss of vision secondary to BRAO.

Eccentric macular holes after vitrectomy with peeling of epimacular proliferation.

Purpose: To describe six patients (six eyes) who developed an eccentric macular hole after surgery for idiopathic epimacular proliferation. Methods: In a retrospective review of 631 consecutive patients who underwent vitrectomy with peeling of the epimacular proliferation and in most cases the internal limiting membrane (ILM) from May 2001 to May 2005, 6 patients were found to have developed an eccentric macular hole postoperatively. Results: Eccentric macular holes developed 9 days to 8 months (mean, 3.1 months) after epimacular proliferation peeling. The ILM was peeled in addition to the epimacular proliferation in five of the six cases. Of the six eccentric macular holes, four were located temporal to the fovea, one was located superior to the fovea, and one was located nasal to the fovea. Final visual acuities after a mean follow-up period of 17.3 months were 20/20 in 2 eyes, 20/25 in 1 eye, 20/40 in 2 eyes, and 5/200 in 1 eye. The eye with the eccentric macular hole nasal to the fovea had the poorest final visual acuity of 5/200. Conclusion: Eccentric macular hole occurring after vitrectomy to remove epimacular proliferation is an uncommon postoperative finding. To our knowledge, this is the largest case series of such patients reported. Various explanations have been suggested for the etiology of these holes, but there remains no consensus.

Ocular neovascularization in eyes with a central retinal artery occlusion or a branch retinal artery occlusion

Purpose To investigate the ocular neovascularization (ONV) rate in eyes with a branch retinal artery occlusion (BRAO) or a central retinal artery occlusion (CRAO), and to study factors that may influence the ONV rate secondary to CRAO. Methods This was a retrospective case series of consecutive patients (286 total eyes: 83 CRAOs and 203 BRAOs) who were diagnosed with a retinal artery occlusion from 1998 to 2013 at the Retina Consultants of Alabama and University of Alabama at Birmingham, Birmingham, AL, USA. Generalized estimating equations were used to evaluate the association between hypothesized risk factors and ONV development. Results Twelve (14.5%) of the 83 eyes with a CRAO developed ONV. Eleven of 12 eyes (91.7%) had iris neovascularization, ten of 12 eyes (83.3%) had neovascular glaucoma, and two of 12 eyes (16.7%) had neovascularization of the optic disc. The average time for ONV development secondary to CRAO was 30.7 days, ranging from the date of presentation to 137 days. Only two (<1.0%) of the 203 eyes with a BRAO developed iris neovascularization. Diabetes mellitus type 2 was a risk factor for ONV development following a CRAO with an adjusted odds ratio of 5.2 (95% confidence interval: 1.4–19.8) (P=0.02). Conclusion ONV is an important complication of CRAO and is a less-frequent complication of BRAO. Patients with a CRAO, especially those with diabetes mellitus type 2, should be closely monitored for the first 6 months for ONV.

Nonsupine positioning is preferred by patients over face-down positioning and provides an equivalent closure rate in 25- and 23-gauge macular hole surgery.

PURPOSE Strict face-down positioning after macular hole surgery is very difficult for most patients. Our study seeks to determine if alleviated positioning (avoidance of supine positioning) has equivalent successful closure rates when compared with face-down positioning. A patient survey was also performed to determine patient preference. METHODS A single-center retrospective review of patients undergoing macular hole repair with a questionnaire completed by each patient after air bubble clearance summarizing the two postoperative scenarios. Patients were asked which positioning strategy they would choose if they were having repeat surgery. Eighty-two patients undergoing pars plana vitrectomy with primary full-thickness macular hole repair were identified. Repair was performed with either 3 days of strict face-down positioning (57 of 82 patients) or with the avoidance of supine positioning (25 of 82 patients) but no required face-down positioning. RESULTS The anatomical success rates were similar between the 2 groups with 96% of final hole closure (55/57) in the face-down group versus 100% (25/25) in the nonsupine group. Macular hole size appeared to be similar between the 2 groups (a mean of 408 μm in face-down group vs. that of 483 μm in nonsupine group, with a median of 400 in both groups). Patient preference was in favor of less stringent nonsupine postoperative requirements. Although 100% (25/25) of the nonsupine group would opt for the same strategy with repeat surgery, only 51% (29/57) of the face-down group would opt for face-down positioning with repeat surgery (P < 0.001). CONCLUSION This study demonstrates equivalent closure rates among the patients who were assigned nonsupine versus face-down positioning postoperatively for macular hole repair, and that most patients would prefer to avoid strict face-down positioning if reoperated.