Michael Fielden

Acute intraocular inflammation following intravitreal injection of bevacizumab--a large cluster of cases.

attended our clinic for routine control. Visual acuity of the right eye had decreased from 20 ⁄ 20 to 25 ⁄ 30 over the last year, the left eye was 20 ⁄ 20. Funduscopy revealed moderate NPDR and retinal thickening originating from the upper vessel arcade extending into the macular region. On fluorescein angiograpy, significant exudation was present in this area. Therefore, focal macular laser photocoagulation for clinically significant macular oedema was performed on the right eye utilizing Navilas. Treatment was preplanned on the software system based on colour fundus imaging (Fig. 2A). Navigated, semi-automatic pattern laser application was conducted without complications (laser settings: spot size: 100 lm, time 100 ms, energy 80–100 mW). One week after treatment, Navilas fundus imaging and spectral-domain optical coherence tomography of the treated areas were conducted, and confirmed laser application to the preplanned area (Fig. 2B and C). A 69-year-old man with a longstanding history of type 2 diabetes and NPDR presented with a decrease of vision of his right eye. Visual acuity had decreased from 20 ⁄ 30 to 10 ⁄100 during the last month; visual acuity on the left eye was 25 ⁄ 30. Clinical examination revealed PDR with multiple areas of peripheral retinal neovascularisation and a mild vitreous haemorrhage on the right and moderate NPDR on the left eye. Panretinal full scatter photocoagulation (usually applied over 3–4 sessions at our institution) was suggested as a treatment for the right eye. However, the first treatment session using a conventional 532 -nm slitlamp-based laser and a standard contact lens (‘TransEquator’ by Volk, USA) had to be aborted after 50 laser spots. The patient did not agree to continue treatment, as he could not tolerate the contact lens and felt significant pain from retinal laser application. One week later, panretinal pattern photocoagulation using the Navilas laser device was conducted. Because of the optical design of the device, laser treatment can be applied either with or without the use of a contact lens. Although currently not recommended by the manufacturer in selected cases, such as in patients with corneal irritations or blepharospasm, it might be advantageous to not apply a contact lens. In the current case – without a contact lens – during one session, 59 times a 5 · 5-spot pattern, resulting in 1475 single laser effects, could be applied to the peripheral retina (laser settings, 5 · 5-squared laser patterns; spot size, 200 lm; time, 30 ms; energy, 220 mW; overall treatment time, 7 min 24 second). During and after treatment, the patient reported no significant pain and tolerated treatment well. One week after treatment, widefield fundus imaging of the treated areas was conducted and confirmed laser application and clearing of vitreous haemorrhage (Fig. 2D).

A case of isolated Susac occlusive retinal vasculitis.

Susac syndrome is characterized by encephalopathy, sensorineural hearing loss, and branch retinal artery occlusion. Additional ocular findings include arteriolar wall hyperfluorescence and Gass plaques. We present a 51-year-old Caucasian woman with ophthalmologic findings indicative of Susac syndrome in the setting of tinnitus and migraine with aura.

Treatment of ocular metastasis with anti-VEGF: A literature review and case report

PURPOSE This is the first case report where 1.25mg intravitreal bevacizumab (IVB) correlated with choroidal mass resolution from metastatic breast cancer given concurrently with chemotherapy demonstrating, at best, disease stability in other organs. STUDY DESIGN Case report. METHODS Upon confirmation of choroidal, liver and bone metastasis from breast carcinoma, a 72-year-old female received four intravitreal bevacizumab 1.25mg injections based on the presence of subretinal and intraretinal fluid. Visual outcomes were analyzed by ophthalmologic evaluation, B-scan, fluorescein angiography, and optical coherence tomography. RESULTS After 3 treatments of 1.25mg intravitreal bevacizumab, visual acuity improved from 20/125 OD to 20/30 OD. These results were maintained for 5 months, after which a 4th IVB injection was given to try to further improve visual outcomes. Following this, complete resolution of the mass was observed with remaining pigmentary changes and vision improved to 20/25 one month following this. IVB was administered concurrently to systemic chemotherapy that demonstrated at best disease stability in metastases in other organs. CONCLUSION In this case 1.25mg intravitreal bevacizumab proved to be a safe, effective and relatively easy treatment for choroidal metastasis from breast cancer. An important benefit of intravitreal bevacizumab therapy for choroidal metastasis is the ease of administration and minimal time commitment required as compared to other therapies. Further studies should be conducted to confirm the appropriate dosing and long-term outcomes of intravitreal bevacizumab to treat choroidal metastasis.

Effects of malicious ocular laser exposure in commercial airline pilots

OBJECTIVE Intentional malicious laser strikes on commercial pilots are committed by individuals who target a laser into airplane cockpits during takeoff and landing. Because laser exposure to pilots is a relatively new but growing occurrence, our study investigates the ocular effect of this laser exposure in pilots. DESIGN Retrospective chart review by a single ophthalmologist. PARTICIPANTS All commercial airline pilots (58 male, 3 female) who experienced a laser strike while flying between April 2012 and November 2014 who presented to our clinic were included. METHODS A retrospective chart review was performed in a retinal specialists practice. Ocular assessment was performed within 3 days of laser exposure. A complete ophthalmic evaluation was conducted, including Early Treatment Diabetic Retinopathy Study visual acuity, colour vision, visual fields, intraocular pressure, slit-lamp examination, dilated fundus examination, colour fundus photographs, and ocular coherence tomography. RESULTS Sixty-four laser strike incidents involving commercial pilots were included. All pilots in the study experienced some degree of immediate ocular irritation or light sensitivity. No definite cases of ocular damage were attributed to laser strikes. No pilot had any functional ocular deficits. CONCLUSIONS Our study revealed that laser strikes on aircraft did not result in permanent visual functional or structural deficits. However, laser strikes cause immediate visual effects, including glare, flash blindness, and ocular irritation that can interfere with a pilots visual function. Given the widespread accessibility of high-power lasers and the rapid increase in incidents, laser strikes threaten to jeopardize aviation safety unless effective preventative measures are put in place.

Lid splinting eyelid retraction technique: a minimised sterile approach for intravitreal injections

Background/aims To describe an alternative technique for avoiding contact with the lids and lashes, without the use of a lid speculum, during intravitreal anti-vascular endothelial growth factor injections. Methods Retrospective case series of all patients undergoing intravitreal injections of bevacizumab and ranibizumab, with the lid splinting retraction technique from January 2010 to December 2015. Injections performed by six vitreoretinal specialists were included. The key preinjection ocular surface preparation includes topical anaesthetic, 5% povidone-iodine and a subconjunctival injection of 2% lidocaine with epinephrine. A second instillation of 5% povidone-iodine is given and the intravitreal injection is then performed. No lid speculum is used. A search of the electronic medical records identified patients diagnosed with postinjection endophthalmitis and charts were reviewed to ensure inclusion criteria were met. The main outcome measure was incidence of postinjection endophthalmitis. Results A total of 78 009 consecutive intravitreal injections were performed, of which 22 207 were bevacizumab and 55 802 were ranibizumab. In this cohort of patients (n=6320), 12 cases of endophthalmitis developed, corresponding to a rate of 0.015%. Conclusions The technique of eyelid retraction for intravitreal injection has a low rate of endophthalmitis, similar to the reported rates using a metal lid speculum. This is beneficial for both the physician and the patient as it minimises patient discomfort as well as the duration of the procedure. To our knowledge, this is one of the largest studies performed to date evaluating intravitreal injection-related endophthalmitis.

Pneumatic Vitreolysis for the Treatment of Symptomatic Vitreomacular Traction: A Prospective Pilot Study

Purpose: The purpose of this study was to determine the efficacy of pneumatic vitreolysis in the treatment of symptomatic focal vitreomacular traction (VMT). Methods: Patients choosing intravitreal gas injection as their preferred treatment for symptomatic VMT were invited to participate in this prospective study; 0.3 mL of perfluoropropane gas was injected. Optical coherence tomography was performed pre-and postprocedure to determine the proportion of eyes showing release of VMT. Results: Nine eyes of nine participants were included in the study, with a mean follow-up of 5.0±1.8 months. Gas injection resulted in the release of VMT in 7 of 9 eyes (78%) during the course of the study. Both eyes in which the VMT failed to release also showed an improvement in central macular anatomy. Mean visual acuity improved from logarithm of the minimum angle of resolution (logMAR) 0.33±0.14 (Snellen equivalent, ∼20/42) to logMAR 0.24±0.21 (Snellen, ∼20/35) at final follow-up (P = .03); 8 of 9 patients (89%) reported a subjective improvement in their presenting symptoms and/or vision during the study period. The mean maximum foveal thickness of 480 ± 22 μm at baseline reduced to 282 ± 94 μm by the time of the final visit (P = .002). Two patients had retinopexy for retinal breaks/suspect breaks. Conclusions: Pneumatic vitreolysis is an effective treatment for symptomatic VMT and may offer cost savings for patients and/or health services.

Intravitreal Anti-VEGF Treatment of Myopic Choroidal Neovascularization: Visual Acuity Improves When Treatment Is Initiated Prior to the Development of Fibrosis or Atrophy

Purpose: To determine whether the presenting clinical features of active myopic choroidal neovascularization (CNV), including the presence of fibrosis or atrophy, limit the ultimate visual acuity gains from intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy. Methods: A retrospective analysis of 42 eyes with new-onset subfoveal CNV was performed. Only patients without concurrent age-related macular degeneration and with a spherical equivalent of at least −6.0 diopters were included in the study. All eyes received either intravitreal ranibizumab or bevacizumab injections as the primary treatment on a pro re nata basis for 1 year. Changes in best-corrected visual acuity (BCVA) and central retinal thickness (CRT) were recorded. Results: The mean number of ranibizumab (18 eyes) or bevacizumab (24 eyes) injections was 4.7 ± 0.5 over a mean follow-up time of 12 ± 0.4 months. The mean age of the patients was 62 ± 2.0 years. Based on optical coherence tomography staging at the initiation of treatment for active CNV, 30 had no fibrosis or atrophy (group 1), 5 had fibrotic stage, and 7 had atrophic stage CNV (the latter combined to form group 2). The BCVA for group 1 improved significantly (P < .02) but worsened for group 2 (P < .38), a statistically significant difference (P < .05). The CRT for group 1 also declined significantly more than for group 2 (P < .014). Conclusion: The presence of fibrosis or atrophy in eyes with active myopic CNV at the initiation of anti-VEGF therapy was associated with limited anatomic outcomes and visual gain.

Hydroxychloroquine-induced retinopathy in a 57-year-old woman

A 57-year-old woman was referred to a retinal specialist with concerns of ocular toxicity from hydroxychloroquine. She complained of blurry vision and flashing lights (photopsia). The patient had been taking 400 mg of hydroxychloroquine daily for 10 years for the management of systemic lupus