Milton F. White

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.

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

Association between retinal thickness measured by spectral-domain optical coherence tomography (OCT) and rod-mediated dark adaptation in non-exudative age-related maculopathy.

Aim To examine associations between retinal thickness and rod-mediated dark adaptation in older adults with non-exudative age-related maculopathy (ARM) or normal macular health. Methods A cross-sectional study was conducted with 74 adults ≥50u2005years old from the comprehensive ophthalmology and retina services of an academic eye centre. ARM presence and disease severity in the enrolment eye was defined by the masked grading of stereofundus photos using the Clinical Age-Related Maculopathy grading system. High-definition, spectral-domain optical coherence tomography was used to estimate retinal thickness in a grid of regions in the macula. Rod-mediated dark adaptation, recovery of light sensitivity after a photo-bleach, was measured over a 20-min period for a 500u2005nm target presented at 5° on the inferior vertical meridian. Main outcomes of interest were retinal thickness in the macula (μm) and parameters of rod-mediated dark adaptation (second slope, third slope, average sensitivity, final sensitivity). Results In non-exudative disease retinal thickness was decreased in greater disease severity; thinner retina was associated with reductions in average and final rod-mediated sensitivity even after adjustment for age and visual acuity. Conclusions Impairment in rod-mediated dark adaptation in non-exudative ARM is associated with macular thinning.

Risk factors for severe vision loss immediately after transpupillary thermotherapy for occult subfoveal choroidal neovascularization.

BACKGROUND AND OBJECTIVEnTo determine risk factors for immediate severe vision loss in patients with age-related macular degeneration after transpupillary thermotherapy for occult subfoveal choroidal neovascularization.nnnPATIENTS AND METHODSnRetrospective review of 84 consecutive patients with age-related macular degeneration who received transpupillary thermotherapy for occult subfoveal choroidal neovascularization. Seven cases had severe vision loss and 77 were controls. All patients were treated with a diode infrared laser. Follow-up was completed on all patients 1, 3, and 6 months after treatment with transpupillary thermotherapy.nnnRESULTSnPretreatment visual acuity ranged from 20/40 to 1/200. Seven of 84 consecutive eyes had an immediate visual acuity loss of 6 or more Snellen lines after transpupillary thermotherapy.nnnCONCLUSIONnTranspupillary thermotherapy has a small but significant risk of immediate severe vision loss in patients with age-related macular degeneration with occult subfoveal choroidal neovascularization. Statistically significant risk factors include a subretinal hemorrhage 5 disc areas or greater in size, 9 disc areas or greater of subretinal fluid, and a laser power greater than 550 mW.

Macular holes associated with diabetic tractional retinal detachments.

BACKGROUND AND OBJECTIVEnEvaluation of surgical treatment of full-thickness macular holes secondary to diabetic tractional retinal detachments was conducted.nnnPATIENTS AND METHODSnA retrospective review of medical records, fluorescein angiograms, fundus photographs, optical coherence tomography images, and operative findings of six consecutive patients with full-thickness macular holes and diabetic tractional retinal detachments was completed. Each eye was treated with pars plana vitrectomy, tractional retinal detachment repair, membranectomy, indocyanine green-assisted internal limiting membrane peeling, and intraocular gas tamponade.nnnRESULTSnSurgical intervention resulted in the closure of all full-thickness macular holes. Mean best-corrected visual acuity was 20/250 preoperatively and 20/100 postoperatively, with all patients having improvement after a mean follow-up of 10 months.nnnCONCLUSIONnClosure of tractional retinal detachments related to full-thickness macular holes can be achieved via pars plana vitrectomy, complete membranectomy, and intraocular gas. Vitrectomy with dissection of proliferative membranes helps to relieve the tractional forces responsible for full-thickness macular hole formation, enabling successful closure of the diabetic full-thickness macular holes and resulting in visual acuity improvement.