Mitchell S. Fineman

Arteriovenous adventitial sheathotomy for the treatment of macular edema associated with branch retinal vein occlusion

PURPOSE To report arteriovenous adventitial sheathotomy for treatment of macular edema associated with branch retinal vein occlusion. METHODS Case reports with review. Five eyes of five patients with best-corrected visual acuity of less than 20/200 secondary to branch retinal vein occlusion had pars plana vitrectomy and arteriovenous adventitial sheathotomy and were followed postoperatively for a mean of 6.5 years (range, 5 to 7 years). RESULTS In four of five eyes, the best-corrected visual acuity improved to 20/30 to 20/70. In the remaining eye, visual acuity remained at finger counting secondary to macular ischemia. CONCLUSION Arteriovenous adventitial sheathotomy may be beneficial for select patients with poor vision secondary to branch retinal vein occlusion.

A New Approach to an Old Problem

A patient with progressive visual loss was found to have an optic nerve sheath meningioma. The patient was treated with stereotactic radiotherapy, a computer-guided stereotactic technique that minimizes the risk of radiation-induced optic neuropathy. Six months after treatment, the patient was doing well and showed no signs of radiation-induced optic neuropathy.

Intravitreal bevacizumab (avastin) in central retinal vein occlusion.

Purpose: To describe the effects of intravitreal bevacizumab in eyes with macular edema resulting from central retinal vein occlusions (CRVO). Methods: Retrospective consecutive case series of patients diagnosed with macular edema from CRVO who received intravitreal bevacizumab. Results: Thirty eyes of 29 patients with an average age of 72 years (range, 54–87 years) had intravitreal bevacizumab injections. Mean follow-up was 18.1 weeks. Initial mean visual acuity was 20/394. At the 1- and 2-month follow-up, mean visual acuity improved to 20/237 (n = 26, P = 0.04) and 20/187 (n = 21, P = 0.008), respectively. At the 3- and 4-month follow-up, visual acuity improved from 20/228 to 20/157 (n = 15, P = 0.05) and from 20/313 to 20/213 (n = 11, P = 0.03), respectively. No significant changes in visual acuity were found after 4 months though the number of patients in this group was small. Duration of treatment effect following an injection appears to be limited to 2 months for most patients. No ocular or systemic adverse reactions were noted. Conclusions: The visual benefits of intravitreal bevacizumab for macular edema due to CRVO are apparent early but are not sustained without repeated injections. Larger clinical studies with long-term follow-up will be necessary to better elicit the best regimen for this therapy.

Ultrasound biomicroscopy as a tool for detecting and localizing occult foreign bodies after ocular trauma

OBJECTIVE To show the utility of ultrasound biomicroscopy (UBM) in imaging small ocular foreign bodies of the anterior segment. DESIGN Retrospective case series. PARTICIPANTS Twelve eyes of 12 consecutive patients evaluated in the emergency department or referred to specialty services at 1 institution between August 1994 and November 1997 were examined. INTERVENTION Ocular ultrasound biomicroscopy was performed. MAIN OUTCOME MEASURES Detection and localization of an ocular foreign body were measured. RESULTS An intraocular or superficial foreign body was detected by UBM in 9 (75%) of 12 eyes. The foreign body was classified as corneal in two eyes, subconjunctival in two, intrascleral in three, and intraocular in two eyes. The foreign body was not visible by ophthalmic physical examination in seven of the nine eyes with a confirmed ocular foreign body. In the remaining two eyes, UBM was used to determine the depth of a visible foreign body. In three of the eyes with a confirmed foreign body, computed tomography and/or contact B-scan ultrasonography was obtained and failed to show a foreign body. Six of the foreign bodies were nonmetallic. CONCLUSIONS Clinical detection of ocular foreign bodies after trauma can be hindered by small size, haziness of the optical media, poor patient cooperation, or hidden location. Ultrasound biomicroscopy is a valuable adjunct in the evaluation of suspected ocular foreign bodies, especially in cases involving small, nonmetallic objects.

Hypotony after 25-gauge vitrectomy using oblique versus direct cannula insertions in fluid-filled eyes.

Purpose: To compare intraocular pressure (IOP) and rates of postoperative hypotony with 25-gauge pars plana vitrectomy (PPV) without tamponade using oblique versus direct cannula insertions. Methods: A prospective consecutive series of eyes that underwent 25-gauge PPV without tamponade using an oblique cannula insertion technique was compared with a historical consecutive series of eyes that underwent 25-gauge PPV without tamponade using direct cannula insertions. IOP was recorded before surgery, on postoperative day 1, and on postoperative week 1. Results: Ninety-five eyes had 25-gauge PPV without tamponade, 55 with oblique cannula insertions and 40 with direct insertions. With oblique insertions, there was no statistically significant difference between mean IOPs measured before surgery, on postoperative day 1, and on postoperative week 1. Only 1 (1.8%) of the 55 eyes had hypotony (IOP, ≤5 mmHg) on postoperative day 1. With direct insertions, mean postoperative day 1 IOP was significantly lower than mean preoperative IOP (P = 0.009). Mean preoperative and postoperative week 1 IOPs were similar. Four (10%) of 40 eyes had hypotony on postoperative day 1. Conclusions: Oblique cannula insertions may be superior to direct cannula insertions for lowering rates of absolute and relative postoperative day 1 hypotony in 25-gauge PPV without tamponade.

Melanocytomalytic glaucoma in eyes with necrotic iris melanocytoma.

OBJECTIVE Iris melanocytoma, although histologically benign, may undergo spontaneous necrosis with the resultant pigment dispersion causing secondary open-angle glaucoma. The authors describe the clinical findings in three patients with this syndrome and review the current literature. DESIGN The study design was a small case series. PARTICIPANTS Three patients with secondary glaucoma caused by a necrotic iris melanocytoma participated. INTERVENTION Clinical records and pathologic preparations were reviewed. The diagnosis of iris melanocytoma was confirmed by histopathologic examination in all three cases. RESULTS All patients had intrinsically pigmented localized iris tumors and pigmentation of the angle. Hyperchromic heterochromia iridum was noticeable in all patients. In two instances, a central crater in the lesion signified tumor necrosis. Two patients were treated successfully by surgical resection of the iris tumor and the glaucoma resolved. One patient was treated with enucleation. In all patients, histopathologic analysis disclosed extensively necrotic tumor comprised of maximally pigmented nevus cells with bland nuclei and infiltration of the trabecular meshwork by melanophages. CONCLUSION Secondary glaucoma may result from obstruction of the trabecular meshwork with necrotic iris melanocytoma. Resection of the tumor may relieve the glaucoma.

Branch Retinal Artery Occlusion as the Initial Sign of Giant Cell Arteritis

PURPOSE To describe a patient whose initial sign of giant cell arteritis was a branch retinal artery occlusion. METHODS We examined a 77-year-old woman who developed arteritic anterior ischemic optic neuropathy three weeks after an isolated non-embolic branch retinal artery occlusion occurred in the same eye. RESULTS The diagnosis of giant cell arteritis was confirmed by temporal artery biopsy after the patient was treated with intravenous corticosteroids. CONCLUSIONS Although a rare cause of branch retinal vascular occlusion, giant cell arteritis should be considered in the differential diagnosis of a non-embolic branch retinal artery occlusion in elderly patients.

Efficacy of intravitreal ocriplasmin on vitreomacular traction and full-thickness macular holes.

PURPOSE To analyze a single centers experiences with ocriplasmin on vitreomacular traction (VMT) and the rate of VMT release, full-thickness macular hole (full-thickness MH) closure, and best-corrected visual acuity (BCVA) changes. DESIGN Retrospective interventional case series. METHODS Single-center study of 58 eyes of 56 patients who received intravitreal ocriplasmin for VMT with or without full-thickness MH. VMT release, full-thickness MH closure, visual acuity changes, and anatomic characteristics on spectral-domain optical coherence tomography (SD OCT) were analyzed. RESULTS VMT resolved in 29 of 58 eyes (50%) and nonsurgical closure of full-thickness MH was achieved in 4 of 15 eyes (27%). Mean logMAR BCVA among all treated eyes improved from 0.51 (20/65) at baseline to 0.36 (20/46) at final follow-up (P = .0018) with mean follow-up of 8.7 months. When compared to eyes without VMT release, eyes with successful vitreomacular release had a better pretreatment BCVA (20/48 vs 20/89, P = .004) and final follow-up BCVA (20/31 vs 20/68, P = .0001). Improvement in BCVA was significant in eyes with VMT release (P = .0001). Transient ellipsoid zone changes were noted in 26% of treated eyes (n = 15), of which 14 had successful VMT release. Transient subfoveal fluid accumulation was noted in all these patients with vitreomacular release. Mean time to resolution of ellipsoid zone changes was within 38 days. CONCLUSION In clinical practice, intravitreal injection of ocriplasmin achieved VMT release in approximately one half of treated eyes, with a 27% closure rate for full-thickness MH. Transient ellipsoid changes were evident in 26% of treated eyes, more common in eyes with successful VMT release.

Short-term outcomes of 25-gauge vitrectomy with silicone oil for repair of complicated retinal detachment.

Purpose: To investigate the short-term outcomes of 25-gauge pars plana vitrectomy (PPV) in 18 cases of complicated retinal detachment requiring silicone oil tamponade. Methods: In this retrospective noncomparative review, the primary outcome measures included postoperative anatomical status, preoperative and postoperative visual acuity and intraocular pressure (IOP), cataract progression, development of keratopathy, and other complications. The average follow-up was 5 months (142 days). Results: Thirteen (72.2%) of 18 patients had attachment postoperatively. There was no difference between preoperative visual acuity and visual acuity at the end of follow-up (P = 0.851). One patient (5.6%) who underwent concomitant penetrating keratoplasty had hypotony (IOP, <6 mmHg) postoperatively and until the end of follow-up. Ocular hypertension in two patients was controlled with antiglaucoma drops. Five (55.6%) of 9 patients who were initially phakic underwent cataract extraction or had documented cataract progression. There were no cases of keratopathy or endophthalmitis. Four patients had intraocular or retinal hemorrhage. Two patients developed significant macular epiretinal membranes, and one developed a parafoveal hole. Conclusions: Sutureless 25-gauge PPV with silicone oil is a relatively safe and comparable alternative to 20-gauge PPV with silicone oil for repair of complicated retinal detachment.

Bimanual assisted eyelid retraction technique for intravitreal injections.

Purpose: To describe an alternative technique for avoiding contact with the lids and eyelashes without the use of a metal lid speculum along with the results in clinical practice. Methods: Retrospective review of the medical records of all patients undergoing intravitreal injections of bevacizumab and ranibizumab with lid retraction achieved by bimanual assisted eyelid retraction between November 2010 and December 2011. Results: A total of 10,164 consecutive intravitreal injections were performed, of which 3,834 were bevacizumab and 6,330 were ranibizumab. In this cohort of patients, 3 suspected cases of endophthalmitis developed (2 culture-negative), corresponding to a rate of 0.03%. Conclusion: The technique of bimanual assisted eyelid retraction for intravitreal injection has a low rate of infection similar to the reported rates using a metal lid speculum.