Nauman A Chaudhry

Emerging ciprofloxacin-resistant Pseudomonas aeruginosa

PURPOSE To report a clinical series of ciprofloxacin-resistant ocular isolates of Pseudomonas aeruginosa from a tertiary care ophthalmic center. METHODS Review of in vitro sensitivities of all ocular isolates of P. aeruginosa be tween July 1991 and September 1998. In vitro resistance was defined as a minimum inhibitory concentration of 4 or more microg per ml. RESULTS Nine of 423 ocular isolates of P. aeruginosa showed in vitro resistance to ciprofloxacin. From 1991 to 1994, 0.44% (1/227) of ocular isolates were resistant to ciprofloxacin, whereas from 1995 to 1998, 4.1% (8/ 196) of ocular isolates showed in vitro resistance (P = .014). CONCLUSIONS Ciprofloxacin-resistant P. aeruginosa has been identified in recent clinical ocular specimens. Ciprofloxacin resistance among ocular isolates of P. aeruginosa is a local and worldwide concern.

Intravitreal antiviral injections as adjunctive therapy in the management of immunocompetent patients with necrotizing herpetic retinopathy

PURPOSE To report the use of intravitreal antiviral injections as adjunctive therapy in the management of three immunocompetent patients with necrotizing herpetic retinopathy. METHOD Case series. RESULTS Three patients with necrotizing herpetic retinopathy received intravitreal antiviral injections for treatment of progressive retinitis, despite standard intravenous acyclovir therapy. The retinitis resolved and visual acuity improved after a minimum of 6 months of follow-up in each case. CONCLUSION Intravitreal antiviral injections may be a safe and efficacious adjunctive therapy in the management of patients with necrotizing herpetic retinopathy.

Intraoperative echographic localization of iodine-125 episcleral plaque for brachytherapy of choroidal melanoma.

PURPOSE To report intraoperative echographic localization of iodine-125 episcleral plaque for brachytherapy of choroidal melanoma. METHODS In a retrospective study, 117 eyes with medium-sized choroidal melanoma in 117 patients not participating in the Collaborative Ocular Melanoma Study underwent iodine-125 episcleral plaque radiotherapy with intraoperative echographic verification of plaque placement between January 1992 and December 1998 at the Bascom Palmer Eye Institute. RESULTS After initial plaque placement using standard localization techniques, intraoperative echography demonstrated satisfactory tumor-plaque apposition in 76% of eyes (89 of 117). In the 28 eyes (28 of 117, 24%) that required repositioning of the plaque, the extent of misplacement was less than 1 mm in 10 eyes, 1.1 to 3.0 mm in six eyes, and greater than 3 mm in eight eyes. Two eyes had tilting of the plaque, and in two additional eyes, although the plaque covered all tumor margins, the centration was considered suboptimal. Repositioning was necessary in 1 eye with an anteriorly located tumor (1 of 13, 7.7%) and in 20 eyes with peripapillary or posterior pole tumors (20 of 67, 26.3%). Anteriorly located tumors required plaque repositioning significantly less frequently than did posteriorly located tumors (P = .041). Misalignment involved one tumor margin in 23 eyes and two margins in five eyes. The most commonly misaligned margins were the lateral (35%) and posterior margins (26%). In no case was an anterior marginal misalignment documented. At a mean follow-up of 37 months, no tumor-related death or metastatic disease was noted. Two of the 117 patients (1.7%) had local tumor recurrence and underwent enucleation. CONCLUSIONS Intraoperative echography is an effective adjunct for localization and confirmation of tumor-plaque relationship. This technique facilitates the identification and correction of suboptimal plaque placement at the time of surgery, potentially minimizing treatment failures.

Endogenous endophthalmitis caused by histoplasma capsulatum var. capsulatum: A case report and literature review

OBJECTIVE We report the first case of clinically diagnosed endogenous endophthalmitis caused by Histoplasma capsulatum var. capsulatum in a patient with the acquired immune deficiency syndrome. DESIGN Interventional case report and literature review. INTERVENTION Pars plana vitrectomy and scleral buckling procedure in the left eye with intravenous and intravitreal amphotericin in both eyes. MAIN OUTCOME MEASURES The clinical features, culture results, visual outcome, and complications were studied. RESULTS This case demonstrates a bilateral endophthalmitis with severe subretinal exudation, choroidal granulomas, and intraretinal hemorrhage leading to exudative bilateral retinal detachments. Vitreous cultures grew H. capsulatum var. capsulatum. Treatment consisted of intravenous amphotericin, intravitreal amphotericin (both eyes), pars plana vitrectomy (left eye), and scleral buckling procedure (left eye) with resulting counting fingers vision (right eye) and 20/300 (left eye). Four cases of Histoplasma endophthalmitis have been reported previously, all of which had a documented history of disseminated histoplasmosis and resulted in enucleation. CONCLUSIONS H. capsulatum should be considered a possible etiologic agent of endophthalmitis, especially in patients with a history of disseminated histoplasmosis and/or immune deficiency.

Retinal detachment associated with macular hole surgery: characteristics, mechanism, and outcomes.

OBJECTIVE To study the frequency, features, and outcomes of retinal detachment (RD) occurring after macular hole surgery. METHODS Retrospective review of all cases of macular hole surgery. Cases with postoperative RD were identified for study. Outcome measures included baseline demographic and ocular characteristics, RD features, surgical procedure, macular hole status, and final visual and anatomic outcomes. RESULTS Retinal detachment occurred in 8 (1.8%) of 438 eyes undergoing macular hole surgery. The rate of RD was 3.5% early in the course of the surgeons experience (first 200 cases) and 0.4% later in the surgeons experience (after 200 cases) (P = 0.026). Two of the eight eyes with RD had undergone previous macular hole surgery. All six primary cases occurred after repair of stage 3 macular holes, which had involved peeling of the posterior cortical face. The RD involved the inferior quadrants in seven eyes and the macula in two eyes. The pathogenic retinal break was in the equatorial region in four eyes, was anterior to the equator in two eyes, and remained undetermined in two eyes. The retina was attached and the macular hole was closed in all cases at the final follow-up examination (mean 30 months). The macular hole reopened 2 years following successful reattachment of the RD in one eye. Final visual acuity was > or =20/60 in four eyes and <20/200 in one eye. CONCLUSION Retinal detachment after macular hole surgery is uncommon, and may be related to posterior cortical vitreous stripping. Early detection of RD minimizes adverse visual and anatomic outcomes.

Combined pars plana vitrectomy and lens management in complex vitreoretinal disease

Concurrent cataract and vitreoretinal disorders are relatively common. Additionally, a considerable number of phakic eyes develop visually significant cataract following pars plana vitrectomy. The ophthalmic literature is replete with reports of a combined procedure consisting of simultaneous cataract extraction, intraocular lens implantation, and pars plana vitrectomy to treat a wide range of vitreoretinal disorders and co-existing cataracts. Historical concerns of increased risk of complications with the combined procedure have been shown not to be clinically significant. The combined procedure offers the advantages of a single procedure, including faster recovery time and cost effectiveness. Earlier reports of the combined procedure describe pars plana lensectomy and extracapsular cataract extraction as techniques for cataract extraction. Currently, phacoemulsification with implantation of a foldable posterior intraocular lens implantation has become the preferred technique of cataract removal. With advances in instrumentation and surgical techniques, the combined procedure offers a safe and effective way to manage concurrent cataract and complex vitreoretinal disease.

Combined cataract surgery and vitrectomy for recurrent retinal detachment.

Purpose: To report our experience with combined cataract surgery, posterior chamber intraocular lens implantation, and pars plana vitrectomy in the management of recurrent retinal detachment (RD) and visually significant cataract. Methods: Retrospective chart review of patients with cataract and recurrent RD who underwent combined cataract extraction, posterior chamber intraocular lens implantation, and pars plana vitrectomy between January 1991 and September 1998 at the Bascom Palmer Eye Institute. Sixteen eyes were included. All eyes had visually significant cataract and had undergone primary repair of the RD with encircling scleral buckle; eight eyes also had undergone pars plana vitrectomy during the primary repair. The technique of cataract extraction included phacoemulsification (10 eyes), extracapsular cataract extraction (5 eyes), and pars plana lensectomy (1 eye). All eyes underwent pars plana vitrectomy, membrane peeling, fluid‐air exchange, endolaser treatment, and placement of a retinal tamponade. Perfluoropropane (C3F8) gas was used in 14 eyes, and silicone oil was placed in two eyes. Results: The postoperative follow‐up interval ranged from 4 to 64 months (mean, 16 months). Preoperative visual acuity ranged from 20/60 to hand motions and was better than 20/200 in 3 (19%) eyes. Postoperatively, 9 (56%) eyes improved to better than 20/200. Anatomic success was achieved after the initial reoperation in 13 (81 %) eyes. With further surgery, the overall success rate was 94%. Conclusions: Combined cataract surgery, posterior chamber intraocular lens implantation, and pars plana vitrectomy in selected patients with cataract and recurrent RD was successful in improving visual acuity and achieving retinal reattachment in most of these reoperated patients.

Combined lensectomy, vitrectomy and scleral fixation of intraocular lens implant after closed-globe injury.

PURPOSE To describe our experience in the surgical management of cataracts in patients with complications of closed-globe injury using pars plana lensectomy (PPL), pars plana vitrectomy (PPV), and scleral fixation of posterior chamber intraocular lens (PCIOL). METHODS We retrospectively reviewed charts of all patients with closed-globe injury who underwent PPL, PPV and scleral fixation of PCIOL at our institution between January 1991 and July 1997. We identified 28 eyes; because of less than 2 weeks follow-up, 4 eyes were excluded from the current study. All eyes had lens subluxation/dislocation and visually significant cataract. Additional indications for surgery included secondary glaucoma (10 eyes), vitreous hemorrhage (3 eyes) and retinal detachment (1 eye). RESULTS The postoperative follow-up interval ranged from 6 to 61 months (mean 18.5 months). Preoperative visual acuity (VA) ranged from 20/60 to hand motion and was 20/100 or better in 6 eyes (25%). Postoperatively, 19 eyes (79%) improved to 20/100 or better. Five eyes had subsequent surgery for the following indications: retinal detachment (2 eyes), poorly controlled glaucoma (2 eyes), and epiretinal membrane formation (1 eye). CONCLUSIONS In patients undergoing PPL, PPV and scleral fixation of PCIOL for cataract after a closed-globe injury, a substantial visual improvement occurred in a majority of the involved eyes.

Preoperative use of tissue plasminogen activator for large submacular hemorrhage.

BACKGROUND AND OBJECTIVE Tissue Plasminogen Activator (TPA) has been used as an adjunct in the surgical removal of submacular hemorrhage. It is usually used intraoperatively, but may not provide enough time for effective fibrinolysis, especially for a large hemorrhage. The present study was conducted to evaluate the efficiency and safety of preoperative use of TPA for large submacular hemorrhages. METHODS Five eyes with large submacular hemorrhage secondary to age-related macular degeneration underwent subretinal injection of TPA in the office 24 hours before surgery. All hemorrhages were less than seven days old and at least 3 mm thick. RESULTS Preoperative visual acuity ranged from counting fingers to hand motion (HM). Patient follow-up ranged from 3 months to 24 months (mean, 11 months). Final visual acuity ranged from 20/30 to HM. Four of the five eyes (80%) showed improved visual acuity after surgery and 3/5 (60%) attained visual acuity of 20/200 or better. CONCLUSION Preoperative use of TPA for drainage of large submacular hemorrhage appears to be safe and may result in efficient clot removal. The true efficacy of TPA in the treatment of submacular hemorrhage can only be proven by a prospective randomized trial.

Outcomes of cataract surgery in patients with neovascular age-related macular degeneration in the era of anti-vascular endothelial growth factor therapy

PURPOSE: To evaluate the visual outcomes, choroidal neovascular complex status, and adverse events in patients with visually significant cataract and neovascular age‐related macular degeneration (AMD) who had cataract surgery. SETTING: Private practices, Beverly Hills, California, and New London, Connecticut, USA. DESIGN: Case series. METHODS: Data were abstracted from the medical records of patients with neovascular AMD treated by anti‐vascular endothelial growth factor (anti‐VEGF) therapy who had cataract surgery. The main outcome measures were Snellen corrected distance visual acuity (CDVA), perioperative adverse events, and status of the choroidal neovascular complex. RESULTS: The study enrolled 30 eyes of 28 patients. The CDVA was 20/40 or better in 10% of eyes preoperatively and 40% postoperatively; 20/50 to 20/100 in 53% and 33%, respectively; and 20/200 or worse in 37% and 27%, respectively. The change in CDVA from preoperatively to postoperatively was statistically significant, with a mean change of 0.22 logMAR ± 0.27 (SD) at 2 months (P<.0001), 0.22 ± 0.36 logMAR at 6 months (P=.001), and 0.17 ± 0.54 logMAR at the last follow‐up (P=.01). Patients received a mean of 0.32 injections per month postoperatively compared with 0.49 injections per month preoperatively. Perioperative macular adverse events did not occur in any eye. CONCLUSIONS: With regular evaluations and appropriate treatment with anti‐VEGF agents, cataract surgery did not appear to be associated with an increased incidence of perioperative complications or macular adverse events. Financial Disclosures: Dr. Tabandeh is a consultant/advisor to Alcon and Allergan. Dr. Boyer is a consultant/advisor to Alcon, Allergan, Genentech, Regeneron, Novartis, Pfizer, and Optos and has received lecture fees from Allergan, Alcon, Genentech, and Pfizer. No other author has a financial or proprietary interest in any material or method mentioned.