Neelakshi Bhagat

Diabetic Macular Edema: Pathogenesis and Treatment

Diabetic macular edema is a major cause of visual impairment. The pathogenesis of macular edema appears to be multifactorial. Laser photocoagulation is the standard of care for macular edema. However, there are cases that are not responsive to laser therapy. Several therapeutic options have been proposed for the treatment of this condition. In this review we discuss several factors and mechanisms implicated in the etiology of macular edema (vasoactive factors, biochemical pathways, anatomical abnormalities). It seems that combined pharmacologic and surgical therapy may be the best approach for the management of macular edema in diabetic patients.

Post-traumatic Infectious Endophthalmitis

Post-traumatic endophthalmitis is an uncommon yet devastating complication of an open globe injury. Risk factors include presence of an intraocular foreign body (IOFB), lens rupture, delayed primary globe repair, rural trauma, and trauma with contaminated objects. Visual prognosis in post-traumatic endophthalmitis is affected by the virulence of the microbe, the presence of a retinal break or detachment, the timing of treatment, the presence or absence of an IOFB, and the extent of initial injury. Treatment should be started emergently with systemic and intravitreal antibiotics. In the setting of penetrating ocular trauma, antibiotic prophylaxis of endophthalmitis should be considered. The best treatment regimen has not been determined. The most frequent prophylactic regimens are: treatment with oral antibiotics, a short course of intravenous antibiotics followed by oral antibiotics, or intravitreal antibiotics plus oral antibiotics.

Vitrectomy with silicone oil infusion in severe diabetic retinopathy

Aims: To determine the results of pars plana vitrectomy (PPV) and silicone oil infusion (SOI) in severe proliferative diabetic retinopathy (PDR). Methods: The records of 23 eyes (21 patients: 12 males, nine females) with PDR who had undergone PPV and SOI were reviewed retrospectively. Results: Average follow up was 5.4 months (range 1–25). Surgical indications were tractional retinal detachment (TRD) (17.4%), traction-rhegmatogenous retinal detachment (TRRD) (8.7%), TRD with vitreous haemorrhage (VH) (48%), TRD with neovascular glaucoma (NVG) (8.6%), TRD with fibrinoid syndrome (FS) (17.3%). With one operation, the retinal reattachment rate was 17/23 (74%). Among these 23 eyes, 11 (48%) had previously failed vitrectomy, and the retina was attached in 8/11 (73%) with a single procedure. With additional surgery employing PPV and SOI, the final reattachment rate was 20/23 (87%). The only cases with intraocular pressure <5 mm Hg had retinal detachment. Postoperative visual acuity (VA) improved in 10 eyes (44%), was unchanged in three (12%), and decreased in 10 eyes (44%). Conclusion: SO tamponade is useful in severely diseased eyes with PDR, even in the presence of rubeosis iridis (RI) and NVG, FS, or in cases with previously failed vitrectomy, especially in the presence of RI.

Complications in resident-performed phacoemulsification cataract surgery at New Jersey Medical School

Aim: To describe the complications related to cataract surgery performed by phacoemulsification technique by third-year ophthalmology residents at New Jersey Medical School, who are trained to perform phacoemulsification without any prior experience with extracapsular extraction. Design: Retrospective, observational case series. Methods: A retrospective chart review of 755 patients who underwent cataract surgery by third-year residents between July 2000 and June 2005 at the Institute of Ophthalmology and Visual Science was performed. Details of intraoperative complications (posterior capsular rupture, vitreous loss, subluxation of lens fragments into the vitreous, extracapsular cases converted to phacoemulsification, retinal detachment, vitreous haemorrhage and haemorrhagic choroidals) of the cases done by phacoemulsification technique were recorded. Results were analysed and compared with complication rates reported from other residency programmes and from experienced ophthalmologists. Results: Of 755 cataract surgeries, 719 were performed using phacoemulsification technique. Posterior capsule disruption occurred in 48 (6.7%), vitreous loss in 39 (5.4%) and dislocated lenticular fragments in 7 (1.0%) of 719 cases that underwent phacoemulsification technique. Subsequent pars plana lensectomy was required in 5 (0.7%) cases; 1 case (0.1%) experienced retinal detachment and haemorrhagic choroidal detachment. Conclusion: The residents can perform phacoemulsification well with a very low complication rate, without prior training with extracapsular cataract extraction technique.

An outbreak of Fusarium keratitis associated with contact lens use in the northeastern United States.

Purpose: To report an outbreak of Fusarium keratitis in contact lens (CL) wearers in the northeastern United States. Methods: Over a 41-month period, all cases with culture-proven corneal ulceration secondary to Fusarium at 2 tertiary care eye centers were identified through the microbiology departments of each institution, and a retrospective review of charts was performed. Statistical analyses were performed to evaluate a possible association of Fusarium keratitis with specific CL and CL solution brands. Results: Fifteen cases of Fusarium keratitis were reported at the 2 tertiary centers between July 2005 and May 2006 (16.4 cases/yr) compared with 6 cases over the previous 30 months from January 2003 to June 2005 (2.4 cases/yr). All 15 of the more recent cases were CL users, and none had a history of trauma. All 15 patients claimed use of ReNu brand contact lens solution when they developed keratitis. Twelve (80.0%) of 15 patients were Acuvue soft contact lens users. Ten (66.7%) of 15 patients used tap water to rinse their contact lens cases. Six (40.0%) of 15 cases have thus far required corneal transplantation. Conclusions: The incidence of corneal ulceration secondary to Fusarium has increased sevenfold over the reported 11-month period at 2 tertiary eye care centers in the northeastern United States compared with the previous 30 months. There seems to be an association between the recent outbreak of Fusarium keratitis among CL users and the use of ReNu contact lens solution. Medical treatment of Fusarium keratitis may be ineffective, and emergent penetrating keratoplasty (PKP) may be required in some patients. CL users and their physicians should reconsider the risks of CL use and discuss proper lens care techniques.

Rifabutin-associated hypopyon uveitis in human immunodeficiency virus–negative immunocompetent individuals

OBJECTIVE To report the occurrence of rifabutin-associated hypopyon uveitis in human immunodeficiency virus (HIV)-negative immunocompetent individuals. DESIGN Retrospective case series. PARTICIPANTS Three HIV-negative subjects on rifabutin and clarithromycin for Mycobacterium avium complex infections with hypopyon uveitis are described. One subject was iatrogenically immunosuppressed because of a prior lung transplant. Two subjects had no known immunosuppressive conditions. INTERVENTION Topical and regional steroid therapy. Discontinuation of rifabutin was required in two subjects. MAIN OUTCOME MEASURES Visual acuity, resolution of hypopyon, anterior uveitis, and vitreitis. RESULTS All subjects had resolution of hypopyon after therapy, two within 24 hours of beginning topical steroids. Vitreitis resolved with the discontinuation of rifabutin in two subjects. Chronic low-grade anterior uveitis and vitreitis were observed in the remaining subject, whose rifabutin dose was lowered but not discontinued because of active Mycobacterium avium complex osteomyelitis. CONCLUSIONS Rifabutin-associated uveitis is well described in HIV-positive individuals, but it has been reported only once in an HIV-negative individual. We report two cases of hypopyon uveitis in immunocompetent individuals and one case in an immunosuppressed HIV-negative individual. All three subjects were receiving concurrent rifabutin and clarithromycin. Awareness that this entity can occur in HIV negative and nonimmunosuppressed individuals and that it can mimic infectious endophthalmitis may spare the subject from an invasive workup of systemic infection.

Gender Differences in Promotion and Scholarly Impact: An Analysis of 1460 Academic Ophthalmologists

OBJECTIVES In recent years, gender differences in academic promotion have been documented within surgical fields. To the best of our knowledge, gender discrepancies in association with scholarly productivity have not been well assessed among academic ophthalmologists. Because research productivity is strongly associated with academic career advancement, we sought to determine whether gender differences in scholarly impact, measured by the h-index, exist among academic ophthalmologists. DESIGN Academic rank and gender were determined using faculty listings from academic ophthalmology departments. h-index and publication experience (in years) of faculty members were determined using the Scopus database. SETTING Academic medical center. RESULTS From assistant professor through professor, the h-index increased with subsequent academic rank (p < 0.001), although between chairpersons and professors no statistical difference was found (p > 0.05). Overall, men had higher h-indices (h = 10.4 ± 0.34 standard error of mean) than women (h = 6.0 ± 0.38 standard error of mean), a finding that was only statistically significant among assistant professors in a subgroup analysis. Women were generally underrepresented among senior positions. When controlling for publication range (i.e., length of time publishing), men had higher h-indices among those with 1 to 10 years of publication experience (p < 0.0001), whereas women had scholarly impact equivalent to and even exceeding that of men later in their careers. CONCLUSION Women in academic ophthalmology continue to be underrepresented among senior faculty. Although women surpass men in scholarly productivity during the later stages of their careers, low scholarly impact during the earlier stages may impede academic advancement and partly explain the gender disparity in senior academic positions.

Management of pseudophakic cystoid macular edema

Pseudophakic cystoid macular edema (PCME) is a common complication following cataract surgery. Acute PCME may resolve spontaneously, but some patients will develop chronic macular edema that affects vision and is difficult to treat. This disease was described more than 50 years ago, and there are multiple options for clinical management. We discuss mechanisms, clinical efficacy, and adverse effects of these treatment modalities. Topical non-steroidal anti-inflammatory agents and corticosteroids are widely used and, when combined, may have a synergistic effect. Intravitreal corticosteroids and anti-vascular endothelial growth factor (anti-VEGF) agents have shown promise when topical medications either fail or have had limited effects. Randomized clinical studies evaluating anti-VEGF agents are needed to fully evaluate benefits and risks. When PCME is either refractory to medical therapy or is associated with significant vitreous involvement, pars plana vitrectomy has been shown to improve outcomes, though it is associated with additional risks.

Twelve-Year Review of Pediatric Traumatic Open Globe Injuries in an Urban U.S. Population

PURPOSE To evaluate the epidemiology, anatomical characteristics, and clinical outcomes of pediatric traumatic open globe injuries and to compare the observed final visual acuity to the expected visual acuity as predicted by the Ocular Trauma Score (OTS). METHODS Retrospective chart review of 89 pediatric patients (89 eyes) with open globe injury presenting between 1997 and 2008. RESULTS Sixty-five patients (73%) were male, average age was 9.7 years, and mean follow-up was 22.6 months. The most common causes of trauma were: accidents (79%), violence (10%), and motor vehicle accidents (9%). Penetrating ocular injury was the most common trauma (54%), followed by blunt rupture (34%). Zone 1 injuries represented 49% of cases, and zones 2 and 3 represented 29% and 21%, respectively. No patient developed endophthalmitis. The average presenting and final visual acuities were logarithm of the minimum angle of resolution 1.927 and 1.401, respectively. Lens trauma was noted in 44 (49%) eyes. Twenty-eight patients (31%) had retinal detachment within 6 months of presentation. Total retinal attachment was achieved in 12 (63%) of 19 eyes undergoing repair. Enucleation was performed in 9 (10%) patients. Final visual acuities were not statistically different from visual acuities predicted by OTS (P > .05). CONCLUSIONS The visual prognosis in pediatric open globe injury is poor. The zone of injury may correlate with poor final visual acuity, risk of retinal detachment, and subsequent need for an enucleation. The final predicted visual acuity correlated well with the observed final visual acuity in these patients.

Diagnostic Value of Clinical Examination and Radiographic Imaging in Identification of Intraocular Foreign Bodies in Open Globe Injury

Purpose To evaluate the diagnostic accuracy of clinical eye examination and radiographic imaging in the identification of intraocular foreign bodies (IOFBs) in open-globe traumatic injuries. Methods This was a retrospective chart review of open-globe traumatic injuries with IOFBs presenting to University Hospital (UH) at New Jersey Medical School between 1998 and 2008. Results A total of 527 patients with traumatic open globe injuries presented to UH, Newark, New Jersey, USA, between 1998 and 2008. Of these, 74 patients had surgically confirmed IOFBs. Mean age of patients with traumatic open globe injury and an IOFB was 33 years (range, 8-69 years); mean follow-up was 17.6 months (range, 1 day–90 months). Foreign bodies were identified as glass (13), metal (58), wood (1), plastic (0), and other (2). There were 24 anterior segment (AS) IOFBs, 45 posterior segment (PS) IOFBs, and 5 noted in both segments. Clinical eye examination at presentation identified an IOFB in 34 (45.6%) of 74 patients. B-scan echography revealed an IOFB in 14 (51.9%) of 27 cases. Computed tomography scan of the orbits identified IOFBs in 56 (94.9%) of 59 cases. Clinical eye examination was performed in all (100%) patients. B-scan was performed only when posterior segment pathology was suspected. Computed tomography scan was performed when an IOFB or orbital fracture was suspected. Conclusions Computed tomography scan was the most reliable method for identifying IOFBs in patients presenting with open globe injuries in comparison to clinical eye examination and B-scan echography. This result was consistent regardless of IOFB location within the globe.