Paris Tranos

Visual function and quality of life following vitrectomy and epiretinal membrane peel surgery

Aim: To investigate the effect of epiretinal membrane (ERM) peel on patients’ health related quality of life (HR-QOL) and to explore the association between self reported HR-QOL and conventional measures of visual function. Methods: The National Eye Institute 25 Item Visual Function Questionnaire (VFQ-25) and the 36 Item Short-Form Health Survey (SF-36) were self administered by 20 patients before and 4 months following surgery. Preoperative and postoperative data collected included logMAR near and distant visual acuity (VA), contrast sensitivity, and metamorphopsia. Questionnaire scores were compared preoperatively and postoperatively and their correlation with traditional methods of visual function evaluation analysed. Results: Postoperatively there was no significant improvement in mean logMAR VA. However, eight (40%) subjects improved by two or more ETDRS lines and nine eyes (45%) reached a final VA of 6/18 or better. Metamorphopsia decreased significantly (p = 0.019) and there was significant improvement in VFQ-25 mean scores for the general vision (p = 0.03), distance activities (p = 0.05), and composite score (p = 0.03). Baseline binocular VA was significantly correlated with baseline VFQ-25 composite score (r = 0.631, p = 0.004). Conclusions: ERM surgery appears to improve patients’ subjective perception of visual function as indicated by higher composite scores in VFQ-25 and improved metamorphopsia in the absence of significant improvement in mean logMAR VA.

The effect of pars plana vitrectomy on cystoid macular oedema associated with chronic uveitis: a randomised, controlled pilot study

Aim: To evaluate the efficacy of pars plana vitrectomy (PPV) in the management of chronic uveitic cystoid macular oedema (CMO). Methods: A prospective, interventional, randomised, controlled, pilot study. 23 eyes of 23 patients with CMO secondary to chronic intermediate or posterior uveitis unresponsive to medical treatment were randomised into a surgical (group S) or medical group (group M). 12 patients in group S underwent PPV as opposed to 11 patients in group M who received systemic corticosteroid and/or immunosuppressive treatment during the study period. The primary outcome measures of the study were change in visual acuity and angiographic appearance of CMO at 6 months. Results: Mean visual acuity in group S improved significantly from 1.0 (0.62) at baseline to 0.55 (0.29) at 6 months following vitrectomy (p = 0.011), with five (42%) eyes reaching vision of 20/40 or better. Conversely, mean visual acuity in group M improved only marginally by 0.03 (0.27) (p = 0.785). CMO after vitrectomy was angiographically improved in four (33%) eyes, remained unchanged in seven (58%) eyes, and deteriorated in one (8%) eye. In the medical group, fluorescein leakage decreased in one eye, did not alter in four eyes, and deteriorated in two eyes. Conclusion: PPV for macular oedema secondary to chronic uveitis despite angiographic improvement in only one third of the patients, seems to have a significant beneficial effect on visual function. This study provides enough evidence to justify a large scale trial which would define the role of vitrectomy in uveitic macular oedema.

Visual perception during phacoemulsification cataract surgery under subtenons anaesthesia

AbstractAim The aim of this study was to record the subjective visual experience of patients during phacoemulsification and intraocular lens implantation under subtenons anaesthesia.Methods Prospective, nonrandomised, cohort, postoperative questionnaire based study. Patients selected underwent routine phacoemulsification and intraocular lens implantation under regional subtenons anaesthesia. χ2 and Fishers exact tests (two-tail) were used to evaluate the data.Results A total of 104 patients were selected, 38 (36.5%) were male and 66 (63.5%) were female. The mean age of patients was 74.0±8.8 years. In all, 87.5% saw light during the operation with 9.6% finding this painful. Photophobia was highest among younger patients (P=0.002). Coloured lights were seen by 56.7% and 13.5% found the visual experience frightening. Frightening visual experiences were significantly associated with the perception of colour (P=0.005) and photophobia (P=0.003). A volume of anaesthetic greater than 4 m was associated with a significant reduction in anxiety as a result of the visual experience (P=0.003). None of the other visual phenomena recorded were associated with a frightening visual experience.Conclusions Patients undergoing regional anaesthesia experience a wide variety of visual sensations during cataract surgery. Perception of colour and volumes of anaesthetic less than 4 m appear to be associated with the visual experience being more frightening. Detailed preoperative counselling is mandatory. It should include comprehensive information about visual perception during the procedure relieving the patients from unnecessary distress.

Resistance to antivascular endothelial growth factor treatment in age-related macular degeneration

Age-related macular degeneration (AMD) is the main cause of visual impairment and blindness in people aged over 65 years in developed countries. Vascular endothelial growth factor (VEGF) is a positive regulator of angiogenesis and its proven role in the pathological neovascularization in wet AMD has provided evidence for the use of anti-VEGF agents as potential therapies. In this study, we review the literature for the possible causes of failure after treatment with anti-VEGF agents and attempt to propose an algorithm of suggestive actions to increase the chances of successful management of such difficult cases.

Same-day versus first-day review of intraocular pressure after uneventful phacoemulsification

Purpose: To compare the incidence and the spectrum of postoperative complications detected when the intraocular pressure (IOP) is reviewed 4 to 6 hours or the day after uneventful phacoemulsification cataract extraction and intraocular lens (IOL) implantation. Setting: Royal Free Hospital, London, United Kingdom. Methods: The study cohort consisted of 141 patients who had uneventful phacoemulsification and IOL implantation under regional (peribulbar/topical) or general anesthesia. Postoperative evaluation of the patients was performed by an ophthalmologist using a standard form at 4 to 6 hours or 24 hours. Results: The mean IOP at 4 to 6 hours and 24 hours was 22.85 mm Hg ± 9.56 (SD) and 19.44 ± 7.04 mm Hg, respectively. The IOP was more likely to be greater than 30 mm Hg when measured on the same day, resulting in a significantly higher intervention rate than on the first day (P = .037). The best corrected visual acuity was significantly better at 24 hours than at the same‐day review (P < .001). There was no significant difference in the extent of anterior chamber activity, patient comfort, or state of the wound between the same‐ or next‐day follow‐up. All patients attended a follow‐up appointment 3 weeks after surgery, had an IOP of 21 mm Hg or less, and were subsequently discharged. Conclusions: The results indicate that moderate IOP spikes (<40 mm Hg) can be left untreated if they are not associated with corneal edema or patient discomfort as they decline spontaneously. Before they are discharged, patients with compromised optic discs or predisposed to retinal or optic nerve pathology should be carefully evaluated the day after surgery to treat IOP elevations.

Long-term follow-up of inflammatory cystoid macular edema.

Purpose: To determine the long-term functional and anatomical outcome of idiopathic uveitic cystoid macular edema (UCME). Methods: A longitudinal retrospective study was undertaken of the medical records of patients with UCME. All individuals were examined in the uveitis Service at the Moorfields Eye Hospital. The main outcome measures were change in visual acuity and anatomical outcome of UCME at diverse time points. Results: A total of 109 eyes (92 patients) with UCME were included in the analysis. Mean follow-up was 60 ± 45 months (median, 48 months). Mean logarithm of the minimum angle of resolution visual acuity 1 month after the intervention improved significantly (P < 0.001) by 0.21 ± 0.27 and maintained at similar levels throughout the follow-up period. Visual acuity at the final follow-up improved in 75 eyes (69%), was deteriorated in 21 eyes (19%), and remained unchanged in 13 eyes (12%). Younger age and better visual acuity at baseline were associated with more favorable visual outcome (P < 0.001). Optical coherence tomography documentation of improvement or total resolution of UCME was observed in 84 eyes (77%) at the final follow-up. Conclusion: Cystoid macular edema is a major complication in uveitis. Current management provides satisfactory long-term results for the majority of those individuals. Visual acuity 1 month after the intervention is usually indicative of the final functional outcome.

Twenty-four hour efficacy of glaucoma medications.

Current medical therapy of glaucoma aims to attain a meaningful and consistent reduction of intraocular pressure (IOP) to a predetermined level of target IOP, which will commensurate with either stability, or delayed progression of visual loss. Glaucoma is a 24-h disease and the damaging effect of elevated IOP is continuous. Therefore, it is reasonable that we should endeavor to identify the true efficacy of currently available and future antiglaucoma medications throughout the 24-h period. This review chapter deals first with the concept and value of diurnal and 24-h pressure monitoring. It then evaluates existing evidence on the 24-h efficacy of medical therapy options. Unfortunately, significant gaps exist in our present understanding of the short-term and particularly the long-term 24-h efficacy of most antiglaucoma medications. More long-term controlled evidence is needed in the future to improve our understanding of the 24-h efficacy of current medical glaucoma therapy, the ideal 24-h target pressure and the precise impact of IOP characteristics upon the different stages of the various forms of glaucoma.

Bilateral diffuse iris atrophy after the use of oral clarithromycin

Abstract Purpose: To report a newly recognised advert event of clarithromycin. Methods: Retrospective, case report. Results: A 30-year old female referred to our centre with bilateral diffuse iris atrophy after the use of oral clarithromycin for a pulmonary infection. Conclusions: Bilateral acute depigmentation of the iris is a new clinical entity. Iris transillumination and sphincter paralysis are recognised adverse effects of oral antibiotic therapy, but to our knowledge no other publication has referred to uveitis-like syndrome due to oral administration of clarithromycin.

Ranibizumab in the Treatment of Diabetic Macular Edema: A Review of the Current Status, Unmet Needs, and Emerging Challenges

Diabetic retinopathy (more specifically diabetic macular edema, DME) is the most common cause of loss of vision in the working population in developed countries. Anti-vascular endothelial growth factor (anti-VEGF) agents considerably changed the treatment algorithms and improved prognosis of center-involving DME. Ranibizumab was the first approved anti-VEGF agent that revolutionized DME treatment. The vast increase in the number of patients undergoing intravitreal treatment and the role of anti-VEGF pharmacotherapy as the mainstay of DME treatment have triggered several challenges. Among them, of considerable interest is the quest for an optimal dosing scheme and the search for combination therapies. Although a significant body of research is directed towards other molecules that could potentially be new therapeutic targets, VEGF inhibition is expected to play an important long-term role in the treatment of DME considering the pathogenesis of the disease. Finally, recent studies revealed that ranibizumab may constitute a significant treatment modality in the management of other diabetic vision-threatening complications including proliferative diabetic retinopathy.

Current Perspectives of Prophylaxis and Management of Acute Infective Endophthalmitis.

Endophthalmitis is an intraocular inflammatory condition which may or may not be caused by infective agents. Noninfectious (sterile) endophthalmitis may be attributable to various causes including postoperative retained soft lens matter or toxicity following introduction of other agents into the eye. Infectious endophthalmitis is further subdivided into endogenous and exogenous. In endogenous endophthalmitis there is hematogenous spread of organisms from a distant source of infection whereas in exogenous endophthalmitis direct microbial inoculation may occur usually following ocular surgery or penetrating eye injury with or without intraocular foreign bodies. Acute infective endophthalmitis is usually exogenous induced by inoculation of pathogens following ocular surgery, open-globe injury and intravitreal injections. More infrequently the infective source is internal and septicemia spreads to the eye resulting in endogenous endophthalmitis. Several risk factors have been implicated including immunosuppression, ocular surface abnormalities, poor surgical wound construction, complicated cataract surgery with vitreous loss and certain types of intraocular lens. Comprehensive guidelines and recommendations on prophylaxis and monitoring of surgical cases have been proposed to minimize the risk of acute endophthalmitis. Early diagnosis and prompt management of infective endophthalmitis employing appropriately selected intravitreal antibiotics are essential to optimize visual outcome.