Paul B. Greenberg

Intravitreal triamcinolone for refractory diabetic macular edema

PURPOSE To determine if intravitreal injection of triamcinolone acetonide is safe and effective in treating diabetic macular edema unresponsive to prior laser photocoagulation. DESIGN Prospective, noncomparative, interventional case series. PARTICIPANTS Sixteen eyes with clinically significant diabetic macular edema (CSME) that failed to respond to at least two previous sessions of laser photocoagulation. METHODS Eyes were diagnosed with CSME and treated with at least two sessions of laser photocoagulation according to Early Treatment Diabetic Retinopathy Study guidelines. At least 6 months after initial laser therapy, the response was measured by clinical examination and optical coherence tomography (OCT). Eyes with a residual central macular thickness of more than 300 microm (normal, 200 microm) and visual loss from baseline were offered intravitreal injection of 4 mg triamcinolone acetonide. The visual and anatomic responses were observed as well as complications related to the injection procedure and corticosteroid medication. MAIN OUTCOME MEASURES Visual acuity and quantitative change in OCT macular thickening were assessed. Potential complications were monitored, including intraocular pressure response, cataract progression, retinal detachment, vitreous hemorrhage, and endophthalmitis. RESULTS All patients completed 3 months of follow-up, and 8 of 16 patients (50%) completed 6 or more months of follow-up. Mean improvement in visual acuity measured 2.4, 2.4, and 1.3 Snellen lines at the 1-, 3-, and 6-month follow-up intervals, respectively. The central macular thickness as measured by OCT decreased by 55%, 57.5%, and 38%, respectively, over these same intervals from an initial pretreatment mean of 540.3 microm (+/-96.3 microm). Intraocular pressure exceeded 21 mmHg in 5, 3, and 1 eye(s), respectively, during these intervals. One eye exhibited cataract progression at 6 months. No other complications were noted over a mean follow-up of 6.2 months. Reinjection was performed in 3 of 8 eyes after 6 months because of recurrence of macular edema. CONCLUSIONS Intravitreal triamcinolone is a promising therapeutic method for diabetic macular edema that fails to respond to conventional laser photocoagulation. Complications do not appear to be prohibitive. Further study is warranted to assess the long-term efficacy and safety, and the need for retreatment.

Intravitreal triamcinolone acetonide for macular oedema due to central retinal vein occlusion

No proved treatment exists for macular oedema secondary to central retinal vein occlusion (CRVO) despite the potential for significant visual loss in affected eyes. We report a patient with bilateral non-ischaemic CRVOs and macular oedema treated with intravitreal triamcinolone acetonide. An 80 year old woman presented with a 2 week history of acute visual loss in her left eye (LE). She had a 9 month history of poor vision in her right eye (RE). On examination, visual acuity was counting fingers RE and 20/400 LE. Intraocular pressures were 12 and 14 mm Hg, respectively. Anterior segment examination showed bilateral pseudophakia with no evidence of neovascularisation. Dilated fundus examination revealed bilateral CRVOs with macular oedema. Collateral disc vessels were present in the RE. Fluorescein angiography showed diffuse leakage and blockage from intraretinal haemorrhages in both eyes with no areas of non-perfusion (Fig 1). …

The prevalence and effects of adult attention deficit/hyperactivity disorder on work performance in a nationally representative sample of workers.

Objective: The prevalence and workplace consequences of adult attention deficit/hyperactivity disorder (ADHD) are unknown. Methods: An ADHD screen was included in a national household survey (n = 3198, ages 18–44). Clinical reinterviews calibrated the screen to diagnoses of Diagnostic and Statistical Manual of Mental Disorders, 4th edition ADHD. Diagnoses among workers were compared with responses to the WHO Health and Work Performance Questionnaire (HPQ). Results: A total of 4.2% of workers had ADHD. ADHD was associated with 35.0 days of annual lost work performance, with higher associations among blue collar (55.8 days) than professional (12.2 days), technical (19.8 days), or service (32.6 days) workers. These associations represent 120 million days of annual lost work in the U.S. labor force, equivalent to

Attention-Deficit/Hyperactivity Disorder: Increased Costs for Patients and Their Families

19.5 billion lost human capital. Conclusions: ADHD is a common and costly workplace condition. Effectiveness trials are needed to estimate the region of interest of workplace ADHD screening and treatment programs.

Optical coherence tomography findings following photodynamic therapy of choroidal neovascularization

OBJECTIVE To estimate the direct (medical and prescription drug) and indirect (work loss) costs of children treated for attention-deficit/hyperactivity disorder (ADHD) and their family members. METHOD The data source was an administrative database from a national, Fortune 100 manufacturer that included all medical, pharmaceutical, and disability claims for beneficiaries (n > 100,000). The analysis involved four samples. The ADHD patient sample included individuals age 18 or younger with at least one ADHD claim during the study period (1996-1998). Resource utilization of ADHD patients was contrasted with a matched control sample of patients who did not have claims for ADHD. The ADHD and non-ADHD family samples included non-ADHD family members of ADHD patients and their matched controls. RESULTS The annual average expenditure (direct cost) per ADHD patient was

Generic Competition in the US Pharmaceutical Industry

1,574, compared to

Economic Implications of Treatment-Resistant Depression Among Employees

541 among matched controls. The annual average payment (direct plus indirect cost) per family member was

Retinal implants: a systematic review.

2,728 for non-ADHD family members of ADHD patients versus

Prevalence and predictors of ocular complications associated with cataract surgery in United States veterans.

1,440 for family members of matched controls. Both patient and family cost differences were significant at the 95% confidence level. CONCLUSIONS ADHD imposes a significant financial burden regarding the cost of medical care and work loss for patients and family members.

High-speed, ultra-high-resolution optical coherence tomography of acute macular neuroretinopathy

PURPOSE To develop an optical coherence tomography (OCT) classification system that monitors the response of eyes treated with photodynamic therapy (PDT) with verteporfin for subfoveal choroidal neovascularization (CNV) from age-related macular degeneration (AMD). DESIGN Retrospective interventional case series. METHODS Ninety eyes (88 patients) with AMD and predominantly classic subfoveal CNV treated with PDT using verteporfin were identified by a laser log and retrospectively reviewed. Optical coherence tomography and fluorescein angiography (FA) were performed before treatment and at subsequent follow-up examinations in all eyes. Optical coherence tomography findings were evaluated and compared with corresponding FA. RESULTS A five-stage OCT classification of eyes treated with PDT was created from the evaluation of 79 total eyes (77 patients). Stage I (two eyes) is recognized within the first week of treatment and demonstrates an acute inflammatory response with increased subretinal fluid. Stage II (28 eyes) represents the restoration of a near-normal fovea contour with diminished subretinal fluid occurring 1 to 4 weeks after treatment. Stage III (79 eyes) occurs between 4 to 12 weeks following treatment and is subdivided into two categories based on the amount of subretinal fibrosis and fluid present. Stage IIIa (15 eyes) contains a greater subretinal fluid to fibrosis ratio indicating an active CNV process. Lesions in stage IIIb (64 eyes) less actively leak and have more prominent fibrosis with minimal intraretinal fluid. Cystoid macular edema defines a stage IV lesion (11 eyes). In stage V lesions (19 eyes) the subretinal fluid resolves with thinning of the retina as well as fibrosis merging with the retinal pigment epithelial layer (RPE). CONCLUSION Optical coherence tomography appears to be useful in monitoring the retinal changes that occur following PDT of CNV and may assist in understanding the changes observed on angiography.