Philip Storey

The role of topical antibiotic prophylaxis to prevent endophthalmitis after intravitreal injection.

OBJECTIVE To compare the incidence of endophthalmitis after intravitreal injection with and without topical postinjection antibiotic prophylaxis. DESIGN Retrospective case-control study. PARTICIPANTS All patients treated with intravitreal injection of ranibizumab, bevacizumab, or aflibercept for a variety of retinal vascular diseases at a single, large retina practice between January 1, 2009, and October 1, 2012, were included. METHODS The total numbers of patients and injections were determined from a review of billing code and practice management records. Endophthalmitis cases were determined from billing records and from an infection log. All cases of endophthalmitis were confirmed with chart review. A 28-month period when topical antibiotics were prescribed after intravitreal injection was compared with a 9-month period when topical antibiotics were not prescribed. Patients treated during an 8-month transition period were excluded to allow for the conversion of antibiotic prescription practices. MAIN OUTCOME MEASURES Incidence of endophthalmitis, visual acuity outcomes, and microbial spectrum. RESULTS During the study period, a total of 117 171 intravitreal injections were performed (57 654 injections during the topical antibiotic period, 24 617 during the transition period, and 34 900 during the no-antibiotic period), with a total of 44 cases of suspected endophthalmitis (0.038%; 1 in 2663 injections), 17 of which showed culture-positive results (0.015%; 1 in 6892 injections). During the 28-month topical antibiotic period, there were 28 cases of suspected endophthalmitis (0.049%; 1 in 2059 injections), 10 of which showed culture-positive results (0.017%; 1 in 5765 injections). During the 9-month no-antibiotic period, there were 11 cases of suspected endophthalmitis (0.032%; 1 in 3173 injections), 4 of which showed culture-positive results (0.011%; 1 in 8725 injections). Topical antibiotic use was associated with a trend toward increased risk of suspected endophthalmitis (odds ratio [OR], 1.54; 95% confidence interval [CI], 0.77-3.10) and culture-positive endophthalmitis (OR, 1.51; 95% CI, 0.47-4.83). CONCLUSIONS The incidence of endophthalmitis after intravitreal injection is low. Using postinjection topical antibiotic drops does not reduce the risk of endophthalmitis developing and is associated with a trend toward higher incidence of endophthalmitis.

Pars plana vitrectomy and scleral buckle versus pars plana vitrectomy alone for patients with rhegmatogenous retinal detachment at high risk for proliferative vitreoretinopathy.

Purpose: To compare using pars plana vitrectomy (PPV) combined with a scleral buckle versus primary vitrectomy alone in patients with rhegmatogenous retinal detachment at high risk for postoperative proliferative vitreoretinopathy (PVR). Methods: Six hundred and seventy-eight patients were identified from billing data as having rhegmatogenous retinal detachment between April 1, 2010 and August 1, 2012. Patients were considered at high risk for PVR if they presented with retinal detachment in 2 or more quadrants, retinal tears >1 clock hour, preoperative PVR, or vitreous hemorrhage. Results: Of the 678 patients with rhegmatogenous retinal detachment, 65 were identified as high risk for PVR. Thirty-six patients were treated with simultaneous PPV–scleral buckle and 29 patients were treated with PPV alone, with an overall success rate of 63.1%. The use of PPV–scleral buckle was associated with significantly higher single surgery anatomical success compared with patients treated with PPV alone (odds ratio, 3.24; 95% confidence interval, 1.12–9.17; P = 0.029). Visual acuity at 3 months postprocedure or final follow-up was no different between the treatment groups. Overall, 23.1% of patients developed postoperative PVR with no difference between surgical approaches. Conclusion: For patients at high risk for PVR, PPV–scleral buckle was associated with significantly higher rates of anatomical success compared with PPV alone.

Outcomes of anti-vascular endothelial growth factor therapy in the management of choroidal neovascularization associated with choroidal osteoma.

Purpose: To investigate the efficacy of serial anti–vascular endothelial growth factor injections for choroidal neovascularization associated with choroidal osteoma. Methods: In this retrospective interventional case series, eyes with choroidal osteoma and associated choroidal neovascularization were treated with intravitreal ranibizumab or bevacizumab with or without photodynamic therapy consolidation. Resolution of subretinal fluid on optical coherence tomography and best-corrected visual acuity were assessed. Results: Eight eyes in eight patients were treated with monthly intravitreal anti–vascular endothelial growth factor injections with or without photodynamic therapy. Resolution of subretinal fluid on optical coherence tomography was achieved in 7 of 8 eyes (87%) with a mean of 12.3 ± 12.6 injections (range, 1–40). Four eyes (50%) experienced at least 1 recurrence of exudation at a mean interval of 10 months (median, 7.5; range, 5–21 months), necessitating further therapy. The mean Snellen visual acuity improvement was 1 ± 4 lines (range, loss 3 to gain 7 lines) at a mean of 32-months follow-up. Conclusion: Serial anti–vascular endothelial growth factor therapy alone or with photodynamic therapy consolidation for choroidal neovascularization due to choroidal osteoma resulted in anatomical improvement and modest visual gain.

Microbial spectrum and outcomes of endophthalmitis after intravitreal injection versus pars plana vitrectomy

Purpose: To compare infectious organisms and visual outcomes of endophthalmitis after intravitreal injection (IVI) with endophthalmitis after pars plana vitrectomy (PPV). Methods: Retrospective, comparative, consecutive case series of patients diagnosed with presumed infectious endophthalmitis after IVI of an anti-vascular endothelial growth factor medication or PPV between January 1, 2009, and October 1, 2012, from one center. Main outcome measures were infectious organism and final visual acuity. Results: Forty-four cases of presumed infectious endophthalmitis (17 culture positive) occurred after IVI and 19 cases (9 culture positive) occurred after PPV. Of note, 56.3% of culture-positive IVI cases were due to bacteria associated with oral flora, primarily Streptococcus species, compared with none in the PPV group (P = 0.01). There was a trend approaching significance for IVI patients to have lost ≥3 lines of visual acuity compared with PPV patients at final follow-up (P = 0.07). Within the IVI group, patients were more likely to have lost ≥6 lines of visual acuity at final follow-up when endophthalmitis was due to an organism associated with oral flora (P = 0.007). Conclusion: Endophthalmitis after IVI has a higher likelihood of being due to oral flora compared with endophthalmitis after PPV. Among IVI patients, worse visual outcomes occurred when endophthalmitis was due to oral flora.

Incidence and clinical features of post-injection endophthalmitis according to diagnosis

Purpose To compare the incidence and clinical features of endophthalmitis after intravitreal antivascular endothelial growth factor (VEGF) therapy for diabetic eye disease, neovascular age-related macular degeneration (AMD) and retinal vein occlusion (RVO). Methods Multicentre, retrospective, consecutive case–control study. All patients treated with intravitreal bevacizumab, ranibizumab or aflibercept for diabetic eye disease, neovascular AMD or RVO between 1 January 2009 and 30 September 2013 at three retina practices were included in this study. The total number of anti-VEGF injections administered for the three indications was calculated using billing records. Endophthalmitis cases were identified using both endophthalmitis log sheets and billing records. Patient charts were reviewed to confirm that endophthalmitis was directly related to anti-VEGF injection and to record clinical features and culture results. Results During the study period, a total of 353 978 intravitreal anti-VEGF injections were performed. Presumed infectious endophthalmitis occurred in 119 of 296 017 injections performed for neovascular AMD (1/2487, 0.040%), 12 of 24 541 for diabetic eye disease (1/2045, 0.049%) and 4 of 32 418 for RVO (1/8104, 0.012%). χ2 analysis found endophthalmitis rates to be higher in diabetic eye disease compared with RVO (p=0.010) and higher in neovascular AMD compared with RVO (p=0.014), while diabetic eye disease and neovascular AMD (p=0.517) had similar rates. The average age of the overall neovascular AMD patient population (81.9 years) was significantly older than the diabetic eye disease (64.7 years, p<0.001) and RVO (73.4 years, p<0.001) populations. Conclusions Endophthalmitis rates appear to be lower in eyes with RVO compared with diabetic eye disease and neovascular AMD, possibly due to impaired immunity in diabetics and waning immunity in the generally older AMD population.

IMPACT OF PHYSICIAN COMMUNICATION ON DIABETIC EYE EXAMINATION ADHERENCE: Results From a Retrospective Cohort Analysis.

Purpose: To evaluate the effect of written communication between an ophthalmologist and a primary care physician (PCP) on patient adherence to diabetic eye examination recommendations. Methods: In a retrospective cohort study of a multiethnic population at an urban ophthalmology center, records of all patients with diabetes and clinic visits between 2007 and 2010 were reviewed. Data collected included patient demographics, insurance status, hemoglobin A1C, severity of diabetic retinopathy, follow-up examinations, and written communication between a patients ophthalmologist and PCP. Statistical analyses were performed to examine the relationship between physician communication and adherence to diabetic eye examination based on the American Academy of Ophthalmology–published recommendations. Results: A total of 1,968 people with diabetes were included. Written communication from an ophthalmologist to a PCP was associated with increased adherence to follow-up eye examination recommendations (Odds Ratio: 1.49; 95% Confidence Interval: 1.16–1.92; P = 0.0018). Communication from a PCP to an ophthalmologist was also associated with increased adherence (Odds Ratio: 1.94; 95% Confidence Interval: 1.37–2.77; P = 0.0002). Multivariable analysis controlling for other factors associated with examination adherence confirmed that communication both to and from an ophthalmologist was independently and significantly associated with increased follow-up adherence. Conclusion: Patients with communication between ophthalmologists and PCPs are more likely to adhere to diabetic eye examinations.

Non-adherence to eye care in people with diabetes

Objective Evaluate individual factors that impact adherence to eye care follow-up in patients with diabetes. Design and methods A 4-year retrospective chart review was conducted for 1968 patients with diabetes over age 40 from an urban academic center. Data collected included demographics, insurance, visual acuity, smoking status, medications, dates of dilated fundus examinations (DFE), and reported hemoglobin A1C and blood glucose levels. The primary outcome was timely DFE follow-up adherence following the initial eye exam visit. Results Overall, 41.6% of patients adhered to initial follow-up eye care recommendations. Multivariable analysis demonstrated that patients with severe diabetic retinopathy (DR) were more adherent than patients with mild DR (OR 1.86). Other variables associated with increased adherence were visual impairment and reported A1C or blood glucose. Smoking was associated with decreased adherence. Ethnicity and insurance were also significantly associated with adherence. Longitudinal follow-up rates were influenced by additional factors, including ethnicity and neighborhood deprivation index. Conclusions Patients with moderate to severe DR and/or visual impairment were more likely to adhere to timely DFE follow-up. This could relate to the presence of visual symptoms and/or other systemic manifestations of diabetes. Smokers were less likely to adhere to timely DFE follow-up. One hypothesis is patients who smoke have other symptomatic health problems which patients prioritize over asymptomatic ocular disorders. In order to reduce vision loss from DR, practitioners should be aware that patients with mild and moderate DR, patients with normal vision, and smokers are at greater risk for poor follow-up eye care adherence.

Contemporary Management of Rhegmatogenous Retinal Detachment Due to Giant Retinal Tears: A Consecutive Case Series

BACKGROUND AND OBJECTIVE To investigate outcomes of contemporary surgical techniques for repair of rhegmatogenous retinal detachments (RRD) associated with giant retinal tears (GRT). PATIENTS AND METHODS Retrospective, consecutive case series including 58 eyes of 58 patients. Mean age was 52 years (range: 16 to 83 years). All patients underwent 23-gauge pars plana vitrectomy with use of perfluorocarbon liquid and intravitreal tamponade (28 with silicone oil, 25 with octafluoropropane gas, and five with sulfur hexafluoride gas). Scleral buckle (SB) was placed in 30 eyes (52%). RESULTS At a mean follow-up of 17 months, mean visual acuity improved from 20/500 preoperatively to 20/88 at final follow-up. Fifty-one patients (88%) had single-surgery anatomic success, and all patients achieved final retinal reattachment. Use of SB (P = 1.0), silicone oil (P = .1), or 360° endophotocoagulation (P = .7) did not correlate with higher rates of successful repair. CONCLUSION Contemporary vitreoretinal surgery techniques achieve high rates of primary anatomic success in GRT-related RRDs.

Alternating Bi-Weekly Intravitreal Ranibizumab and Bevacizumab for Refractory Neovascular Age-Related Macular Degeneration with Pigment Epithelial Detachment*

Abstract Objective: To describe visual and anatomical outcomes following bi-weekly intravitreal ranibizumab/bevacizumab injections in eyes with refractory neovascular age-related macular degeneration (AMD) and pigment epithelial detachment (PED). Design: Retrospective, consecutive, interventional case series. Participants: Eighteen patients diagnosed with neovascular AMD that were refractory to anti-VEGF therapy and received alternating biweekly ranibizumab/bevacizumab injections were included. Methods: Patients with neovascular AMD and PED that were refractory to at least 11 monthly ranibizumab or bevacizumab injections were included in this study at a large, single retina practice. Following inclusion, patients received four bi-weekly alternating ranibizumab/bevacizumab intravitreal injections. After completing a course of four bi-weekly injections, patients were treated with variable regimens of intravitreal anti-vascular endothelial growth factor (VEGF) therapy. The primary outcomes of the study included change in visual acuity (VA) and central foveal thickness (CFT) at eight weeks follow-up. Results: Study eyes had previously received a mean of 22 intravitreal anti-VEGF injections. At enrollment, mean VA was 20/95 and mean CFT was 455 µm. After four bi-weekly anti-VEGF injections, mean VA improved to 20/65 (p < 0.001), and mean CFT decreased to 387 µm (p = 0.029). In patients with PED, there was a mean 27.9% reduction in height (p = 0.046) at eight weeks’ follow-up. Conclusions: Four injections of bi-weekly alternating ranibizumab/bevacizumab improved visual acuity and reduced macular thickness in a number of patients with refractory neovascular AMD and PED.

Comparing methodologies for imputing ethnicity in an urban ophthalmology clinic.

Abstract Purpose: To compare methodologies for imputing ethnicity in an urban ophthalmology clinic. Methods: Using data from 19,165 patients with self-reported ethnicity, surname, and home address, we compared the accuracy of three methodologies for imputing ethnicity: (1) a surname method based on tabulation from the 2000 US Census; (2) a geocoding method based on tract data from the 2010 US Census; and (3) a combined surname geocoding method using Bayes’ theorem. Results: The combined surname geocoding model had the highest accuracy of the three methodologies, imputing black ethnicity with a sensitivity of 84% and positive predictive value (PPV) of 94%, white ethnicity with a sensitivity of 92% and PPV of 82%, Hispanic ethnicity with a sensitivity of 77% and PPV of 71%, and Asian ethnicity with a sensitivity of 83% and PPV of 79%. Overall agreement of imputed and self-reported ethnicity was fair for the surname method (κ 0.23), moderate for the geocoding method (κ 0.58), and strong for the combined method (κ 0.76). Conclusion: A methodology combining surname analysis and Census tract data using Bayes’ theorem to determine ethnicity is superior to other methods tested and is ideally suited for research purposes of clinical and administrative data.