Rajen U. Desai

Surveillance for potential adverse events associated with the use of intravitreal bevacizumab for retinal and choroidal vascular disease.

Purpose: To systematically study potential adverse events associated with the use of intraocular bevacizumab at a single medical center. Methods: Retrospective study of all consecutive patients receiving intraocular bevacizumab injections at the Stanford University Department of Ophthalmology between November 15, 2005 and July 14, 2006. Bevacizumab was given for exudative age-related macular degeneration, retinal vascular occlusion, diabetic macular edema, neovascular glaucoma, and five other indications. Results: We analyzed medical records of 186 subjects (203 eyes) who received a total of 578 injections of 1.25 mg of bevacizumab. The average follow-up was approximately 6 months. Five eyes with exudative age-related macular degeneration developed retinal pigment epithelial (RPE) tears, all with preexisting RPE detachments. These five eyes represented 2.9% of all age-related macular degeneration eyes treated and 7% of the age-related macular degeneration eyes with preexisting RPE detachments at initiation of treatment. Other adverse events were rare and included retinal ischemia, subretinal hemorrhage, vitreous hemorrhage, ocular irritation or pain, worsened hypertension, and headache. No death or thromboembolic events were observed. Conclusion: Intraocular bevacizumab appears to be well tolerated for the treatment of a variety of retinal and choroidal vascular diseases. RPE tears may occur when treating choroidal neovascularization, particularly in patients with preexisting RPE detachment.

Solar retinopathy: comparison of optical coherence tomography (OCT) and fluorescein angiography (FA).

Purpose: To compare optical coherence tomography with fluorescein angiography in 11 patients (21 eyes) with central foveal damage from solar retinopathy. Methods: Retrospective, observational case series of 11 patients with solar retinopathy. Dilated funduscopic examination was performed as well as photographic, fluorescein angiography, optical coherence tomography, and Humphrey visual field assessment. Results: Significant foveal pathology was identified in each of the 21 eyes (11 patients). Visual acuity in affected eyes ranged from 20/25 to 20/200. Optical coherence tomography demonstrated foveal atrophy associated with a characteristic defect at the level of the inner and outer segment junction of the photoreceptors in all 21 affected eyes, whereas fluorescein angiography identified classic window defects in 19 eyes (10 of 11 patients). There was a modest correlation between foveal thickness and visual acuity. Conclusion: Fluorescein angiography did not detect lesions characteristic of solar retinopathy in all patients with a definitive history of sungazing and visual loss. Conversely, optical coherence tomography did detect significant foveal atrophy in all affected eyes and a characteristic defect at the photoreceptor–retinal pigment epithelium junction. Optical coherence tomography improves the diagnosis and assessment of the degree and nature of foveal damage in patients with solar retinopathy and may be an important tool in identifying foveal damage not detected by standard fluorescein angiography.

Long-term follow-up of hyperopic laser in situ keratomileusis correction using the Star S2 excimer laser

PURPOSE: To prospectively evaluate the safety, efficacy, predictability, and long‐term stability of hyperopic laser in situ keratomileusis (LASIK) using the Star S2 excimer laser (Visx). SETTING: Department of Ophthalmology, Stanford University School of Medicine, Stanford, California, USA. METHODS: This study evaluated 41 eyes of 27 patients who had LASIK for the correction of spherical hyperopia. Patients were divided into 3 groups based on preoperative cycloplegic refraction: low hyperopia (less than +2.00 diopters [D]), medium hyperopia (+2.00 to +4.00 D), and high hyperopia (more than +4.00 D). RESULTS: In all eyes, the mean preoperative spherical equivalent (SE) was +2.53 D (range +0.75 to +5.25 D) and the mean attempted SE was +2.58 D (range +0.75 to +5.25 D). At the last visit (mean 5.29 years), the mean SE was +0.44 D ± 0.69 (SD) in the low hyperopia group, +0.58 ± 0.56 D in the medium hyperopia group, and +0.59 ± 1.18 D in the high hyperopia group. The percentage of eyes within ±1.00 D of emmetropia was 82.4%, 75.0%, and 66.7%, respectively (68.9% overall). The uncorrected visual acuity was 20/40 or better in 100% of eyes in the low hyperopia group, 91.7% in the medium hyperopia group, and 66.7% in the high hyperopia group (87.8% overall). The hyperopic shift between 1 year and the last visit was +0.18 D, +0.30 D, and +0.55 D, respectively (+0.40 D overall; range −1.25 to +2.63 D). CONCLUSIONS: Hyperopic LASIK using the Star S2 excimer laser was safe, effective, and predictable for hyperopia up to +4.10 D (mean of high group). A mild regression of the refractive effect was seen over the 5‐year follow‐up.

Baylisascaris Procyonis Neural Larva Migrans in an Infant in New York City.

Neural larva migrans (NLM) with eosinophilic meningoencephalitis secondary to raccoon roundworm (Baylisascaris procyonis) infection has been reported in rural and suburban areas of North America and Europe with extant raccoon populations. Most cases have occurred in infants less than two years of age exposed to areas of raccoon fecal contamination. Here, we present a case of Baylisascaris-induced NLM from the densely populated borough of Brooklyn in New York City and alert urban pediatricians to consider this cause of clinical neurologic disease even in areas not typically thought to be associated with endemic risk factors. Infected raccoons also occur in urban settings, and urban children may be exposed to environmental areas or materials contaminated with their feces and the parasites eggs.

Vancomycin-Resistant Enterococcal Endophthalmitis

V ancomycin-sensitive enterococcal acute endophthalmitis has been reported following cataract extraction, penetrating keratoplasty, trabeculectomy, and pupilloplasty. However, vancomycinresistant enterococcal (VRE) endophthalmitis has been described in only 3 patients to date: an immunocompromised, hospitalized patient with underlying bacteremia, an immunocompetent patient following keratoplasty with infected donor tissue, and an immunocompetent patient 20 years following trabeculectomy. We report the first case, to our knowledge, of postcataract VRE endophthalmitis.

Argon Laser Photocystotomy of a Vitreous Cyst

Free-floating idiopathic vitreous cysts are rare entities. For symptomatic patients, treatment options include laser photocystotomy or pars plana vitrectomy (PPV) with cyst excision. Historically, size of the cyst impacted treatment approaches. Laser treatments have been used for smaller cysts ranging 3 to 5 mm in diameter. PPV has been utilized for cysts larger than 4 mm. Successful laser photocystotomy has been reported, utilizing both argon and Nd: YAG lasers. Herein, we present a case of successful argon laser photocystotomy of a 7.1 mm diameter vitreous cyst, the largest documented cyst ever treated. Treatment should be individualized based on patient age, ability to cooperate in an office setting, phakic status, status of the posterior hyaloid, cyst morphology, and location. In our case, because of pigment on the anterior cyst surface, and the presence of an attached posterior hyaloid, the argon green laser was used.

Resident-performed Ahmed glaucoma valve surgery.

BACKGROUND AND OBJECTIVE To evaluate the safety and efficacy of residents performing glaucoma valve surgery at a metropolitan county hospital. PATIENTS AND METHODS A retrospective analysis was performed of consecutive resident-performed Ahmed valve (New World Medical, Inc., Rancho Cucamonga, CA) glaucoma surgeries from 1993 to 2005. Data of 50 eyes of 48 patients were evaluated for intraocular pressure (IOP) and best-corrected visual acuity. RESULTS The mean follow-up period was 34.7 +/- 30.5 months, with an IOP decrease from 30.8 +/- 11.3 mm Hg preoperatively to 15.3 +/- 11.6 mm Hg at last visit. Success, defined by a postoperative IOP of greater than 5 mm Hg and at most 21 mm Hg or less or a decreased postoperative IOP of at least 25% if the preoperative IOP was already 21 mm Hg or less, occurred in 78% of eyes. Best-corrected visual acuity decreased in 58% of eyes. Four eyes (8%) required subsequent penetrating glaucoma procedures. CONCLUSION This retrospective study suggests that placement of an Ahmed valve can be a safe and effective procedure in the hands of residents under appropriate attending physician supervision.

Endogenous Fungal Endophthalmitis After Cardiac Surgery

The authors present a single-patient interventional case report of endogenous fungal endophthalmitis (EFE) in a patient with an implanted prosthetic device. A 74-year-old man underwent a double coronary artery bypass graft with a bioprosthetic pericardial valve and transvenous dual chamber pacemaker. Four months later, he presented with EFE. Despite aggressive local and systemic antifungal therapy, the patient died of septic shock due to a fungally infected pacemaker. Successful management of post-cardiac surgery EFE requires aggressive local and systemic antifungal therapy, but without surgical removal of implanted thoracic hardware these modalities alone may be insufficient for a cure.

Streptococcus bovis causing perforating corneal ulcer.

Purpose: The purpose of this study was to report the first case of Streptococcus bovis causing a perforating corneal ulcer in a healthy adult. Methods: Observational case report. Results: A healthy 77-year-old man presented with rapidly progressing corneal ulcer, resulting in perforation within 4 days. Preoperative and operative cultures isolated the same organism, S. bovis, susceptible only to vancomycin and ceftriaxone. The patient underwent a successful corneal transplantation, with histopathology revealing full-thickness necrosis and scattered bacteria. Conclusions: Although a rare pathogen in ocular infections, we report a case of devastating corneal infection caused by S. bovis and highlight consideration of this pathogen in rapidly progressing corneal ulcers.