Richard M. Feist

Incidence Of Acute Onset Endophthalmitis Following Intravitreal Bevacizumab (avastin) Injection

Purpose: To report the incidence of acute endophthalmitis as a complication of intravitreal bevacizumab (Avastin) (IVB) injection in a tertiary vitreoretinal group practice. Methods: A retrospective chart review of 5,233 consecutive eyes that underwent IVB injection at Retina Consultants of Alabama (RCA) from October 1, 2005, to August 31, 2007, was performed to identify cases of acute endophthalmitis. Results: During the 23-month study interval, the overall incidence rate of postinjection endophthalmitis was 0.019% (1/5,233). In the single case of acute endophthalmitis, bacterial cultures revealed coagulase-negative Staphylococcus (CNS) species. Visual acuity after treatment for endophthalmitis was improved (baseline 4/400) to 20/400 at two months after the initial IVB injection. Conclusions: Acute endophthalmitis is a rare potential complication of IVB. Prophylaxis with topical povidone-iodine and adherence to aseptic technique minimizes the risk of postinjection infection. Summary Statement: A retrospective review of 5,233 consecutive intravitreal injections of bevacizumab (Avastin) revealed only a single case of acute endophthalmitis. Adherence to aseptic technique and the use of povidone-iodine prophylaxis minimizes the risk of postinjection intraocular infection.

Incidence of hemorrhagic complications after intravitreal bevacizumab (avastin) or ranibizumab (lucentis) injections on systemically anticoagulated patients.

Purpose: To assess the risk of hemorrhagic complications when performing intravitreal injections on systemically anticoagulated patients. Methods: A single-center retrospective case series of 520 consecutive patients (675 eyes) receiving 3,106 antivascular endothelial growth factor injections. Patients on the systemic anticoagulants Coumadin (warfarin sodium) or Plavix (clopidogrel bisulfate) were identified, as well as patients on aspirin. Demographic parameters were recorded, as well as relevant anticoagulant medications, preoperative/postoperative best-corrected visual acuities and intraocular pressures, previous ocular surgery, relative ocular diagnoses, and injection complications. Results: Of all patients, 104 were on Coumadin (134 eyes; 548 injections), 90 were on Plavix (123 eyes; 523 injections), 7 were on both Coumadin and Plavix (8 eyes; 33 injections), and 319 were not anticoagulated (400 eyes; 2002 injections). Also, 1,254 injections were on patients taking aspirin. There were no hemorrhagic complications (choroidal hemorrhage, vitreous hemorrhage, or increased submacular hemorrhage) noted in the Plavix (P = 1.0000; 95% confidence interval = 0.0000-0.0088), Coumadin (P = 1.0000; 95% confidence interval = 0.0000-0.0084), or aspirin (P = 1.0000; 95% confidence interval = 0.0000-0.0037) groups. Conclusion: The risk of hemorrhagic complications in systemically anticoagulated patients receiving intravitreal injections is extremely low. Because of the demonstrated thromboembolic risk of stopping anticoagulant therapy, we recommend that patients continue their current regiment without cessation.

Incidence of endophthalmitis following 20-gauge and 25-gauge vitrectomy.

Incidence of Endophthalmitis Following 20-Gauge and 25-Gauge Vitrectomy The 25-gauge transconjunctival sutureless pars plana vitrectomy (PPV) system enables sutureless three-port PPV without the need for conjunctival peritomies, decreases mean operative times, decreases surgically-induced trauma at sclerotomy sites, and reduces postsurgical patient discomfort.1 Decreased traumatic conjunctival and scleral manipulation with less postoperative inflammation, as well as less induced corneal astigmatism, allows for more rapid postoperative visual recovery. The self-sealing nature of the incisions in sutureless transconjunctival vitrectomy surgery, however, does pose theoretical concerns for possible increased risk of hypotony, vitreous incarceration, and postoperative intraocular infection.2–4 Postoperative endophthalmitis following ophthalmic surgery remains rare with an incidence of approximately 0.1%.5–7 Endophthalmitis following 20-gauge PPV has been reported as 0.07% by Cohen et al7 in their 10-year survey published in 1995. Although cases of endophthalmitis have been reported after 25-gauge transconjunctival sutureless PPV,2–4 the exact incidence was unknown until two very recent series were published.8,9 Scott et al8 and Kunimoto and Kaiser9 both reported an increased rate of endophthalmitis following 25-gauge PPV compared with 20gauge PPV. The purpose of the current study was to examine the incidence of endophthalmitis following 25-gauge transconjunctival sutureless PPV in a large, single institution, single surgical location, consecutive case series. Methods

Safety, Efficacy, And Quality Of Life Following Sutureless Vitrectomy For Symptomatic Vitreous Floaters

Purpose: To determine the safety, efficacy, and quality of life improvement following sutureless 25-gauge pars plana vitrectomy for symptomatic floaters. Methods: Patients with symptomatic vitreous floaters who underwent sutureless vitrectomy between January 2008 and January 2011 were included. Data were collected regarding baseline preoperative characteristics, postoperative outcomes, complications, and a nine-item quality-of-life survey completed by each patient. Results: One hundred and sixty-eight eyes (143 patients) underwent sutureless 25-gauge pars plana vitrectomy for symptomatic vitreous floaters. Mean Snellen visual acuity was 20/40 preoperatively and improved to 20/25 postoperatively (P < 0.0001). Iatrogenic retinal breaks occurred in 12 of 168 eyes (7.1%). Intraoperative posterior vitreous detachment induction was not found to increase the risk of retinal breaks (P = 1.000). Postoperative complications occurred in three eyes, of which one had transient cystoid macular edema and two had transient vitreous hemorrhage. Approximately 88.8% of patients completed a quality-of-life survey, which revealed that 96% were “satisfied” with the results of the operation, and 94% rated the experience as a “complete success.” Conclusion: Sutureless 25-gauge pars plana vitrectomy for symptomatic vitreous floaters improved visual acuity, resulted in a high patient satisfaction quality-of-life survey, and had a low rate of postoperative complications. Sutureless pars plana vitrectomy should be considered as a viable means of managing patients with symptomatic vitreous floaters.

Bilateral Ocular Shotgun Injury

We retrospectively studied 14 patients with bilateral ocular shotgun injury in order to determine overall visual prognosis and factors affecting individual prognosis. Although only eight of 28 eyes (29%) in this series recovered visual acuity of 20/100 or better, six of 14 patients (43%) recovered at least 20/100 and eight of 14 patients (57%) recovered visual acuity of at least 20/400. Tissue destruction in the form of severe ocular disorganization or direct injury of optic nerve or macula was the primary limiting factor to visual recovery in 16 of 20 eyes (80%) not recovering to 20/100, while retinal detachment was the limiting factor in only four of these 20 eyes (20%). While extensive ocular disorganization, direct optic nerve or macular injury, no light perception on initial examination, and multiple pellet injuries were predictive of poor outcome, retinal detachment and double perforating injury were not.

Myofibroblast and extracellular matrix origins in proliferative vitreoretinopathy.

BackgroundTo evaluate origins of the fibrocontractive cell populations and their relation to collagens I and II in proliferative vitreoretinopathy (PVR).MethodsHuman PVR membranes were evaluated by indirect immunofluorescence for GFAP, cytokeratin-18 (CK-18), α-smooth muscle actin (αSMA), collagens I and II. Collagen expression by porcine Müller and retinal pigment epithelial cells (RPE) was evaluated using RT-PCR of RNA harvested from freshly isolated primary and proliferating cultures.ResultsCollagen I was detected in all PVR samples and was widely distributed in the extracellular matrix. In contrast, collagen II was present in only two of the ten samples and was localized to thin, acellular bands near the border of the tissues. Using cell type-specific markers CK-18 and GFAP, RPE and glia were localized to the collagen I-rich matrices. Cells positive for GFAP and CK-18 can also co-express αSMA. Normal and proliferating RPE express collagen I, but Müller cells show no evidence of collagen I expression until they proliferate in culture. In contrast, normal RPE and Müller cells contain message for collagen II which is lost shortly after introduction into culture.ConclusionsCollagen I appears to be the predominate fibrillar collagen in human PVR membranes and collagen II a comparatively minor component. Müller cells and RPE are physically associated with the collagen I matrix and are capable of expressing this protein suggesting that they are the origin. It also appears that the majority of myofibroblasts in PVR membranes are derived from either RPE or Müller cells suggesting that they play a major role in membrane development.

Vitrectomy in asteroid hyalosis

Asteroid hyalosis (AH), a condition in which calcium-lipid complexes form in the collagen meshwork of the vitreous, affects from 0.5% to 0.9% of the general population. In patients with dense AH and visual loss, obscuration of fundus detail on opthalmoscopy and even on fluorescein angiography may complicate the diagnosis and treatment of underlying posterior segment disease. To evaluate the usefulness of vitrectomy in AH, we reviewed 7 cases of dense AH in 6 patients who underwent vitrectomy in the setting of decreased visual acuity of uncertain cause. Additional diagnoses made following surgery included age-related macular degeneration (ARMD) in 2 eyes, ARMD with associated epiretinal membrane in one eye, and the staging of diabetic retinopathy as proliferative in one eye. Although no major surgical complications occurred in this series, the potential for serious complications exists, and pars plana vitrectomy (PPV) should be considered only after less invasive diagnostic evaluations and therapeutic approaches have been exhausted.

Association between retinal thickness measured by spectral-domain optical coherence tomography (OCT) and rod-mediated dark adaptation in non-exudative age-related maculopathy.

Aim To examine associations between retinal thickness and rod-mediated dark adaptation in older adults with non-exudative age-related maculopathy (ARM) or normal macular health. Methods A cross-sectional study was conducted with 74 adults ≥50 years old from the comprehensive ophthalmology and retina services of an academic eye centre. ARM presence and disease severity in the enrolment eye was defined by the masked grading of stereofundus photos using the Clinical Age-Related Maculopathy grading system. High-definition, spectral-domain optical coherence tomography was used to estimate retinal thickness in a grid of regions in the macula. Rod-mediated dark adaptation, recovery of light sensitivity after a photo-bleach, was measured over a 20-min period for a 500 nm target presented at 5° on the inferior vertical meridian. Main outcomes of interest were retinal thickness in the macula (μm) and parameters of rod-mediated dark adaptation (second slope, third slope, average sensitivity, final sensitivity). Results In non-exudative disease retinal thickness was decreased in greater disease severity; thinner retina was associated with reductions in average and final rod-mediated sensitivity even after adjustment for age and visual acuity. Conclusions Impairment in rod-mediated dark adaptation in non-exudative ARM is associated with macular thinning.

Eccentric macular holes after vitrectomy with peeling of epimacular proliferation.

Purpose: To describe six patients (six eyes) who developed an eccentric macular hole after surgery for idiopathic epimacular proliferation. Methods: In a retrospective review of 631 consecutive patients who underwent vitrectomy with peeling of the epimacular proliferation and in most cases the internal limiting membrane (ILM) from May 2001 to May 2005, 6 patients were found to have developed an eccentric macular hole postoperatively. Results: Eccentric macular holes developed 9 days to 8 months (mean, 3.1 months) after epimacular proliferation peeling. The ILM was peeled in addition to the epimacular proliferation in five of the six cases. Of the six eccentric macular holes, four were located temporal to the fovea, one was located superior to the fovea, and one was located nasal to the fovea. Final visual acuities after a mean follow-up period of 17.3 months were 20/20 in 2 eyes, 20/25 in 1 eye, 20/40 in 2 eyes, and 5/200 in 1 eye. The eye with the eccentric macular hole nasal to the fovea had the poorest final visual acuity of 5/200. Conclusion: Eccentric macular hole occurring after vitrectomy to remove epimacular proliferation is an uncommon postoperative finding. To our knowledge, this is the largest case series of such patients reported. Various explanations have been suggested for the etiology of these holes, but there remains no consensus.

Ocular lawnmower injuries

In the 10-year period from 1977 to 1987, lawnmowers have been responsible for approximately 70,000 injuries annually with an estimated 5% (3300) involving the eyes. Hyphema, angle recession, and traumatic retinopathy are especially common forms of lawnmower ocular trauma. A series of 14 cases of lawnmower-induced eye injuries is presented along with demographics of the patient population involved. An analysis of various types of lawnmowers currently in use are also included, and preventive measures are suggested.