Rita Ehrlich

Association of neovascular age-related macular degeneration and hyperhomocysteinemia

PURPOSEnTo assess the relationship between plasma homocysteine levels and exudative neovascular age-related macular degeneration (AMD).nnnDESIGNnCross-sectional study.nnnMETHODSnA prospective comparative cross-sectional study was conducted in outpatient ophthalmology clinics in a university-affiliated medical institution. The cohort consisted of 59 patients (25 male, 34 female) with a mean age of 78 years (standard deviation [SD] = 8.4) with neovascular AMD who were candidates for photodynamic treatment. Patients were compared for plasma homocysteine levels with 58 patients who had dry AMD (24 male, 34 female) with a mean age of 76.3 years (SD = 8.4) and with a control group of 56 age-matched subjects (27 male, 29 female), with a mean age of 77.3 years (SD = 8.2). A 3-ml venous blood sample was obtained from each participant after an 8-hour fast. Levels of plasma homocysteine were measured by high performance liquid chromatography. The main outcome measure was hyperhomocysteinemia, defined as a plasma homocysteine level above 15 micromol/l.nnnRESULTSnHomocysteine levels were higher by 27.9% in the neovascular AMD than in the dry AMD group, and by 21.9% than in the control group (P <.02). Hyperhomocysteinemia was found in 44.1% of the study group, in 22.4% of the dry AMD group, and in 21.4% of the control group (P =.011).nnnCONCLUSIONSnThis study suggests an association between an elevated plasma level of homocysteine and exudative neovascular AMD but not dry AMD.

Diode laser treatment of retinopathy of prematurity: anatomical and refractive outcomes.

Purpose: To examine the anatomical and refractive outcomes of infrared diode laser photocoagulation (DLPC) for the treatment of threshold retinopathy of prematurity (ROP). Methods: The charts of all consecutive premature neonates with ROP treated by DLPC at our tertiary center from December 1, 1996, to December 31, 2004, were reviewed. Results: The group included 100 neonates (194 eyes) with a mean birth weight ± SD of 833.9 ± 250.3 g and a mean gestational age ± SD of 26 ± 1.9 weeks. Sixty-two percent of neonates had zone I or posterior zone II ROP. Each eye received a mean ± SD of 1,740 ± 990 laser applications, and 21% of eyes received an additional 1 to 2 rows posterior to the ridge. Neonates treated after December 2003 (cutoff date of the Early Treatment of Retinopathy of Prematurity study) underwent a significantly greater number of laser applications (mean ± SD, 2,286 ± 1,087) than did neonates treated earlier. Anatomical results of laser treatment were favorable for 179 eyes (92.3%) at a mean follow-up ± SD of 33.6 ± 27.2 months. After vitreoretinal surgery, partial or total retinal detachment was documented for 2.5% of patients who received posterior-to-the-ridge laser treatment and 3.8% of patients treated only on the avascular retina. Refractive data were available for 134 eyes: 55.2% had myopia of −5 diopters (31.3%) or greater (23.9%). Strabismus was found in 21 (28.8%) of 73 neonates tested. Gestational age was correlated with corrected age at treatment, zone of ROP, number of laser applications, and spherical equivalent. Snellen visual acuity of 6/12 or more occurred in 17 of 24 patients who complied with testing. Conclusion: DLPC is a safe and effective treatment for ROP. Neonates of lower gestational age and birth weight require earlier and more aggressive laser treatment and may have a higher refractive error.

Outcome Of Bevacizumab (avastin) Injection In Patients With Age-related Macular Degeneration And Low Visual Acuity

Objective: To study the effect of intravitreal bevacizumab for the treatment of long-standing exudative age-related macular degeneration (AMD) and low visual acuity. Methods: Forty-seven patients (48 eyes) aged 57 to 90 years with AMD for 5 months or more and visual acuity of 20/150 or less were treated with one or more injections of bevacizumab 1.25 mg/0.05 mL between December 2005 and March 2007. The files were reviewed for background data, visual acuity, fluorescein angiography, retinal thickness, and complications. Results: Thirty-two eyes were treated previously with photodynamic therapy. Mean duration of symptoms was 17.9 ± 17.5 months; mean number of bevacizumab injections was 3.41 ± 2; and mean follow-up was 27 ± 15 weeks. Snellen visual acuity improved from 20/150 to hand movements (mean logMAR 1.34 ± 0.29) to 20/50 to counting fingers (mean logMar 1.2 ± 0.42) (P = 0.003, paired t-test). Visual acuity improved by≥3 lines in 12 eyes (25%); showed no change in 9 eyes (19%); and deteriorated by ≥3 lines in 4 eyes (8.3%). Visual acuity was at least 20/150 in 16 eyes (33.3%) at the end of follow-up compared with 4 eyes (8.3%) before treatment (P = 0.02, McNemar test). Mean central retinal thickness (measured in 22 eyes) decreased from 324 ± 121 &mgr;m to 264 ± 65 &mgr;m (P = 0.02, paired t-test). Conclusions: Patients with chronic exudative AMD and low visual acuity may benefit from intravitreal bevacizumab injections.

Timing of acute macula-on rhegmatogenous retinal detachment repair.

Purpose: To determine if same-day or next available surgery changed the outcome of patients presenting with acute macula-on rhegmatogenous retinal detachments. Methods: A retrospective review of patients presenting with acute macula-on rhegmatogenous retinal detachments treated with small-gauge vitrectomy was performed. Data collection included subjects demographics, duration of symptoms, location and extent of the retinal detachment, and timing of surgery. The primary outcome was anatomical and functional success rate for patients having same-day surgery compared with those for whom surgery was delayed. Results: One hundred and fourteen patients were included in this study. Sixty-two patients operated on day of presentation, 46 patients operated the day after presentation, and in 6 patients, surgery was delayed from 2 to 5 days. Time to surgery in hours ranged between 1 and 120 hours (mean 14.5 ± 15.05 hours). Retinal reattachment was achieved in 95.6% of patients, with 80% requiring only one procedure. Mean initial visual acuity was logarithm of the minimum angle of resolution 0.42 (SD 0.6), and mean final visual acuity was logarithm of the minimum angle of resolution 0.39 (SD 0.67) (P = 0.53). Time to surgery was not found to effect final anatomical outcome (P = 0.56). No statistically significant association was observed between change in visual acuity and time to surgery (P = 0.99). Conclusion: Modest delay in timing of surgery for macula-on rhegmatogenous retinal detachment did not adversely impact on patients outcome.

Pneumatic Displacement of Submacular Hemorrhage due to Age-Related Macular Degeneration

Purpose: Subretinal hemorrhage is one of the most serious complications of exudative age-related macular degeneration (AMD). Treatment with vitreous surgery with or without plasminogen activator, fluid-gas exchange, or perfluorocarbon yields only a small improvement in visual acuity. Patients and Methods: The files of 24 patients with submacular hemorrhage secondary to AMD who were treated by injection of perfluoropropane gas (C3F8) (11 patients) or sulfur hexafluoride (SF6) (13 patients) were reviewed for visual acuity before and after the procedure and time of treatment from onset of symptoms. Results: For the whole sample, pneumatic displacement led to a statistically significant improvement in mean visual acuity (p = 0.015). A significant difference between pre- and postoperative visual acuity was found for the patients treated with SF6 (p = 0.034), but not for the patients treated with C3F8 (p = 0.245). Conclusion: The use of gas injection to displace submacular hemorrhage can significantly improve visual acuity.

Bevacizumab for choroidal neovascularization related to inflammatory diseases.

Purpose:The purpose of this study was to report our experience with intravitreal bevacizumab for inflammation-related choroidal neovascularization in two tertiary centers. Methods:This study was a retrospective analysis of patients with choroidal neovascularization related to inflammatory diseases, treated with intravitreal bevacizumab injections (1.25 mg/0.05 mL). Results:Ten eyes of 10 patients (range, 14-78 years; mean age, 44 years) with underlying uveitis were treated with intravitreal bevacizumab for inflammation-related choroidal neovascularization from 2006 to 2008. Mean follow-up time was 13 ± 8 months, and the mean number of injections was 2.7 ± 2. Resolved leakage on fluorescein angiography and resolution of subretinal fluid on optical coherence tomography occurred in all patients, with improvement in visual acuity in 9 of 10 eyes and no change in visual acuity in 1 of 10 eyes. Seven patients received additional treatment based on the underlying condition. Mean macular thickness on optical coherence tomography decreased from 394 ± 116 μm to 254 ± 52 μm (P < 0.01). Mean visual acuity improved from 0.87 ± 0.74 logarithm of the minimum angle of resolution to 0.38 ± 0.63 (P = 0.005). Seven patients reached a visual acuity of 0.2 logarithm of the minimum angle of resolution (Snellen 6/9) or better. Conclusion:Intravitreal bevacizumab is an effective treatment for choroidal neovascularization related to inflammatory diseases when inflammation is controlled.

Intracameral cefuroxime and the incidence of post-cataract endophthalmitis: an Israeli experience.

PurposeThe European Society of Cataract & Refractive Surgeons (ESCRS) study reported a decrease in endophthalmitis rates from 0.34xa0% to 0.08xa0% with the use of intracameral cefuroxime. The purpose of this study was to compare the endophthalmitis rates before and after the introduction of intracameral cefuroxime (ICC) routinely at the end of cataract surgery.MethodsA retrospective consecutive cohort study. We compared the rates of endophthalmitis between the years 2000–2006, and the years 2007–2014, after the pivotal publication of the ESCRS. Data collected included age, gender, culture results, initial and final visual acuity, and complications. Only patients that presented with endophthalmitis following cataract surgery performed at the two centers were included.ResultsTwenty-two cases of endophthalmitis occurred between the years 2000 and 2006, out of 26,663 cataract operations performed at the two centers, a rate of 0.083xa0%. Ten cases occurred between the years 2007 and 2014 out of 29,431 cataract operations, a rate of 0.034xa0%. The difference was statistically significant (pu2009=u20090.03)ConclusionsThe introduction of prophylactic use of intracameral cefuroxime was associated with a significant reduction in post-operative endophthalmitis rates in our centers. We strongly recommend adoption of this routine by for all cataract operations except when contraindicated.

Augmented trabeculectomy in paediatric glaucoma.

Aims: To report the experience with trabeculectomy augmented with mitomycin C and 5-fluorouracil for the treatment of paediatric glaucoma. Methods: Retrospective, interventional case series design was used. The sample included 17 children (29 eyes) with primary (19 eyes) or secondary (10 eyes) glaucoma who were treated with augmented trabeculectomy as the primary procedure between 1990 and 2002. Data were collected on age and family history, preoperative and end of follow up intraocular pressure, cup/disc ratio (evaluated by drawing), visual acuity, complications, and post-surgery treatment. Results: Patient age at surgery ranged from 1 month to 8 years; most patients (nu200a=u200a14, 82.3%) were aged less than 1 year (range 1 month–8 months, mean 3.95 (SD 2.56) months); three patients (17.7%) were aged 3, 5, and 8 years. The duration of follow up was 3–120 months (mean 46 months). Intraocular pressure significantly improved from 21 mm Hg to 60 mm Hg (mean 33.1 (10) mm Hg) before surgery to 6–26 mm Hg (mean 17.1 (6) mm Hg) after, (p <0.0001). There was no significant change in cup/disc ratio: 0.1–0.8 (mean 0.42 (0.26)) before and 0.1–1.0 (mean 0.511 (0.27)) after (pu200a=u200a0.45). In 22 eyes (75.8%), intraocular pressure was controlled at less than 20 mm Hg and the cup/disc ratio remained stable or improved. The life table success rate for intraocular pressure control remained stable at 86% at the 12, 24, and 36 months and after 48 months decreased to 53%. There was no significant difference in the life table results between primary and secondary glaucoma. 14 eyes (48.2%) had a visual acuity better than 20/120 by the end of follow up. Repeated surgery was necessary in eight eyes (27.5%), and additional antiglaucoma treatment in 13 (44.8%). Complications included retinal detachment 1 year after surgery, choroidal detachment, and blebitis (one eye each). Conclusions: Augmented trabeculectomy with mitomycin C and 5-fluorouracil may serve as the primary procedure in a selected group of paediatric patients with glaucoma.

Pupillary block following posterior chamber intraocular lens implantation in adults

Background: Pupillary block rarely occurs after cataract extraction with posterior chamber intraocular lens implantation. Methods: A series of six patients (seven eyes) treated for pupillary block after posterior chamber intraocular lens implantation between 1990 and 2001 is described; in one eye, the attack occurred after phacoemulsification. Results: The interval between pupillary block development and the cataract surgery ranged from 1 day to 5 years. In all eyes, treatment consisted of neodymium-YAG laser peripheral iridotomy. In four eyes, the laser peripheral iridotomy relieved the block (one procedure in two; two to three procedures in two). One patient was also treated with YAG capsulotomy, and two patients needed additional surgical intervention. Conclusion: Despite the rarity of the complication of pupillary block after posterior chamber intraocular lens implantation, physicians should be aware of the sometimes difficult course of recovery after treatment.

Combined photodynamic therapy and intravitreal triamcinolone acetonide injection for neovascular age-related macular degeneration with pigment epithelium detachment.

The authors report a case of acute development of an extensive retrobulbar abscess 3 weeks after an orbital floor fracture. Urgent drainage of the abscess was performed by an anterior transconjunctival approach. A dramatic recovery was observed a few days following the operation. The visual acuity increased from hand motions to 0.7 to 0.8 in the early postoperative period and to 1.0 shortly thereafter. The severity of infection, the importance of antibiotic prophylaxis for blowout fractures, and the efficacy of the transconjunctival approach on the final visual and functional outcome are described.A 38-year-old man with human immunodeficiency virus was referred for evaluation of retinal lesions in both eyes. Optical coherence tomography was performed after dilating the pupils. Biomicroscopy of the retina showed an atypical, solitary, yellowish-white lesion in the macula of both eyes with no inflammation of the vitreous. Optical coherence tomography of the lesions showed an area of extremely low reflectivity with well-defined but irregular borders in the outer retina. The surrounding retina showed normal reflectivity and was of normal thickness. Optical coherence tomography showed selective necrosis of the outer layers due to progressive outer retinal necrosis. Optical coherence tomography may serve as a useful tool for the early diagnosis of progressive outer retinal necrosis.