Robert A. Mittra

Endophthalmitis After 25-gauge And 20-gauge Pars Plana Vitrectomy: Incidence and Outcomes

Purpose: To compare the rates of endophthalmitis after 20-gauge versus 25-gauge pars plana vitrectomy (PPV) and to investigate clinical features of, and visual acuity outcomes, for patients with endophthalmitis after PPV. Methods: A computerized database search was performed at each author’s institution to identify all patients who underwent PPV by any of the authors between January 1, 2005, and December 31, 2006, and were subsequently treated for endophthalmitis. In addition, all patients who underwent PPV and were subsequently treated for endophthalmitis at Pennsylvania State College of Medicine (Hershey, PA) and Bascom Palmer Eye Institute (Miami, FL) during the study period were included. The medical records of these patients were reviewed to confirm that the endophthalmitis was associated with PPV and to collect clinical data to meet the study objectives. Results: The incidence of endophthalmitis during the study period was 2 cases per 6,375 patients (or 1 case per 3,188 patients; 0.03%) for 20-gauge PPV compared with 11 cases per 1,307 patients (or 1 case per 119 patients; 0.84%) for 25-gauge PPV (P < 0.0001). Of 11 eyes that developed endophthalmitis after 25-gauge PPV, 9 received endophthalmitis prophylaxis with subconjunctival cefazolin after surgery. Median intraocular pressure on postoperative day 1 was 13 mmHg (range, 5–27 mmHg). Median time between PPV and endophthalmitis presentation was 3 days (range, 1–15 days). Presenting vision was hand motions or better in all eyes. Initial treatment included vitreous tap and injection of antibiotics in nine eyes and PPV and injection of antibiotics in two. All patients received intraocular treatment with vancomycin, and 10 received ceftazidime treatment. Eight patients had final visual acuity of ≥20/400, and four had visual acuity of ≥20/63. Cultures were negative in three cases; no culture specimens were obtained in one case. Six of the seven isolates were coagulase-negative staphylococci, and one was enterococcus. Five of six isolates tested for sensitivity to vancomycin were sensitive, and both isolates tested for sensitivity to ceftazidime were sensitive. Conclusions: The rate of endophthalmitis after 25-gauge PPV was significantly higher than that after 20-gauge PPV. Endophthalmitis after 25-gauge PPV occurred within 15 days of PPV, was usually due to coagulase-negative staphylococci sensitive to vancomycin, and was associated with variable visual outcomes.

Combined photodynamic therapy with verteporfin and intravitreal bevacizumab for choroidal neovascularization in age-related macular degeneration.

Purpose: To examine the 7-month results for patients treated with combined photodynamic therapy (PDT) with verteporfin and intravitreal bevacizumab for choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD). Methods: This is a retrospective series of 24 eyes with juxtafoveal or subfoveal CNV secondary to AMD. Patients were treated with PDT with verteporfin and 1.25 mg of intravitreal bevacizumab. All patients were naive to treatment and had either treatment within a 14-day interval. Main outcome measures were visual acuity stabilization (defined as no change or a gain in visual acuity) and retreatment rate. Results: At the 7-month follow-up, 20 (83%) of 24 patients had stabilization of visual acuity. Sixteen eyes (67%) had improvement in visual acuity. Mean improvement in visual acuity (n = 24) was 2.04 Snellen lines. Fifteen eyes (63%) required only a single combined treatment for CNV resolution. There were no complications, including endophthalmitis, uveitis, and ocular hypertension. Conclusion: The results of this study suggest that combined treatment of PDT with verteporfin and intravitreal bevacizumab may be useful in treating neovascular AMD by reducing retreatment rates and improving visual acuity. Further investigation with large, controlled trials is warranted to outline the appropriate treatment paradigm for combination therapy.

Techniques, rationale, and outcomes of internal limiting membrane peeling

Background: The internal limiting membrane represents the structural interface between the retina and the vitreous and has been postulated to serve several essential functions. Recently, internal limiting membrane peeling has been used in the treatment of a variety of retinal disorders. We review the history, techniques, rationale, and outcomes of internal limiting membrane peeling. Methods: A review of the literature. Results: Internal limiting membrane peeling has been used to successfully treat a variety of retinal disorders including macular hole, epiretinal membrane, diabetic macular edema, retinal vein occlusion, and others. Conclusion: Internal limiting membrane peeling may serve as an important component in the armamentarium of retinal surgery.

Incidence of endophthalmitis after 20-gauge vs 23-gauge vs 25-gauge pars plana vitrectomy

PurposeTo compare endophthalmitis rates after 20-gauge versus 23-gauge versus 25-gauge pars plana vitrectomy (PPV) in 2007–2008, and compare the rates with those of 2005–2006.MethodsMulticenter study including all patients who developed endophthalmitis following PPV performed by any of the authors during 2005–2008, and all patients who developed endophthalmitis following PPV at Penn State College of Medicine and Bascom Palmer Eye Institute during 2005–2008. The endophthalmitis rates after 20-gauge, 23-gauge and 25-gauge PPV during 2007–2008 were compared to those from 2005–2006.ResultsThe endophthalmitis incidence during 2007–2008 was 1/4,403 (0.02%) for 20-gauge PPV, 1/3,362 (0.03%) for 23-gauge PPV, and 1/789 (0.13%) for 25-gauge PPV. There is no significant difference among these rates between any two of the three groups. Compared with the endophthalmitis rates among the same group of surgeons during 2005–2006, the 2007–2008 endophthalmitis rates following 20-gauge and 23-gauge PPV were stable, and the rate following 25-gauge PPV was marginally lower (p = 0.056; odds ratio = 0.15; 95% CI: (0.003, 1.03)).ConclusionsThere was no significant difference in the 2007–2008 rates of endophthalmitis following 20-gauge versus 23-gauge versus 25-gauge PPV; among the same group of surgeons, the 2007–2008 rate of endophthalmitis following 25-gauge PPV was marginally lower than the 2005–2006 rate.

Intravitreal injection of bevacizumab combined with verteporfin photodynamic therapy for choroidal neovascularization in age-related macular degeneration.

Purpose: To report the outcome for eyes treated with intravitreal injection of bevacizumab combined with verteporfin photodynamic therapy (PDT) for choroidal neovascularization (CNV) in age-related macular degeneration (AMD). Study Design and Participants: Interventional, consecutive, retrospective case series including 40 eyes of 40 patients with newly diagnosed juxtafoveal or subfoveal CNV secondary to AMD. Methods: The charts of patients treated with a 1.25-mg intravitreal injection of bevacizumab followed by PDT within a 2-week period were reviewed. Main outcome measures were visual acuity stabilization (defined as no change or a gain in visual acuity) and need for retreatment. Results: Thirty-three (83%) of 40 eyes had stabilization of visual acuity. Mean improvement in visual acuity was 1.73 lines. Twenty-six eyes (65%) required only a single intravitreal injection of bevacizumab combined with PDT. Of the 23 eyes with 12 months of follow-up, 17 (74%) had stabilization of visual acuity, while 9 (40%) had improvement in visual acuity (mean, 1.22 Snellen lines). Eleven eyes (48%) required only a single combined treatment for CNV resolution at the 12-month follow-up. Fifteen (88%) of 17 eyes with only 6 months of follow-up required only a single combined treatment. There were no complications such as endophthalmitis, uveitis, or ocular hypertension. Conclusion: These findings suggest that eyes treated with both intravitreal injection of bevacizumab and PDT require none to a minimal number of re-treatments to have stabilization of vision, even at 12 months of follow-up. Further investigation with large controlled trials is warranted to outline the appropriate treatment paradigm for combination therapy.

Visual outcomes after pars plana vitrectomy for epiretinal membranes associated with pars planitis

OBJECTIVE To evaluate the results of pars plana vitrectomy and membrane stripping for visually significant macular epiretinal membranes associated with chronic idiopathic pars planitis. DESIGN Consecutive noncomparative case series. PARTICIPANTS AND METHODS The records of all patients who underwent pars plana vitrectomy for pars planitis from 1988 through 1997 were retrospectively reviewed. Seven eyes of five patients who were diagnosed with visually significant epiretinal membranes associated with pars planitis and who underwent vitrectomy and membrane stripping were analyzed. Patients were diagnosed with pars planitis based on characteristic clinical signs and pertinent negative laboratory test results. INTERVENTION Pars plana vitrectomy and epiretinal membrane stripping. MAIN OUTCOME MEASURES Visual acuity and inflammatory grade were compared between the last preoperative visit and the most recent follow-up visit. Intraoperative and postoperative complications were also analyzed. RESULTS The mean patient age was 31 years (range, 6 to 45 years). The mean duration of uveitis was 6.4 years (range, 6 months to 13 years). All patients were treated with combinations of periocular, topical, and oral corticosteroids before surgery. Five eyes had laser retinopexy, and two eyes had cryopexy to the inferior retina at the time of surgery. Five eyes had at least 3 Snellen lines of visual acuity improvement, and visual acuity in one eye worsened by 2 lines. Mean preoperative visual acuity was 20/73 (range, 20/50 to 20/300), and mean final visual acuity was 20/37 (range, 20/25 to 20/70). Five eyes had a final visual acuity of 20/40. Vitritis improved in all cases. Mean follow-up was 23 months (range, 3 to 54 months). Six of seven eyes had progressive cataract development, four of which underwent cataract extraction. No other intraoperative or postoperative complications occurred. CONCLUSIONS Removal of epiretinal membranes associated with pars planitis can be safely performed and may result in improved visual acuity. Patients often require subsequent cataract extraction to obtain the best long-term final acuity.

ISIS-DME: a prospective, randomized, dose-escalation intravitreal steroid injection study for refractory diabetic macular edema.

Purpose: To determine safety and efficacy of intravitreal triamcinolone acetonide (IVTA) for refractory clinically significant diabetic macular edema (DME). Design: Prospective, randomized, dose-escalation pilot study comparing single injection of 2 mg versus 4 mg doses of IVTA. Methods: Inclusion criteria included clinically significant DME persisting ≥3 months after maximal laser treatment and visual acuity ≤20/40. Best-corrected ETDRS vision, intraocular pressure, presence of DME, and fluorescein angiography (FA) were evaluated at 3 months and 6 months after injection. Results: Mean change in visual acuity at 3 months compared to baseline was 7.1 letters (P = 0.01) in the 2 mg group and 12.5 letters in the 4 mg group (P < 0.0001). However, there was not a significant difference in visual improvement between the 2 mg and 4 mg dose groups (P = 0.11). Vision improved >15 letters at 3 months in 23% (3/13) of 2 mg group and in 33% (5/15) of 4 mg group (P = 0.69), and 0% (0/11) and 21% (3/14) at 6 months, respectively (P = 0.23). Visual improvement was more likely in cystoid-type DME than diffuse DME. Intraocular pressure rise of ≥10 mmHg occurred in 19% (3/16) of 2 mg group and 41% (7/17) of 4 mg group. Conclusions: Both doses of IVTA were well tolerated and had significant positive effects on refractory DME for short term. There were consistent trends throughout the study that suggest that a 4 mg IVTA may be more effective than a 2 mg dose. The benefit of IVTA was greater for cystoid-type DME.

Primary ocular Epstein-Barr virus-associated non-Hodgkin's lymphoma in a patient with AIDS: a clinicopathologic report.

OBJECTIVE To report an unusual case of chronic multifocal chorioretinitis with vitritis in a patient with acquired immunodeficiency syndrome (AIDS) that was resistant to antiviral and antitoxoplasmic medication and required a retinal biopsy for definitive diagnosis. METHODS Vitreous biopsy, pars plana vitrectomy, and retinal biopsy were performed. The vitreous biopsy material was sent for bacterial, fungal, and viral culture, and the vitreous cassette was sent for cytology. The retinal biopsy material was divided and sent for polymerase chain reaction testing for toxoplasmosis and virology and pathologic tissue analysis. RESULTS Vitreous cytology showed a mixed population of lymphocytes and histiocytes, but all other microbiologic and virologic studies were negative. Tissue analysis revealed an infiltrate of atypical mononuclear cells extending from the inner limiting membrane through the outer plexiform layer characteristic of a B cell, non-Hodgkins lymphoma of the central nervous system (NHL-CNS). In situ hybridization for the Epstein-Barr virus (EBV) was positive. An extensive systemic evaluation did not show evidence of extraocular tumor. CONCLUSION Although rare, primary ocular NHL-CNS can be seen in patients with AIDS, and its clinical presentation often closely resembles other disorders. To our knowledge, this case represents the first ocular NHL in which EBV is shown to be associated.

Rate of vascularization of coralline hydroxyapatite spherical implants pretreated with saline/gentamicin, rTGF-β2, and autogenous plasma

Several authors have reported significant exposure rates using the hydroxyapatite orbital implant in the treatment of the anophthalmic socket. Histologic studies by ourselves and others have suggested that lack of fibrovascular ingrowth into the implants may contribute to conjunctival breakdown and exposure. Recently, much attention has been given to angiogenic factors, such as rTGF-β2 and those found in plasma, in accelerating wound healing and fibrovascular ingrowth. This pilot study compares the rate of vascularization of hydroxyapatite orbital implants pretreated with plasma, rTGF-β2, and a saline/gentamicin solution with that in untreated controls in a population of New Zealand albino rabbits. Hydroxyapatite orbital spheres were implanted subcutaneously and in enucleated orbits. Untreated implants were used as a control. Implants pretreated with plasma, rTGF-β2, and a saline/gentamicin solution were removed and examined histologically at weekly intervals for the first 3 weeks after implantation. Histologic studies demonstrated that the rate of vascularization significantly increased between 2 and 3 weeks postoperatively in all study groups. Pretreating the implants with rTGF-β2 in phosphate buffered solution (PBS) or autogenous plasma did not significantly increase the rate of vascularization in comparison with controls at weeks 1 and 2. However, pretreating the implants with a saline/gentamicin solution or PBS alone was associated with an increased rate of vascularization at weeks 2 and 3. No statistically significant difference in vascularization was noted between the subcutaneous and orbital implants at any week. Hydroxyapatite implants pretreated with saline/gentamicin or phosphate buffered solutions underwent more rapid vascularization at weeks 2 and 3 in comparison with controls. Additionally, all groups were noted to have a more rapid rate of ingrowth between weeks 2 and 3 than between weeks 1 and 2. Plasma and rTGF-β2 (at the dose used) did not significantly alter the rate of vascularization of hydroxyapatite implants during the first 2 to 3 weeks. The significance of these findings is discussed.

Progression of diabetic retinopathy after endophthalmitis.

OBJECTIVE To determine the effect of endophthalmitis on diabetic retinopathy. DESIGN Noncomparative case series. METHODS The records of all consecutive patients with endophthalmitis treated between 1992 and 1997 at the Medical College of Wisconsin were retrospectively reviewed. Those patients with diabetes mellitus were analyzed. PARTICIPANTS From 77 reviewed records, 11 patients (12 eyes; 14%) were identified as diabetics with endophthalmitis and were studied. MAIN OUTCOME MEASURES Stage of diabetic retinopathy, time to retinopathy progression, and visual acuity. RESULTS Mean patient age was 68 years, and mean duration of diabetes was 11.7 years. Mean patient follow-up was 17 months. Of the six cases without evidence of retinopathy before the endophthalmitis, none went on to develop retinopathy. Of six eyes with pre-existing nonproliferative retinopathy, four showed evidence of progression within 6 months of the infection. Three developed severe proliferative disease and macular edema, and one developed severe nonproliferative disease. More patients without pre-existing retinopathy achieved a final visual acuity of 20/40 or greater. CONCLUSIONS Patients with pre-existing diabetic retinopathy may be at increased risk for rapid retinopathy progression and a poorer visual outcome after endophthalmitis. These results support the concept that inflammation may exacerbate diabetic retinopathy.