Roger A. Goldberg

An outbreak of streptococcus endophthalmitis after intravitreal injection of bevacizumab.

PURPOSE To report a series of patients with Streptococcus endophthalmitis after injection with intravitreal bevacizumab prepared by the same compounding pharmacy. DESIGN Noncomparative consecutive case series. METHODS Medical records and microbiology results of patients who presented with endophthalmitis after injection with intravitreal bevacizumab between July 5 and July 8, 2011, were reviewed. RESULTS Twelve patients were identified with endophthalmitis, presenting 1 to 6 days after receiving an intravitreal injection of bevacizumab. The injections occurred at 4 different locations in south Florida. All patients received bevacizumab prepared by the same compounding pharmacy. None of the infections originated at the Bascom Palmer Eye Institute, Miami, Florida, although 9 patients presented to its tertiary-care ophthalmic emergency room for treatment, and 3 additional patients were seen in consultation. All patients were treated initially with a vitreous tap and injection; 8 patients subsequently received a vitrectomy. Microbiology cultures for 10 patients were positive for Streptococcus mitis/oralis. Seven unused syringes of bevacizumab prepared by the compounding pharmacy at the same time as those prepared for the affected patients also were positive for S. mitis/oralis. After 4 months of follow-up, all but 1 patient had count fingers or worse visual acuity, and 3 required evisceration or enucleation. Local, state, and federal health department officials have been investigating the source of the contamination. CONCLUSIONS In this outbreak of endophthalmitis after intravitreal bevacizumab injection, Streptococcus mitis/oralis was cultured from the majority of patients and from all unused syringes. Visual outcomes were generally poor. The most likely cause of this outbreak was contamination during syringe preparation by the compounding pharmacy.

Streptococcus Endophthalmitis Outbreak after Intravitreal Injection of Bevacizumab: One-Year Outcomes and Investigative Results

PURPOSE To report the 1-year clinical outcomes of an outbreak of Streptococcus endophthalmitis after intravitreal injection of bevacizumab, including visual acuity outcomes, microbiological testing, and compound pharmacy investigations by the Food and Drug Administration (FDA). DESIGN Retrospective consecutive case series. PARTICIPANTS Twelve eyes of 12 patients who developed endophthalmitis after receiving intravitreal bevacizumab prepared by a single compounding pharmacy. METHODS Medical records of patients were reviewed; phenotypic and DNA analyses were performed on microbes cultured from patients and from unused syringes. An inspection report by the FDA based on site visits to the pharmacy that prepared the bevacizumab syringes was summarized. MAIN OUTCOME MEASURES Visual acuity, interventions received, time to intervention, microbiological consistency, and FDA inspection findings. RESULTS Between July 5 and 8, 2011, 12 patients developed endophthalmitis after intravitreal bevacizumab from syringes prepared by a single compounding pharmacy. All patients received initial vitreous tap and injection, and 8 patients (67%) subsequently underwent pars plana vitrectomy (PPV). After 12 months follow-up, outcomes have been poor. Seven patients (58%) required evisceration or enucleation, and only 1 patient regained pre-injection visual acuity. Molecular testing using real-time polymerase chain reaction, partial sequencing of the groEL gene, and multilocus sequencing of 7 housekeeping genes confirmed the presence of a common strain of Streptococcus mitis/oralis in vitreous specimens and 7 unused syringes prepared by the compounding pharmacy at the same time. An FDA investigation of the compounding pharmacy noted deviations from standard sterile technique, inconsistent documentation, and inadequate testing of equipment required for safe preparation of medications. CONCLUSIONS In this outbreak of endophthalmitis, outcomes have been generally poor, and PPV did not improve visual results at 1-year follow-up. Molecular testing confirmed a common strain of S. mitis/oralis. Contamination seems to have occurred at the compounding pharmacy, where numerous problems in sterile technique were noted by public health investigators.

Noninfectious Inflammation After Intravitreal Injection of Aflibercept: Clinical Characteristics and Visual Outcomes

PURPOSE To report the presenting features and clinical outcomes of a series of patients with noninfectious inflammation after intravitreal aflibercept injection. DESIGN Noncomparative consecutive case series. METHODS Medical records of patients who presented with noninfectious inflammation after intravitreal aflibercept injection between November 18, 2011 and June 30, 2013 were retrospectively reviewed. RESULTS A total of 20 cases of postinjection inflammation were identified in 5356 aflibercept injections. The patients presented 1-13 days after aflibercept injection (median 3 days); all noted decreased vision, while 3 of 20 (15%) had pain and 2 of 20 (10%) had conjunctival injection. One patient had a hypopyon (0.5 mm), and the average anterior chamber cell was 1.8+ (range 0 to 4+). All eyes had some degree of vitritis (average 1.8+; range 0.5+ to 4+). Patients on average had received 6 prior aflibercept injections (range 0-16). Only 1 patient-the first to present with inflammation in this series-received an intravitreal tap (culture negative) and injection of antibiotics. All patients were managed with frequent topical steroids and were followed closely for signs of improvement. All but 1 patient regained their preinjection visual acuity (average: 33 days; range: 7-73 days). Four patients were subsequently rechallenged with aflibercept, and 1 developed inflammation again after 5 additional aflibercept injections. The overall incidence of inflammation after intravitreal aflibercept injection was 20 of 5356 injections (0.37%) or 19 of 844 patients (2.25%). However, a disproportionate number of cases clustered around 1 provider (17/20, 85%; P < .001 vs all other providers) and around the 2 office locations where this physician primarily worked (16/20, 75%; P < .001 vs 5 other offices). CONCLUSIONS Noninfectious inflammation after intravitreal aflibercept injection typically presents without pain, conjunctival injection, or hypopyon, and responds to topical steroid therapy. The visual outcomes are generally favorable, though the return to baseline acuity can take many weeks.

Optical coherence tomography in the preoperative and postoperative management of macular hole and epiretinal membrane

Optical coherence tomography (OCT) imaging plays an essential role in the diagnosis and treatment of macular diseases, including those of the vitreomacular interface. OCT enables accurate diagnosis and differentiation of full thickness macular hole, lamellar macular hole and epiretinal membrane, with or without the presence of vitreomacular adhesion. This information enables earlier diagnosis and treatment when necessary, and can guide the choice of therapy. OCT is useful to facilitate discussions with patients and manage the visual expectations. Postoperatively, OCT can be helpful to optimise patient comfort and visual outcomes. As the technology continues to improve, OCT will become increasingly critical for all aspects of care for patients with macular hole and epiretinal membrane.

Primary Intravitreal Ranibizumab for High-Risk Retinopathy of Prematurity

BACKGROUND AND OBJECTIVE To evaluate initial treatment of high-risk retinopathy of prematurity (ROP) with low-dose intravitreal ranibizumab. PATIENTS AND METHODS Case series of premature infants with high-risk pre-threshold or threshold posterior ROP receiving primary therapy with 0.2 mg ranibizumab. Pre-treatment and post-injection examination, RetCam (Clarity Medical Systems, Pleasanton, CA) images, fluorescein angiography, resolution of ROP and plus disease, and stability of examinations were assessed. RESULTS Eight eyes of four infants received primary ranibizumab treatment. Plus disease resolved within 48 hours of unilateral injection, and there was no change in ROP appearance in the contralateral eye. Complete resolution of stage 3 ROP occurred 1 week after injection. Recurrent progressive stage 2 or 3 ROP in mid to anterior zone 2 was noted 8 to 11 weeks after ranibizumab in all eyes. Treatment of recurrent ROP with peripheral laser led to complete ROP regression. Comparison of images before ranibizumab injection to images after ROP recurred demonstrated anterior retinal growth. Retina examinations remained stable without ROP recurrence or detachment at follow-up 8 to 18 months after ranibizumab injection. CONCLUSION Intravitreal ranibizumab induces rapid, complete regression of high-risk posterior ROP with continued retina growth peripherally. The potential for recurrent ROP after a single 0.2 mg ranibizumab injection for posterior ROP requires vigilant monitoring. Subsequent peripheral laser for ROP recurrences may spare the posterior retina from photocoagulation effects.

Fuchs endothelial corneal dystrophy: clinical characteristics of surgical and nonsurgical patients

Purpose To review the patient and clinical characteristics of patients with Fuchs endothelial corneal dystrophy (FECD). Methods Review of records for every patient who presented to the Bascom Palmer Eye Institute between 2003 and 2009 whose visit was coded for endothelial corneal dystrophy (International Classification of Diseases, Ninth Revision [ICD9] 371.57), bullous keratopathy (ICD9 371.23), or who underwent a corneal surgery with or without cataract extraction. Demographic, clinical, and ancillary testing data were collected from the time of presentation, diagnosis, and follow-up, and the use, timing, and type of surgical interventions was documented, with 6-month and final visual acuities recorded. Results A total of 2,370 charts were included in this study, of which 966 patients had a diagnosis of FECD. Of these, 197 patients (21%) received a corneal transplantation procedure. The surgery most often performed was penetrating keratoplasty with or without cataract extraction (66%), followed by endothelial keratoplasty with or without cataract extraction (34%). The risk factors for surgery include worse visual acuity at presentation (20/60 Snellen visual acuity in surgical patients versus 20/40 Snellen visual acuity in nonsurgical patients, P<0.001), greater average central corneal thickness (635 μm versus 592 μm, P<0.001), loss of visual acuity over time (two lines lost versus zero lines lost, P<0.001), increasing age (P<0.001), and male sex (P=0.008). Over half of patients (52%) did not receive surgery despite poor vision. Conclusion During this time period, FECD did not have a consistent pattern for management or treatment, and despite advances in surgical techniques, most patients were still managed without surgery.

Treatment of dystrophic calcification on a silicone intraocular lens with pars plana vitrectomy

Purpose Dense, vision-obscuring calcification on the posterior aspect of silicone intraocular lenses (IOLs) is often not amenable to neodymium:yttrium-aluminum-garnet capsulotomy, and, in prior reports, has required IOL exchange. We report the successful removal of dense calcium deposition on the posterior surface of a three-piece silicone lens using pars plana vitrectomy (PPV). Materials and methods A 23-gauge PPV was performed using the Stellaris® vitrectomy system. A light pipe was used to retroilluminate the IOL, and a dense fibrous tissue setting with a low cut-rate and high aspiration rate was able to clear the visual axis of the dystrophic calcification without damaging the IOL optic. Results Visual acuity improved from 20/100 to 20/25. Conclusion Small-gauge PPV may be utilized to remove dense dystrophic calcium deposits on the lens surface in lieu of IOL exchange.

ENDOSCOPY-ASSISTED VITRECTOMY AND MEMBRANE DISSECTION OF ANTERIOR PROLIFERATIVE VITREORETINOPATHY FOR CHRONIC HYPOTONY AFTER PREVIOUS RETINAL DETACHMENT REPAIR.

Purpose: To review 6-month outcomes for patients with hypotony secondary to anterior proliferative vitreoretinopathy after previous retinal detachment repair who were treated with endoscopic vitrectomy and anterior membrane dissection. Methods: Retrospective review. All individuals underwent endoscopic vitrectomy with removal of anterior proliferative vitreoretinopathy involving the ciliary body. Outcome measurements included intraocular pressure (IOP), visual acuity, and development of phthisis bulbi. Results: Fifteen eyes of 15 patients had an average of 4.5 previous intraocular surgeries (range 1–8). Forty Percent of eyes had silicone oil at the time of endoscopic surgery. Six months postoperatively, 4 eyes had IOP >11 mmHg while 11 had IOP <6 mmHg. The nonresponder group was older in age, had more previous intraocular surgeries, and a lower preoperative IOP. There were no differences in visual acuity or the development of prephthisis at any point. No eyes underwent enucleation or evisceration. Conclusion: Endoscopy-assisted vitrectomy with removal of anterior proliferative vitreoretinopathy from the ciliary body is an effective treatment for chronic hypotony after previous retinal detachment repair in a minority of cases. The IOP improved in patients who tended to be younger and who had fewer previous intraocular surgeries. Further study is indicated to evaluate long-term outcomes and predictors of surgical success.

Progressive Outer Retinal Necrosis Secondary to Herpes Simplex Virus Type 2.

Progressive outer retinal necrosis is an aggressive form of necrotizing herpetic retinitis that presents in immunocompromised patients. It is usually secondary to varicella zoster virus or, rarely, herpes simplex virus type 1. The authors report a case of progressive outer retinal necrosis associated with herpes simplex virus type 2 in a patient with a history of congenital herpes. [Ophthalmic Surg Lasers Imaging Retina. 2014;45:xxx-xxx.].

Presumed Solitary Circumscribed Retinal Astrocytic Proliferation in the Fovea With OCT Angiography: A Misnomer

The retinal lesion known as the presumed solitary circumscribed retinal astrocytic proliferation (pSCRAP) is a benign retinal tumor. Although many of the clinical characteristics of the lesion have been described, much about the pathogenesis of this uncommon tumor is not yet known. Here, the authors report a pSCRAP lesion in the fovea with secondary vision loss occurring in middle age. Structural optical coherence tomography (OCT) scans indicate that the lesion arises from the deep retina or retinal pigment epithelium (RPE), whereas OCT angiography characteristics of the lesion show a lack of intrinsic or paralesional vascular flow, indicating that this lesion is fibrous and likely derived from the RPE or deep retina and not the retinal astrocytes. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:212-214.].