Rohan W. Essex

Endogenous endophthalmitis: 10-year experience at a tertiary referral centre

PurposeEndogenous endophthalmitis (EE) is a sight-threatening emergency and the aetiology is often multifactorial. Delayed diagnosis may exacerbate the poor visual prognosis. We describe the management and visual outcomes of EE presenting to a tertiary referral centre.Patients and methodsA prospective consecutive case series of 64 patients presenting with presumed EE from 1997 to 2007 to the Royal Victorian Eye and Ear Hospital were included. All data were collected in a standardized manner. Outcome measures included: visual acuity, microbial profiles, and vitrectomy rate.ResultsIn total, 64 cases of EE were identified over the study period with a mean age of 57.5 years, and 53.5% were male. Presenting acuities ranged from Snellen 6/6 to no perception of light (NPL). Identifiable risk factors were present in 78.1%, with the majority related to intravenous drug abuse. A 64.1% culture positivity rate was recorded. A vitrectomy rate of 57, 56, and 21% was recorded in documented bacterial, fungal, and no growth cases, respectively. Final Snellen acuities ranged from 6/6 to NPL. A total of 5 out of 64 eyes were enucleated, of which 3 identified Klebsiellaspecies. Better visual outcome was documented in fungal cases.ConclusionEE is a serious ocular condition and has a varied aetiology. Visual outcomes are often poor, irrespective of the method of management. Fungal aetiology often confers a better prognosis, and vitrectomy is advocated for bacterial proven cases.

Avastin as an adjunct to vitrectomy in the management of severe proliferative diabetic retinopathy: a prospective case series

Purpose:u2002 Bevacizumab (Avastin) is a monoclonal antibody which targets all isoforms of vascular endothelial growth factor A. Its potent anti‐angiogenic effects have been shown to cause regression of neovascularization in proliferative diabetic retinopathy. The aim of this study is to investigate the role of Avastin as an adjunct to vitrectomy in the management of severe diabetic eye disease.

Amniotic membrane grafting in the surgical management of primary pterygium

Background:u2002To evaluate the efficacy of amniotic membrane transplantation in primary pterygium surgery.

Efficient capture of high-quality data on outcomes of treatment for macular diseases: The fight retinal blindness! project

Purpose: To describe the development of a web-based high-quality data collection tool to track the outcomes of treatment of macular disease in routine practice. Methods: Testing of a larger data collection tool established which fields a clinician would reliably fill out. The program, which was developed using freely available software, consists of modules interacting with a core system. The module for neovascular age-related macular degeneration is described here. Results: Data for initial visits can be entered within 30 seconds, 15 seconds for follow-up visits. Fifteen centers from Australia, New Zealand, and Switzerland are currently contributing data. Finalized data from 2,052 eyes of 1,693 participants dating from January 2006 were analyzed. Median (25th and 75th percentiles) visual acuity at the index visit was 55 (41, 68) logarithm of the minimum angle of resolution letters with the following lesion types: minimally classic 17.2%, predominantly classic 24.6%, occult 52.0%, idiopathic polypoidal choroidal vasculopathy 1.2%, and retinal angiomatous proliferation 3.2%. Conclusion: This software tool will facilitate the collection of large amounts of data on the routine use of treatments of neovascular age-related macular degeneration. This will allow us to analyze important potentially modifiable variables, such as the effect of different treatment patterns on visual outcomes, and to evaluate new treatments as they are introduced into practice.

Dichoptic multifocal pupillography reveals afferent visual field defects in early type 2 diabetes.

PURPOSEnMultifocal pupillographic perimetry was used to examine differences in the visual fields of 23 subjects with early type 2 diabetes (T2D) and 23 age- and sex-matched control subjects.nnnMETHODSnIndependent stimuli were delivered to 44 regions of each eye while pupil responses were recorded with infrared cameras. The stimuli were presented in 8 segments of 30 seconds, and both eyes of each subject were tested twice. The direct and consensual responses provided 88 responses per eye. The diagnostic power of the method was then examined by applying receiver operator analysis to the peak regional contraction amplitudes, time to peaks, and linear combinations of those.nnnRESULTSnDichoptic multifocal pupillography provided response amplitudes with a median z-score of 2.63 +/- 0.26 (SE). The diagnostic performance (expressed as areas under ROC plots) of the eight subjects (32 fields) who had had T2D for at least 10 years was 0.87 +/- 0.06 (mean +/- SE) for response amplitude deviations from normative data, rising to 0.95 +/- 0.04 when between-eye symmetry was considered. Mean pupil size did not have diagnostic power. Comparison of direct and consensual response fields indicated that the observed localized field defects were afferent.nnnCONCLUSIONSnReasonable diagnostic power was obtained, especially for the 16 eyes that had had T2D for more than 10 years, inferring that even in the near absence of visible diabetic retinopathy, some retinal damage had been sustained. This result, if confirmed in a wider group, suggests the that the method may be clinically useful in screening for early damage to the retina in T2D diabetes.

Three cases of post-traumatic endophthalmitis caused by unusual bacteria.

Three cases of post‐traumatic endophthalmitis caused by unusual bacteria are presented. The pathogens identified were: (i) Bacillus cereus and Citrobacter freundii; (ii) Pseudomonas fluorescens; and (iii) Chryseobacterium meningosepticum and Stenotrophomonas maltophilia. Two of these pathogens have not previously been reported to cause endophthalmitis. The available literature regarding the individual cases is summarized and a brief discussion of post‐traumatic endophthalmitis is presented, with reference to a recently published large series at the authors’ institution.

Multifocal pupillographic assessment of age-related macular degeneration.

Purpose. To investigate retinal function in subjects with unilateral exudative age-related macular degeneration (AMD) using multifocal pupillographic objective perimetry (mfPOP) and to assess the diagnostic accuracy of this technique. Methods. We tested each of 20 exudative AMD patients and 20 control subjects with 4 different mfPOP stimulus variants. Multifocal stimuli consisting of 24 or 44 independent stimulus regions per eye extending from fixation to 15° eccentricity were presented dichoptically. The aperiodic stimuli were presented at 1 or 4 s mean intervals. Video cameras recorded pupil responses under infrared illumination. Test duration consisted of 8 segments of 30 s. Stimuli were presented at a luminance of 250 cd/m2 and a background of 10 cd/m2. Peak regional contraction amplitudes, time to peaks, and a linear combination of these were used to produce receiver operator characteristic (ROC) curves to measure the diagnostic accuracy of this method. Results. Mean constriction amplitudes of exudative AMD subjects were decreased by 0.77 ± 0.15 dB (p < 5 × 10−7). Stimulus ensembles with 44 regions and faster presentation rates produced the largest effect on response sizes (t = 3.63; p < 0.0002). When comparing the control eyes to exudative AMD eyes, the area under the curve of ROC plots was 0.96 ± 0.03 (mean ± SE). This was achieved for asymmetry analysis of the difference in response amplitudes obtained from the two eyes at each point in the visual field. Conclusions. The mean effect of exudative AMD on contraction amplitudes reflected the severity of disease, and ROC analysis from amplitude deviations improved the sensitivity of detection of exudative AMD. A longitudinal investigation into the mfPOP responses of patients with non-exudative AMD may detect and classify visual fields with poor prognosis.

Photodynamic therapy in practice: a review of the results of the first 12 months experience with verteporfin at the Royal Victorian Eye and Ear Hospital

Purpose:u2002To review the 12‐month results of the first 136 eyes treated with photodynamic therapy (PDT) with verteporfin at a single institution, and to determine if this treatment when used in the broader community could reproduce the results achieved in the Treatment of Age‐related Macular Degeneration (AMD) with PDT (TAP) study.

Effects of switching from ranibizumab to aflibercept in eyes with exudative age-related macular degeneration

Aims To examine 12-month outcomes of eyes switching from intravitreal ranibizumab to aflibercept for neovascular age-related macular degeneration (nAMD). Methods Database observational study of eyes with nAMD tracked by the Fight Retinal Blindness outcome registry that received ranibizumab for at least 12u2005months before switching to aflibercept and followed for at least 12u2005months after the switch. Visual acuity (VA) recorded at 12u2005months after the switch was analysed using locally weighted scatterplot smoothing curves. Lesion activity was graded according to a prospectively identified definition. Main outcomes were change in VA and treatment intervals 12u2005months after the treatment switch. Secondary outcomes included change in activity grading, effect of duration of treatment before switching and analysis of eyes that switched back. Results A total of 384 eyes switched from ranibizumab to aflibercept after a mean duration of 39.8u2005months on the original treatment. The mean VA did not change from the time of switching treatment (63.4, SD 15.9 logarithm of the minimum angle of resolution letters) to 12u2005months later (63.3, SD 16.7). While 10% of eyes gained 10 or more letters 12u2005months after the switch, 13% lost the same amount. The mean number of injections decreased by around one injection in the 12u2005months after switching (p<0.001), with a decrease in the proportion of choroidal neovascular membrane lesions that were graded as active. Eyes that had been treated for the longest time (49 or more months) before switching had worse vision at the point of switch but neither change in VA nor treatment interval was different between groups. The small proportion (6.9%) of eyes that switched back again to ranibizumab had already lost a mean of 5.2 letters from the first switch to the switch back and continued to lose vision at a similar rate for at least 6u2005months. Conclusions The mean VA of eyes that switched treatments from ranibizumab to aflibercept was not different 12u2005months later. There was a modest increase in treatment intervals and a somewhat greater proportion of eyes that were graded as inactive after the switch.

Multifocal pupillography in early age-related macular degeneration.

Purpose To investigate the potential of multifocal pupillographic objective perimetry to assess changes in retinal function with clinical severity of age-related macular degeneration (AMD). Methods Pupil responses were recorded from 40 subjects with AMD and 23 normal control subjects (mean ± SD age, 71.3 ± 5.1 years). Age-related macular degeneration subjects were classified according to the Age-Related Eye Disease Study (AREDS) classification system and allocated into one of four AMD severity groups. Three multifocal pupillographic objective perimetry stimulus variants that were identical in luminance but varied in spatiotemporal sequence were used. In one of the three protocols, stimuli were presented with a pedestal flicker for 266 milliseconds at 15 Hz. Results On average, response amplitudes demonstrated a significant change in sensitivity with progression from early-stage (0.32 ± 0.08 dB, t = 3.88) to late-stage (−1.60 ± 0.12 dB, t = −12.7) age-related macular degeneration. Response delays followed a similar trend with the longest delays in AREDS4 (57.2 ± 1.9 milliseconds, t = 29.5). Ring analysis identified the largest mean effect on responses within the central 6 degrees of fixation. The NewStimuli protocol achieved the best diagnostic accuracy across all severity groups with area under the curve values of 0.85 ± 0.066 (AREDS1), 0.908 ± 0.085 (AREDS2), 0.929 ± 0.040 (AREDS3), and 1.0 ± 0.0 (AREDS4). Conclusions The mean effect of AMD on contraction amplitudes and response delays reflected the severity of disease, and the NewStimuli protocol achieved good diagnostic accuracy across all AMD severity groups. Multifocal pupillographic objective perimetry may potentially be a useful method in monitoring progression of AMD and assessing change in retinal function with novel interventions in early AMD. Longitudinal studies are required to identify biomarkers that predict eyes at risk of progression.