Ryan M. Tarantola

Intravitreal bevacizumab during pregnancy.

Purpose: To report the clinical course of four women treated with intravitreal bevacizumab during pregnancy. Methods: Observational case series. Results: Four pregnant women were treated with intravitreal bevacizumab for choroidal neovascularization (CNV) because of presumed ocular histoplasmosis syndrome punctate inner choroidopathy, or sarcoid uveitis. Patients received a mean of 2.6 ± 2.3 injections (range, 1-6 injections) while pregnant. One patient was treated with five additional injections while breastfeeding. The mean follow-up duration after the most recent injection was 14 ± 2.9 months (range, 11-18 months). Snellen visual acuity improved in all 4 patients with a mean of 5.75 ± 2.2 lines (range, 3-8 lines). At the most recent follow-up, all patients had involuted CNV that did not require additional treatment. All patients had an uneventful prenatal course and delivered healthy full-term infants. All children have remained healthy, exhibiting normal development and growth during infancy. Conclusion: Offering pregnant patients intravitreal bevacizumab therapy during pregnancy for off-label ocular indications can result in significant visual improvement. No adverse events related to treatment occurred in any patient included in this study. Additional studies with more patients and longer follow-up duration are required to identify any risks associated with treatment.

Fungal Eye Disease at a Tertiary Care Center: The Utility of Routine Inpatient Consultation

PURPOSE Hematogenous dissemination of fungus of the eyes can manifest as chorioretinitis or endophthalmitis. Early reports of this condition describe the prevalence to range from 10% to 40%; however, more recent studies have suggested a declining prevalence, presumably because of widespread use of prophylactic antifungal therapy and earlier diagnosis and treatment of systemic illness before ocular symptoms become apparent. This study estimates the current prevalence and microbial profile of fungal chorioretinitis and endophthalmitis among patients with positive fungal cultures at a tertiary care medical center. DESIGN Retrospective case series. PARTICIPANTS A total of 211 adult and pediatric inpatients with fungemia. METHODS All inpatient consultations at our institution to evaluate for ocular involvement by fungal organisms from June 3, 2006, to September 3, 2009, were reviewed. MAIN OUTCOME MEASURES The presence or absence of ocular lesions consistent with disseminated fungus. RESULTS A total of 211 patients (83 pediatric, 128 adult) had consult requests indicating concern for ocular fungal infection. More than 97% of these patients had at least 1 positive fungal culture. In decreasing order of frequency, the organisms identified were Candida albicans, C. parapsilosis, C. glabrata, C. tropicalis, and others. More than 98% of all patients were receiving systemic antifungal therapy (average duration 6.5 days) at the time of examination. No pediatric patients and only 2 adult patients had positive findings (i.e., chorioretinitis or endophthalmitis); 1 of these 2 patients was able to verbalize symptoms and reported floaters and blurring, whereas the other patient was unable to verbalize. Visual symptoms were rare (3.5%) among patients with negative findings who could verbalize visual symptoms. Three adults had nonspecific fundus lesions that were considered inconsistent with chorioretinitis. CONCLUSIONS Disseminated ocular fungal infection is rare in the current era of widespread prophylactic antifungal therapy. Less than 1% of patients in our study had ocular involvement from fungus, and no patients who were asymptomatic had involvement. We suggest that routine ophthalmic consultation on fungemic inpatients is not an efficient use of clinical resources; however, validation of these findings via a prospective study is desired. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Uveitis following intravitreal bevacizumab: a non-infectious cluster.

BACKGROUND AND OBJECTIVE In this retrospective case series, the authors report seven cases of bevacizumab-related uveitis that occurred within a 4-month period. PATIENTS AND METHODS Seven eyes of six patients developed non-infectious uveitis following bevacizumab intravitreal injections in a cohort of 978 consecutive bevacizumab injections. RESULTS The mean age of patients was 74.6 years (range: 26 to 92). All patients developed symptom onset within 1 day of injection. Shared signs and symptoms included corneal edema, anterior chamber and vitreous cell, conjunctival injection, ocular pain, and lack of hypopyon. In all patients, visual acuity returned to within one line of baseline acuity. All seven eyes had been previously injected with bevacizumab, with a mean number of antecedent injections of 6.1 (range: 3 to 12). CONCLUSION A cluster of sterile bevacizumab-related uveitic reactions was described in this case series. Acute onset of symptoms, absence of hypopyon, a predominant anterior segment reaction, and prompt improvement on topical steroid therapy are useful clinical features distinguishing this uveitic syndrome from infectious endophthalmitis.

Intraoperative sclerotomy-related retinal breaks during 23-gauge pars plana vitrectomy.

Purpose: To study the incidence and characteristics of intraoperative sclerotomy-related retinal breaks encountered during 23-gauge pars plana vitrectomy. Methods: A retrospective consecutive case series was assembled from the surgical logs and charts of patients who underwent 23-gauge pars plana vitrectomy. Demographic data and preoperative, intraoperative, and postoperative records were examined. Results: A total 548 eyes met the inclusion criteria. Of them, 145 eyes underwent pars plana vitrectomy for repair of a rhegmatogenous retinal detachment (RRD) and 403 eyes for other indications. Sclerotomy-related retinal breaks were found in 8 of 548 (1.45%) eyes. No breaks were found in the 145 RRD eyes. In non-RRD cases, 8 of 403 (1.98%) eyes had sclerotomy-related breaks. All breaks were adjacent to the superior sclerotomies. The incidence of postoperative retinal detachment was 0% (0 of 403) in the non-RRD group. In eyes with breaks, the primary surgical indication was vitreomacular traction in six of eight eyes and epiretinal membrane in two of eight eyes. Posterior vitreous detachment was absent in six of eight eyes, and six of eight eyes were phakic. Eyes with vitreomacular traction had a significantly higher incidence of breaks (P < 0.0001). Eyes with a surgical indication other than RRD had a higher incidence of breaks, but this was not statistically significant when compared with eyes with RRD (P = 0.087). Conclusion: Pars plana vitrectomy (23-gauge) is associated with a low incidence of sclerotomy-related retinal breaks and postoperative retinal detachments. Eyes with breaks are more likely to be phakic and without a preoperative posterior vitreous detachment. The presence of vitreomacular traction may be a risk factor for the development of intraoperative sclerotomy-related breaks.

Intraoperative choroidal detachment during 23-gauge vitrectomy.

Purpose: To review intraoperative choroidal detachments during 23-gauge vitrectomy and examine possible mechanism(s) involved. Methods: A retrospective consecutive case review of 23-gauge vitrectomies was performed. Main outcomes included choroidal detachment incidence, location, extent, relation to infusion cannula, and postoperative course. Laboratory study of human donor eyes was conducted by placing 23-gauge cannulas at various angles through the pars plana and injecting viscoelastic material after cannula retraction. Results: Among 338 consecutive 23-gauge vitrectomy cases, 12 (3.55%) intraoperative choroidal detachments occurred. These included 6 (1.77%) serous detachments, 4 (1.18%) limited hemorrhagic detachments, and 1 case each of gas and silicone oil during an exchange. In four of six serous detachments and three of four hemorrhagic detachments, the detachment originated from the infusion cannula site. Intraoperative infusion cannula retraction (5 of 12 cases) and blockage (2 of 12 cases) caused transient hypotony. All cases of serous, hemorrhagic, and gas detachment resolved without intervention. Cannulas were placed at various angles to the sclera in human donor eyes. Choroidal detachments were produced after injecting viscoelastic material through obliquely placed cannulas after 1 mm of retraction. Conclusion: Infusion cannula retraction is an important mechanism and risk factor for the development of intraoperative choroidal detachment during 23-gauge vitrectomy. Precautions to prevent retraction and intraoperative repositioning may help avoid this complication.

Macular Hole Closure With Internal Limiting Membrane Abrasion Technique

IMPORTANCE Internal limiting membrane (ILM) abrasion is an alternative surgical technique for successful full-thickness macular hole (MH) repair. OBJECTIVE To study the effects of ILM abrasion as an alternative method of MH repair. DESIGN, SETTING, AND PARTICIPANTS Retrospective consecutive case series from January 2006 to December 2008. Demographic data and preoperative, intraoperative, and postoperative examination records of all patients were reviewed for patients who underwent ILM abrasion with a diamond-dusted membrane scraper during vitrectomy for MH repair. A total of 100 eyes underwent ILM abrasion as an alternative to traditional ILM peeling. MAIN OUTCOMES AND MEASURES Rate of MH closure and visual acuity (VA) outcomes at 3 months after surgery. RESULTS Macular hole closure was achieved with a single surgical procedure in 94 of 100 eyes (94.0%; 95% CI, 87.4%-97.8%). Among all patients, the median preoperative VA was 20/100 (range, 20/30 to hand motions; 25th quartile, 20/60; and 75th quartile, 20/160), and the median postoperative VA at 3 months after surgery was 20/60 (range, 20/20 to hand motions; 25th quartile, 20/40; and 75th quartile, 20/100). Among all patients with stage 2 MHs, 30 of 38 patients (78.9%) had at least 2 lines of VA gain: 15 of 23 (65.2%) were phakic, and 15 of 15 (100%) were pseudophakic. Four of 38 patients (10.5%) with stage 2 MHs had at least 2 lines of VA loss, and all were phakic. Among all patients with stage 3 or 4 MHs, 42 of 62 (67.7%) had at least 2 lines of VA gain, of which 30 of 38 (78.9%) were phakic and 22 of 24 (91.7%) were pseudophakic. Six of 62 patients (9.7%) with stage 3 or 4 MHs had at least 2 lines of VA loss: 4 were phakic, and 2 were pseudophakic. In total, 35.0% (95% CI, 25.7%-44.3%) of patients achieved 20/40 vision or better, and 52.0% (95% CI, 42.2%-61.8%) of patients achieved 20/50 vision or better. CONCLUSIONS AND RELEVANCE Abrasion of the ILM with a diamond-dusted membrane scraper at the time of vitrectomy achieves high rates of MH closure. This technique avoids complete removal of the retinal ILM basement membrane and subjacent tissues and appears to provide MH closure rates similar to those of traditional ILM peeling.

Effect of Internal Limiting Membrane Abrasion on Retinal Tissues in Macular Holes

PURPOSE The purpose of this study was to identify the structural and histological effects of a Tano diamond-dusted membrane scraper (DDMS) on the retinal surface after internal limiting membrane (ILM) abrasion in macular hole surgery. METHODS Institutional experimental study was performed in 11 eyes. All eyes underwent ILM abrasion in the operating room with a DDMS for macular hole repair as an alternative to traditional ILM peeling. Three human donor eyes underwent an identical procedure in the laboratory. Retinal tissues were removed by ILM abrasion with a DDMS during vitrectomy for macular hole repair and retinal tissues remaining in human donor eyes. Main outcome measures were microscopic and immunohistological characteristics of instrument tip tissues and retinal structure after ILM abrasion. RESULTS The tips of the Tano DDMS showed evidence of cellular membranes and ILM removal. The retinas showed distinct areas of lamellar ILM removal without penetration of the retinal nerve fiber layer (RNFL). CONCLUSIONS Application of the Tano DDMS instrument is sufficient to remove membranes from the surface of the ILM and layers of the ILM without disruption of the underlying RNFL. Internal limiting membrane abrasion can be a useful and effective alternative to complete ILM removal for macular surgery.

Long-term outcomes in patients undergoing vitrectomy for retinal detachment due to viral retinitis

Purpose To determine the outcomes in patients with rhegmatogenous retinal detachment (RRD) secondary to viral retinitis. Patients and methods This was a retrospective, consecutive, noncomparative, interventional case series of 12 eyes in ten patients with RRD secondary to viral retinitis. Results of vitreous or aqueous biopsy, effect of antiviral therapeutics, time to retinal detachment, course of visual acuity, and anatomic and surgical outcomes were investigated. Results There were 1,259 cases of RRD during the study period, with 12 cases of RRD secondary to viral retinitis (prevalence of 0.95%). Follow-up was available for a mean period of 4.4 years. Varicella zoster virus was detected in six eyes, herpes simplex virus in two eyes, and cytomegalovirus in two eyes. Eight patients were treated with oral valacyclovir and two patients with intravenous acyclovir. Lack of optic nerve involvement correlated with improved final visual acuity of 20/100 or greater. Pars plana vitrectomy (n=12), silicone-oil tamponade (n=11), and scleral buckling (n=10) provided successful anatomic retinal reattachment in all cases, with no recurrent retinal detachment and no cases of hypotony during the follow-up period. Conclusion Varicella zoster virus was the most frequent cause of viral retinitis, and lack of optic nerve involvement was predictive of a favorable visual acuity prognosis. Vitrectomy with silicone-oil tamponade and scleral buckle placement provided stable anatomical outcomes.

Long-term Results of Combined Endoscope-assisted Pars Plana Vitrectomy and Glaucoma Tube Shunt Surgery

Purpose: To assess outcomes after endoscope-assisted pars plana vitrectomy with concurrent pars plana tube shunt placement. Methods: Records of 18 adult patients (19 eyes) with uncontrolled chronic angle-closure glaucoma associated with corneal opacification or fibrosed pupils were retrospectively reviewed. All eyes underwent endoscope-assisted pars plana vitrectomy with Baerveldt tube shunt placement into the vitreous cavity between 1997 and 2005. Intraocular pressure reduction, glaucoma medication reduction, complications, and visual acuity were analyzed. Results: Mean follow-up duration was 62 months (range, 10-106 months). Mean preoperative intraocular pressure was 31.3 ± 10.5 mmHg on 3.4 ± 1.0 glaucoma medications. Intraocular pressure was significantly reduced at each postoperative time point examined. In the 17 eyes without phthisis, intraocular pressure was significantly reduced at the final follow-up examination to a mean of 11.4 ± 2.9 mmHg (P < 0.0001) on 1.3 ± 1.2 medications (P < 0.0001). No complications occurred in 14 of 19 eyes. Postoperatively, best-attained visual acuity improved in 14 of 19 eyes, remained unchanged in 4 of 19 eyes, and was reduced in 1 of 19 eyes. Conclusion: Combined endoscope-assisted pars plana vitrectomy with placement of a Baerveldt tube shunt into the vitreous cavity is a useful intervention in patients with uncontrolled chronic angle-closure glaucoma, media opacities, and limited surgical options.

Temporal approach for small-gauge pars plana vitrectomy combined with anterior segment surgery.

Purpose: To describe our preliminary experience with temporal small-gauge pars plana vitrectomy (PPV) techniques used to treat anterior and posterior segment pathology. Methods: A retrospective consecutive case review of patients who underwent temporal PPV was performed. Patients underwent combined temporal small-gauge PPV and anterior segment intervention. Pre- and postoperative visual acuity, intraocular pressure, surgical indications, intraoperative techniques, postoperative course, and a survey to determine how the change in position affected surgery were examined. Results: Temporal PPV was performed on 23 eyes with various posterior segment indications and anterior segment pathologies including cataract, pupillary membrane, endophthalmitis, superior filtering blebs, and anterior vitreous membranes. In 20 eyes, 23-gauge instruments were used, and in 3 eyes, 25-gauge instruments were used. Mean postoperative follow-up duration was 7.6 ± 5.0 months (range, 3–22 months). Surgical objectives were achieved in all cases, and no complications occurred in any study eye. Preoperative logarithm of the minimum angle of resolution mean visual acuity was 1.89 ± 0.76 and improved significantly on postoperative Week 1 (1.45 ± 0.81, P = 0.0003), Month 1 (1.13 ± 0.86, P = 0.0001), and at final follow-up (0.88 ± 0.79, P = 0.0001). There was no significant difference in preoperative and postoperative intraocular pressures. Surgeon surveys indicated significant advantages with a temporal approach for each anterior segment indication, no significant differences in performing the basic surgical steps of PPV, and relative ease of adopting this technique. Conclusion: Performing PPV from the temporal position seems to be advantageous in cases combining posterior and anterior segment surgery such as cataract extraction, pupillary membrane dissection, preservation of superior conjunctival blebs, and trimanual vitrectomy.