Saad Shaikh

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.

Trabeculectomy with intraoperative mitomycin C versus 5-Fluorouracil: Prospective randomized clinical trial

OBJECTIVE To evaluate the relative efficacy and safety of 5-fluorouracil (5-FU) and mitomycin C (MMC) when used as adjuncts with primary trabeculectomy in eyes not at high risk for failure. DESIGN Prospective multicenter, randomized clinical trial. PARTICIPANTS One hundred thirteen patients with primary open-angle, pseudoexfoliative, pigmentary, or angle-closure glaucoma undergoing primary trabeculectomy were recruited. METHODS One eye of each patient was randomized to receive either 5-FU (50 mg/ml for 5 minutes) or MMC (0.4 mg/ml for 2 minutes). MAIN OUTCOME MEASURES Intraocular pressure (IOP), visual acuity, complications, and interventions were documented at fixed intervals after surgery. The study also examined progression of visual field loss, long-term complications, and bleb appearance 3 years after surgery. RESULTS Of the 108 patients with complete perioperative information, 54 eyes received 5-FU and 54 received MMC. The proportion of patients reaching different predefined target IOPs after surgery was slightly higher in the MMC group than in the 5-FU group. This difference was less than 25%, which would have been necessary to achieve statistical significance with a power of 0.8 and the sample size used. Likewise, there was no statistically significant difference between the groups with regard to mean preoperative IOP, complications, or interventions. Mean postoperative follow-up was 309 and 330 days in the 5-FU and MMC groups, respectively (P = 0.593). CONCLUSIONS 5-Fluorouracil and MMC were found to be equally safe and effective adjuncts to primary trabeculectomy in the short- and medium-term postoperative periods.

Photodynamic therapy using verteporfin for choroidal neovascularization in angioid streaks.

PURPOSE To evaluate the efficacy of photodynamic therapy with verteporfin in the management of choroidal neovascularization (CNV) associated with angioid streaks. DESIGN Retrospective case series. METHODS Eleven eyes of nine patients with subfoveal or juxtafoveal CNV due to angioid streaks underwent visual acuity testing, ophthalmic examination, color photography, and fluorescein angiography to evaluate the results of photodynamic therapy with verteporfin. Retreatment of persistent CNV was based on criteria from the Treatment of Age-Related Macular Degeneration with Photodynamic Therapy Investigation (TAP) except in one case. Follow-up ranged from 5 to 28 months (mean, 17 months). RESULTS Nine of 11 eyes had subfoveal lesions while two eyes had juxtafoveal lesions on initial examination. Conversion from a choroidal neovascular membrane (CNVM) to a fibrous disciform lesion following photodynamic therapy was observed in nine eyes. Enlargement of the CNVM was noted in seven of these eyes by fluorescein angiography at final follow-up. Initial best-corrected visual acuity (BCVA) ranged from 20/25 to counting fingers (CF) (mean, 20/400; median, 20/200). Final BCVA ranged from 20/20 to CF (mean, 20/600; median, 20/400). Seven eyes with subfoveal CNVM had an initial BCVA of at least 20/200 while only three eyes maintained this level or better at last follow-up. In one patient with a juxtafoveal CNVM in one eye, vision decreased from 20/25 to 20/400 with enlargement and fibrosis of the CNVM and subfoveal extension. In the fellow eye a juxtafoveal CNVM was initially treated and then retreated earlier than TAP criteria at 6 weeks. Vision improved to 20/20 and has remained stable 5 months after the initial treatment. CONCLUSIONS Verteporfin for choroidal neovascularization-associated with angioid streaks does not appear to significantly alter the course of this disease with most eyes undergoing enlargement and disciform transformation of the neovascular process. However, aggressive management of these patients with biomicroscopic and fluorescein angiographic examination and timely photodynamic therapy with early retreatment when indicated may be beneficial in certain cases.

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.

Untoward outcomes in 25-gauge versus 20-gauge vitreoretinal surgery.

Purpose: This study compares the incidence of complications in eyes undergoing 25-gauge versus 20-gauge vitreoretinal procedures. Methods: Retrospective case series. A chart review of consecutive patients who underwent primary 25-gauge (129 eyes) and 20-gauge (129 eyes) vitreoretinal surgery by four surgeons at a single center between September 2002 and November 2005 was conducted. Results: Mean follow-up was 9.1 ± 4.9 months in 25-gauge eyes and 14.3 ± 8.4 months in 20-gauge eyes (P < 0.01). Intraoperative complications were mainly rhegmatogenous in nature and occurred at statistically similar incidence (4.7% in 25-gauge eyes, 6.9% in 20-gauge eyes). Postoperative complications that were significantly associated with surgical method included hypotony and serous choroidal effusions (7.9% in 25-gauge eyes, 1.6% in 20-gauge eyes, P = 0.02). Other postoperative complications noted included retinal tears and detachments (5.4% in 25-gauge eyes, 4.7% in 20-gauge eyes), persistent vitreous hemorrhage (5.4% in each group), and new vitreous hemorrhage (3.9% in 25-gauge eyes, 0.8% in 20-gauge eyes). Endophthalmitis was noted only in 25-gauge eyes in 2 cases (1.6%). Cataract progression occurred at similar rates in both groups (46%). Conclusion: 25-gauge surgery is associated with a significantly greater incidence of postoperative serous choroidal effusions and hypotony. Of particular concern in 25-gauge surgery is the increased risk of associated endophthalmitis. Operative indications and case selection may be important in minimizing the tendency toward certain postoperative events.

Progression to end-stage glaucoma after laser in situ keratomileusis

We describe 2 patients, one a glaucoma suspect because of family history and the other with juvenile glaucoma. Both patients developed complications after laser in situ keratomileusis that required frequent topical steroids, leading to steroid-induced glaucoma. In both cases, corneal edema from the acute rise in intraocular pressure (IOP) caused inaccurate IOP measurement by standard methods. The inability to recognize glaucoma early may have resulted in significant irreversible vision loss.

Leber hereditary optic neuropathy associated with antiretroviral therapy for human immunodeficiency virus infection

PURPOSE Antiretroviral therapy has reduced the morbidity and mortality associated with human immunodeficiency virus (HIV) infection. However, side effects are increasingly recognized, including a commonly reported toxic mitochondrial myopathy. We report such a case of Leber hereditary optic neuropathy in a patient with antiretroviral therapy for HIV infection and speculate on a possible toxic etiologic role in the development of Leber hereditary optic neuropathy by a shared mitochondrial mechanism. METHODS Case Report. Bilateral optic disk abnormalities observed in a 38-year-old HIV positive man with a family history of Leber hereditary optic neuropathy were documented with fundus photography, color vision testing, and visual field testing. Mitochondrial DNA testing was used to confirm the genetic predisposition to Leber hereditary optic neuropathy. RESULTS Progressive bilateral optic nerve pallor temporally associated with the administration of antiretroviral medication was observed. Diagnostic testing revealed progressive visual field and color vision loss as well as a mitochondrial DNA mutation consistent with Leber hereditary optic neuropathy. CONCLUSION Antiretroviral therapy may be associated with the onset of Leber hereditary optic neuropathy in genetically predisposed patients.

Adjuvant methods in macular hole surgery: Intraoperative plasma-thrombin mixture and postoperative fluid-gas exchange

BACKGROUND AND OBJECTIVE The optimal method for surgical management of idiopathic macular holes remains unknown. Adjuvant methods including intraoperative cytokines and postoperative fluid-gas exchange with and without laser have been described. We report on the safety and final results of routine intraoperative autologous plasma-thrombin mixture and postoperative fluid-gas exchange when necessary as an adjunct to the surgical therapy of this disease. PATIENTS AND METHODS A consecutive series of 114 patients (mean age 66.9 years) with primary idiopathic full thickness Stage II, III, and IV macular holes were primarily treated by vitrectomy, fluid/perfluorocarbon gas exchange, and application of autologous plasma-thrombin mixture to the macular hole. Visible epiretinal membranes were peeled but the normal appearing internal limiting membrane was not routinely stripped. Outcome measures included final Snellen visual acuity, rate of macular hole closure, complications, and number of supplemental procedures performed. RESULTS Closed at one month, were 110 of 121 (91%) macular holes, including two that underwent repeat fluid/gas exchange and laser within the first two weeks after surgery. At the time of final follow-up (mean: 10.9 months), 110 of 121 (91%) macular holes were closed. This included 8 of 9 eyes that had reopening of the macular hole between one and 21 months successfully treated by repeat fluid-gas exchange and 2 eyes that underwent a second successful pars plana vitrectomy, membrane peeling, and repeat fluid-gas exchange. Overall, 98 of 121 eyes overall (81%) were successfully treated by a single surgery; 94 of 121 (78%) achieved two lines or greater of visual improvement; 83 of 121 (69%) achieved 20/70 or better vision; and 47 eyes (39%) achieved 20/40 or better vision. Complications in this series included infectious endophthalmitis (1 eye), intraoperative retinal break (2 eyes), late retinal detachment (5 eyes), transient mild intraocular pressure elevation (46 eyes), inflammatory response (six eyes), epiretinal membrane (6 eyes), intraretinal hemorrhages (1 eye), and cataract (33 of 99 phakic eyes underwent cataract extraction during the follow-up). CONCLUSION A combination of intravitreal perfluorocarbon gas and autologous plasma-thrombin mixture (tissue glue) was well tolerated in most patients and did not result in any specific long-term complications. The use of supplemental fluid-gas exchange when necessary improved the final success rate. Further well-controlled and randomized studies will be required to determine the efficacy of this as an adjunct or alternative to other methods of treatment for macular holes.

Iatrogenic keratoconus as a complication of radial keratotomy

A 47-year-old man with a family history of keratoconus had uneventful bilateral radial keratotomy (RK) with astigmatic keratotomy (AK) enhancements 12 years earlier. He noticed a gradual onset of blurry vision with progressively increasing myopic shift. Visual acuity remained poor even with spectacles or soft contact lenses. Slitlamp examination revealed 16 well-healed RK scars and 2 AK scars with marked corneal steepening inferiorly in an area of astigmatic enhancement in the left eye but an otherwise normal fellow eye with 16 well-healed RK scars. He subsequently had penetrating keratoplasty for decreased vision not correctable by rigid gas-permeable contact lenses. Microscopic examination of the corneal button showed findings consistent with keratoconus. This case represents the first documented incidence of corneal ectasia as a complication of primary RK.

Fluorescein angiographic findings in ocular siderosis.

PURPOSE To report a case of siderosis from a retained intraocular iron foreign body manifesting localized retinal capillary nonperfusion documented by fluorescein angiography. METHODS Case Report. In a 35-year-old man with decreased vision in the left eye, studies included fundus photography, fluorescein angiography, visual field testing, and electrophysiology. Surgical foreign body extraction and histopathologic examination were performed. RESULTS Preoperatively, in the left eye, humphrey visual fields and electrophysiology testing revealed marked depression. Fluorescein angiography demonstrated nasal capillary nonperfusion with occlusion of the second- and third-order arterioles extending along a gradient from the foreign body. Microscopic examination of the lens capsule confirmed the diagnosis of siderosis secondary to a retained iron foreign body. CONCLUSION Extensive capillary nonperfusion may be associated with a retained iron intraocular foreign body, as documented by fluorescein angiography.