Sandra Lora Cremers

Clinical pseudophakic cystoid macular edema: Risk factors for development and duration after treatment

PURPOSE: To characterize the incidence, duration, and risk factors for and outcome of cystoid macular edema (CME) after cataract surgery and investigate the effects of treatment regimens on visual outcome and duration. SETTING: University‐based comprehensive ophthalmology practice. METHODS: This study included 1659 consecutive cataract surgeries performed by residents between 2001 and 2006. Cases were classified according to the presence of CME. Subset analysis excluded patients with diabetes mellitus (DM). The CME groups were analyzed according to type of treatment to compare duration of CME and final best corrected visual acuity. RESULTS: The incidence of postoperative CME was 2.35% (39/1659), and history of retinal vein occlusion (RVO) was predictive of postoperative CME (odds ratio [OR], 47.12; P<.001). When patients with DM were excluded, the incidence of CME was 2.14% (29/1357) and history of RVO (OR, 31.75; P<.001), epiretinal membrane (ERM) (OR, 4.93; P<.03), and preoperative prostaglandin use (OR, 12.45; P<.04) were predictive of postoperative CME. Patients with DM and/or intraoperative complications did not have an increased risk for CME when treated with prophylactic postoperative nonsteroidal antiinflammatory drugs (NSAIDs) for 3 months. Groups treated with NSAIDs plus a steroid had significantly shorter resolution times than the untreated group (P = .004). CONCLUSIONS: A history of RVO, ERM, and preoperative prostaglandin use were associated with an increased risk for pseudophakic CME. Treatment with NSAIDs plus steroids was associated with faster resolution of CME than no treatment. Treating high‐risk patients with NSAIDs after cataract surgery decreases the incidence of postoperative CME to that of patients who are not at high risk.

Incidence of intraoperative complications in cataract surgery performed by left-handed residents.

PURPOSE: To compare the incidence of intraoperative complications during cataract surgery performed by left‐handed and right‐handed residents and to find predictor variables for complications in resident‐performed surgery. SETTING: Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA. METHODS: This retrospective chart review comprised cataract extractions performed by postgraduate fourth‐year residents from July 1, 2001, to June 30, 2006. The incidence of posterior capsule tear and vitreous loss were the main outcomes. Univariate and multivariate logistic analyses incorporated the variables of patient age and sex; laterality of surgical eye; presence of diabetes mellitus, glaucoma, or age‐related macular degeneration; history of vitrectomy; axial length; pseudoexfoliation; small pupils; white cataract; posterior polar cataract; handedness of resident; and academic quarter during which surgery occurred. RESULTS: Left‐handed residents performed 170 (9.8%) of the 1730 surgeries. The incidence of posterior capsule tear and vitreous loss was significantly lower in surgeries performed by left‐handed residents than in those performed by right‐handed residents (P = .03 and P<.001, respectively). Multivariate logistic analysis showed that resident right‐handedness and older patient age were predictive of an increased incidence of posterior capsule tear and vitreous loss. A small pupil was predictive of an increased incidence of vitreous loss. CONCLUSIONS: The incidence of posterior capsule tear and vitreous loss was significantly lower in cataract surgeries performed by left‐handed residents. Handedness and patient age were significant predictor variables for these complications.

Increased intraocular pressure on the first postoperative day following resident-performed cataract surgery

PurposeThe aim of this study was to investigate the incidence of intraocular pressure (IOP) elevation after resident-performed cataract surgery and to determine variables, which influence postoperative day 1 (POD1) IOP.MethodsIn all, 1111 consecutive cataract surgeries performed only by training residents between 1 July 2001 and 30 June 2006 were included. Elevated IOP was defined as ≥23 mm Hg. Surgeries were classified according to the presence of POD1-IOP elevation. Fishers exact test and Student t-test were used to compare both groups. Multivariate analyses using generalized estimating equations were performed to investigate predictor variables associated with POD1-IOP elevation.ResultsThe average preoperative IOP was 16.0±3.2 mm Hg and the average POD1-IOP was 19.3±7.1 mm Hg, reflecting a significant increase in IOP (P<0.001, paired t-test). The incidence of POD1-IOP elevation ≥23 mm Hg was 22.0% (244/1111). Presence of glaucoma and ocular hypertension, higher preoperative IOP, and longer axial length were frequently encountered variables in the POD1-IOP elevation group (all P<0.05). Using a multivariate analysis, presence of glaucoma (P=0.004, OR=2.38; 95% confidence interval (95% CI)=1.31–4.30), presence of ocular hypertension (P=0.003, OR=6.09; 95% CI=1.81–20.47), higher preoperative IOP (P<0.001, OR=3.73; 95% CI=1.92–7.25), and longer axial length (P=0.01, OR=1.15; 95% CI=1.03–1.29) were significant predictive factors for POD1-IOP elevation.ConclusionsIOP elevation on the first postoperative day following resident-performed cataract surgery occurred frequently (22.0%). Increased early postoperative IOP was associated with presence of glaucoma and ocular hypertension, higher preoperative IOP, and longer axial length.

Multifocal nodular episcleritis and scleritis with undiagnosed Hodgkin's lymphoma.

PURPOSE To report the case of a patient with undiagnosed Hodgkins lymphoma who presented with coexistent unilateral nodular episcleritis and scleritis. DESIGN Interventional case report and literature review METHODS Review of clinical history, laboratory findings, histology of episcleral and cervical lymph node biopsies, and follow-up. RESULTS A 20-year-old female presented with a 5-month history of redness and pain in her left eye, with associated symptoms of dyspnea, malaise, and fever. The patient was found to have multifocal nodular episcleritis and scleritis that was not responsive to topical steroids or systemic nonsteroidal anti-inflammatory treatment. Laboratory tests subsequently revealed evidence of systemic inflammation, and radiologic studies showed extensive mediastinal and cervical adenopathy. A cervical lymph node biopsy showed Reed-Sternberg cells and a chronic lymphocytic infiltrate consistent with nodular sclerosing Hodgkins lymphoma. Histopathologic analysis of an episcleral nodule revealed a necrotizing granuloma with vasculitis. Systemic chemotherapy was instituted for the Hodgkins disease; this therapy abolished the nodular scleritis. CONCLUSIONS This case raises the possibility of concurrent undiagnosed systemic vasculitis with only an ocular manifestation with Hodgkins lymphoma, either as a coincidence or as a paraneoplastic syndrome. Moreover, it emphasizes the important role of tissue biopsy in establishing diagnosis and directing treatment.

Perioperative prophylaxis for postcataract extraction endophthalmitis.

According to the most recently reported study, the incidences of postcataract extraction endophthalmitis (PCE) range from 0.06% to 0.29%. A retrospective study performed at the Massachusetts Eye and Ear Infirmary showed the overall rate of PCE from October 1994 to July 2005 to be 0.15% (65/43,356). The relatively low incidence of PCE renders it difficult to conduct a well-designed prospective study and identify the risk factor clearly. The most common bacteria causing PCE are presumably derived from patients’ conjunctiva or eyelids. The organisms isolated from the vitreous of PCE patients were genetically the same as the bacteria isolated from the conjunctiva, eyelids, or nose in 82% (14/17) of cases. In the Endophthalmitis Vitrectomy Study, 68% (71/105) of coagulasenegative Staphylococci obtained from the vitreous or anterior chamber of postoperative endophthalmitis (POE) patients were genetically identical to the bacteria isolated from their eyelids. In another Endophthalmitis Vitrectomy Study series, 69.3% (291/420) of patients had confirmed microbiologic growth of their aqueous or vitreous samples. The most common bacteria isolated were Gram-positive coagulase-negative micrococci (consists of coagulase-negative staphylococci, predominantly Staphylococcus epidermidis, plus an isolate of Micrococcus kristinae (70%), Staphylococcus aureus (10%), and streptococcal species (9%). These 2 studies were criticized, however, because bacteria were retroactively

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