Shailesh K Gupta

Factors associated with visual acuity outcomes after vitrectomy for diabetic macular edema: diabetic retinopathy clinical research network.

Purpose: To evaluate factors ¶associated with favorable outcomes after vitrectomy for diabetic macular edema. Methods: Data were collected prospectively on 241 eyes undergoing vitrectomy for diabetic macular edema. Multivariate models were used to evaluate associations of 20 preoperative and intraoperative factors with 6-month outcomes of visual acuity and retinal thickness. Results: Median central subfield thickness decreased from 412 μm to 278 μm at 6 months, but median visual acuity remained unchanged (20/80, Snellen equivalent). Greater visual acuity improvement occurred in eyes with worse baseline acuity (P < 0.001) and in eyes in which an epiretinal membrane was removed (P = 0.006). Greater reduction in central subfield thickness occurred with worse baseline visual acuity (P < 0.001), greater preoperative retinal thickness (P = 0.001), removal of internal limiting membrane (P = 0.003), and optical coherence tomography evidence of vitreoretinal abnormalities (P = 0.006). No associations with clinicians preoperative assessments of the posterior vitreous were identified. Conclusion: These results suggest that the removal of epiretinal membranes may favorably affect visual outcome after vitrectomy. Preoperative presence of vitreoretinal abnormalities appeared to be associated with somewhat greater reductions in retinal thickness but not with visual acuity outcome. These results may be useful for future studies evaluating vitrectomy for diabetic macular edema.

Intracameral Avastin dramatically resolves iris neovascularization and reverses neovascular glaucoma.

Purpose To report the biologic effect of intracameral bevacizumab in patients with iris neovascularization secondary to proliferative retinal vasculopathies. Methods Sixteen eyes of 15 patients with iris neovascularization associated with or without neovascular glaucoma secondary to proliferative retinal vasculopathies received intracameral bevacizumab (1.25 mg). Ophthalmic evaluations included Snellen visual acuity (VA), complete ophthalmic examination, fluorescein iris angiography, and slit lamp photography Main outcome measure was change in degree of iris neovascularization. Secondary outcomes included fluorescein iris angiographic leakage, control of intraocular pressure, and changes in VA. Results All patients with neovascularization demonstrated by slit lamp photography and fluorescein angiography (16/16 eyes) had complete (or at least partial) reduction in leakage of the neovascularization within 3 weeks after the injection. Leakage from iris neovascularization resolved in 12 of 16 (75%) eyes. In two cases recurrent leakage was seen as early as 4 weeks necessitating repeat injection. Intraocular pressure was controlled with maximum medical therapy in eight of nine eyes reducing the need for glaucoma surgery. Visual acuity improved from a median of hand motions to 20/200. Conclusions In summary, intracameral bevacizumab was effective in reversing iris neovascularization in the majority of patients. It also facilitated intraocular pressure control in patients with associated glaucoma.

Retinal thickness in people with diabetes and minimal or no diabetic retinopathy: Heidelberg Spectralis optical coherence tomography.

PURPOSE To evaluate macular thickness in people with diabetes but minimal or no retinopathy using Heidelberg Spectralis optical coherence tomography (OCT). METHODS In a multicenter, cross-sectional study of mean retinal thickness, on Spectralis OCT in the nine standard OCT subfields, spanning a zone with 6-mm diameter, center point, and total retinal volume were evaluated. Central subfield (CSF) thickness was evaluated for association with demographic and clinical factors. Stratus OCT scans also were performed on each participant. RESULTS The analysis included 122 eyes (122 participants) with diabetes and no (n = 103) or minimal diabetic retinopathy (n = 19) and no macular retinal thickening on clinical exam. Average CSF thickness was 270 ± 24 μm. Central subfield thickness was significantly greater in males relative to females (mean 278 ± 23 μm vs. 262 ± 22 μm, P < 0.001). After adjusting for gender, no additional factors were found to be significantly associated with CSF thickness (P > 0.10). Mean Stratus OCT CSF thickness was 199 ± 24 μm. CONCLUSIONS Mean CSF thickness is approximately 70 μm thicker when measured with Heidelberg Spectralis OCT as compared with Stratus OCT among individuals with diabetes in the absence of retinopathy or with minimal nonproliferative retinopathy and a normal macular architecture. CSF thickness values ≥ 320 μm for males and 305 μm for females (~2 SDs above the average for this normative cohort) are proposed as gender-specific thickness levels to have reasonable certainty that diabetic macular edema involving the CSF is present using Spectralis measurements.

TTO utility scores measure quality of life in patients with visual morbidity due to diabetic retinopathy or ARMD

PURPOSE To evaluate the utility scores in patients with varying degrees of visual morbidity due to diabetic retinopathy or ARMD. METHODS Patients with vision =20/40 in one eye due to diabetic retinopathy or ARMD were enrolled. Utility scores were measured by the time trade-off (TTO) method after stratifying the patient population with visual impairment in the better eye (group 1, 20/20 to 20/40; group 2, 20/50 to 20/100; group 3, 20/200 to no light perception). RESULTS Sub-group analysis revealed that subjects in group 1 were willing to give up a median of 1 year as compared to 3 years by the subjects in group 3 for perfect bilateral visual acuity (P < 0.05). The median utility score was 0.94 for group 1, 0.96 for group 2 and 0.80 for group 3. While the utility scores for groups 1 and 2 were comparable (P > 0.05), there was a significant difference in the utility scores between groups 1 and 3 and between groups 2 and 3 (P < 0.05). There was no significant effect on the utility scores of age, educational level or prior ocular surgery. CONCLUSION Substantial visual loss secondary to diabetic retinopathy or ARMD is associated with a significant decrease in utility scores. However, TTO scores were not sensitive enough to demonstrate a difference between subjects with mild (group 1) and moderate (group 2) visual loss in the better eye secondary to diabetic retinopathy or ARMD.

Intracameral bevacizumab effectively reduces aqueous vascular endothelial growth factor concentrations in neovascular glaucoma

Vascular endothelial growth factor (VEGF) concentrations in both the aqueous and vitreous are raised in ocular ischaemia secondary to exudative age-related macular degeneration, diabetes mellitus and other retinal vascular diseases.1 2 Retinal ischaemia upregulates VEGF production, resulting in neovascularisation of the retina and the iris (NVI). VEGF is significantly increased in neovascular glaucoma (NVG).3 In the following case series, we show increased aqueous VEGF concentrations in two patients with NVI, which significantly declined, with concurrent resolution of NVI, after off-label intracameral injections of bevacizumab. Two patients with NVI secondary to proliferative diabetic retinopathy were included in the study. After informed consent had been obtained, according to a protocol approved by the University of Florida Institutional Review Board, aqueous was collected before the injection of 0.05 ml intracameral bevacizumab (25 mg/ml) and …

Pars plana modified Baerveldt implant versus neodymium:YAG cyclophotocoagulation in the management of neovascular glaucoma

OBJECTIVE To determine the relative effectiveness of neodymium:YAG cyclophotocoagulation (NCYC) and pars plana modified Baerveldt implant (PPBI) surgery on intraocular pressure (IOP) control in eyes with neovascular glaucoma (NVG). PARTICIPANTS In this retrospective comparative group study, 30 patients with NVG treated with contact NCYC were compared with 18 patients who underwent PPBI. Patients groups were not statistically dissimilar with respect to the underlying disorder-causing angle and iris neovascularization, intraocular pressure, and patients age. RESULTS During a follow up of 6 months, an IOP control of > or = 6 and < or = 21 mm Hg was achieved in 23 eyes (76.6%) treated with NCYC compared with 17 eyes (94.4%) receiving PPBI (P = 0.13). Among eyes that had unsuccessful outcome in both groups, the proportions with persistently high IOP or hypotony were greater in the NCYC group than in the PPBI group. Based on our criteria, the cumulative proportion of failure in the NCYC group was 23.3% at 6 months as compared to 5.6% in the PPBI group. Seven eyes (23.3%) in the NCYC group lost light perception versus 1 eye (5.6%) in the PPBI group. The incidence of postoperative choroidal effusion (36%) was higher in the PPBI group. CONCLUSIONS This study suggests that in the management of NVG, PPBI surgery more frequently controls IOP in a medically acceptable range with less hypotony and greater preservation of visual acuity than NCYC.

Foveal structure defined by spectral domain optical coherence tomography correlates with visual function after macular hole surgery

Purpose. To study the correlation between final visual acuity after successful anatomic macular hole repair and features on spectral domain optical coherence tomography (SD-OCT). Methods. Retrospective review of charts of patients who underwent macular hole surgery. Data collection included pre- and postoperative best-corrected visual acuity (BCVA), central subfield foveal thickness (CSFT), and presence or absence of inner segment-outer segment (IS-OS) line changes on SD-OCT. Data collected from SD-OCT were correlated with Snellen BCVA, which was converted to logMAR score. Subjects were divided into 2 groups: group I had improvement in BCVA of 2 lines or more and group II improved less than 2 lines or had worsening of BCVA. Results. A total of 35 eyes of 32 patients had successful anatomic closure, which was documented both clinically and on SD-OCT. Mean age of the patients was 74.1 years and 71.2% (23/32) of patients were female. Overall, the mean BCVA changed from 1.01±0.38 preoperatively to 0.89±0.48 postoperatively (p=0.33). Based on the postoperative visual outcome, 16 eyes belonged to group I and 19 eyes belonged to group II. On the SD-OCT, the mean CSFT was 252.7±69.1 μm. No correlation was found between the mean CSFT and BCVA in either group. All the 16 patients in group I had a continuous IS-OS line on SD-OCT at the fovea in contrast to 26.3 % (5/19) of patients in group II (p=0.03). Conclusions. Establishment of continuity of IS-OS line is an important indicator of visual recovery in eyes with successful anatomic closure of macular hole.

Management of vitreous loss during cataract surgery under topical anesthesia with transconjunctival vitrectomy system.

Purpose A new technique to manage posterior capsular rupture with vitreous prolapse into the anterior chamber during phacoemulsification under topical anesthesia using the sutureless self-sealing 25-gauge transconjuctival vitrectomy system. Method In the event of vitreous prolapse into the anterior chamber, the corneal wound is sutured and cleared of vitreous. A trans conjunctival 25-gauge sclerotomy through the pars plana is made. The high speed 25-guage trans-conjunctival vitrectomy system (TVS-25) under topical anesthesia is introduced and vitrectomy is performed to clear the anterior chamber of vitreous. An anterior vitrectomy is also done. A foldable intraocular lens is subsequently inserted. Results The vitrectomy is performed in a closed chamber maintaining normal intraocular pressure. The high-speed cutter exerts minimal traction on the vitreous. The accessibility to vitreous improves through the pars plana route ensuring more complete removal of the vitreous and restoration of normal anatomy. Topical anesthesia avoids the risks of globe perforation, retrobulbar hemorrhage, and prolonged postoperative akinesia of the eye. Conclusions The 25-gauge pars plana incision is small and self-sealing. This makes the procedure fast, effective, painless and safe.

Illuminated curved 25-gauge vitrectomy probe for removal of subsclerotomy vitreous in vitreoretinal surgery

Incarceration of vitreous in sclerotomy sites during pars plana vitrectomy can lead to wound-related complications similar to vitreous incarceration in cataract surgery. We describe an illuminated curved 25-gauge vitrectomy probe for removing vitreous from sclerotomy sites. Polyester tubing is used to secure a fiber optic endoilluminator (0.5 mm) with the curved 25-gauge vitrector (0.5 mm). The resultant illuminated curved vitrector (20 G) has a diameter of 1.0 mm. It facilitates complete removal of vitreous around the internal sclerotomies under direct visualization in both phakic and pseudophakic eyes. The same was confirmed with ultrasound biomicroscopy of the sclerotomy sites. Curved vitrector reduces postoperative complications related to incarcerated vitreous in phakic and pseudophakic eyes and other sclerotomy-related wound complications.

Rituximab effectively reverses papilledema associated with cerebral venous sinus thrombosis in antiphospholipid antibody syndrome.

Purpose A case of bilateral papilledema secondary to cerebral venous sinus thrombosis treated with Rituximab, an anti-CD20 monoclonal antibody. Methods A 23 year old obese female with a one week history of blurred vision, headaches and vomiting presented with bilateral papilledema. Her BCVA was 20/50 in right eye and 20/200 in the left eye with severe reduction of visual fields. Laboratory investigations revealed thrombocytopenia, prolonged prothrombin time (not reversed when mixed with normal plasma) and anticardiolipin antibodies. Besides, cerebral angiogram showed presence of cerebral venous thrombosis. The patient was diagnosed to have anti phospholipid antibody syndrome and treated with rituximab I.V. 375 mg/m 2 weekly x 4 doses, acetazolamide 500 mg BID, methyl prednisolone I. V. QID x 4. Results At 1-month, her headaches and vision improved to 20/30 in both eyes with partial resolution of papilledema and complete restoration of visual fields. Nine months later, patient had 20/25 vision in right eye and 20/30 in left eye with complete resolution of papilledema and cerebral sinus thrombosis. Conclusions Rituximab was effective in reversing papilledema and cerebral sinus thrombosis, while preserving the vision in patient with antiphospholipid antibody syndrome. It is efficacious in treating papilledema in patients refractory to treatment with systemic steroids and immunoglobulin, with better clinical compliance and no side effects.