Sumit P. Shah

Endophthalmitis after Pars Plana Vitrectomy: A 20- and 25-Gauge Comparison

OBJECTIVE Recent retrospective analyses have suggested that postoperative endophthalmitis may be more frequent with 25- than 20-gauge pars plana vitrectomy (PPV). Because the infection risk may depend on the suturing status of the sclerotomy, and the perioperative anti-infection protocol, we compared the incidence rate of endophthalmitis after sutureless 25-gauge versus sutured 20-gauge PPV on a large cohort of patients operated with a standardized perioperative anti-infection protocol. DESIGN Retrospective comparative case series. PARTICIPANTS Consecutive patients who underwent 20- or 25-gauge PPVs at a single center over a multi-year period. METHODS We analyzed 3597 consecutive PPVs. Patients with a pre-PPV diagnosis of endophthalmitis, PPVs performed for implantation of drug delivery devices, or 25-gauge PPVs with all sclerotomies sutured closed were excluded. Patients with > or =1 week of follow-up were divided into 2 study groups by sclerotomy status at the end of surgery: the 20-gauge group had 3 sutured 20-gauge sclerotomies, and the 25-gauge group had > or =1 unsutured 25-gauge sclerotomy. Endophthalmitis was defined by clinical criteria independent of microbiological results. MAIN OUTCOME MEASURES The incidence of endophthalmitis was compared between 25- versus 20-gauge groups. RESULTS Of 3372 PPV surgeries meeting inclusion and exclusion criteria, 1948 and 1424 surgeries were 20- and 25-gauge PPVs, respectively. Average age (+/- standard deviation) of patients was 54.6 (+/- 22.6) and 64.4 (+/- 16.5) years in the 20- and 25-gauge PPV groups, respectively (P<0.0001). Median post-PPV follow-up time was not significantly different between the 2 groups (12.5 vs 13.0 months; P = 0.69). Endophthalmitis was observed in 1 patient (0.07%; 95% confidence interval, 0%-0.21%) from the 25-gauge group and none in the 20-gauge group (P = 0.42; Fisher exact test, 2-tailed). The use of air/gas endotamponade (P<0.0001) and intravitreal triamcinolone (P<0.001) was more common in 25- versus 20-gauge PPV. CONCLUSIONS The incidence of endophthalmitis was low in both groups. We were unable to show a significant difference in the incidence of endophthalmitis between sutureless 25-gauge and sutured 20-gauge PPV, and conclude that a careful perioperative anti-infection protocol may reduce 25-gauge PPV endophthalmitis risk to that of 20-gauge PPV.

Optical coherence tomography-guided facedown positioning for macular hole surgery.

Purpose: To use spectral domain optical coherence tomography–guided duration of facedown positioning to study anatomical macular hole closure rates. Methods: Retrospective review of patients with macular holes undergoing 23-gauge pars plana vitrectomy and intraocular gas tamponade. Spectral domain optical coherence tomography imaging was done on postoperative Day 1. Patients remained facedown for 2 more days if the macular hole was closed or 6 more days facedown if the macular hole was open or indeterminate. Results: There were 8 Stage 2, 12 Stage 3, and 12 Stage 4 macular holes. On postoperative Day 1, 24 holes were closed by spectral domain optical coherence tomography and instructed to remain facedown for two more days. Twenty-three of 24 holes remained closed during the postoperative period. Eight holes were open or indeterminate on postoperative Day 1 and remained facedown for 6 more days. Six of 8 holes (75%) were closed at their last follow-up. The overall closure rate was 29/32 (90.6%). Average follow-up was 334 days. Conclusion: Confirming early closure of macular holes with spectral domain optical coherence tomography imaging can serve as an important guide to significantly shorten the duration of prone positioning while maintaining high closure rates.

Endophthalmitis in microincision vitrectomy: outcomes of gas-filled eyes.

Purpose: To assess whether performing an air or gas exchange at the conclusion of a microincision vitrectomy procedure is beneficial regarding the rate of endophthalmitis. Methods: This was a collaborative, multicenter, retrospective chart review of 2,336 eyes that underwent microincision sutureless vitrectomy (23 or 25 gauge) with either SF6 or C3F8 gas endotamponade for macular hole between January 2008 and December 2009. For all eyes, the search methodology was structured to identify the main outcome measure, which was the occurrence of acute postoperative endophthalmitis (<6 weeks after pars plana vitrectomy). Results: Of the cumulative 2,336 consecutive cases over a 2-year period, only 1 (0.04%) had postoperative endophthalmitis. All eyes had near-complete gas-fluid exchange at the end of surgery; C3F8 was the most common endotamponade agent. The majority of cases were performed with 23-gauge vitrectomy. No other complications were noted. Conclusion: Endophthalmitis was a rare occurrence in this large series of gas-filled eyes after macular hole surgery (0.04%). Gas endotamponade after microincision sutureless vitrectomy may be beneficial in reducing the risk of postoperative endophthalmitis; however, additional studies are necessary to make a definitive recommendation.

The Value of Optos Panoramic 200MA™ Imaging for the Monitoring of Large Suspicious Choroidal Lesions

Purpose: Suspicious elevated choroidal lesions require close monitoring for potential malignant transformation. We describe a case of a large choroidal lesion in which conventional digital photography was not optimal for documenting baseline clinical features. The Optos Panoramic 200MA™ system documented the lesion in its entirety. Design: Observational case report. Method: A 75 year old female presented with decreased vision and a large pigmented choroidal lesion (> 10 mm in diameter). Result: Standard 30 degree fundus photography yielded poor images due to the large size of the lesion and media opacity from cataract. The Optos system allowed for the entire lesion to be readily captured in a single photograph for serial evaluations over time. Conclusion: Large dimension choroidal lesions of the fundus may be more easily and accurately documented with Optos ultrawide-field imaging.

Optos Panoramic 200MA™ Ultrawide-Field Imaging of Peripheral RPE Adenoma

Purpose: To illustrate the utility of ultrawide-angle fundus imaging in documenting a suspicous lesion in the far retinal periphery. Design: Observational case report. Method: A 48 year-old female with new onset floaters in the left eye was noted to have an elevated and heavily pigmented lesion in the far retinal periphery. Optos Panoramic200MA™ ultrawide-field photography and fluorescein angiography allowed for accurate serial documentaton of the lesion which was determined to be a retinal pigment epithelial adenoma. Result: Over a four year period of observation, Optos ultrawide-field photography of the retinal pigment epithelial adenoma demonstrated stability of the lesion size and mild lesion depigmentation with overlying vitreous pigmentation. Conclusion: The Optos ultra-widefield system demonstrates the ability to rapidly and reproducibily obtain images to monitor a peripheral retinal pigment epithelial adenoma for objective and comparitive detection of change.

Ultra–High-Resolution Optical Coherence Tomographic Findings in Commotio Retinae

Commotio retinae is a self-limited opacification of the retina secondary to direct blunt ocular trauma. Histologic studies of monkeys and humans relate this clinical observation to damaged photoreceptor outer segments and receptor cell bodies.1–3 Reports using time-domain optical coherence tomography (OCT) and spectral-domain OCT support the involvement of the photoreceptor layer, but these techniques lack the resolution necessary to confirm results of histologic analysis.4–6 Prototype high-speed ultra–high-resolution OCT (hs-UHR-OCT) images demonstrate these anatomical changes in a patient with acute commotio retinae.

Frequency and characteristics of intraocular inflammation after aflibercept injection.

Purpose: To report the frequency and characteristics of intraocular inflammation after intravitreal aflibercept injection. Methods: A single-center retrospective study was performed in patients who received intravitreal aflibercept from November 2011 through June 2013. Results: There were 28 cases of intraocular inflammation after a total of 5,905 aflibercept injections among 1,660 patients. The mean baseline acuity was 20/57, which decreased to 20/179 at diagnosis (P < 0.0001) but recovered to 20/59 at Month 1, 20/57 at Month 3, and 20/52 at Month 6 (P = not significant). Vitreous culture and injection of antibiotics were performed in eight cases, and all were culture negative; the remainder received only topical corticosteroids. Conclusion: The frequency of inflammation after aflibercept was 0.47% per injection. Visual acuity and inflammation returned to baseline within 1 month in most cases with topical corticosteroid treatment.

Optos Optomap Panoramic 200MA imaging of a serous choroidal detachment responsive to furosemide.

Purpose: To describe a case of a serous choroidal detachment which resulted after discontinuation of furosemide and illustrate the utility of ultrawide-angle fundus imaging in documenting this lesion in the retinal periphery. Design: Observational case report. Method: An 85 year old female presented with symptoms of a “brown curtain” descending over the left eye which was temporally related to recent discontinuation of oral furosemide. Ultrawide-field photography allowed for accurate documentaton of the choroidal detachments. Result: After resuming furosemide, the serous choroidal detachments resolved. Conclusion: We hypothesize a shift of free water following discontinuation of furosemide as a novel etiology for the development of serous chordoidal detachments. Ultrawide-field fundus photography was useful to document this lesion.

INTRAVITREAL OCRIPLASMIN IN CLINICAL PRACTICE: Predictors of Success, Visual Outcomes, and Complications

Purpose: To investigate predictors of success, visual outcomes, and complications of intravitreal ocriplasmin for the treatment of symptomatic vitreomacular adhesion in a clinical care setting. Methods: Retrospective chart review of 49 consecutive eyes of 47 patients who received intravitreal ocriplasmin. Spectral domain optical coherence tomography scans were examined for vitreomacular traction (VMT) release, full-thickness macular hole (FTMH) closure, and other changes in retinal anatomy. Results: Pharmacologic VMT release occurred in 41% of eyes; positive predictors included age ⩽75 years (P = 0.001), phakic status (P = 0.016), VMT width ⩽750 &mgr;m (P = 0.001), and absence of retinal comorbidities (P = 0.035). Pharmacologic FTMH closure occurred in 25% of cases; positive predictors included successful VMT release (P = 0.042), better preinjection best-corrected visual acuity (P = 0.036), and smaller FTMH aperture width (P = 0.033). Eyes that achieved VMT release and did not undergo surgery attained significant improvement in best-corrected visual acuity (P = 0.015). Complications included subfoveal lucency (33%), ellipsoid zone disruption (33%), and FTMH base enlargement (75%). Only FTMH base enlargement resulted in worse visual outcomes (P = 0.024). Subgroup analysis of 14 eyes with ideal characteristics (all positive predictors listed above) yielded a 93% VMT release rate. Conclusion: Proper case selection may facilitate successful pharmacologic vitreolysis with ocriplasmin, improve visual outcomes, and minimize potential complications.

Limited long‐term efficacy of intravitreous anti‐VEGF pharmacotherapy in sarcoidosis complicated by peripapillary choroidal neovascular membrane

Editor, S arcoidosis is a multi-organ disorder characterized by non-caseating granulomas. This disease has been reported to be the most common of confirmed aetiologies among all categories of uveitis (Kitamei et al. 2009). Choroidal neovascular membrane (CNVM) occurs very rarely, but is vision-threatening when it involves peripapillary locations (Gragoudas & Regan 1981; Hoogstede & Copper 1982). Reported treatments of sarcoidrelated peripapillary CNVM, including systemic, oral and periocular steroids and argon laser photocoagulation, are controversial and not universally effective (Gragoudas & Regan 1981; Spalton & Sanders 1981; Hoogstede & Copper 1982; Frank & Weiss 1983). Elevated vascular endothelial growth factor (VEGF) has been implicated in systemic sarcoidosis (Matsuda et al. 2004). A recent report with short-term follow-up reported significant therapeutic response to bevacizumab in a patient with sarcoidosis-related posterior uveitis complicated by CNVM (Kurup et al. 2009). Likewise, sustained resolution was reported in a patient with inflammatory CNVM related to toxoplasmosis when treated with intravitreous bevacizumab (Guthoff & Goebel 2008). In contradiction, we report a patient with sarcoid peripapillary CNVM which was only transiently less active when treated with multiple ranibizumab and bevacizumab intravitreous injections over a longterm period. In December 2002, a 62-year-old man presented with bilateral panuveitis and a peripapillary CNVM in the left eye (Fig. 1). His best corrected visual acuity (BCVA) was 20 ⁄ 20 OD and 20 ⁄ 50 + 2 OS. The patient was diagnosed with biopsy-proven sarcoidosis and treated unsuccessfully with high-dose oral prednisone and periocular triamcinolone. There was complete resolution of the CNVM after adequate peripapillary argon laser photocoagulation (Fig. 2). The patient was lost to follow-up and presented to our institute again in November 2006. Visual acuity was 20 ⁄ 20 ) 2 OD with peripapillary haemorrhage and subretinal fluid along the temporal optic disc margin without an anterior or posterior chamber cellular reaction; VA OS was 20 ⁄ 40 and an inactive peripapillary photocoagulation scar was noted. From November 2006 to January 2007, the patient received monthly injections of intravitreous ranibizumab in the right eye. Temporary anatomical and functional improvement was noted after each injection. In March 2007, a new, second CNVM was observed along the superior peripapillary distribution with subretinal fluid. The eye was re-injected with intravitreous ranibizumab. One month later, growth and activity of both CNV lesions persisted. Because the new lesion was located along the superior edge of the optic nerve outside the maculopapular bundle, it was treated with peripapillary argon laser photocoagulation in April 2007. Although the superior CNVM resolved within 2 weeks of photocoagulation, submacular fluid from the temporal CNVM persisted (Fig. 3). Between April 2007 and December 2007, the patient received five additional intravitreous ranibizumab injections with transient improvement, but global growth of the CNVM continued. During this time–course the patient was noted to have a worsening cataract and epiretinal membrane in the right eye. He underwent 25-gauge pars plana vitrectomy, lensectomy, posterior chamber intraocular lens implant, membrane peel and intravitreous injection of 0.1 cc of triamcinilone 40 mg ⁄ cc in December 2007. Although postoperative VA improved to 20 ⁄30 ) 2, the CNVM remained active through to March 2008, despite two additional bevacizumab injections. Overall, despite nine ranibizumab and two bevacizumab injections administered over a 16-month period, subretinal fluid began to encroach closer to the fovea (Fig. 5A). The patient was finally treated with peripapillary photocoagulation along the (A)