Swati Agarwal

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.

Acute bilateral simultaneous angle closure glaucoma after topiramate administration: a case report

IntroductionA case of severe acute bilateral angle closure glaucoma with complete visual loss after oral topiramate therapy.Case presentationA 34 year-old woman developed bilateral severe visual loss 2 days after doubling the dosage of topiramate. Her best-corrected visual acuity (BCVA) was counting fingers in both eyes (OU). Intraocular pressures were 49 mm and 51 mm of Hg in right and left eyes respectively, with conjunctival chemosis, corneal edema, shallow anterior chamber and closed angles on gonioscopy. B-scan ultrasound revealed annular peripheral choroidal effusions in both eyes.ConclusionIntraocular pressures and anterior chamber depth were normalized after discontinuation of topiramate and initiation of antiglaucoma therapy. Two weeks later, visual acuities improved to 20/25 in the right eye and 20/40 in the left eye. B-scan ultrasound showed resolution of choroidal effusion. Topiramate, an oral sulpha-derivative medication is known to cause ciliochoroidal effusions, which lead to forward rotation of the ciliary body and displacement of the lens-iris diaphragm, with resultant acute angle closure glaucoma and myopic shift.

Evaluation of cytotoxic effects of bevacizumab on human corneal cells.

Purpose: Corneal neovascularization contributes to corneal opacification in inflammatory conditions of the cornea and severely compromises the success of corneal transplantation. Vascular endothelial growth factor (VEGF) plays an important role in stimulating and maintaining corneal neovascularization. Anti-VEGF therapy, especially the use of anti-VEGF antibody bevacizumab, has gained popularity in the management of retinal neovascularization and is being used topically for corneal neovascularization. The aim of this study was to investigate the safety profile of bevacizumab on human corneal cell lines. Methods: Human corneal epithelial and fibroblast cell lines and an umbilical vascular endothelial cell line were treated with increasing doses of bevacizumab. The effect of this treatment on cell viability was assessed by WST-1 and crystal violet staining assays. Cytotoxicity was also assessed by fluorescent microscopy and flow cytometric evaluation of propidium iodide-stained cells. Results: In the cytotoxicity experiments, there was no difference in cell numbers after 24-hour exposure compared with control in any of the cell lines at the concentrations tested (P > 0.05 to 0.98). Conclusion: Bevacizumab was nontoxic to human corneal epithelial and fibroblast cells at 3 different concentrations.

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.

Complications of AlphaCor keratoprosthesis: a clinicopathologic report.

Purpose: To describe the clinical and histopathologic features of intractable secondary glaucoma induced by AlphaCor keratoprosthesis. Methods: An elderly woman with pseudoexfoliation glaucoma and pseudophakic bullous keratopathy in the right eye had graft failures after penetrating keratoplasty. Her best-corrected visual acuity at presentation was counting fingers in the right eye and 20/30 in the left eye. Examination showed severe corneal neovascularization. Chirila keratoprosthesis type II was implanted in 2 stages. Ten months later, the patient developed dense retrocorneal membrane, 360° occlusion of angles, intractable glaucoma, no light perception, and nasal stromal melting associated with partial extrusion of the keratoprosthesis. Results: Histopathology revealed invasion of the porous material of the keratoprosthesis by reactive fibroblasts and multinucleated foreign-body giant cells. In the area of dehiscence, we noted thinning and lysis of the collagen fibers, infiltration of lymphocytes, and plasma cells with a sheet of fibroinflammatory tissue extending into the anterior chamber. Conclusions: Corneal stromal melting and retrocorneal prosthetic membrane formation after AlphaCor keratoprosthesis implantation led to intractable glaucoma and extrusion of the implant.

Successful management of melanocytoma-associated choroidal neovascularization with photodynamic therapy.

Purpose To report the efficacy of photodynamic therapy in treatment of choroidal neovascular membrane (CNV) associated with melanocytoma of the optic disc. Methods A middle-aged man with visual acuity of 20/200 in right eye was treated with photodynamic therapy for juxtafoveal classic CNV overlying the papillomacular bundle. CNV was secondary to ocular melanocytoma, a rare event. Results At the 6-month follow-up, a scarred CNV with final visual acuity of 20/30 was noted clinically and angiographically Tomography revealed high reflective scar tissue with flat macula and microperimetry showed restoration of retinal sensitivity over the papillomacular bundle. Conclusions Photodynamic therapy effectively resolved CNV that involved papillomacular bundle (secondary to melanocytoma) and restored retinal function in papillomacular bundle.

Sutureless Limited Vitrectomy for Positive Vitreous Pressure in Cataract Surgery

A sutureless transconjunctival pars plana vitrectomy with the 25-gauge transconjunctival vitrectomy system is used to facilitate phacoemulsification in eyes with positive posterior vitreous pressure and shallow anterior chamber. Peribulbar local anesthesia is administered. In eyes with shallow anterior chamber, if an injection of a viscoelastic substance through anterior chamber paracentesis fails to deepen the anterior chamber, a limited pars plana vitrectomy is performed to remove a small amount of retro-lental vitreous (approximately 0.2 to 0.3 cc) with a 25-gauge high-speed cutter. Phacoemulsification is subsequently performed. The limited pars plana vitrectomy reduces the chances of intraoperative vitreous loss and suprachoroidal hemorrhage. It also increases the anterior chamber depth, facilitates intraoperative steps such as pupil stretching and capsulorhexis, and results in a phacoemulsification procedure that is less complex and safer.

Illuminated curved vitrectomy probe for vitreoretinal surgery.

BACKGROUND AND OBJECTIVE To compare the effectiveness of augmented superior oblique Z-tenotomy (SOZT) with fixed standard SOZT in canceling preoperative superior oblique overaction associated with A pattern anisotropia or V pattern in Browns syndrome. PATIENTS AND METHODS Sixteen consecutive patients with superior oblique overaction or Browns syndrome were treated by removal of a triangular piece of the superior oblique tendon near its insertion (augmented SOZT). Outcome was compared with 20 consecutive historical controls after standard SOZT. RESULTS The decrease in superior oblique overaction in the right and left eyes and fundus intorsion and the collapse of A pattern anisotropia were more significant for patients with superior oblique overaction (P = .003, P = .007, P = .05, P = .0015, respectively) and patients with Browns syndrome (P = .025, P = .03, and P = .05, respectively). No study patient with superior oblique overaction and A pattern anisotropia required reoperation compared with 5 of 14 controls (37.5%); rates for patients with Browns syndrome were 0 for the study group and 3 of 6 (50%) for the control group. CONCLUSIONS Augmented SOZT is superior to standard SOZT for correcting superior oblique overaction, intorsion, A or V pattern, and stereopsis. It is not associated with complications or reoperation. The size of the Z-tenotomy can be modified according to the intraoperative assessment to achieve symmetric results.

Cataract surgery under topical anesthesia using 2% lignocaine jelly and intracameral lignocaine: Is manual small incision cataract surgery comparable to clear corneal phacoemulsification?

A prospective comparative study was undertaken to compare the patients’ pain experience, surgical outcome and surgeon’s experience in phacoemulsification and manual small incision cataract surgery (MSICS) under topical anesthesia supplemented with intracameral lignocaine (TASIL). In Group 1 (n=88) phacoemulsification was done and in Group 2 (n=92) MSICS was done. Pain scores were marked by the patients on a Visual analog scale (VAS) after the surgery. The surgical experience was noted on a questionnaire by the operating surgeon. Descriptive analysis and one-tailed Mann-Whitney test were used to draw results. The average VAS score in Group 1 was 0.65 (SD 1.31) and in Group 2 it was 0.90 (SD 1.22). This difference in the average was not statistically significant with P=0.09. The study demonstrates that MSICS and phacoemulsification both can be done safely under TASIL with acceptable patient comfort, and the pain experienced by the patients during the procedures is comparable.