Syed K. Gibran

Can an intraoperative bevacizumab injection prevent recurrent postvitrectomy diabetic vitreous hemorrhage

Purpose To evaluate the recurrence of vitreous hemorrhage (VH) in patients treated with intravitreal bevacizumab (IVB) injection (2.5 mg/0.1 mL) intraoperatively at the end of vitrectomy for treatment of diabetic nonclearing VH. Methods A prospective pilot study of 30 eyes of 28 consecutive diabetic patients who underwent pars plana vitrectomy and IVB injection intraoperatively at the end of vitrectomy was performed. The amount of VH was graded with slit lamp biomicroscopy by three masked retinal specialists from grade 0 to grade 3. Main outcome measures were rate of recurrence of the VH, improvement in visual acuity, incidence of cataract formation, and postoperative complications through a follow-up of 6 months. Results The percentage of severe recurrent VH with no fundus details (grade 3) was 7%, 13%, 27%, and 30%, respectively, at 7 days and 1-, 3-, and 6-month follow-up. At 6-month follow-up, the best-corrected visual acuity improved from 1.00 to 0.4 logMAR (p=0.01) in 21 out of 30 eyes (70%). Nine out 20 (40%) phakic patients developed cataract during the follow-up period, and 7 (31%) of them underwent cataract surgery. Conclusions The study suggests that intravitreal bevacizumab injection cannot prevent rebleeding in eyes undergoing pars plana vitrectomy for treatment of diabetic vitreous hemorrhage.

Management of exudative retinal detachment in choroidal melanoma.

Exudative retinal detachment is the most common source of visual loss associated with malignant melanoma of the uveal tract. Management has historically been conservative, leading to irreversible visual loss from photoreceptor damage during the several months needed for post‐radiation resolution. The purpose of this paper is to describe timely vitreoretinal surgical intervention for exudative retinal detachments associated with choroidal melanomas. This was an interventional case series including six consecutive patients with malignant melanoma who experienced VA reduction secondary to associated exudative retinal detachment. Patients underwent complete ophthalmic evaluation and B‐scan ultrasound. Treatment included proton‐beam radiation or brachytherapy, prognostic transretinal tumour biopsy with 25‐gauge vitrector and surgical treatment of exudative retinal detachment, including vitrectomy and drainage of subretinal fluid at the time of irradiation. Successful management of exudative retinal detachments associated with choroidal melanomas was observed in all cases, with significant restoration of vision. Steady regression of tumour thickness was noted clinically and ultrasonographically, without extrascleral extension or metastasis, and with no recurrence of exudative retinal detachment found over follow up. In the present study, the investigators have showed effective surgical treatment of exudative retinal detachment associated with malignant melanoma. These patients had significant restoration of vision, confirming that timely intervention of exudative retinal detachment associated with malignant melanoma can reverse visual loss in these patients. These findings are in contrast to previous reports of irreversible visual loss after exudative retinal detachments, and suggest that photoreceptor atrophy might play a role in visual loss associated with chronic exudative retinal detachments.

Perfluorocarbon liquid assisted large retinal epithelium patching in sub-macular hemorrhage secondary to age related macular degeneration

BackgroundWe investigate the safety and feasibility of large retinal pigmentary epithelium (RPE)-Choroid-free graft after surgical drainage of massive sub-macular hemorrhage (SMH) due to age-related macular degeneration (ARMD).MethodsFour previously untreated patients (three females and one male) underwent to three port pars plana vitrectomy, induction of retinal detachment and peripheral temporal 180° retinotomy. The retina was then folded nasally, to allow access for removal of sub-macular Hg and CNV complex. A full-thickness-large autologus Chorio-RPE patch was grafted. Silicone oil was used as endotemponade for approximately 12xa0weeks. After removal of silicone oil, the patients were followed-up for 6xa0months.ResultsSMH was completely removed in all cases. It was possible to graft a large RPE patch safely that is sufficiently large to cover the entire defect of macular RPE. At last follow-up, improvement in visual acuity (from 3u2009±u20090.9 to 55u2009±u20099 ETDRS letters) and recovery of central fixation was observed in all patients.ConclusionsOur surgical technique for large elevated SMH seems to be feasible and efficacious approach to harvest and relocate large RPE patch and to save limited vision in selected patients.

A Comparison of Two-Way Text Versus Conventional Paging Systems in an Academic Ophthalmology Department

Alphanumeric paging systems are unidirectional without prioritization capabilities. Newer electronic communication devices such as two-way text paging systems are capable of bidirectional paging and prioritization. While previous studies have evaluated alphanumeric paging systems in academic hospital settings, bidirectional two-way text paging systems have not been investigated. The goal of this study was to evaluate efficiency and impact on patient care delivery of a two-way text paging system compared to conventional one-way alphanumeric pagers. This unmasked, crossover prospective study was divided into three phases. In phase one, surveys were distributed to all ophthalmology attending physicians, residents, clinical technicians, and secretaries to assess the conventional alphanumeric paging system. In phase two, these participants used two-way text pagers without instruction (unstructured format) that they subsequently compared to the alphanumeric system with devised surveys assessing (on a scale of 0 to 100) time saved, increased daily efficiency, facilitation in patient care, and overall impression (helpfulness).In phase three, participants used a specific communication prioritization protocol (structured format) with the two-way text pagers with subsequent comparison and assessment with the same surveys. Compared to traditional alphanumeric pagers, new digital two-way text pagers were found to be statistically (pu2009<u20090.0001) more helpful by participants in all categories: as a time saver (80.33 vs. 56.95) pu2009<u20090.0001, increased daily efficiency (78.15 vs. 57.13) pu2009<u20090.0001, facilitation in patient care (78.79 vs. 56.95) pu2009<u20090.0001, and overall impression (helpfulness) (61.82 vs. 84.33) pu2009<u20090.0001. When compared to the alphanumeric pager, the two-way text pager was found to decrease subjectively call backs (73.6% to 45.6%, pu2009<u20090.0001), reduce interruptions of learning activities (43.63% to 26.6%, pu2009<u20090.0001) and enabled better patient care (59.8% to 42.2%, pu2009<u20090.0001). No significant statistical difference was found between the structured and unstructured system. Two-way text paging (structured versus unstructured guidance) was preferred over the conventional one-way alphanumeric paging system in every participant category. Two-way text paging is an effective alternative to alphanumeric paging, demonstrating saved time, increased daily efficiency, reduced call backs and interruptions of educational activities, and facilitation in patient care.

Trans‐vitreal endoresection for vasoproliferative retinal tumours

We present an interventional consecutive case series to describe our experience of transvitreal endoresection (TVE) for vasoproliferative retinal tumours (VPRTs). Three patients with VPRTs refractory to conventional treatment modalities of cryotherapy, plaque radiotherapy and anti‐VEGF presented with macular exudative changes and were offered TVE. Complete ophthalmic examination with colour fundal photographs was performed before and during the follow‐up period. All patients were followed up for 6u2003months following silicone oil removal. At the last follow up, resolution of macular and retinal exudative changes with parallel improvement in vision was observed. No recurrences were detected during the follow‐up period. Two of three patients had simultaneous cataract surgery and developed fibrinous uveitis, requiring management with intensive topical steroids. After 3u2003months, these patients had a fibrotic pupillary membrane enveloping the intraocular lens (IOL) with posterior synechiae. These two patients underwent SO removal, IOL explantation and artisan IOL (iris clipped) insertion, resulting in visual improvement. We did not observe any PVR complications in our cases. TVE represents an effective and safe option for the treatment of VPRTs refractory to other treatment modalities. Further studies with a larger sample size and long‐term follow up are indicated to evaluate the role of TVE in the management of VPRTs.

Visual loss associated with tacrolimus: case report and review of the literature

Tacrolimus is an immunosuppressive medication in the class of calcineurin inhibitors that acts by inhibiting T-cell and interleukin-2 activity, and is commonly used after allogeneic organ transplant. We present a patient who used tacrolimus after cadaveric kidney transplant and experienced blurry vision. Ocular examination and patient’s course subsequently revealed aqueous tear deficiency as a dose-dependent adverse effect of oral tacrolimus.

Efficacy of combined intravitreal bevacizumab and triamcinolone for branch retinal vein occlusion

Purpose: To evaluate the efficacy of combined treatment with intravitreal bevacizumab (IVB) and triamcinolone acetate (IVT) for patients with macular edema secondary to branch retinal vein occlusion (BRVO). Materials and Methods: Retrospective analysis of 20 eyes injected with 1.25 mg IVB and 2 mg IVT for clinically identified BRVO within 8 weeks of onset. All patients lacked concomitant ocular pathology and completed 6 months’ follow-up. Clinical examination including LogMAR visual acuity (VA) and central macular thickness (CMT) by spectralis optical coherence tomography (OCT) was performed preoperatively and at 1, 3 and 6 months post-operatively. Results: Mean patient age was 61.3 years with a mean BRVO diagnosis time of 3 weeks at presentation. VA improved from logMAR 1.08 preoperatively to Mean logMAR VA of 0.55 ± 0.17 at 1 month (P < 0.001), 0.56 ± 0.21 at 3 months (P < 0.001), and 0.38 ± 0.1 at 6 months (P < 0.001) Mean CMT improved from 482 ± 107 μm preoperatively to 319 ± 53 μm at 1 month (P < 0.001), 344 ± 89 μm at 3 months (P < 0.001), and 241 ± 29 μm at 6 months (P < 0.001). Mean IOP preoperatively was 16.5 mmHg, 21 mmHg at 1 month, and 15 mmHg at 6 months. Six out of 20 patients (30%) were re-injected with IVB and IVT at 3 months. Conclusions: Early combined treatment with IVB and IVT is effective in improving anatomic and functional outcomes in patients with macular edema secondary to BRVO.

Ophthalmic manifestations and risk factors for mortality of HIV patients in the post-highly active anti-retroviral therapy era: comment.

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Regarding comparison of different techniques of cataract surgery in bacterial contamination of the anterior chamber in diabetic and non-diabetic population.

Dear Editor, n nWe read with great interest the authors’ recent report on pre-operative povidone-iodine and ofloxacin instillation in diabetics and non-diabetic patients prior to cataract surgery.[1] The evaluation of antiseptic techniques is particularly important in diabetic patients who may have an increased predisposition to post-operative infection. Evaluating povidone-iodine in diabetic patients is particularly interesting because both can prove to be individually toxic to the cornea. We were interested if the authors did a systematic corneal evaluation as part of their pre-operative and post-operative examination as we did not notice this documented in the study? n nDiabetes mellitus has been associated with corneal epitheliopathy, decreased corneal oxygen uptake, and altered corneal hysteresis with some evidence suggesting a positive weak correlation with elevated serum glucose levels.[2,3] Povidone-iodine (5%) (PI) has also been associated with toxic corneal epitheliopathy including induction of epithelial cell death and delayed corneal epithelial healing.[4,5] Following pars plana vitrectomy (PPV) for proliferative diabetic retinopathy in poorly controlled diabetics, we have noted a particularly high incidence of peri-operative corneal epitheliopathy. We have speculated that PI and poorly controlled diabetes mellitus may have a synergistic effect in compounding post-operative corneal epitheliopathy. n nTo evaluate this, a retrospective study was conducted of 68 patients who underwent PPV for proliferative diabetic retinopathy. Each patient had thorough pre-operative and post-operative corneal examination, including documentation of fluorescein staining pattern, tear-film breakup time, punctuate epithelial erosions, and epithelial defects. All patients underwent pre-operative preparation with 5% PI to the eyelids, eyelashes, and by flushing the conjunctival fornices with mean contact time of 5 minutes. Fifty percent of eyes developed post-operative corneal epitheliopathy (34 eyes). The average HbA1c for the epitheliopathy group was 8.01% while the average for the non-epitheliopathy group was 8.44%, and this difference was not statistically significant (P = 0.45). There was no statistically significant difference in surgical duration (mean 55 minutes) between patients developing corneal epitheliopathy and not developing corneal epitheliopathy, and there were no cases of endophthalmitis. n nThis study demonstrates a high incidence of corneal epitheliopathy in diabetic patients who underwent PPV for proliferative diabetic retinopathy. There was no correlation between glycosylated hemoglobin levels and corneal epitheliopathy. Further formal studies are warranted to fully investigate this. We would be interested in the authors’ experiences of post-operative corneal evaluation and glycosylated hemoglobin levels from their study, if available.