Tito Fiore

Combined pars plana vitrectomy and phacoemulsification to restore visual acuity in patients with chronic uveitis

Purpose: To report the outcomes of combined phacoemulsification and pars plana vitrectomy (PPV) to restore visual acuity in patients with cataract and posterior segment involvement secondary to chronic uveitis. Setting: Ocular Immunology and Uveitis Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA. Methods: This study comprised 34 patients (20 women, 14 men; 36 eyes) with posterior segment involvement secondary to chronic uveitis who had combined phacoemulsification and PPV from 1998 to 2002. The main outcome measures were visual acuity, intraocular pressure, and cystoid macular edema. Results: The mean patient age was 45 years ± 16.09 (SD). The mean duration of uveitis before surgery was 56 ± 44.17 months. In 24 eyes (66.7%), an intraocular lens (IOL) was implanted during surgery; 12 eyes (33.3%) were left aphakic. Five eyes (13.8%) received an intraocular steroid injection intraoperatively. Visual acuity improved in 26 eyes (72.2%), deteriorated in 5 (13.9%), and was unchanged in 5 (13.9%). The main reason for decreased visual acuity was refractory macular edema. During the follow‐up, 2 IOLs were explanted secondary to lens intolerance. One IOL was repositioned because of iris capture by the haptics, and 1 dislocated inferiorly, causing monocular diplopia. The mean follow‐up was 23.4 ± 16.7 months. Conclusions: Results indicate that combined phacoemulsification and PPV is a feasible technique for the removal of cataract and pathologic vitreous in eyes with chronic uveitis. Although the exact role of vitrectomy in patients with uveitis remains to be determined, the combined surgery successfully restored useful vision in most cases.

A Pilot Study on Ocular Safety of Intravitreal Infliximab in a Rabbit Model

PURPOSE To determine whether infliximab may be used safely as an intraocular drug, the ocular safety of intravitreal infliximab in rabbits was studied by clinical examination, electroretinography (ERG), and histology in rabbits. METHODS Twelve New Zealand albino rabbits were selected for this study. Different infliximab doses, namely 1.0 mg, 1.7 mg, and 3.3 mg in 0.1 mL, were injected intravitreally into one eye each of three rabbits. As a control, the vehicle solution was injected into the fellow eye of each animal. Eye clinical examination and ERG recordings were made before and 2, 6, and 12 weeks after injection. Eventually, the rabbits were humanely killed, and the retinas were examined by light microscopy. In addition, the elimination half-life of the drug in the vitreous was assessed. RESULTS Slit lamp biomicroscopy, indirect funduscopy, and ERG evidenced no significant differences between control and infliximab-injected eyes in this rabbit model, at any of the tested doses. Histologic examination revealed no retinal abnormality in the rabbits injected with 1 mg and 1.7 mg intravitreal infliximab. In two of three eyes injected with 3.3 mg infliximab, significant edema of the nerve fibers was detected compared with the control group. The half-life of the drug was estimated to be 8.5 days. CONCLUSIONS These results indicate that infliximab may be a safe intravitreal drug in the rabbit model at a dose of up to 1.7 mg. If proven safe and efficacious in further studies, intravitreal injection of infliximab could be considered an alternative to systemic administration in selected patients.

Macular Thickness Measured by Optical Coherence Tomography in a Healthy Population Before and After Uncomplicated Cataract Phacoemulsification Surgery

Purpose: To examine macular changes before and after uncomplicated cataract surgery in a healthy population. Material and Methods: In a prospective study, we evaluated 62 eyes of healthy patients having elective cataract phacoemulsification. We performed optical coherence tomography (OCT) measurements preoperatively and at 3, 6, 12, 20, and 28 weeks after surgery. The retinal map was divided into minimal foveal thickness, a central 1-mm disk area, and two peripheral ring areas with diameters of 3 mm and 6 mm, respectively, and centered on the fovea. We compared the postoperative OCT values against the respective preoperative values. Results: Two eyes (3.2%) developed cystoid macular edema (CME) after cataract surgery and were excluded from the study. With respect to preoperative values, visual acuity improved significantly postoperatively, and at 12 weeks, we observed an asymptomatic increase in retinal thickness at 3 mm and 6 mm. Macular volume showed a statistically significant increase at the 12th week after surgery. There was no correlation between macular changes and best corrected visual acuity (BCVA) or ultrasound time. Conclusions: Our data indicate that the onset of clinically significant CME is rare after uncomplicated phacoemulsification cataract surgery, but with respect to preoperative values we observed an asymptomatic increase in macular thickness and volume at 12 weeks. The possible onset of macular alterations after uncomplicated cataract surgery must be taken into account as a potential later complication, because it can lead to a permanent loss of visual acuity.

Rituximab Treatment for Persistent Scleritis Associated with Rheumatoid Arthritis

Purpose: To report a clinical case of a patient with severe scleritis associated with rheumatoid arthritis (RA) refractive to conventional treatment that was treated effectively with rituximab. Methods and Results: A 55-year-old man with RA, on etanercept and oral methotrexate, was referred with diagnosis of acute stromal keratitis, anterior uveitis, and anterior nodular scleritis in his right eye. Cyclophosphamide induced complete regression of acute stromal keratitis and anterior uveitis, but scleritis was still active and persistent. After two 1000-mg infusions of rituximab, scleritis regressed completely and is still in remission 9 months after the second rituximab infusion, without any concomitant use of oral steroids. Conclusion: Rituximab may be a treatment alternative in severe scleritis that is refractive to conventional therapy. Considering its safety profile, further studies are needed to refine its mechanism of action, optimal indications, and dosing in ocular inflammation.

Acute Posterior Multifocal Placoid Pigment Epitheliopathy: Outcome and Visual Prognosis

Objectives: To examine the clinical outcomes and the effect of treatment in patients with acute posterior multifocal placoid pigment epitheliopathy. Methods: Cases of acute posterior multifocal placoid pigment epitheliopathy treated at the Massachusetts Eye and Ear Infirmary from 1990 to 2002 and cases from the literature were identified. Data on visual acuity, ocular symptoms, bilateral involvement, foveal involvement at presentation, and treatment regimens were recorded. Results: Visual acuity was 20/25 or worse in 226 (76.6%) eyes and 20/40 or worse in 172 (58.3%) eyes at presentation. At the last follow-up visit, visual acuity was 20/25 or less in 125 (42.3%) eyes and 20/40 or less in 70 (23.7%) eyes. Topical or systemic therapy was given in nearly half of the cases (54.4%). Overall, 87 (71.9%) eyes were symptomatic at last follow-up visit. Finally, measured visual acuity was more than 20/25 in 20 (87.5%) eyes without foveal involvement at presentation and in 28 (39.2%) eyes with foveal involvement. Conclusions: Although acute posterior multifocal placoid pigment epitheliopathy shows a relatively benign prognosis, especially when compared with some of the other white dot syndromes, there are patients who experience incomplete visual recovery.

Somatostatin for Uveitic Cystoid Macular Edema (CME)

Purpose: To report the favorable response of bilateral recalcitrant uveitic cystoid macular edema (CME) to treatment with a somatostatin analog. Methods: Medical ophthalmic history and the results of ophthalmic examinations were recorded. Fluorescein angiography (FA) studies were reviewed. Results: A 52-year-old white female with intermediate uveitis developed bilateral recalcitrant CME. Treatment with subcutaneous injections of the somatostatin analog octreotide resulted in partial resolution of the CME and improvement of visual acuity. Conclusions: Somatostatin may play a role in the treatment of CME secondary to uveitis.

Automated Quantitative Analysis of Retinal Microvasculature in Normal Eyes on Optical Coherence Tomography Angiography

PURPOSE To describe a new automated quantitative technique for displaying and analyzing macular vascular perfusion using optical coherence tomography angiography (OCT-A) and to determine a normative data set, which might be used as reference in identifying progressive changes due to different retinal vascular diseases. DESIGN Reliability study. METHODS A retrospective review of 47 eyes of 47 consecutive healthy subjects imaged with a spectral-domain OCT-A device was performed in a single institution. Full-spectrum amplitude-decorrelation angiography generated OCT angiograms of the retinal superficial and deep capillary plexuses. A fully automated custom-built software was used to provide quantitative data on the foveal avascular zone (FAZ) features and the total vascular and avascular surfaces. A comparative analysis between central macular thickness (and volume) and FAZ metrics was performed. Repeatability and reproducibility were also assessed in order to establish the feasibility and reliability of the method. RESULTS The comparative analysis between the superficial capillary plexus and the deep capillary plexus revealed a statistically significant difference (P < .05) in terms of FAZ perimeter, surface, and major axis and a not statistically significant difference (P > .05) when considering total vascular and avascular surfaces. A linear correlation was demonstrated between central macular thickness (and volume) and the FAZ surface. Coefficients of repeatability and reproducibility were less than 0.4, thus demonstrating high intraobserver repeatability and interobserver reproducibility for all the examined data. CONCLUSIONS A quantitative approach on retinal vascular perfusion, which is visible on Spectralis OCT angiography, may offer an objective and reliable method for monitoring disease progression in several retinal vascular diseases.

Adverse drug reactions to treatments for ocular toxoplasmosis: A retrospective chart review

OBJECTIVE This study evaluated the incidence and types of adverse drug reactions (ADRs) associated with medications used to treat active toxoplasmic chorioretinitis. METHODS This was a retrospective review of the clinical records of a consecutive series of patients with active toxoplasmic chorioretinitis, examined between March 1991 and August 1998. For inclusion in the review, patients had to have been diagnosed with active toxoplasmic chorioretinitis, been treated with a single drug or drug combination indicated for this condition, and been followed for at least 8 weeks. Patients who were lost to follow-up or who had incomplete chart data were excluded. Demographic data, pertinent aspects of the medical history, drug treatments, and ADRs associated with antitoxoplasmic treatment were recorded. RESULTS Fifty-five patients met the criteria for inclusion in the review. In descending order of frequency, they received antitoxoplasmic treatment with clindamycin (n = 50), sulfadiazine (n = 40), pyrimethamine (n = 33), trimethoprim-sulfamethoxazole (n = 16), and atovaquone (n = 10), alone or in combination. Twenty-two patients (40.0%) had a total of 27 ADRs. The most frequently occurring ADRs were rash (19 [34.5%]), mostly associated with sulfadiazine (9/40 [22.5%]) and clindamycin (6/50 [12.0%]), and gastrointestinal ADRs such as diarrhea (6 [10.9%]), stomach upset (6 [10.9%]), and bleeding (1 [1.8%]), mostly associated with clindamycin (5/50 [10.0%], 3/50 [6.0%], and 1/50 [2.0%], respectively). The incidence of ADRs associated with individual antitoxoplasmic drugs was 30.0% (3/10) for atovaquone, 26.0% (13/50) for clindamycin, 22.5% (9/40) for sulfadiazine, 12.5% (2/16) for trimethoprim-sulfamethoxazole, and 12.1% (4/33) for pyrimethamine. There were 2 serious ADRs: gastrointestinal bleeding in a patient treated with clindamycin and leukopenia in a patient treated with pyrimethamine. Twenty-five ADRs were reversed on drug discontinuation; the remaining 2 were mild and did not require drug discontinuation. CONCLUSIONS The overall incidence of treatment-associated ADRs was high (40.0%) in these patients with ocular toxoplasmosis. The most frequently occurring ADRs were rash and gastrointestinal complaints.

Ocular penetration of topical antibiotics: study on the penetration of chloramphenicol, tobramycin and netilmicin into the anterior chamber after topical administration

To compare penetration in the aqueous humour of topically applied antibiotics.

Repeatability and Reproducibility of Retinal Thickness Measurements in Diabetic Patients with Spectral Domain Optical Coherence Tomography

ABSTRACT Background: To determine the repeatability and reproducibility of optical coherence tomography (OCT) Spectralis retinal thickness measurements in diabetic patients with clinically significant macular edema (CSME). Methods: Twelve eyes of 12 volunteers (without macular pathology – control group) and 21 eyes of 21 diabetic patients with CSME were included in the study. Reproducibility, repeatability, intraclass correlation coefficients (ICCs) and intrasession correlation coefficients were tested with 20 × 15 degree raster scans consisting of 19 high-resolution line scans that were repeated three times by two experienced examiners. Results: In the control group, examining all regions, coefficient of repeatability was less than 1.1%, while coefficient of reproducibility was less than 2.2%. In diabetic patients, examining all regions, coefficient of repeatability was less than 2.6%, while coefficient of reproducibility was less than 2.4%. ICCs were, respectively, greater than or equal to 0.98 in the control group and 0.99 in diabetic patients. Intrasession coefficients of variation were less than 0.4% in the control group and less than 0.5% in diabetic patients. Conclusion: Retinal thickness measurements are repeatable and reproducible with OCT Spectralis in both the control group and diabetic patients. The results indicate that a change in central subfield thickness exceeding 12 µm and 3% in the diabetic patients is likely to be real.