Vincent A. Deramo

Retinal pigment epithelium tears after intravitreal injection of bevacizumab (avastin) for neovascular age-related macular degeneration.

Background: Intravitreal bevacizumab (Avastin, Genentech, Inc., South San Francisco, CA) treatment of neovascular age-related macular degeneration (AMD) has become an important part of clinical retinal practice. We describe retinal pigment epithelium (RPE) tears that were noted after intravitreal injection of bevacizumab. Methods: In this multimember, retrospective case series, data on eyes that developed RPE tears after intravitreal bevacizumab injection were collected and analyzed. Previous treatments, type of lesion, time to tear, and preinjection and final visual acuities were all compared. The total numbers of bevacizumab injections were available from all four institutions and compiled to estimate the incidence rate. Results: Four retina centers administered a total of 1,455 intravitreal 1.25-mg bevacizumab injections for neovascular AMD during the 9-month study period. Twelve patients presented with RPE tears within 4 days to 8 weeks of injection (mean ± SD, 24.3 ± 15.2 days from injection to tear). In each case, the RPE tear was preceded by an RPE detachment, and all had a component of serous sub-RPE fluid. On the basis of our collective data, we estimate an incidence rate of ≈0.8%. Conclusions: RPE tears can occur after intravitreal injection of bevacizumab. The low incidence of this adverse event should not preclude anti–vascular endothelial growth factor therapy counseling for patients with neovascular AMD, but eyes with serous RPE detachments appear to be most vulnerable to this adverse event.

Visual Outcome and Bacterial Sensitivity After Methicillin-Resistant Staphylococcus aureus–Associated Acute Endophthalmitis

PURPOSE To determine the frequency, visual outcome, and bacterial sensitivity in cases of methicillin-resistant Staphylococcus aureus (MRSA)-associated acute postoperative endophthalmitis occurring after cataract surgery. DESIGN Retrospective, consecutive, observational case series. METHODS Sixty-four cases of acute endophthalmitis occurring within six weeks after cataract surgery were identified over a three-year interval at a single vitreoretinal practice. Cases related to MRSA were studied and visual outcomes and bacterial sensitivities were recorded. RESULTS Thirty-three of the 64 eyes were culture positive, and six of the 33 cases (18.2%) demonstrated MRSA infection. All six eyes were started on fluoroquinolone antibiotics two or three days before surgery. Corneal abnormalities were noted in five of the six cases (83.3%), ranging from wound infection to diffuse corneal opacification. Visual acuity at last follow-up was no light perception (NLP) in two eyes, hand movements in two eyes, and 20/30 or better in two eyes. One eye with NLP vision underwent enucleation within three days of presentation because of panophthalmitis and impending sepsis. All six organisms were sensitive in vitro to both gentamicin and vancomycin. No organism was sensitive to any fluoroquinolone antibiotic, although not all organisms were tested against all fluoroquinolones. CONCLUSIONS MRSA infection accounts for 18% of culture-positive cases of endophthalmitis in this study and was associated with a poor visual outcome in two-thirds of our patients. MRSA organisms may be resistant in vitro to all generations of fluoroquinolone antibiotics, but do seem to be sensitive to gentamicin and vancomycin. The incidence of MRSA endophthalmitis seems to have increased significantly since the Endophthalmitis Vitrectomy Study was published in 1996.

Vision-related quality of life in persons with unilateral branch retinal vein occlusion using the 25-item National Eye Institute Visual Function Questionnaire

Aim To evaluate vision-related quality of life in persons with branch retinal vein occlusion (BRVO) using the 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25). Design Observational, cross-sectional, interviewer-administered study. Methods 46 patients with unilateral BRVO were included in this study. Scores on the VFQ-25 were analysed and converted to scaled scores per NEI VFQ-25 algorithms. Clinical data including age, gender, employment status, living arrangements, visual acuity, number of systemic diseases and duration of BRVO were also recorded. Subscale results were compared with previously published data, and subgroup analyses were performed. Results Mean adjusted subscale responses among BRVO patients were higher (except for ocular pain) than known averages in patients with diabetic retinopathy, central retinal vein occlusion, age-related macular degeneration and low vision, but lower than known averages in a reference group of people without ocular disease. Subscale responses correlated significantly with visual acuity in the involved eye. This observation held true in eight of 12 subscales, even in patients who maintained vision of 20/25 or better in the uninvolved eye. The General Health subscale and number of systemic diseases correlated significantly with both the General Vision and Peripheral Vision subscale scores. There was no correlation between subscale responses and age. Conclusions BRVO is a retinal vascular disease that is associated with a decrease in vision-related quality of life as determined by the VFQ-25. A decrease in VFQ-25 score is correlated with involved eye visual acuity, even when good visual acuity is maintained in the uninvolved eye.

Central retinal vein occlusion in patients treated with long-term warfarin sodium (Coumadin) for anticoagulation.

Purpose: To describe the clinical features of persons who developed central retinal vein occlusion (CVO) while being treated with Coumadin for chronic anticoagulation. Methods: In a retrospective, comparative, noninterventional case series of patients diagnosed with CVO while being treated with Coumadin as a systemic anticoagulant, visual and anatomical outcomes were compared with those for a cohort of patients diagnosed with CVO who were not treated with any systemic anticoagulation. Results: Fourteen eyes of 14 patients treated with Coumadin were identified. At presentation, the median international normalization ratio (INR) was 2.20 (range, 1.3–5.0). Eight patients (57%) had a therapeutic INR at the time of CVO. Their visual acuity and perfusion status were similar to those of patients with subtherapeutic INR. At the last follow-up (median, 16 months), visual acuity and perfusion status of the group of 14 eyes were similar to baseline findings (P = 0.62). Clinical features and outcomes were similar to those for a cohort of patients with CVO who were not being treated with systemic anticoagulation. Conclusion: CVO can occur in patients being treated with Coumadin for systemic anticoagulation. Final visual acuity and perfusion status were similar to those in a cohort of patients with CVO who were not treated with Coumadin. Although visual acuity is unaffected, ensuring that the INR for these patients remains in the therapeutic range may be important to help prevent secondary systemic thrombotic and embolic disease.

Hypotony caused by scleral buckle erosion in Marfan syndrome

PURPOSE To describe hypotony caused by erosion of the conjunctiva and sclera by a silicone scleral buckle. METHODS Interventional case report. A 33-year-old man with Marfan syndrome presented with hypotony maculopathy and a collapsed globe 17 months after repair of retinal detachment with a silicone sponge and silicone encircling band. RESULTS Examination in the operating room revealed extrusion of the buckle through the conjunctiva and full-thickness scleral erosion. The silicone buckle was removed, and the scleral defect was closed with interrupted 8-0 nylon sutures. Postoperative glaucoma was treated with cyclophotocoagulation. Eight months after scleral repair, visual acuity was RE: 20/40, intraocular pressure was 10 mm Hg, and the retina was attached. CONCLUSION Full-thickness scleral erosion secondary to a silicone exoplant causing hypotony is a rare long-term complication in patients with thin sclera.

Increased incidence of sterile endophthalmitis following intravitreal preserved triamcinolone acetonide

Aim: To report an increased incidence of sterile endophthalmitis following intravitreal injection of preserved triamcinolone acetonide (IVTA) from 1 May to 31 July 2006. Methods: Charts were reviewed for all patients who underwent IVTA injections between 1 January 2005 and 31 July 2006 at the offices of a referral vitreo-retinal practice. Patients were included if they presented post-IVTA with a clinical picture consistent with endophthalmitis. Results: Between 1 January 2005 and 31 July 2006, 554 eyes underwent IVTA. Eleven eyes (1.9%) developed an endophthalmitis. All eleven eyes underwent vitreous tap and intravitreal injection of antibiotics. All cultures and gram stains were negative for bacterial or fungal organisms. From 1 May to 31 July 2006, 97 eyes underwent IVTA. Nine eyes (9.3%) developed sterile endophthalmitis. This represented a statistically significant (p<0.0001) clustering of cases. Triamcinolone acetonide phials from affected lot numbers were analysed and were all found to be negative for bacterial endotoxin (<0.05 EU/ml). Conclusion: Over the 19-month period analysed, 11 cases of sterile endophthalmitis occurred following IVTA, and nine of these cases were clustered over a 3-month period. No endotoxin was detected in the phials tested. The aetiology of this increased incidence of sterile endophthalmitis is still unclear.

Recombinant tissue plasminogen activator injected into the vitreous cavity may penetrate the retinal veins of a porcine model of vascular occlusion

Aim: To determine if recombinant tissue plasminogen activator (rtPA) injected into the vitreous cavity can penetrate the retinal vessels of porcine eyes with or without vascular occlusion. Methods: Eight eyes (group I) of four pigs underwent clamping of the optic nerve flush with the globe for 90 minutes. One hour after reperfusion, one eye of each pig was injected with 75 μg of rtPA, and the fellow eye was injected with balanced salt solution (BSS). Eyes were processed for immunohistochemistry. Four additional eyes (group II) of two pigs were subjected to the same injections, but without optic nerve clamping. Results: After reperfusion, the clinical picture was similar to that of a central retinal vein occlusion. Immunoperoxidase staining showed rtPA only in the retinal veins but not the retinal arteries in all eyes injected with rtPA in both groups I and II. Those eyes also showed intense rtPA staining at the level of the internal limiting membrane (ILM). No staining was seen at the level of the ILM or inside the retinal vessels in the BSS injected eyes. Immunofluorescence staining showed intense staining at the level of the ILM, but not inside the retinal vessels in the rtPA-injected eyes. Conclusions: rtPA may penetrate the retinal veins, but not the arteries of porcine eyes with and without vascular occlusion. The ILM may play a part in preventing rtPA penetration.

Intraoperative choroidal hemorrhage in the Osler-Rendu-Weber syndrome

PURPOSE To describe a patient with Osler-Rendu-Weber syndrome who developed a nonsimultaneous intraoperative choroidal hemorrhage in each eye. METHOD Interventional case report. A 65-year-old Caucasian woman with Osler-Rendu-Weber syndrome developed a choroidal hemorrhage in the left eye during vitrectomy for a complicated retinal detachment with a poor visual outcome. Fifteen years later, she developed a macula on retinal detachment in the right eye, which also had a dense cataract. Immediately after uncomplicated phacoemulsification and intraocular lens implantation, under monitored anesthesia care and retrobulbar block, and without valsalva stress, ophthalmoscopy demonstrated a choroidal hemorrhage. A planned scleral buckle was replaced by pneumatic retinopexy. RESULTS Seven months postoperatively, the retina remained attached with resolution of the choroidal hemorrhage. Visual acuity was 20/30. CONCLUSION Choroidal hemorrhage may occur more commonly in individuals with Osler-Rendu-Weber syndrome. Recognition of this possible association and institution of appropriate intraoperative precautions may facilitate a good visual outcome.

Using optical coherence tomography to elucidate the impact of fixation on retinal laser pathology

Purpose: The direct comparison of in-vivo OCT images with fixed tissues sections assumes the fixation of tissue has no effect on the size and configuration of final pathology images such as light micrographs. Fixation artifact has been a concern in numerous studies of the pathology of retinal laser lesions. We tested this hypothesis. Methods: The Humphrey OCT model 2000 with a custom mirror and lens assembly was used to scan tissue phantoms and both fresh and fixed ex-vivum tissue samples. The optical configuration was determined by optimization of the contrast and signal strength on tissue phantoms. Fresh porcine retinas were scanned using this optimal configuration, then fixed using either glutaraldehyde or formalin. OCT images were taken of the tissue at various stages during the fixation process. Additionally, we examined fixed retinal tissue containing retinal laser lesions as a part of our study of ultrashort-pulsed laser effects on the macacca mulatta retina. Histologic sections were prepared and evaluated. Results: In this presentation, we describe our optical setup and image optimization process and assess the effects of glutaraldehyde and formalin processing on OCT image quality. The OCT images of glutaraldehyde-fixed laser lesions are compared with similar images of laser lesions in-vivo. Fixation artifacts appeared on OCT at 2 to 24 hours. Opacification of the lumen of large vessels was seen at two hours with both glutaraldehyde and formalin, while fixation induced retinal detachment appeared at 24 hours. Overall, there was a grater delineation of the laser lesions by OCT at 24 hours when compared to at 1 or 2 hours of fixation. Conclusions: Fixations induced changes in OCT scans of retinal tissue are present as early as 2 hours after immersion in fixative. Although both glutaraldehyde and formalin fixation preserve much of the tissue structure, these method of fixation have s significant effect on OCT imaging of both normal retinal tissue and laser lesions.