Outcomes of Eyes Undergoing Multiple Surgical Interventions after Failure of Primary Rhegmatogenous Retinal Detachment Repair

PURPOSE

To assess outcomes among eyes undergoing surgery for recurrent rhegmatogenous retinal detachment (RRD) and investigate variables that correlate with visual and anatomic outcomes.

DESIGN

Retrospective, consecutive case series.

PARTICIPANTS

Eyes in which initial RRD repair failed that underwent ≥2 surgeries for RRD repair between January 1, 2016, and December 31, 2020.

METHODS

A retrospective analysis of eyes that underwent ≥2 RRD repairs. Eyes with etiologies of retinal detachment other than RRD, previous vitreoretinal surgery, and proliferative diabetic retinopathy were excluded. One-way analysis of variance with Tukey honestly significant difference testing and multivariate regression analyses were used to assess statistical significance.

MAIN OUTCOME MEASURES

Anatomic success rate and habitual best recorded visual acuity (VA) at postoperative time intervals and at final follow-up.

RESULTS

The single-operation success rate (SOSR) among eyes that underwent primary RRD repair over a 5-year period was 92.4% (2021 of 2187 eyes). The remaining 166 eyes (164 patients) in which primary RRD repair failed were included in this study. Although the anatomic success rates after the second and third RRD repairs were lower than the SOSR (71.7% and 68.1%, respectively), the final anatomic success rates did not significantly differ between eyes that underwent ≥2 RRD repairs (range, 90.6%-100%) (P > 0.05), and final anatomic success was achieved in 95.8% of the eyes. The average VA at both postoperative time intervals and final follow-up decreased with an increased total number of RRD repairs. Eyes that received silicone oil endotamponade during the second RRD repair were 20.3% (P = 0.03) and 38.4% (P = 0.04) less likely to require a third RRD repair compared with eyes that received octafluoropropane and sulfur hexafluoride gases, respectively. Eyes that developed a third RRD due to proliferative vitreoretinopathy (PVR) (n = 43) were 110% more likely to require a fourth RRD repair than eyes that developed a third RRD due to a new tear or failure to reattach (n = 4) (P = 0.04).

CONCLUSIONS

In this series, the rates of anatomic success appeared consistent after each surgery when multiple reoperations were required for RRD. The VA decreased with an increased total number of RRD repairs, and the endotamponade choice might have affected the risk of additional reoperations. Proliferative vitreoretinopathy was a significant prognostic factor for RRD recurrence.

Dissociations of the Fluocinolone Acetonide Implant: The Multicenter Uveitis Steroid Treatment (MUST) Trial and Follow-up Study

PURPOSE

To describe fluocinolone acetonide implant dissociations in the Multicenter Uveitis Steroid Treatment (MUST) Trial.

DESIGN

Randomized clinical trial with extended follow-up.

METHODS

Review of data collected on the first implant in the eye(s) of participants. Dissociation was defined as the drug pellet no longer being affixed to the strut and categorized as spontaneous or surgically related.

RESULTS

A total of 250 eyes (146 patients) had at least 1 implant placed. Median follow-up time after implant placement was 6 years (range 0.5-9.2 years). Thirty-four dissociations were reported in 30 participants. There were 22 spontaneous events in 22 participants; 6-year cumulative risk of a spontaneous dissociation was 4.8% (95% confidence interval [CI]: 2.4%-9.1%). The earliest event occurred 4.8 years after placement. Nine of 22 eyes with data had a decline in visual acuity ≥5 letters temporally related to the dissociation. Thirty-nine implant removal surgeries were performed, 33 with replacement. Twelve dissociations were noted during implant removal surgeries in 10 participants (26%, 95% CI 15%-48%); 5 of these eyes had a decline in visual acuity ≥5 letters after surgery. The time from implant placement to removal surgery was longer for the surgeries at which dissociated implants were identified than for those without one (5.7 vs 3.7 years, P < .001). Overall, visual acuity declined 15 or more letters from pre-implant values in 22% of affected eyes; declines were frequently associated with complications of uveitis or its treatment.

CONCLUSION

There is an increasing risk of dissociation of Retisert implants during follow-up; the risk is greater with removal/exchange surgeries, but the risk of both spontaneous and surgically related events increases with longevity of the implants. In 22% of affected eyes visual acuity declined by 15 letters. In the context of eyes with moderate to severe uveitis for years, this rate is not unexpected.

Efficacy of intravitreal ocriplasmin for treatment of vitreomacular adhesion: subgroup analyses from two randomized trials

PURPOSE

To evaluate the efficacy of a single intravitreal injection of ocriplasmin 125 μg across relevant subpopulations of patients with symptomatic vitreomacular adhesion (VMA)/vitreomacular traction (VMT), including when associated with macular hole.

DESIGN

Two multicenter, randomized, placebo-controlled, double-masked, 6-month studies.

PARTICIPANTS

A total of 652 randomized patients (464 receiving ocriplasmin; 188 receiving placebo).

METHODS

A single intravitreal injection of ocriplasmin 125 μg or placebo in the study eye.

MAIN OUTCOME MEASURES

Prespecified subgroup analyses were conducted to evaluate the effects on the proportion of patients with nonsurgical resolution of focal VMA at day 28, nonsurgical full-thickness macular hole (FTMH) closure at month 6, and categoric improvement in best-corrected visual acuity (BCVA) at month 6.

RESULTS

Resolution of VMA at day 28 was achieved more often in younger patients (<65 years), eyes without epiretinal membrane, eyes with FTMH, phakic eyes, and eyes with a focal VMA ≤ 1500 μm. Eyes with FTMH width ≤ 250 μm were more likely to achieve nonsurgical FTMH closure. Categoric ≥ 2-line and ≥ 3-line improvement in BCVA occurred more often in younger patients (<65 years) and in patients with a lower baseline BCVA (<65 letters). Treatment differences in favor of ocriplasmin were generally observed across each subgroup of subpopulations studied.

CONCLUSIONS

Subgroup analyses confirmed the positive effect of ocriplasmin across relevant subpopulations.

Enzymatic vitreolysis with ocriplasmin for vitreomacular traction and macular holes

BACKGROUND

Vitreomacular adhesion can lead to pathologic traction and macular hole. The standard treatment for severe, symptomatic vitreomacular adhesion is vitrectomy. Ocriplasmin is a recombinant protease with activity against fibronectin and laminin, components of the vitreoretinal interface.

METHODS

We conducted two multicenter, randomized, double-blind, phase 3 clinical trials to compare a single intravitreal injection of ocriplasmin (125 μg) with a placebo injection in patients with symptomatic vitreomacular adhesion. The primary end point was resolution of vitreomacular adhesion at day 28. Secondary end points were total posterior vitreous detachment and nonsurgical closure of a macular hole at 28 days, avoidance of vitrectomy, and change in best-corrected visual acuity.

RESULTS

Overall, 652 eyes were treated: 464 with ocriplasmin and 188 with placebo. Vitreomacular adhesion resolved in 26.5% of ocriplasmin-injected eyes and in 10.1% of placebo-injected eyes (P<0.001). Total posterior vitreous detachment was more prevalent among the eyes treated with ocriplasmin than among those injected with placebo (13.4% vs. 3.7%, P<0.001). Nonsurgical closure of macular holes was achieved in 40.6% of ocriplasmin-injected eyes, as compared with 10.6% of placebo-injected eyes (P<0.001). The best-corrected visual acuity was more likely to improve by a gain of at least three lines on the eye chart with ocriplasmin than with placebo. Ocular adverse events (e.g., vitreous floaters, photopsia, or injection-related eye pain--all self-reported--or conjunctival hemorrhage) occurred in 68.4% of ocriplasmin-injected eyes and in 53.5% of placebo-injected eyes (P<0.001), and the incidence of serious ocular adverse events was similar in the two groups (P=0.26).

CONCLUSIONS

Intravitreal injection of the vitreolytic agent ocriplasmin resolved vitreomacular traction and closed macular holes in significantly more patients than did injection of placebo and was associated with a higher incidence of ocular adverse events, which were mainly transient. (Funded by ThromboGenics; ClinicalTrials.gov numbers, NCT00781859 and NCT00798317.).

Use of nepafenac (Nevanac) in combination with intravitreal anti-VEGF agents in the treatment of recalcitrant exudative macular degeneration requiring monthly injections

Purpose

The purpose of this study is to determine the efficacy of combining topical nepafenac with monthly intravitreal injections of ranibizumab or bevacizumab in the treatment of recalcitrant exudative macular degeneration.

Methods

This was a retrospective, consecutive case series of patients with exudative macular degeneration requiring maintenance therapy of antivascular endothelial growth factor ( anti-VEGF) injections at least every 6 weeks, who were started on topical nepafenac. Despite frequent anti-VEGF dosing, all patients included in the study had persistence of any combination of the following: intraretinal cysts, subretinal fluid, and/or pigment epithelial detachment. Patients underwent pinhole visual acuity, clinical exam, and optical coherence tomography (OCT) at baseline and every follow-up visit. Response to therapy was graded by reviewing quantitative and qualitative OCT data, and statistical analysis was done with paired Student’s t-test.

Results

Twenty-five patients (average age 77; 14 male and 11 female) were reviewed; the mean number of previous injections was 17.4 (range 3–31). Baseline mean visual acuity was 20/55, and final mean visual acuity after 3 months of treatment was 20/51 (P = 0.13). Monthly mean central foveal thickness measurements were 248, 250, 257, and 247 μm (P = 0.53) at baseline, 1, 2, and 3 months, respectively. By the end of the 3-month time point, qualitative OCT findings on 13 patients treated with nepafenac were classified as stable, 10 as better, and 2 as worse.

Conclusions

There was no significant change in visual acuity or quantitative OCT measurements, but there appeared to be a mild trend toward improved anatomy and qualitative OCT findings when topical nepafenac was added to monthly anti-VEGF injections in patients with persistent intraretinal cysts, subretinal fluid, and/or pigment epithelial detachment. Further prospective studies with longer follow-up may be warranted.

Spectral domain optical coherence tomography as an effective screening test for hydroxychloroquine retinopathy (the "flying saucer" sign)

Purpose

While the long-term incidence of hydroxychloroquine (HCQ) retinopathy is low, there remains no definitive clinical screening test to recognize HCQ toxicity before ophthalmoscopic fundus changes or visual symptoms. Patients receiving HCQ were evaluated with spectral domain optical coherence tomography (SD OCT) to assess the feasibility of identifying HCQ retinopathy at an early stage.

Methods

Twenty-five patients referred for the evaluation of hydroxychloroquine toxicity underwent a comprehensive ocular examination, Humphrey visual field (HVF) perimetry, time domain OCT, and SD OCT. Some patients with screening abnormalities also underwent further diagnostic testing at the discretion of the treating providers.

Results

Five patients were found to have SD OCT findings corresponding to HCQ toxicity and retinal damage as seen by clinical exam and/or HVF perimetry. Two patients with advanced toxicity were found to have significant outer retina disruption in the macula on SD OCT. Three patients with early HCQ toxicity and HVF 10-2 perifoveal defects were found to have loss of the perifoveal photoreceptor inner segment/outer segment (IS/OS) junction with intact outer retina directly under the fovea, creating the “flying saucer” sign. While two of these three patients had early ophthalmoscopic fundus changes, one had none.

Conclusion

Outer retinal abnormalities including perifoveal photoreceptor IS/OS junction disruption can be identified by SD OCT in early HCQ toxicity, sometimes even before ophthalmoscopic fundus changes are apparent. SD OCT may have a potential complementary role in screening for HCQ retinopathy due to its quick acquisition and because it is more objective than automated perimetry.

Lucentis using Visudyne study: determining the threshold-dose fluence of verteporfin photodynamic therapy combined with intravitreal ranibizumab for exudative macular degeneration

Purpose

Combination verteporfin photodynamic therapy (vPDT) and antivascular endothelial growth factor (anti-VEGF) therapy may decrease the need for injections while maintaining visual acuity in exudative age-related macular degeneration. This pilot study was designed to determine the threshold fluence dose of vPDT (the dose required to demonstrate an effect on choroidal perfusion) combined with ranibizumab.

Methods

Seven patients were randomized to sham vPDT (two patients), 20% fluence vPDT (two patients), or 40% fluence vPDT (three patients) in combination with three-monthly intravitreal 0.5 mg ranibizumab injections. Intravitreal ranibizumab was reinjected if disease activity was seen on fluorescein angiography, optical coherence tomography, or clinical examination. Indocyanine green-determined choroidal hypoperfusion was graded in a masked fashion.

Results

Patients with 20% vPDT had mild hypoperfusion defects at seven days that resolved by week 4 (threshold dose); patients with 40% fluence vPDT had marked hypoperfusion at seven days that persisted as long as 12 months. Recruitment was stopped after limited efficacy was observed. One patient with 20% fluence vPDT lost 19 letters at one year; no other patient lost or gained >10 letters. Central retinal thickness decreased in six of seven patients, but ranibizumab injections did not decrease.

Conclusion

This pilot study shows that the threshold fluence dose of vPDT (when combined with ranibizumab) is approximately 20% standard fluence, and that mild and transient choroidal hypoperfusion can occur. Forty percent fluence vPDT causes a more prolonged and striking hypoperfusion. Despite hypoperfusion, no decrease in visual acuity or injections required was noted, suggesting that even higher fluence levels of vPDT may be necessary to decrease the number of anti-VEGF injections.

A placebo-controlled trial of microplasmin intravitreous injection to facilitate posterior vitreous detachment before vitrectomy

PURPOSE

To evaluate the safety and efficacy of a preoperative intravitreous injection of microplasmin in patients scheduled for vitreous surgery.

DESIGN

Phase 2, multicenter, placebo-controlled, double-masked, parallel-group, dose-ranging clinical trial.

PARTICIPANTS

One hundred twenty-five patients scheduled for pars plana vitrectomy (PPV), primarily for treatment of either vitreomacular traction or macular hole.

INTERVENTION

A single intravitreous injection of either microplasmin at 1 of 3 doses (25 microg, 75 microg, or 125 microg in 100 microl) or placebo injection administered 7 days before PPV.

MAIN OUTCOME MEASURES

Presence or absence of posterior vitreous detachment (PVD) at the time of PPV, progression of PVD, and resolution of vitreomacular interface abnormality precluding the need for PPV.

RESULTS

Rates of total PVD at the time of surgery were 10%, 14%, 18%, and 31% in the placebo group (n = 30), 25-microg (n = 29), 75-microg (n = 33), and 125-microg microplasmin groups (n = 32), respectively. The secondary end point resolution of vitreomacular interface abnormality precluding the need for vitrectomy at the 35-day time point was observed at rates of 3%, 10%, 15%, and 31% in the placebo, and the 25-microg, the 75-microg, and the 125-microg microplasmin groups, respectively. At the 180-day time point, the equivalent rates were 3%, 7%, 15%, and 28%, respectively.

CONCLUSIONS

Microplasmin injection at a dose of 125 microg led to a greater likelihood of induction and progression of PVD than placebo injection. Patients receiving microplasmin were significantly more likely not to require vitrectomy surgery. More definitive evaluation in phase 3 clinical trials therefore is warranted.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Selected clinical comparisons of spectral domain and time domain optical coherence tomography

The authors report four cases where spectral domain optical coherence tomography (SD-OCT) imaged pathology not captured by time domain optical coherence tomography (TD-OCT). These cases include one of angioid streaks, two of juxtafoveal telangiectasia, and one of age-related macular degeneration. In each case, the improved images provided by SD-OCT changed either the management of the patient or the counseling of their disease process.

Retinal pigment epithelium tears following ranibizumab for exudative age-related macular degeneration

PURPOSE

To report two cases of retinal pigment epithelium (RPE) tears following intravitreous ranibizumab injection for age-related macular degeneration (AMD)-associated serous pigment epithelium detachment (PED).

DESIGN

Noncomparative case series.

METHODS

The charts of two patients who received intravitreous ranibizumab for AMD-associated PED and developed RPE tears were reviewed. Fundus photography, fluorescein angiography and optical coherence tomography performed prior to injection and upon follow-up confirmed the diagnosis.

RESULTS

Two patients with serous PED and occult choroidal neovascularization associated with AMD developed RPE tears within four weeks of injection with ranibizumab.

CONCLUSIONS

RPE tears may complicate ranibizumab intravitreous injection for the treatment of AMD-associated PEDs. Further studies need be undertaken to determine whether this complication may also occur when treating choroidal neovascular membranes not associated with PED and whether certain angiographic subtypes are more susceptible to this complication.

Full-thickness eccentric macular hole following vitrectomy with internal limiting membrane peeling

A 65-year-old man presented after macular hole surgery with trypan blue-assisted internal limiting membrane peeling in his left eye. Although the patient had no visual complaints in the left eye, on clinical examination an eccentric full-thickness macular hole was noted just inside the superior vascular arcade and documented by optical coherence tomography. The patient was observed and continued to remain asymptomatic.

Short-term Course of Intraocular Pressure after Intravitreal Injection of Triamcinolone Acetonide

OBJECTIVE

To describe the natural history of intraocular pressure (IOP) within the first 30 minutes after intravitreal injection of triamcinolone acetonide (TA).

DESIGN

Prospective, interventional, consecutive case series.

PARTICIPANTS

Thirty-eight consecutive patients who met inclusion and exclusion criteria and underwent intravitreal injection of 0.1 ml (4 mg) of TA were studied.

METHODS

Intraocular pressure was measured by Goldmann applanation tonometry at baseline; immediately after injection; and at 2, 5, 10, 20, and 30 minutes after injection.

MAIN OUTCOME MEASURES

Intraocular pressure measurements at baseline; immediately after intravitreal injection; and 2, 5, 10, 20, and 30 minutes after injection, and percentage of patients with IOP < or = 24 mmHg at 30 minutes.

RESULTS

Patients who did not experience vitreous reflux (30/38 [78.9%]) at the site of injection had a significant initial elevation of IOP that rapidly normalized. Patients who experienced vitreous reflux (8/38 [21.1%]) at the site of injection had either no change in IOP or a small drop in IOP that rapidly normalized. The IOP measured in millimeters of mercury immediately after injection (45.9 [no reflux], 12.6 [reflux]), 2 minutes after injection (39.9 [no reflux], 13.5 [reflux]), 5 minutes after injection (33.3 [no reflux], 13.8 [reflux]), 10 minutes after injection (26.4 [no reflux], 15.1 [reflux]), and 20 minutes after injection (21.8 [no reflux], 15.0 [reflux]) showed a statistically significant difference between the 2 groups. The difference in IOP between the 2 groups was not significant at baseline or 30 minutes after injection. At 30 minutes, 90% (95% confidence interval, 85.8%-95.2%) of patients without vitreous reflux had an IOP < 24 mmHg.

CONCLUSIONS

Patients undergoing intravitreal injection of TA with no vitreous reflux have a risk of short-term elevation of IOP that rapidly normalizes over 30 minutes. In patients with vitreous reflux after the injection, the IOP declines immediately after injection and rapidly normalizes over 10 minutes.

Optical coherence tomography of idiopathic juxtafoveolar telangiectasia

BACKGROUND AND OBJECTIVE

To document optical coherence tomography (OCT) findings in a series of eyes with group 2A idiopathic juxtafoveal telangiectasia.

PATIENTS AND METHODS

This study is a retrospective review of patient charts, OCT, fundus photography, and fluorescein angiography involving 23 eyes (12 patients). Mean retinal thickness in 9 macular areas was calculated and compared to previously published measurements from normal eyes.

RESULTS

OCT in 8 of 13 stage 3 eyes revealed foveal cysts without evidence of cystoid macular edema on fluorescein angiography or biomicroscopy, and 1 lamellar hole. In stage 3 eyes, mild retinal thickening was found in 7 of 9 macular areas (P < .05).

CONCLUSIONS

OCT commonly reveals foveal cysts in stage 3 idiopathic juxtafoveal telangiectasia. Consistent findings of associated mild macular thickening and lack of late petaloid hyperfluorescence on fluorescein angiography suggest that these cysts differ in pathophysiology from cystoid macular

Clearance of Intravitreal Moxifloxacin

PURPOSE

To study the clearance of moxifloxacin after intravitreal injection in rabbits.

METHODS

Intravitreal injections of 200 microg/0.1 mL of moxifloxacin were administered to rabbits. Four eyes per time point after injection (1 hour and 6, 12, 24, and 36 hours) and three eyes at 48 hours, respectively, were enucleated and immediately frozen and stored at -80 degrees C. Ocular dissection and isolation of frozen vitreous was performed. Vitreous samples were acquired at the various time intervals after injection. Antibiotic assays were performed with high performance liquid chromatography.

RESULTS

The concentration of intravitreal moxifloxacin showed an exponential decay with a half-life of 1.72 hours. The mean vitreous concentration was 120.49 +/- 49.23 microg/mL 1 hour after injection, and declined to 20.23 +/- 5.85 microg/mL at 6 hours and 1.06 +/- 0.81 microg/mL at 12 hours, respectively.

CONCLUSIONS

The vitreous concentrations achieved were several orders of magnitude greater than the MIC90 of organisms commonly involved in bacterial endophthalmitis, and therapeutic levels were maintained at 12 hours in uninflamed, phakic rabbit eyes. The pharmacokinetic data suggest that intravitreal moxifloxacin may have a role in the treatment of bacterial endophthalmitis.

Acute endophthalmitis incidence: intravitreal triamcinolone

OBJECTIVE

To report the incidence of acute postinjection endophthalmitis following intravitreal injection of triamcinolone acetonide (IVTA) as an office procedure.

METHODS

Retrospective, noncomparative, consecutive, interventional case series of all patients who had received IVTA at 2 clinical centers between January 1, 2000, and January 30, 2004.

RESULTS

A total of 1006 eyes received IVTA. None of the eyes developed acute, culture-positive, postoperative endophthalmitis in the 6 weeks following the procedure. One patient developed acute, culture-negative, postoperative endophthalmitis 4 days after receiving IVTA, resulting in an incidence of 0.10%. In this case, the presenting symptoms were decreased vision and acute conjunctival erythema. The case was notable for the absence of pain or hypopyon.

CONCLUSION

Although acute postoperative endophthalmitis may follow IVTA, our experience suggests that this is a relatively uncommon event.

Anterior chamber and sutured posterior chamber intraocular lenses in eyes with poor capsular support

PURPOSE

To compare the clinical outcomes and complications of patients who had surgical placement of anterior chamber (AC IOLs) and sutured posterior chamber intraocular lenses (PC IOLs) after cataract surgery resulting in poor capsular support.

SETTING

Department of Ophthalmology, Bascom Palmer Eye Institute, Miami, Florida.

METHODS

A retrospective interventional comparative case series of 181 eyes of 181 patients that had implantation of an intraocular lens with inadequate capsular support was conducted. A chart review of all patients that had implantation of AC IOLs or sutured PC IOLs at a tertiary care eye hospital between 1995 and 2001 was conducted.

RESULTS

Outcome measures included final best-corrected visual acuity, spherical equivalent, and postoperative complications (pseudophakic bullous keratopathy, elevated intraocular pressure [IOP] inflammation, retinal detachment, suture erosion, cystoid macular edema). Of 702 charts reviewed, 181 were found to fit inclusion and exclusion criteria. The postoperative complication risk ratio was 0.80 (95% confidence interval [CI]: 0.52-1.23) for AC IOLs compared with PC IOLs. The most common complication experienced by patients having implantation of either lens type was elevated IOP (AC IOL: 38%; PC IOL: 42%). The incidence of other complications was similar between the groups. Best-corrected visual acuity was similar; however, final spherical equivalent trended toward more myopic values in the PC IOL group (-0.82 +/- 1.67 for AC IOL versus -1.32 +/- 2.12 for PC IOL).

CONCLUSIONS

The findings suggest that no significant differences in outcome exist when comparing AC IOLs to sutured PC IOLs in complicated cataract extraction with poor capsular support. Recent advances in AC IOL design have yielded lenses that provide a safe, effective alternative to sutured PC IOLs.

Intravitreal clearance of moxifloxacin

PURPOSE

To study the clearance of a single dose of intravitreally injected moxifloxacin in rabbits.

METHODS

Intravitreal injections of 200 microg/0.1 mL of moxifloxacin were performed in rabbits. Four eyes per time interval after injection (1, 6, 12, 24, 36 hours) and three eyes at 48 hours were enucleated, immediately frozen, and placed at -80 degrees C. Ocular dissection and isolation of frozen vitreous were performed. Antibiotic assays were performed with use of high-performance liquid chromatography.

RESULTS

The concentration of intravitreal moxifloxacin showed an exponential decay with a half-life of 1.72 hours. The mean vitreous concentration was 120.49 +/- 49.23 microg/mL 1 hour after injection, which declined to 20.23 +/- 5.85 microg/mL at 6 hours and 1.06 +/- 0.81 microg/mL at 12 hours. The aqueous levels of moxifloxacin showed an exponential decay from 10 microg/mL at 1 hour after intravitreal injection to undetectable levels by 12 hours after injection.

CONCLUSIONS

Moxifloxacin clearance from the vitreous is rapid and consistent with previous clearance studies of ciprofloxacin. Given that the injected dose corresponds to several times the minimum inhibitory concentration at which 90% of isolates are inhibited (MIC90) of organisms commonly involved in endophthalmitis, and that therapeutic levels are present up to 12 hours after injection, intravitreal moxifloxacin may have a role in the treatment of endophthalmitis.

Immediate Postoperative Use of a Topical Agent to Prevent IntraocularPressure Elevation After Pars Plana Vitrectomy With Gas Tamponade

OBJECTIVE

To determine whether a single topical aqueous suppressant applied immediately after pars plana vitrectomy with long-acting gas tamponade prevents intraocular pressure (IOP) elevation.

METHODS

Fifty patients who met the inclusion criteria and underwent pars plana vitrectomy with long-acting gas tamponade were randomized to receive a combination of timolol maleate and dorzolamide hydrochloride, long-acting timolol alone, dorzolamide alone, or placebo at the conclusion of surgery. The IOP was checked by a portable, handheld tonometer (Tono-Pen) at the conclusion of surgery and at 5 hours, 1 day, and 1 week after surgery.

RESULTS

There were no significant differences in IOP among the groups at the conclusion of surgery. The IOP at 5 hours after surgery (27.0 vs 17.4 mm Hg; P<.001) and 1 day after surgery (26.1 vs 19.9 mm Hg; P =.01) showed a statistically significant difference between the placebo and timolol-dorzolamide groups. The timolol-dorzolamide group showed greater IOP control than either the timolol alone or the dorzolamide alone groups at 5 hours (P =.04 for both).

CONCLUSION

The use of a single topical aqueous suppressant (timolol-dorzolamide) given after pars plana vitrectomy with long-acting gas tamponade effectively prevents significant postoperative IOP elevation at 5 hours and 1 day after surgery.

Culture-proven endogenous endophthalmitis: clinical features and visual acuity outcomes

PURPOSE

To investigate clinical features and visual acuity outcomes associated with endogenous endophthalmitis.

DESIGN

Retrospective, observational case series.

METHODS

Twenty-one eyes of 21 patients treated at Bascom Palmer Eye Institute for culture-proven endogenous endophthalmitis between 1996 and 2002 were reviewed.

RESULTS

Patients were followed a mean of 3 months (range, 1 to 12 months). Fungal isolates occurred in 13 eyes (62%), gram-positive isolates in 7 (33%), and gram-negative isolates in 1 (5%). Twelve patients (57%) were hospitalized at the time of diagnosis and 6 patients (29%) died within 2 months of diagnosis. Initial treatment included tap and injection of intravitreal medication in 10 eyes (48%) and pars plana vitrectomy with injection of intravitreal medication in 11 eyes (52%). Final visual outcomes were obtainable for 18 eyes (two patients died within 10 days of diagnosis, and one patient was lost to follow-up). Eight (44%) of these 18 eyes achieved a visual acuity of 20/400 or better and 10 (56%) of 18 eyes achieved a visual acuity worse than 20/400, including 3 that were either enucleated or eviscerated. Three eyes with Aspergillus endophthalmitis had worse visual outcomes than eyes with either Candida (P =.036) or bacterial endophthalmitis (P =.024).

CONCLUSIONS

Compared with published series of postoperative or post-traumatic endophthalmitis, patients with endogenous endophthalmitis are more likely to have fungal isolates with a predominance of Candida albicans. Endogenous endophthalmitis is generally associated with high mortality and poor visual acuity outcomes, particularly when caused by more virulent species such as Aspergillus.

Salvage external beam radiotherapy of retinal capillary hemangiomas secondary to von Hippel-Lindau disease: visual and anatomic outcomes

OBJECTIVE

To examine the visual and anatomic outcomes of patients with retinal capillary hemangiomas secondary to von Hippel-Lindau (VHL) disease treated with globe-salvaging fractionated external beam radiotherapy (EBRT) after progression of hemangiomas despite initial therapy.

DESIGN

Retrospective noncomparative consecutive case series.

PARTICIPANTS

Review of medical records of 5 patients with retinal capillary hemangiomas secondary to VHL disease.

INTERVENTION

External beam radiotherapy delivered to a total dose of 2160 cGy given over 12 daily fractions.

MAIN OUTCOME MEASURES

Data on visual acuity and tumor size were collected at baseline, 1, 3, 6, and 12 months after EBRT, and at final follow-up, using echography, fundus photographs, and clinical examination.

RESULTS

Six eyes of 5 patients were treated. Mean follow-up was 28.3 months (range, 6-51). Mean baseline visual acuity was 20/70. Mean visual acuity at last follow-up was 20/45 (range, 20/25-20/60). Tumor volume reduction was 27.5 mm(3) (range, 0.9-109.6 mm(3)). Mean percentage reduction in tumor volume was 39.6% (range, 3.3%-71.1%).

CONCLUSIONS

External beam radiotherapy is a useful option in the treatment of retinal hemangiomas secondary to VHL disease that progress despite standard therapy. External beam radiotherapy leads to improvement in visual acuity, reduction in tumor volume, and stabilization of retinal detachment in most patients treated.

Endophthalmitis isolates and antibiotic sensitivities: a 6-year review of culture-proven cases

PURPOSE

To investigate the spectrum of organisms causing culture-proven endophthalmitis and their sensitivities to commonly used antimicrobial agents.

DESIGN

Retrospective, noncomparative, consecutive case series.

METHODS

Medical records were reviewed of all patients with culture-proven endophthalmitis at a single institution between January 1, 1996, and December 31, 2001. Endophthalmitis categories included postoperative, posttraumatic, endogenous, and miscellaneous (for example, keratitis). The outcome measures included intravitreal isolates identified, antibiotic sensitivities, and category of endophthalmitis.

RESULTS

In all, 313 organisms were isolated from 278 patients during the study interval. The most common organisms identified were Staphylococcus epidermidis in 27.8% (87/313), Streptococcus viridans group in 12.8% (40/313), other coagulase-negative staphylococci in 9.3% (29/313), Staphylococcus aureus in 7.7% (24/313), and Propionibacterium acnes in 7.0% (22/313). Overall, 246 of 313 (78.5%) isolates were gram-positive organisms, 37 (11.8%) were gram-negative organisms, and 27 (8.6%) were fungi. For gram-positive organisms, sensitivities were the following: vancomycin 100%, gentamicin 78.4%, ciprofloxacin 68.3%, ceftazidime 63.6%, and cefazolin 66.8%. For gram-negative organisms, sensitivities were the following: ciprofloxacin 94.2%, amikacin 80.9%, ceftazidime 80.0%, and gentamicin 75.0%. Fungal isolates were Candida species (9/313), Aspergillus species (9/313), and other molds (9/313). Among the endophthalmitis categories, the most frequent organisms were the following: (1) acute-onset postoperative: S epidermidis, 46.9%; (2) delayed-onset postoperative: S epidermidis, 22.7%; (3) delayed-onset bleb-associated: fastidious gram-negative rods, 20.4%; (4) posttraumatic: S epidermidis, 20.8%; (5) endogenous: Aspergillus species, 20.8%; and (6) miscellaneous: molds (other), 36.4%.

CONCLUSIONS

In considering antibiotic treatment of endophthalmitis, it is important to recognize that no single antibiotic provided coverage for all of the microbes isolated from eyes with endophthalmitis. Combination therapy is recommended as the initial empiric treatment of suspected bacterial endophthalmitis. Appropriate history and characteristic clinical features may justify the use of initial antifungal agents. Knowledge of the most frequent causative organisms in various categories will help direct appropriate initial therapy.

Magnetically Integrated Microporous Implant

OBJECTIVE

To evaluate the surgical technique and morbidity related to secondary posting of a previously implanted 12-mm microporous high-density polyethylene implant (MEDPOR) and the enhanced motility associated with magnetic coupling of the prosthesis and the implant in a rabbit model.

METHODS

Eight New Zealand rabbits underwent primary evisceration surgery with implantation of a 12-mm microporous high-density polyethylene implant. At 6 weeks, a 4 x 6-mm stainless steel, titanium-coated post was secondarily inserted in 6 rabbit eyes using a bilevel incision. Four weeks after the second surgery, 3 rabbits were fitted with a magnet-embedded prosthesis. Motility was measured by evaluating lateral prosthetic excursion during direct observation. At 3, 6, and 12 months the implants and surrounding tissues were harvested for histopathologic examination.

RESULTS

Secondary placement of the post within the implant was accomplished without difficulty. No signs of erosion, dehiscence, or extrusion were found after a12-month follow-up in any of the study eyes. Clinical grading documented increased movement of the magnetically coupled prostheses compared with nonmagnetically integrated control eyes.

CONCLUSION

This study establishes the safety of secondary posting and the efficacy of magnetically integrated microporous high-density polyethylene implants in the rabbit model.

CLINICAL RELEVANCE

This technique may offer an alternative to patients with previously implanted microporous high-density polyethylene implants seeking enhanced cosmesis and prosthetic motility.

Uveal melanoma presenting as acute angle-closure glaucoma: report of two cases

PURPOSE

To present two cases of uveal melanoma presenting as acute angle-closure glaucoma.

DESIGN

Observational case reports. Assessment and management of two patients with uveal melanoma presenting with acute angle-closure glaucoma.

RESULTS

One patient was initially treated with antiglaucoma medications, and a laser peripheral iridotomy was performed. The second patient had opaque media preventing visualization of the posterior segment, but the presence of an occult mass was suspected as the cause of angle closure. In both cases, B-scan ultrasonography revealed the presence of a tumor causing angle-closure glaucoma. The eyes were enucleated, and the diagnosis of uveal malignant melanoma was confirmed by histopathology.

CONCLUSION

Although acute angle-closure as the initial presentation of uveal melanoma is rare, the presence of a uveal melanoma should be suspected in eyes unresponsive to medical therapy, especially in unilateral cases in which the view of the posterior segment is obscured.

Comparison of retinoblastoma reduction for chemotherapy vs external beam radiotherapy

OBJECTIVE

To determine the time course and extent of tumor reduction associated with systemic chemotherapy or external beam radiotherapy (EBRT) in the treatment of advanced intraocular retinoblastoma.

METHODS

Retrospective review of children with Reese-Ellsworth stages IV and V retinoblastoma undergoing primary globe-conserving therapy with either systemic chemoreduction or EBRT. Study variables were recorded at baseline, at monthly intervals for the first 6 months, and at 12 months after the initiation of treatment. Tumor volumes were calculated using basal area and height values determined by ultrasonography, physical examination, and fundus photographic review.

MAIN OUTCOME MEASURES

Outcome measures included tumor volume, tumor reduction, regression pattern, treatment-related complications, metastases, and survival.

RESULTS

Twenty-six eyes of 26 patients were evaluated for tumor response; 18 patients were treated with systemic chemotherapy and 8 patients were treated with EBRT. Median follow-up was 36 months. A mean 68% reduction in tumor volume occurred after 1 cycle of chemotherapy compared with a 12% reduction at a similar time point (1 month) after initiation of EBRT (P<.004). There was no statistically significant difference in tumor volume reduction between treatment modalities at the 12-month follow-up visit. Both systemic chemoreduction and EBRT achieved 100% globe conservation and 100% patient survival in this series.

CONCLUSIONS

Retinoblastoma reduction exhibits a differential time course based on the applied primary treatment. Systemic chemotherapy is associated with earlier tumor reduction than EBRT.

Progressive outer retinal necrosis in immunocompetent patients treated initially for optic neuropathy with systemic corticosteroids

PURPOSE

To report two cases of progressive outer retinal necrosis occurring in immunocompetent individuals after treatment with corticosteroids for presumed optic neuropathy.

DESIGN

Observational case report.

SETTING

University-based tertiary eye hospital.

METHODS

Retrospective review of existing clinical records.

RESULTS

Two patients were treated empirically with systemic corticosteroids for suspected inflammatory papillopathy. Subsequently, both were diagnosed with necrotizing herpetic retinitis with features of progressive outer retinal necrosis. Anterior chamber paracentesis confirmed varicella-zoster infection. Both patients were human immunodeficiency virus negative; one patient with rheumatoid arthritis was taking etanercept. Both became completely blind in one eye despite intensive treatment with antiviral medication intravenously and intravitreally.

CONCLUSIONS

Progressive outer retinal necrosis is not confined to patients with underlying severe immunodeficiency, such as acquired immune deficiency syndrome. Initial treatment of acute, unexplained vision loss with systemic corticosteroids may lead to catastrophic visual loss in patients with evolving necrotizing herpetic retinopathy.

Increased diode laser uptake in inner retinal layers after indocyanine green staining of the internal limiting membrane

Intraoperative use of indocyanine green to stain the internal limiting membrane assists in its visualization and removal. This article describes increased uptake of diode laser energy by the superficial layers of the retina after indocyanine green staining of the internal limiting membrane in a patient with diabetic macular edema and a taut, attached posterior hyaloid. The patient was undergoing pars plana vitrectomy, removal of the posterior hyaloid, and indocyanine green-assisted peeling of the internal limiting membrane. In addition, panretinal diode laser endophotocoagulation was performed after discovering retinal neovascularization. In areas that were more intensely stained with indocyanine green, the clinical appearance and optical coherence tomography scans demonstrated markedly increased laser energy uptake in the superficial layers of the retina. This case indicates near-infrared or infrared laser procedures performed in areas of indocyanine green-stained internal limiting membrane may necessitate adjustment of laser power and technique.

Retinal detachment in patients with a preexisting glaucoma drainage device: anatomic, visual acuity, and intraocular pressure outcomes

PURPOSE

To report anatomic, visual acuity, and intraocular pressure (IOP) outcomes after retinal detachment (RD) repair in patients with a preexisting glaucoma drainage device.

METHODS

Consecutive case series including patients with a preexisting glaucoma drainage device who underwent RD repair at Bascom Palmer Eye Institute between 1989 and 1999.

RESULTS

Ten patients were identified with a mean follow-up of 18 months. Initial RD repair included pars plana vitrectomy (PPV) and fluid-gas exchange in four patients, scleral buckling procedure (SBP) in two, PPV and SBP in three, and pneumatic retinopexy in one. Three patients initially treated with SBP or pneumatic retinopexy developed recurrent RD secondary to proliferative vitreoretinopathy. All patients eventually underwent PPV. At 6 months, the retina was attached in eight patients, and nine patients had an IOP no greater than 21 mmHg. Although postoperative vision was stable or improved compared to preoperative levels in seven patients, visual acuity at 6 months was worse than 2/200 in only four patients, largely because of preexisting advanced glaucoma.

CONCLUSIONS

In eyes with RD and a preexisting glaucoma drainage device, PPV with fluid-gas exchange was the most successful approach in achieving retinal reattachment. Although anatomic success is usually achieved and IOP is usually controlled, visual acuity outcomes are often poor, largely because of preexisting advanced glaucoma.