A cluster of presumed, noninfectious endophthalmitis after intravitreal injection of bevacizumab: long-term follow-up.

PURPOSE: To report the outcome of 5 consecutive cases of presumed, noninfectious endopththalmitis following intravitreal injection of bevacizumab (IVB). METHODS: Ten pre-loaded syringes of bevacizumab (1.25 mg/50 µL) furnished by a compounding pharmacy were injected intravitreally. Treatments were performed in the operating room by the same surgeon on 2 consecutive days. RESULTS: Of 10 eyes, 5 showed moderate to severe ocular inflammation within a few days of injection. All patients were treated in the same surgical session. Vitreous tap performed in the patient presenting with the most severe grade of inflammation was negative for bacteria and fungi. At the time of the vitreous biopsy, this patient was injected with vancomycin 1 mg/100 µL in the vitreous cavity. Other eyes with moderate inflammation received topical and systemic antibiotics and topical steroid treatment. Visual acuity returned to pre-endophthalmitis or better levels in all eyes within 1 month. The other 5 patients treated with IVB from the same batch in the other surgical session did not develop inflammation. CONCLUSIONS: IVB can induce noninfectious endophthalmitis. The use of compounded syringes can explain clustering of the inflammation. We were unable to identify the reasons for the variable grade of inflammation we observed in our patients.

Spectral domain optical coherence tomography findings in patients with acute syphilitic posterior placoid chorioretinopathy.

PURPOSE: To describe the appearance of acute syphilitic posterior placoid chorioretinitis, a rare ocular manifestation of syphilis, on spectral domain optical coherence tomography (SD OCT) both before and after treatment. METHODS: Ophthalmic examination and imaging studies of 30 eyes of 19 confirmed cases were analyzed both at the time of presentation and at each follow-up visit. Patients with SD OCT and fluorescein angiography at the time of presentation, and at least three documented follow-up visits after initiation of therapy, were included in the study. Standard treatment of neurosyphilis was given to each patient, including 4 million units of penicillin G administered intravenously every 4 hours for 14 days. RESULTS: Fundus examination and imaging studies were consistent with previous reports and confirmed the diagnosis of acute syphilitic posterior placoid chorioretinitis. In 13 eyes (43.3%), baseline SD OCT scans were performed within 1 to 2 days of presentation and revealed a small amount of subretinal fluid, disruption of the inner segment/outer segment junction, and hyperreflective thickening of the retinal pigment epithelium (RPE). All 30 eyes were again scanned between Days 7 and 9 after presentation and revealed loss of the inner segment/outer segment and OS/RPE bands, and irregular hyperreflectivity of the RPE with prominent nodular elevations but without subretinal fluid. Early disruption of the external limiting membrane and punctate choroidal hyperreflectivity were seen in 1 of the 30 eyes (3.3%) and 14 of the 30 eyes (46.6%), respectively. Vision improved and the outer retinal abnormalities normalized in 28 of the 30 eyes (93.3%) after the treatment of neurosyphilis. The external limiting membrane, inner segment/outer segment band, and/or linear outer segment/RPE junction remained substantially abnormal despite treatment in 2 eyes left with 20/200 vision. CONCLUSION: Patients with acute syphilitic posterior placoid chorioretinitis show characteristic outer retinal abnormalities on SD OCT imaging, including disruption of the inner segment/outer segment band, nodular thickening of the RPE with loss of the linear outer segment/RPE junction, and, in some cases, loss of the external limiting membrane, accumulation of subretinal fluid, and punctate hyperreflectivity in the choroid. Vision improved and these abnormalities reversed after treatment of neurosyphilis in most of the patients. Persistently, poor vision despite treatment was associated with long-term loss or disruption of outer retinal anatomy on SD OCT.

Combined reduced fluence photodynamic therapy and intravitreal ranibizumab for polypoidal choroidal vasculopathy.

PURPOSE: We performed a prospective noncomparative study to report the results of reduced fluence photodynamic therapy (PDT) combined with intravitreal ranibizumab in patients with polypoidal choroidal vasculopathy with active exudation and hemorrhage. METHODS: Seventeen polypoidal choroidal vasculopathy eyes were treated, and follow-up for all patients was 12 months. Photodynamic therapy was administered with reduced fluence (exposure time of 70'') and followed (48 hours later) by intravitreal ranibizumab (0.5 mg in 50 µL). Intravitreal ranibizumab, with or without reduced fluence PDT, was repeated as indicated by clinical and angiographic findings. RESULTS: During the follow-up, the mean best-corrected visual acuity significantly improved from 0.45 ± 0.29 logarithm of the minimum angle of resolution at baseline to 0.29 ± 0.28 logarithm of the minimum angle of resolution at 12 months. The mean total macular volume (documented by optical coherence tomography retinal map examination) decreased from 7.5 ± 1.18 mm to 6.7 ± 0.8 mm. In 95% of the cases, best-corrected visual acuity remained stable or improved. CONCLUSION: Reduced fluence PDT limits laser exposure, minimizing the risks of PDT-induced adverse effects. Intravitreal injections of ranibizumab 0.5 mg reduced bleeding and leakage in polypoidal choroidal vasculopathy eyes and interfere with rebound upregulation of vascular endothelial growth factor because of PDT-induced choroidal hypoperfusion. Combined treatment may improve treatment outcomes in polypoidal choroidal vasculopathy while minimizing ocular and systemic complications of treatment.

Validity and limits of the rebound tonometer (ICare®): clinical study.

PURPOSE: The aim of this study was to evaluate the measurement of intraocular pressure (IOP) using a new induction/impact rebound tonometer (ICare®) compared with Goldmann applanation tonometry (GAT). We also aimed to quantify the systematic and random errors (bias) of the 2 methods, to evaluate the sensitivity and specificity of the ICare® tonometer in identifying patients with 21 mmHg or more measured with the GAT, and to study the influence of corneal thickness on IOP measurement with the 2 tonometers. METHODS: We compared the IOP values obtained with the 2 instruments in 97 patients. RESULTS: Analysis based on the Bland and Altman method revealed that the IOP values recorded with the ICare® tonometer were slightly higher than those obtained with the GAT. The estimated bias for right eye measurements was 0.78 mmHg with 95% limits of agreement ±3.55 mmHg. This overestimation, which is not clinically relevant, was confirmed when we used the IOP values corrected according to central corneal thickness for data analysis. The sensitivity and specificity were 0.90 and 0.95, respectively. CONCLUSIONS: The ICare® tonometer proved to be comparable with other nonconventional tonometers and can be used by nonophthalmologists and paramedical personnel during screening tests of populations. In addition, the ICare® tonometer could be considered a valid alternative to GAT when GAT is not available.

Compassionate use of intravitreal pegaptanib in patients with age-related macular degeneration.

The study aim was to evaluate the short-term safety and efficacy of pegaptanib sodium injections (Macugen, Eyetech Pharmaceuticals, Inc., New York, NY) in the compassionate-use therapy of choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD). Intravitreal pegaptanib was used to treat 41 eyes in 40 patients with CNV. Injections were given every 6 weeks, and a minimum of three injections were planned. The mean change in BCVA for all lesions was a loss of 0.03 Snellen lines. Seven eyes (17.1%) gained more than 3 lines, three (7.31%) lost 6 lines or more, and in 75.6% the BCVA stabilized or improved.

Efficacy of 2% ibopamine on the dilation of patients with pseudoexfoliation syndrome.

PURPOSE: To compare the mydriatic effects of 2% ibopamine and collyrium containing 10% phenylephrine + 0.5% tropicamide and to study the associated drug in patients with ocular pseudoexfoliation (PEX) syndrome. METHODS: This was a prospective, comparative, interventional clinical study. The study group consisted of 20 patients with ocular PEX syndrome. Intervention procedures included administration of 10% phenylephrine-0.5% tropicamide versus 2% ibopamine versus 2% ibopamine followed by the combination drug. Main outcome measurement was mydriatic efficacy measured in terms of mean pupil diameter. Adverse effects on intraocular pressure (IOP) were measured with a Goldmann applanation tonometer. Mean premedication pupil diameters in all patients were less than 3.5 mm. RESULTS: Instillation of 10% phenylephrine-0.5% tropicamide caused significantly greater mydriasis than 2% ibopamine (pupil diameters: 6.17 mm, SD=1.14 versus 5.33 mm, SD=1.34; p<0.001). Combined use of both collyria significantly increased mydriasis (7.19 mm; SD=0.69) compared with that induced by either of the products alone (p<0.001). Inadequate mydriasis (pupil diameters < 5.5 mm) was observed in 2 patients after administration of 10% phenylephrine-0.5% tropicamide and in 10 following instillation of 2% ibopamine, but the addition of 10% phenylephrine -0.5% tropicamide to ibopamine-treated eyes resulted in adequate dilation in all cases. IOP increases of 4 mmHg over baseline values were observed in 12 (60%) patients after 2% ibopamine. CONCLUSIONS: In patients with ocular PEX, instillation of 2% ibopamine exerts a significant additive effect on mydriasis induced with 10% phenylephrine-0.5% tropicamide with only minimal increases in IOP.

Nationwide incidence of endophthalmitis among the general population and the subjects at risk of endophthalmitis in Italy.

PURPOSE: To investigate the incidence of endophthalmitis in Italy. METHODS: The Ministry of Health Hospital Admissions online database was searched to identify cases of endophthalmitis and cases with risk factors for endophthalmitis (corneal ulcer, open wound of the eyeball, and intraocular surgery including retinal, iris, and lens procedures with or without vitrectomy). Annual Incidence rates (overall, and age- and gender-specific) were computed in the general population and in the population with one or more of the risk factors for endophthalmitis. RESULTS: The overall annual incidence of endophthalmitis / 100,000 inhabitants was 2.0 (95% confidence interval (CI):1.8-2.1) in 2003. The risk for endophthalmitis and for most factors that cause predisposition to endophthalmitis was higher in males. The annual incidence rates of corneal ulcer, open wounds of the eyeball, retinal procedures, iris procedures, lens procedures, and other intraocular procedures were respectively (per 100,000 inhabitants) 4.6, 4.8, 43.0, 9.2, 775.7, and 63.0. The annual incidence of endophthalmitis per 100,000 predisposed subjects was 220 (95% CI: 210-230), and the risk was higher in males (relative risk 1.7, 95% CI: 1.5-1.9). Annual incidence rates remained stable from 1999 to 2003. CONCLUSIONS: Higher rates of open wounds of the eyeball, corneal ulcers, and retinal surgery among males may be responsible for their higher risk for endophthalmitis.

Comparative efficacy of acetazolamide and apraclonidine in the control of intraocular pressure following phacoemulsification.

PURPOSE: The purpose of our study was to compare the effects of systemically administered acetazolamide and topical apraclonidine 0.5% in the control of intraocular pressure (IOP) following phacoemulsification of senile cataracts. SETTING: The study was conducted on patients affected by cataract and followed at the Department of Ophthalmology. METHODS: Seventy-eight eyes in 78 patients were selected. Twenty-six eyes were randomly assigned to postoperative treatment with topical apraclonidine 0.5%, 26 received oral acetazolamide and the remaining 26 received no hypotensive treatment (control group). Statistical analyses were performed mainly by means of analyis of variance. RESULTS: IOPs measured 24 h after surgery were significantly (p = 0.01) lower in the apraclonidine group compared to the control group. CONCLUSIONS: Our double-blind prospective study conducted on patients randomly assigned to treatment with apraclonidine or acetazolamide shows that the former drug is undoubtedly effective in the prevention of IOP increases following phacoemulsification. IOPs recorded in patients treated with this drug were lower than those observed in the acetazolamide and the control groups. Considering the lower risk of toxicity associated with topical administration, apraclonidine 0.5% seems to be preferable to oral acetazolamide in this postoperative setting.

Validity and limitations of the Nidek NT-4000 non-contact tonometer: a clinical study.

Using Goldmann applanation tonometry (GAT) as a gold standard, we evaluated the accuracy of Nidek NT-4000 pneumotonometry (NPT) in adults without corneal disease. Bland and Altman analysis of serial intra-ocular pressures (IOPs) measured with NPT and GAT in 10 healthy subjects revealed that the repeatability coefficients for the two methods were similar. NPT, GAT and ultrasonic pachymetry were then performed in 100 patients. Bland and Altman analysis showed that NPT yielded significantly higher readings than GAT [mean biases for right and left eye measurements were 1.37 mmHg (95% limits of agreement: -3.02-5.76) and 1.17 mmHg (95% limits of agreement: -2.76-5.11) respectively] and was more affected by corneal thickness variations. For detection of IOPs > or =21 mmHg, NPT displayed very high sensitivity (0.90) and good specificity (0.95). NPT may be useful in screening and clinical settings but borderline-high IOP readings should be confirmed with GAT.

Low contrast visual acuity in pseudophakic patients implanted with an anterior surface modified prolate intraocular lens.

PURPOSE: To determine whether implantation of a new intraocular lens (IOL) with a modified prolate anterior surface, designed to reduce the positive spherical aberration of the pseudophakic eyes, results in improved contrast sensitivity assessed in terms of low contrast visual acuity (VA). METHODS: We carried out an intraindividual study of 12 patients with bilateral cataracts, randomized to receive a prolate anterior surface IOL (Tecnis Z9000, Pharmacia) in one eye and a biconvex spherical surface IOL (CeeOn 911 A, Pharmacia) in the other. High and low contrast VA was assessed under photopic conditions, before and after pupil dilation. RESULTS: After mydriasis, the Technis Z9000 provided significantly better low contrast VA at contrast levels < or = 25%. No significant difference was found under normal pupil conditions. CONCLUSION: Our results confirm the hypothesis that the spherical aberration of the eye after cataract surgery can be reduced by an anterior prolate surface IOL.

Association between lens opacities and mortality in the Priverno Eye Study.

BACKGROUND: Lens opacities are associated with a higher risk of death, although there are some discrepancies regarding the specific types of cataract representing risk. The purpose of the present study was to further investigate the relationships between different types of lens opacity and patient survival. METHODS: In 1987, 860 residents of Priverno, Italy, aged 45-69 years underwent an ophthalmologic examination. Based on patient histories and the findings of the slit-lamp examination, each of the 860 patients was classified according to the type of opacity (pure cortical, pure nuclear, pure posterior subcapsular, mixed, and surgical aphakia). The survivors of the original cohort were re-examined in 1994. Death and survival rates were computed by the Kaplan-Meier method. Associations between mortality and significant factors were included in a stepwise Cox proportional-hazards regression model. RESULTS: Forty-four members of the original cohort had died during the 7-year follow-up. Age-adjusted survival curves based on Kaplan-Meier estimates showed significantly lower survival in those whose baseline examinations had revealed pure nuclear opacity (log rank test: P=0.020) and aphakia (log rank test: P<0.001). When adjusted for other mortality risk factors (age, sex, diabetes, cardiovascular diseases), the hazard ratio was 4.32 for pure nuclear opacity (95% CI 1.13-16.4) and 18.3 for aphakia (95% CI 3.21-104.0). CONCLUSIONS: The analysis of the Priverno data seems to confirm an association between lower survival and cataracts, particularly those confined to the lens nucleus and those that had already prompted surgery.

Acute electroretinographic changes during sildenafil (Viagra) treatment for erectile dysfunction.

The authors describe their findings on 12 subjects who were treated with 50 mg of sildenafil (Viagra) and underwent ERG measurements prior to and 1 hour after ingestion. The Naka-Rushton equation was used to describe the b-wave luminance-response function of the scotopic ERG. Statistically significant differences were noted in the Vmax and K values. Sildenafil ingestion resulted in an increase in Vmax (higher rod response to light stimuli) and a decrease in K (higher sensitivity).