LONG-TERM RESULTS OF COMBINED AB INTERNO TRABECULOTOMY (TRABECTOME) AND SMALL-GAUGE PARS PLANA VITRECTOMY.

PURPOSE: To report outcomes of patients who have undergone combined Trabectome and pars plana vitrectomy. METHODS: Institutional Review Board-approved retrospective chart review of patients seen at the Cincinnati Eye Institute before January 2014 undergoing combined Trabectome and pars plana vitrectomy for uncontrolled glaucoma and visually significant retina pathology. Charts were reviewed to identify changes in intraocular pressure, visual acuity, and change in glaucoma medication requirement up to 1 year after surgery. RESULTS: Four patients met the inclusion criteria with 12-month follow-up, and two of the patients were male. All patients underwent 25-gauge pars plana vitrectomy and Trabectome surgery. Mean preoperative LogMAR visual acuity was 0.39 (20/49) and 12-month LogMAR visual acuity was 0.21 (20/32) (P = 0.06). Mean preoperative intraocular pressure was 17 mmHg and mean preoperative glaucoma medication requirement was 2.5 topical medications. Twelve-month mean intraocular pressure was 12.8 mmHg (P = 0.07), and mean topical glaucoma medication requirement was 2.3 medications (P = 0.39). All patients were off steroids and anti-inflammatories at the final visit. One patient developed a hyphema requiring anterior chamber washout at 1 week. No other complications occurred. CONCLUSION: The results suggest that combined Trabectome and pars plana vitrectomy seems effective in the management of glaucoma in patients with visually significant retina pathology.

Cost comparison of intravitreal aflibercept with bevacizumab and ranibizumab for the treatment of wet age-related macular degeneration.

BACKGROUND AND OBJECTIVE: To test the hypothesis that although intravitreal aflibercept (IVA) is expected to be more expensive, the extra cost of treatment would not result in additional vision gain compared with intravitreal bevacizumab (IVB) for the treatment of wet age-related macular degeneration (AMD). PATIENTS AND METHODS: A retrospective chart review of patients receiving IVB or intravitreal ranibizumab (IVR) who were subsequently changed to IVA for active wet AMD. RESULTS: Thirty-three eyes were included in the study. The mean number of IVB, IVR, and IVA injections per eye over a 6-month period was seven, six, and five, respectively. Visual outcomes were similar in all three groups at the end of the study period. The average drug cost of IVB, IVR, and IVA injections per eye over 6 months was $326, $11,400, and $9,720, respectively. CONCLUSION: Aflibercept may allow a modest extension of the treatment interval, but cost makes IVA an expensive alternative without a visual benefit compared with IVB in patients with active wet AMD.

Combined endoscopic vitrectomy with pars plana tube shunt procedure.

PURPOSE: We report a case series of patients with limited fundus view due to advanced and complex anterior segment disease that underwent combined endoscopic vitrectomy and pars plana tube shunt for intraocular pressure (IOP) control. METHODS: The records of 13 eyes of 11 patients operated at Cincinnati Eye Institute from 2006 to 2010 with combined endoscopic pars plana vitrectomy and pars plana tube shunt placement were retrospectively reviewed. Preoperative and postoperative IOP and visual acuity, clinical course and complications were noted. RESULTS: Nine eyes had aniridia, two had chemical burn injury, one had Axenfeld-Rieger syndrome and one had ocular trauma. Median follow-up was 18 months. Preoperative and postoperative mean LogMAR visual acuities were 1.42±0.9 and 1.24±0.7 (p=0.55). Preoperative mean IOP was 23±9 mm Hg and improved to 12±5 mm Hg postoperatively (p<0.0003). No complications were noted. CONCLUSIONS: Endoscopic vitrectomy with pars plana glaucoma tube shunt implantation may be considered in the management of uncontrolled IOP in patients with media opacity. Achieving IOP control prior to attempted anterior segment reconstruction in these severely diseased eyes may increase the success rate and decrease the complexity of subsequent anterior reconstruction procedures.

Primary uveal melanoma in a 4-year-old black child.

Primary uveal melanoma is extremely rare in children and also among blacks. Uveal melanomas may be associated with various preexisting conditions, including congenital ocular melanocytosis and dysplastic nevus syndrome. We report the case of a 4-year-old black girl who presented with pronounced proptosis and no light perception secondary to a massive intraocular tumor with extrascleral extension. Biopsy of the tumor confirmed the diagnosis of primary uveal melanoma, and the patient was treated by enucleation and external beam radiation therapy. Although metastatic disease was ruled out at the time, the patient died approximately 3 months later.

Comparative effectiveness of the dexamethasone intravitreal implant in vitrectomized and non-vitrectomized eyes with macular edema secondary to central retinal vein occlusion.

BACKGROUND AND OBJECTIVE: To compare duration and efficacy of the dexamethasone (DEX) intravitreal implant in vitrectomized (pars plana vitrectomy [PPV] group) and non-vitrectomized eyes (control group) with macular edema related to central retinal vein occlusion (CRVO). PATIENTS AND METHODS: Eyes that received the DEX implant for CRVO related to macular edema were included in a retrospective chart review. Outcomes measured were best-corrected visual acuity (BCVA) and central macular thickness (CMT). RESULTS: Fifteen eyes were included in the study. Eight of 15 eyes had prior vitrectomy. Mean BCVA was 20/160 in both groups. Baseline mean CMT was 550 µm (PPV group) and 556 µm (control group, P = .70), and improved to 307.5 µm (PPV group) and 316.3 µm (control group) (P = .90) after implant. The BCVA was 20/125 (PPV group) and 20/200 (control group) (P = .60). Time to next procedure was similar in both groups. CONCLUSIONS: This retrospective study shows similar CMT reductions with DEX implant treatment for CRVO-related macular edema in vitrectomized and non-vitrectomized eyes.

Effectiveness of treatments for metastatic uveal melanoma.

PURPOSE: To evaluate and comment on published peer-reviewed literature for evidence of effectiveness of treatments for metastatic uveal melanoma. DESIGN: Analytical nonexperimental study of published peer-reviewed data. METHODS: Literature search and analysis of pertinent articles published between January 1, 1980 and June 30, 2008. RESULTS: Of 80 identified publications, 12 (15.0%) were review articles without original information, 2 (2.5%) were review articles combined with case reports, 22 (27.5%) were case reports, 16 (20.0%) were retrospective descriptive case series reports, 3 (3.75%) were pilot studies of a novel intervention, 2 (2.5%) were prospective phase I clinical trials, 8 (10.0%) were prospective phase I/II clinical trials, and 15 (18.75%) were prospective phase II clinical trials. None of the articles reported a prospective, randomized phase III clinical trial. The largest reported unselected patient groups had a median survival of 3 to 4 months after detection of metastasis, whereas the largest selected patient groups showed substantially longer median survival times. CONCLUSIONS: Although median survival time after diagnosis of metastatic uveal melanoma tends to be substantially longer in selected patient subgroups subjected to aggressive invasive interventions than it is in unselected groups, much if not most of this apparent difference in survival is likely to be attributable to selection bias, surveillance bias, and publication bias rather than treatment-induced alteration of expected outcome. Published peer-reviewed articles do not provide compelling scientific evidence of any survival benefit of any method of treatment for any subgroup of patients with metastatic uveal melanoma.

Quality of evidence about effectiveness of treatments for metastatic uveal melanoma.

PURPOSE: To evaluate and comment on the published peer-reviewed literature for evidence of effectiveness of treatments for metastatic uveal melanoma. METHODS: Literature search and analysis of satisfactory articles on treatment of metastatic uveal melanoma published between 1980 and 2007. RESULTS: Of 71 identified articles, 10 (14.1%) were review articles without original case information, 2 (2.8%) were review articles combined with case reports, 17 (24.0%) were case reports, 15 (21.1%) were retrospective descriptive case series reports, 3 (4.2%) were pilot studies of a novel intervention, 2 (2.8%) were reports of a prospective nonrandomized phase I clinical trial, 7 (9.9%) were reports of a prospective nonrandomized phase I/II clinical trial, 14 (19.7%) were reports of a prospective nonrandomized phase II clinical trial, and 1 (1.4%) was a report of a prospective randomized phase II clinical trial. None of the articles was a report of a prospective randomized phase III clinical trial. None of the reports of a prospective study included a comparison group of similar but untreated patients. The largest reported unselected patient groups had a median survival time after detection of metastasis in the range of 3 to 4 months. In contrast, the largest selected patient groups tended to have substantially longer median survival times. CONCLUSIONS: Although median survival time following diagnosis of metastatic uveal melanoma tends to be substantially longer in selected subgroups of patients subjected to aggressive invasive interventions than it is in unselected groups, and although this difference is frequently considered to be evidence of treatment-induced prolongation of patient survival, much if not most of this apparent difference in survival is likely to be attributable to selection bias, surveillance (lead time) bias, and publication bias rather than treatment-induced alteration of the expected outcome. Information about the impact of treatment of any type for patients with metastatic uveal melanoma that has been reported in the peer-reviewed literature is of extremely low quality and does not provide compelling evidence of a beneficial effect of such treatment on survival.