Management of cataract in uveitis patients.

PURPOSE OF REVIEW: This review is timely because the outcomes of surgical invention in uveitic eyes with cataract can be optimized with adherence to strict anti-inflammatory principles. RECENT FINDINGS: All eyes should be free of any cell/ flare for a minimum of 3 months preoperatively. Another helpful maneuver is to place dexamethasone in the infusion fluid or triamcinolone intracamerally at the end of surgery. Recent reports about the choice of intraocular lens material or lens design are germane to the best surgical outcome. Integrating these findings will promote better visual outcomes and allow advancement in research to further refine these surgical interventions in high-risk uveitic eyes. SUMMARY: Control of inflammation has been shown to greatly improve postoperative outcomes in patients with uveitis. Despite better outcomes, more scientific research needs to be done regarding lens placement and materials and further research needs to adhere to the standardized reporting of uveitis nomenclature. Future studies should improve postoperative outcomes in eyes with uveitis so that they approach those of eyes undergoing routine cataract procedures.

Accuracy of an objective binocular automated phoropter for providing spectacle prescriptions.

CLINICAL RELEVANCE: Currently eye examinations are usually based on autorefraction followed by subjective refraction (SR) with a phoropter. An automated phoropter that can also perform autorefraction may facilitate the optometric workflow. BACKGROUND: The efficiency and feasibility of an objective autorefraction and correction system are assessed by comparing objective refractive measurements with SR on the same subjects and evaluating the visual acuity (VA) values obtained after the objective refractive measurement and correction. METHODS: Objective autorefraction and correction was performed on 41 subjects using an automated binocular phoropter system. The auto-phoropter performs autorefraction by wavefront measurement and corrects the spherical and cylindrical errors with tunable fluidic lenses while the patient looks at a visual display inside the instrument. The instrument outputs are optometric constants of spherical and cylindrical aberrations. After measurement and automated correction of the refractive errors, the VA values were assessed by having the subjects look at an integrated Snellen chart. The objective measurement results were statistically compared with their SR. RESULTS: The correlations between SR and objective autorefraction and correction spherical equivalents (M) were 0.98 (0.97-0.99) and 0.96 (0.93-0.98), the vertical Jackson cross cylinder (J0) were 0.96 (0.92-0.98) and 0.95 (0.91-0.97), and the oblique Jackson cross cylinder (J45) were 0.73 (0.55-0.85) and 0.82 (0.69-0.90), for the right and left eyes, respectively, with the 95% confidence interval (CI) values in parentheses. 89.0% of the 82 eyes had at least 6/7.5 VA. CONCLUSIONS: A significant agreement between the SR and objective autorefraction and correction was observed. An all-objective refractive assessment with instantaneous verification may improve the precision of eye prescriptions and possibly reduce the procedure time.

Klebsiella pneumoniae endophthalmitis secondary to liver abscess presenting as acute iridocyclitis.

A 51-year-old man presented with acute iridocyclitis with no evidence of vitritis on B-scan that progressed to endogenous endophthalmitis. Systemic work-up revealed a large liver abscess. Urine, blood, liver abscess, and vitreous aspirate cultures all grew Klebsiella pneumoniae. The eye was enucleated secondary to severe pain from neovascular glaucoma and loss of vision.

Intracameral dexamethasone injection in the treatment of cataract surgery induced inflammation: design, development, and place in therapy.

Cataract surgery is one of the most commonly performed surgeries worldwide, with nearly 20 million cases annually. Appropriate prophylaxis after cataract surgery can contribute to a safe and quick visual recovery with high patient satisfaction. Despite being the current standard of care, the use of multiple postoperative eye drops can create a significant burden on these patients, contributing to documented and significant non-adherence to the postoperative regimen. Over the past 25 years, there have been a few studies analyzing the use of intracameral dexamethasone (DXM) in controlling inflammation following cataract surgery. This review explores various drug delivery approaches for managing intraocular inflammation after cataract surgery, documenting the strengths and weaknesses of these options and examining the role of intracameral DXM (among these other strategies) in controlling postoperative intraocular inflammation. Intracameral DXM has a particular advantage over topical steroids in possibly decreasing postoperative inflammatory symptoms and objective anterior cell and flare scores. Compared to topical steroids, there may be a slightly less theoretical risk of significant intraocular pressure spikes and systemic absorption. In addition, surveys indicate patients prefer an intraoperative intracameral injection over a self-administered postoperative eye drop regimen. However, there are several adverse effects associated with intracameral DXM delivery that are not seen with the noninvasive topical approach. Although it is unlikely that intracameral DXM will replace topical medications as the standard management for postoperative inflammation, it is seemingly another safe and effective strategy for controlling postoperative inflammation after routine cataract surgery.

CENTRAL SEROUS CHORIORETINOPATHY IN POSTMENOPAUSAL WOMEN RECEIVING EXOGENOUS TESTOSTERONE.

PURPOSE: Central serous chorioretinopathy (CSR) is a serous detachment of the neurosensory retina commonly associated with male sex, Type-A personality and corticosteroid use. Exogenous administration of androgens and development of CSR in men has been reported. Only one case of CSR in a postmenopausal woman receiving exogenous androgen therapy has been reported. The authors describe three cases of chronic CSR in postmenopausal women receiving exogenous testosterone therapy. METHODS: Diagnosis was based on characteristic clinical, fluorescein angiographic, and optical coherence tomography findings. The three women were being treated with exogenous testosterone and progesterone therapy for symptoms of menopause and libido loss. RESULTS: Average age at presentation was 54.7 years (53-56 years), average duration of exogenous androgen use was 61 months (36-87 months), with average 19.7-month follow-up. Resolution of symptoms seemed correlated with cessation of androgen use despite treatment with oscillatory photodynamic therapy and intravitreal pharmacotherapy with antivascular endothelial growth factor agents. CONCLUSION: Exogenous testosterone is increasingly prescribed for menopausal symptoms and libido loss. Treatment with oscillatory photodynamic therapy, supplemental bevacizumab intravitreal pharmacotherapy, and cessation of exogenous androgen therapy was successful in three cases of chronic, therapy-resistant CSR. Ophthalmologists should inquire about androgen usage in patients who present with CSR, especially in the setting of therapy resistance.

An adjustable-tip brush for the induction of posterior hyaloid separation and epiretinal membrane peeling.

PURPOSE: To report a new adjustable-tip brush for induction of posterior hyaloid separation and epiretinal membrane peeling. DESIGN: Observational report. METHODS: The adjustable-tip brush made of 10-0 nylon was used during vitrectomy for a variety of vitreoretinal disorders to induce posterior vitreous detachment and to peel internal limiting membrane or epiretinal membranes. RESULTS: The instrument was especially effective in inducing posterior vitreous detachment in eyes with chronic pseudophakic macular edema and diabetic macular edema. It was used successfully to strip thin, immature epiretinal membranes and to unfold rolled edges of giant retinal tears. No complications were associated with the use of the adjustable-tip brush. CONCLUSION: The adjustable-tip brush was useful for posterior hyaloid separation and epiretinal membrane peeling during vitrectomy for a variety of vitreoretinal procedures.

The effect of internal limiting membrane peeling on chronic recalcitrant pseudophakic cystoid macular edema: a report of two cases.

PURPOSE: To describe the effect of internal limiting membrane peeling in chronic recalcitrant pseudophakic cystoid macular edema. DESIGN: Two interventional case reports. METHODS: Two consecutive patients with chronic pseudophakic cystoid macular edema of 11-22 months duration, after uncomplicated cataract surgery, unresponsive to previous treatment, were enrolled. The surgical technique consisted of pars plana vitrectomy and internal limiting membrane peeling. Main outcome measures included best-corrected visual acuity, biomicroscopic appearance, and perifoveal leakage on fluorescein angiography. Optical coherence tomography scans were performed postoperatively. RESULTS: Pars plana vitrectomy with internal limiting membrane peeling resulted in anatomical, angiographic, and functional improvement in both patients, for total follow-up periods of 8 and 11 months, respectively. CONCLUSION: To our knowledge, this is the first report of chronic pseudophakic cystoid macular edema that favorably responded to pars plana vitrectomy with internal limiting membrane peeling, as concluded after a MEDLINE search.

Ocular photodynamic therapy for serous macular detachment in the diffuse retinal pigment epitheliopathy variant of idiopathic central serous chorioretinopathy.

PURPOSE: To describe the anatomical and functional outcome of verteporfin ocular photodynamic therapy (PDT) in serous retinal detachment caused by the diffuse retinal pigment epitheliopathy form of chronic idiopathic central serous chorioretinopathy. DESIGN: Interventional case report. METHOD: A 48-year-old Caucasian man with unilateral exudative retinal detachment from diffuse retinal pigment epitheliopathy and visual acuity of 20/40 was managed with verteporfin PDT applied sequentially in three separate spots targeting all retinal pigment epithelium leaks identified with intravenous fluorescein angiography (IVFA). Outcome measures included visual acuity, biomicroscopic appearance, and leakage on IVFA.Clinical practice. Subretinal fluid resolved within 2 weeks; visual acuity returned to 20/20 with no recurrence at 6 months of follow-up. There was no leakage on IVFA posttreatment and no obvious toxicity. To our knowledge, this is the first report of PDT causing resolution of macular detachment in diffuse retinal pigment epitheliopathy. Its long-term results with regard to the prognosis of the disease and the recurrence rate remain to be evaluated.

Intravitreal triamcinolone acetonide for refractory chronic pseudophakic cystoid macular edema.

PURPOSE: To determine the safety and efficacy of intravitreal triamcinolone acetonide (TAAC) injections in patients with refractory cystoid macular edema (CME) after cataract extraction. SETTING: LSU Eye Center, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA. METHODS: In this nonrandomized retrospective case review, 8 eyes of 8 patients with a history of pseudophakic CME recalcitrant to current standard treatment modalities were enrolled. The mean duration of the CME was 20 months. The patients received intravitreal injections of 1 mg of TAAC and were followed for a mean of 8 months. The main outcome measures included visual acuity, the presence of CME on biomicroscopic examination, angiographic evidence of perifoveal leakage, intraocular pressure (IOP), and complications related to treatment. RESULTS: The visual acuity increased in all patients. The magnitude of improvement was mainly restricted by underlying macular pathology and correlated well with the level of visual acuity at entry into the study. Angiographic improvement occurred in all patients. Temporary increases in IOP were easily controlled with topical medications. No other adverse effects could be attributed to this technique. Repeated injections were required. CONCLUSIONS: Intravitreal administration of TAAC was safe and effective in recalcitrant cases of pseudophakic CME with a beneficial effect on the macular edema and visual acuity. A prospective randomized study is needed to determine with accuracy the efficacy, safety, and exact timing of this technique and possibly to recognize subtypes with a more favorable response. Repeated injections were required in all eyes. The development of a sustained-release intravitreal drug-delivery system would be beneficial.

Ocular photodynamic therapy in choroidal neovascularization complicating idiopathic central serous chorioretinopathy.

Two consecutive patients with idiopathic central serous chorioretinopathy and decreased vision subsequent to subfoveal choroidal neovascular membranes were treated with photodynamic therapy applied using the protocol of the Treatment of Age-Related Macular Degeneration with Photodynamic Therapy Study Group. Main outcome measures included best-corrected visual acuity, biomicroscopic appearance, and leakage on fluorescein and indocyanine green angiography. Photodynamic therapy offered anatomical, angiographic, and functional improvement. After an initial complete response, the patients required re-treatment at 3 and 4 months, respectively. Cessation of leakage with improvement in visual acuity occurred, but subretinal fibrosis posed a possible limitation for full functional recovery. Although choroidal neovascular membranes complicating idiopathic central serous chorioretinopathy portend a poor visual prognosis, the overall response to photodynamic therapy was favorable.

Interaction of intravitreal combination drugs and the effect on the targeted site.

BACKGROUND: After evaluating experimentally the diffusion processes in the retina using peroxidase as a tracer material (previously published work), we found that junctional complexes of the retinal pigment epithelium and retinal capillaries were the major impediment to free diffusion between the retina and choroidal-retinal blood vessels. These experiments indicated that to achieve high therapeutic concentrations of medications inside the eye, it was necessary to administer them by intravitreal injection. Soon after initial experimental work the necessity of combining antibiotics or antibiotics with steroids became obvious. As the use of intravitreal injection grew over the last 2 decades, so did the concept of combination therapy. METHODS: This review describes potential causes of drug-drug interaction and the rationale for combination therapy when injected into the vitreous cavity, encompassing publications between 1971 and 2008. RESULTS: We describe the conditions that can cause physical-chemical interactions between the medications and the need for combination therapy for treatment of various intraocular disease processes. CONCLUSIONS: The intravitreal injection of medication and their combinations has become a part of standard care for many diseases of the retina and choroid. This article reviews the potential interaction of nontoxic doses of medications when injected simultaneously in the vitreous cavity, and disease processes that are now treated with these combination therapies.

Buffering capacity of bovine vitreous.

PURPOSE: To measure the buffering capacity of bovine vitreous to HCl, NaOH, and triamcinolone acetonide. METHODS: Vitreous was dissected from 10 bovine globes, homogenized, and divided into 5.0-mL aliquots. The carbonate/bicarbonate buffer of the vitreous was maintained by performing all subsequent titrations under an atmosphere of 5% CO2/95% air. The pH was monitored during the addition of 0.1 N HCl, 0.1 N NaOH, or 40 mg/mL triamcinolone acetonide to the vitreous sample; 0.9% NaCl was used as control. RESULTS: The buffering capacity of bovine vitreous to HCl was 10 times greater than that of 0.9% NaCl. The buffering capacity of vitreous to NaOH was four times greater than that of 0.9% NaCl. Bovine vitreous was able to resist pH changes from addition of triamcinolone acetonide at levels 20 times greater than commonly injected intravitreally. CONCLUSION: Vitreous had a greater buffering capacity than 0.9% NaCl, indicating a greater capacity to remain stable when acidic or alkaline pharmaceuticals are injected in microliter amounts.

Inhibition of corneal angiogenesis by ascorbic acid in the rat model.

PURPOSE: To evaluate the effect of topically administered ascorbic acid on experimentally induced corneal neovascularization in the rat model. MATERIALS AND METHODS: Corneal chemical cauterization of 72 eyes in Long-Evans male rats was performed using silver nitrate/potassium nitrate sticks. Nine groups of eight eyes were used to evaluate eight concentrations of ascorbic acid with one group of eight eyes serving as a control. Topical instillation of 100 mg/ml non-pH-neutralized ascorbic acid was performed in one group while the remaining seven groups were evaluated using pH-neutralized ascorbic acid in concentrations of 100 mg/ml, 50 mg/ml, 10 mg/ml, 5 mg/ml, 1 mg/ml, 500 microg/ml, and 250 microg/ml. RESULTS: The percentage of corneal neovascularization and burn stimulus score was determined for all the eyes. The means of percent of corneal neovascularization in ascorbic acid 100 mg/ml (non-neutralized), 100 mg/ml, 50 mg/ml, 10 mg/ml, 5 mg/ml, 1 mg/ml, 500 microg/ml, 250 microg/ml, and control group were 17.50 +/- 12.80 (p = 0.001), 17.00 +/- 19.30 (p = 0.001), 15.25 +/- 13.26 (p = 0.001), 17.62 +/- 11.89 (p = 0.001), 28.87 +/- 23.08 (p = 0.001), 29.62 +/- 16.91 (p = 0.001), 60.12 +/- 8.50 (p = 0.04), 65.62 +/- 2.26 (p = 0.185), and 68.25 +/- 4.06, respectively (Tables 1 and 2). All animals had a burn score of 2+ or higher (Table 1). CONCLUSION: Ascorbic acid applied in a topical solution appears to inhibit corneal neovascularization in the rat model of inflammatory neovascularization in concentrations in a dose-dependent manner. The optimal dose-effect relation was in our model found in concentrations between 1 mg and 500 microg/ml. At concentrations below 500 microg/ml there was no statistically significant inhibition in the degree of corneal neovascularization compared to control.