Endophthalmitis after Anti-VEGF Intravitreal Injections with Aqueous Chlorhexidine versus Povidone-Iodine as Ocular Antiseptics.

PURPOSE: To compare the rates and outcomes of endophthalmitis after intravitreal injections (IVIs) for patients pretreated with 5% povidone-iodine (PI) and 0.05% chlorhexidine (CHX). DESIGN: A retrospective, single-center, comparative cohort study. PARTICIPANTS: A total of 8686 patients were included in the study, and a total of 67 695 anti-VEGF injections were performed from January 1, 2019, to November 30, 2021. SETTING: A private retina practice of 13 retina specialists in Colorado. METHODS: Using electronic health records, patients with preinjection preparation with PI or CHX were compiled retrospectively. Use of prefilled versus nonprefilled syringes was also tabulated. Patients with postinjection endophthalmitis (PIE) were identified among the 2 groups. Postinjection endophthalmitis is defined as an inflammation of the eye from infectious agents after an IVI. Logarithm of the minimum angle of resolution (logMAR) visual acuity (VA) was determined at the time of causative anti-VEGF injection, endophthalmitis presentation, and 3-month follow-up. RESULTS: A total of 67 695 IVIs were administered by 13 retina specialists during the study period. A total of 13 of 32 802 (0.0396%; 1 in 2523 injections) cases of presumed endophthalmitis occurred in the PI group, and 9 of 34 893 (0.0258%; 1 in 3877 injections) cases in the CHX group (P = 0.395). For the PI group, there were 2 culture-positive endophthalmitis cases (0.0061%, 1 in 16 401), compared with 2 cases in the CHX group (0.00573%, 1 in 17 447) (P = 1.000). No significant difference was observed in the average logMAR VA of PI and CHX at causative injection (P = 0.3851), endophthalmitis encounter (P = 0.7718), and 3-month follow-up (P = 0.6152). A significant reduction in presumed endophthalmitis (P = 0.0445) and culture-positive cases (P = 0.0130) was present for prefilled IVI compared with nonprefilled injections. CONCLUSIONS: No significant difference in the rate of endophthalmitis or visual outcomes were found in the CHX group compared with the PI group. Prefilled syringes were associated with a significant reduction in endophthalmitis rate. Further multicenter studies are needed to validate the efficacy and safety of CHX compared with PI for IVI preparation. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Clinical and Anatomic Outcomes of 3-Piece Poly(methyl methacrylate) Intraocular Lens Rescue and Needle-Assisted Transconjunctival Intrascleral Lens Fixation.

Purpose: To report the clinical and anatomic outcomes of a single-stage rescue and sutureless 30-gauge needle-assisted transconjunctival intrascleral fixation of dislocated 3-piece rigid poly(methyl methacrylate) (PMMA) intraocular lenses (IOLs). Methods: This retrospective noncomparative single-surgeon interventional study comprised eyes that had concurrent 23- or 25-gauge pars plana vitrectomy and IOL rescue with sutureless transconjunctival needle-assisted flanged haptic intrascleral fixation. Lamellar scleral dissection for haptic fixation was performed 3 mm posterior to the surgical limbus with 30-gauge needles. Primary endpoints included visual acuity (VA), IOL tilt measured with ultrasound biomicroscopy (UBM), and postoperative complications. Results: The study evaluated 25 eyes of 24 patients. The IOL was successfully refixated in 24 of the 25 eyes. The mean preoperative logMAR VA of 1.21 ± 0.79 SD (median 1.3; Snellen equivalent 20/400) improved to 0.28 ± 0.35 (median 0.14; Snellen equivalent 20/30) postoperatively (P < .0001). The mean IOL tilt measured by UBM (n = 7) was 3.79 ± 3.60 degrees. The mean postoperative follow-up was 348 ± 284 days (range, 7-979 days). Postoperative complications included self-clearing vitreous hemorrhage (n = 9), retinal detachment (RD) (n = 1), cystoid macular edema (n = 3), and corneal edema (n = 3). Three eyes (13%) required additional surgery, 1 for RD and 2 for delayed haptic slippage and secondary IOL tilt causing irregular astigmatism. Conclusions: Intrascleral needle-assisted fixation of dislocated or mobile 3-piece PMMA IOLs is an effective, safe method to restore VA.

Prognostic Utility of Whole-Genome Sequencing and Polymerase Chain Reaction Tests of Ocular Fluids in Postprocedural Endophthalmitis.

PURPOSE: To associate detection of potential pathogen DNA in endophthalmitis with clinical outcomes. DESIGN: Prospective cohort study. METHODS: Patients in whom endophthalmitis was diagnosed following an intraocular procedure were recruited. Clinical outcome data from baseline, week-1, month-1, and month-3 visits were collected. Intraocular biopsy samples were cultured by standard methods. Quantitative polymerase chain reaction (qPCR) was performed for specific pathogens and whole-genome sequencing (WGS). RESULTS: A total of 50 patients (mean age 72 years old; 52% male) were enrolled. Twenty-four cases were culture-positive and 26 were culture-negative. WGS identified the cultured organism in 76% of culture-positive cases and identified potential pathogens in 33% of culture-negative cases. Month-1 and -3 visual acuities did not vary by pathogen-positive versus pathogen-negative cases as detected by either culture or WGS. Visual outcomes of Staphylococcus epidermidis endophthalmitis were no different than those of pathogen-negative cases, whereas the patients infected with other pathogens showed worse outcome. Higher baseline bacterial DNA loads of bacteria other than those of S epidermidis detected by WGS were associated with worse month-1 and -3 visual acuity, whereas the S epidermidis loads did not appear to influence outcomes. Torque teno virus (TTV) and Merkel cell polyomavirus (MCV) were detected by qPCR in 49% and 19% of cases, respectively. Presence of TTV at presentation was associated with a higher rate of secondary pars plana vitrectomy (P = .009) and retinal detachment (P = .022). CONCLUSIONS: The presence and higher load of bacteria other than S epidermidis detected by WGS or DNA from TTV by qPCR in ocular fluids is associated with worse outcomes in post-procedure endophthalmitis.

EN FACE VERSUS 12-LINE RADIAL OPTICAL COHERENCE TOMOGRAPHY SCAN PATTERNS FOR DETECTION OF MACULAR FLUID IN NEOVASCULAR AGE-RELATED MACULAR DEGENERATION.

PURPOSE: To compare fluid detection of autosegmented en face to 12-line radial spectral domain optical coherence tomography scan patterns in neovascular age-related macular degeneration. METHODS: Retrospective observational case series. Sixty-seven patients (94 eyes) with neovascular age-related macular degeneration underwent autosegmented en face optical coherence tomography (with associated 304-line raster scan) and 12-line radial scan patterns. Sensitivity and specificity of fluid detection for en face scan and 12-line radial scans were determined by combining radial and 304-line raster scans as a gold standard. RESULTS: Two hundred and fifty-eight en face and 12-line radial spectral domain optical coherence tomography scans were interpreted. Seventy-five scans (58.1%) had fluid, whereas 54 scans (41.9%) did not. En face scan pattern fluid detection sensitivity and specificity was 89.3% and 61.1%, respectively. Twelve-line radial scan pattern fluid detection sensitivity and specificity was 97.3% and 100%, respectively. The difference in fluid detection between scan patterns was statistically significant (P = 0.01). Decreased central macular thickness was associated with false-positive (P = 0.035) and false-negative (P = 0.01) fluid detection on en face scans. CONCLUSION: En face optical coherence tomography alone is not as sensitive or specific as the 12-line radial scan pattern in detecting fluid in neovascular age-related macular degeneration. En face scans should be corroborated with other optical coherence tomography protocols to guide clinical decision making.

Loss to Follow-up After Intravitreal Anti-Vascular Endothelial Growth Factor Injections in Patients with Diabetic Macular Edema.

PURPOSE: To determine the rate of loss to follow-up (LTFU) and associated risk factors in patients with nonproliferative diabetic retinopathy (NPDR) who had diabetic macular edema (DME) and were receiving intravitreal anti-vascular endothelial growth factor (VEGF) injections. DESIGN: Retrospective cohort study. PARTICIPANTS: A total of 2595 NPDR patients with DME who received at least one anti-VEGF injection at a single large retina practice from January 1, 2012, to January 1, 2017. METHODS: A retrospective review based on billing codes was performed. LTFU was defined as no subsequent office visits within 12 months after an intravitreal injection. Patient demographics and clinical features were evaluated, and logistic regression was used to identify independent predictors for LTFU. MAIN OUTCOME MEASURES: LTFU rates and potential risk factors. RESULTS: LTFU was found in 413 (25.3%) of 1632 patients. Examining LTFU by racial groups, 21.3% identified themselves as white, 29.1% as black, 30.6% as Asian, and 35.0% as Hispanic (P < 0.001). A difference in LTFU was also found based on average adjusted gross income (AGI) (P < 0.001) and NPDR stage (P = 0.04). In the multivariate model, factors associated with LTFU included Hispanic (odds ratio [OR] 1.66), American Indian, Pacific Islander, multiple races (OR 2.60), and unknown race (OR 1.59) compared with those who were white. Additional factors included those with an average AGI of $50000 to $75000 (OR 1.37) and <$50000 (OR 1.88) compared with those with an average AGI > $75000. Based on subgroup analysis of patients with available visual acuity data, a significant association was found between decreasing baseline vision and LTFU (P < 0.001). CONCLUSIONS: Approximately 1 in 4 patients with NPDR who had DME had no follow-up visit for at least 1 year after an anti-VEGF injection. Given the importance of ongoing therapy, these real-world findings may help identify at-risk groups for noncompliance with care.

Comparison of a Three-Dimensional Heads-Up Display Surgical Platform with a Standard Operating Microscope for Macular Surgery.

PURPOSE: To assess safety, efficacy, and outcomes of vitreoretinal surgery for macular pathology using a 3-dimensional heads-up display (3D HUD) surgical platform compared with a standard operating microscope (SOM). DESIGN: Prospective, single-center, unmasked, randomized study. PARTICIPANTS: Patients undergoing pars plana vitrectomy (PPV) for epiretinal membrane (ERM) or full-thickness macular hole (MH) at Wills Eye Hospital. METHODS: Patients were randomized 1:1 to undergo surgery with a 3D HUD surgical platform or SOM. Patients who had previous PPV were excluded. Surgical choices, including PPV gauge, were based on surgeon preference. Standard surgical safety parameters, Early Treatment Diabetic Retinopathy Study visual acuity (VA), minimum required endoillumination levels, operative times, and surgeon "ease of use" of the viewing platform were recorded. Patients were followed up to postoperative month 3 (POM3). MAIN OUTCOME MEASURES: The main outcome measures were total operative time, macular peel time, surgeon rating of viewing system ease of use, minimum required endoillumination, intraoperative complication rate, and postoperative VA. RESULTS: Thirty-nine eyes of 39 patients with a mean age of 67.60±8.21 SD years were enrolled. Indications included ERM (n = 26 [3D HUD = 14, SOM = 12]) and MH (n = 13 [3D HUD = 9, SOM = 4]). Minimum required endoillumination was significantly lower with 3D HUD (mean 22.70%±15.10% SD) compared with SOM (mean 39.06%±2.72%; P < 0.001). There was no significant difference in overall operative time, but macular peel time was significantly longer using 3D HUD (mean 14.76±4.79 minutes) than SOM (11.87±8.07 minutes; P = 0.004). Surgeon-reported ease of use was significantly higher (easier) using SOM compared with 3D HUD (P = 0.004). There was no statistically significant difference between the groups in POM3 logarithm of the minimum angle of resolution (logMAR) VA or change in logMAR VA from baseline (all P > 0.681). There were no clinically significant intraoperative complications in either group. CONCLUSIONS: Three-dimensional heads-up display surgical visualization is an evolving technology demonstrating comparable efficacy to the SOM for macular surgery. Although overall surgical times were similar, 3D HUD macular peel times were longer and associated with less ease of use in this study, which may partly be due to a learning curve with new technology.

Loss to Follow-Up in Patients With Retinal Vein Occlusion Undergoing Intravitreal Anti-VEGF Injections.

BACKGROUND AND OBJECTIVE: To identify the proportion of patients with retinal vein occlusion (RVO) with loss to follow-up (LTFU) along with potential risk factors after receiving an intravitreal anti-vascular endothelial growth factor (VEGF) injection. PATIENTS AND METHODS: A retrospective review based on billing codes was performed from January 1, 2012, to January 1, 2017. LTFU was defined as no office visit within 12 months following an intravitreal injection. Potential risk factors for LTFU were screened using univariate analysis for inclusion in a final multivariate logistic regression model. RESULTS: A total of 3,400 unique patients with RVO with macular edema met the study inclusion criteria. Of these, 863 patients (25.4%) were LTFU. Rates of LTFU varied based on race / ethnicity, age, RVO type, distance from clinic, insurance status, and regional average adjusted gross income. In the multivariate analysis, patients with LTFU were more likely to be black (odds ratio [OR] = 1.37), Hispanic (OR = 2.37), and living more than 20 miles away from clinic (OR = 1.47). Patients who were 65 to 80 years old (OR = 0.71) and those with branch retinal vein occlusion (OR = 0.70) were less likely to be LTFU. Subgroup analysis showed that patients with baseline visual acuity better than 20/50 were also less likely to be LTFU. CONCLUSIONS: Approximately one in four patients did not return for a year or more after receiving an intravitreal injection for RVO. Given the importance of ongoing therapy to prevent vision loss, these "real-world" findings are of significant concern. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:159-166.].

Optical Coherence Tomography and Management of a Retinal Granuloma in Presumed Ocular Sarcoidosis.

Purpose: To highlight the utility of EDI-OCT and periocular steroid administration for the treatment of a retinal granuloma due to presumed ocular sarcoidosis. Methods: Retrospective case-study of a single patient. Results: A 45-year-old African-American male with blurred vision in the right eye was found to have a macula-involving retinal granuloma. Laboratory, imaging, and clinical findings were consistent with a diagnosis of presumed ocular sarcoidosis. Optical coherence tomography (OCT) and fundus photographs were used to document granuloma evolution. Oral prednisone 60mg was initiated and tapered to 10mg within 2 months. Due to systemic side-effects and inadequate treatment response with prednisone, 5 sub-Tenon's triamcinolone acetonide (PSTA) injections were then administered over 7 months, and oral prednisone was discontinued at 6 months. Conclusion: This case demonstrated marked granuloma regression occurring with improvement in visual acuity, highlighting the utility of OCT and PSTA in managing retinal sarcoid granulomas.

Loss to Follow-up Among Patients With Neovascular Age-Related Macular Degeneration Who Received Intravitreal Anti-Vascular Endothelial Growth Factor Injections.

Importance: Loss to follow-up (LTFU) after anti-vascular endothelial growth factor (anti-VEGF) injections increases the risk of vision loss among patients with neovascular age-related macular degeneration (nAMD). Objective: To report rates of LTFU among patients with nAMD after anti-VEGF injections and to identify risk factors associated with LTFU in this population. Design, Setting, and Participants: This retrospective cohort study of data from 9007 patients who received anti-VEGF injections for treatment of nAMD was performed at an urban, private retina practice with multiple locations from April 1, 2012, to January 12, 2016. Main Outcomes and Measures: Rates of LTFU after anti-VEGF injections. Loss to follow-up was defined as receipt of 1 or more injections with no subsequent follow-up visit within 12 months. Results: Among the 9007 patients (mean [SD] age, 81.2 [8.8] years; 5917 [65.7%] female; 7905 [87.8%] white), 2003 (22.2%) were LTFU. Odds of LTFU were greater among patients 81 to 85 years of age (odds ratio [OR], 1.58; 95% CI, 1.38-1.82; P < .001), 86 to 90 years of age (OR, 2.29; 95% CI, 2.00-2.62; P < .001), and more than 90 years of age (OR, 3.31; 95% CI, 2.83-3.86; P < .001) compared with patients 80 years of age and younger. Odds of LTFU among African American patients (OR, 1.47; 95% CI, 1.00-2.16; P = .05), Asian patients (OR, 2.63; 95% CI, 1.71-4.03; P < .001), patients of other race (OR, 3.07; 95% CI, 1.38-6.82; P = .006), and patients of unreported race (OR, 2.29; 95% CI, 1.96-2.68; P < .001) were greater than odds of LTFU among white patients. Odds of LTFU were greater among patients with regional adjusted gross income of $50 000 or less (OR, 1.52; 95% CI, 1.30-1.79; P < .001), $51 000 to $75 000 (OR, 1.35; 95% CI, 1.17-1.56; P < .001), and $76 000 to $100 000 (OR, 1.28; 95% CI, 1.08-1.50; P = .004) compared with patients with incomes greater than $100 000. Odds of LTFU for patients living 21 to 30 miles (OR, 1.33; 95% CI, 1.05-1.69; P = .02) and more than 30 miles (OR, 1.55; 95% CI, 1.28-1.88; P < .001) from clinic were greater compared with patients who lived 10 miles or less from the clinic. Odds of LTFU were greater among patients who received unilateral injections (OR, 1.44; 95% CI, 1.28-1.61; P < .001) than among patients who received bilateral injections. Conclusions and Relevance: We found a high rate of LTFU after anti-VEGF injections among patients with nAMD and identified multiple risk factors associated with LTFU among this population. Although our results may not be generalizable, data on LTFU in a clinical practice setting are needed to understand the scope of the problem so that interventions may be designed to improve outcomes.

ENDOPHTHALMITIS AFTER PARS PLANA VITRECTOMY: Efficacy of Intraoperative Subconjunctival Antibiotics.

PURPOSE: To examine rates of acute infectious endophthalmitis after pars plana vitrectomy (PPV) in eyes that received intraoperative subconjunctival antibiotics versus eyes that did not. METHODS: A retrospective, nonrandomized, comparative case series of 18,886 consecutive cases of transconjunctival 23-, 25-, and 27-gauge PPV over a 5-year period was performed. The impact of prophylactic intraoperative subconjunctival antibiotics on the development of acute infectious postoperative endophthalmitis was examined. RESULTS: Of 18,886 cases of PPV, 14,068 (74.5%) received intraoperative subconjunctival antibiotics, whereas 4,818 (25.5%) did not. Sixteen cases (0.085%, 1/1,176) of post-PPV endophthalmitis were identified. The incidence of endophthalmitis in eyes that received subconjunctival antibiotics was 0.078% (11/14,068 cases, 1/1,282), whereas the incidence in those that did not receive subconjunctival antibiotics was 0.10% (5/4,818 cases, 1/1,000). No statistically significant difference was identified in the incidence of endophthalmitis between those that received subconjunctival antibiotics and those that did not (P = 0.598). Microbial culture was performed in 11 cases with 6 culture-positive cases (5/8 cases that received subconjunctival antibiotics and 1/3 cases that did not). CONCLUSION: Prophylactic subconjunctival antibiotics were not associated with a significantly reduced rate of post-PPV endophthalmitis. With consideration of emerging multidrug-resistant bacteria, routine prophylactic subconjunctival antibiotics may not be justified.

Patient Comfort with Yellow (577 nm) vs. Green (532 nm) Laser Panretinal Photocoagulation for Proliferative Diabetic Retinopathy.

PURPOSE: Pain associated with panretinal photocoagulation (PRP) can adversely affect the number and quality of retinal burns delivered and subsequently increase the number of treatment sessions required to achieve regression of proliferative diabetic retinopathy (PDR). We assessed comfort in patients undergoing treatment with yellow (577 nm) vs. green (532 nm) PRP for PDR. DESIGN: Prospective, single-center, randomized crossover clinical trial. SUBJECTS: Patients with PDR with high-risk characteristics. METHODS: Subjects were equally randomized to first receive PRP with a laser indirect ophthalmoscope with either green (IQ 532; IRIDEX, Mountain View, CA) or yellow (IQ 577; IRIDEX) laser, followed by additional treatment with the opposite laser using standardized settings in the superior hemisphere of a single treatment eye per patient. Topical anesthetic was used in all study eyes before each treatment and power was titrated until moderate grey-white retinal burns were achieved. MAIN OUTCOME MEASURES: The primary outcome measure was patient's perceived pain as measured with a standardized 10-point pain scale. Secondary outcome measures included laser power, treatment time, number of treatment shots with each laser, and physician ease-of-use score with each laser on a 10-point scale. RESULTS: Forty patients (40 eyes) with a mean age of 54.0 years were enrolled. Mean pain scores were similar when comparing treatment with yellow and green laser (3.1 ± 2.3 vs. 2.8 ± 2.6; P = 0.40). No significant difference was seen in visual acuity (P = 0.44) or central macular thickness (P = 0.39) 1 month after PRP. Additionally, there were no significant differences when comparing minimum power required (243.2 ± 74.2 vs. 234.0 ± 59.6 mW; P = 0.55), treatment time (5.1 ± 3.6 vs. 5.6 ± 3.9 minutes; P = 0.384), and number of treatment shots (257.6 ± 12.6 vs. 258.0 ± 2.3; P = 0.68). Six of 7 co-investigators (85%) preferred using yellow laser over green and reported ease-of-use scores of 9.0 ± 1.2 and 7.6 ± 1.4, respectively (P = 0.07). No severe adverse events occurred. CONCLUSIONS: Patient comfort during PRP for PDR utilizing laser indirect ophthalmoscopy is similar for green and yellow wavelengths.

A RANDOMIZED DOUBLE-BLIND PLACEBO-CONTROL PILOT STUDY OF EPLERENONE FOR THE TREATMENT OF CENTRAL SEROUS CHORIORETINOPATHY (ECSELSIOR).

PURPOSE: To evaluate the safety and effects of oral eplerenone in chronic central serous chorioretinopathy. METHODS: Prospective, randomized, double-blind, placebo-control study at a tertiary referral academic private practice. For a diagnosis of chronic central serous chorioretinopathy, patients must have had at least 3 months clinical follow-up demonstrating persistent symptoms, subfoveal fluid on spectral-domain optical coherence tomography, and <50% reduction in fluid thickness. Patients were randomized 2:1 (treatment:placebo) to receive eplerenone (25 mg daily for 1 week, then up to 50 mg daily for 8 weeks) or placebo once daily. RESULTS: Fifteen patients completed the study. Ten patients (15 eyes) were randomized into the eplerenone treatment arm, while the remaining 5 patients (6 eyes) received placebo. After 9 weeks of eplerenone therapy, mean logarithm of the minimal angle of resolution visual acuity improved from 0.394 (Snellen equivalent: 20/50) to 0.330 (20/43, P = 0.04). In the placebo group, the mean logarithm of the minimal angle of resolution visual acuity slightly decreased from 0.313 (20/41) to 0.342 (20/44) during the same period (P = 0.21). With respect to anatomic changes, mean maximal subretinal fluid height in the eplerenone group improved from 139.3 µm at baseline to 51.8 µm (P = 0.02), mean subfoveal fluid height improved from 121.4 µm to 29.4 µm (P = 0.01), and mean central subfield thickness improved from 366.2 µm to 283.7 µm (P = 0.02). In comparison with the placebo group, mean maximal subretinal fluid height worsened from 135.9 µm to 172.3 µm (P = 0.32), mean subfoveal fluid height worsened from 92.1 µm to 134.0 µm (P = 0.54), and mean central subfield thickness worsened from 345.0 µm to 380.0 µm (P = 0.37). No patients in either group experienced serious adverse events to result in treatment discontinuation. CONCLUSION: These findings suggest that oral eplerenone therapy is safe and potentially effective in the treatment of chronic central serous chorioretinopathy with persistent subretinal fluid.

Optical Coherence Tomography Findings in Endogenous Fungal Chorioretinitis, Retinitis, and Endophthalmitis.

BACKGROUND AND OBJECTIVE: To describe spectral-domain optical coherence tomography (SD-OCT) findings in eyes with endogenous fungal chorioretinitis and endophthalmitis. PATIENTS AND METHODS: Retrospective, observational case series of subjects at Wills Eye Hospital and William Beaumont Hospital were identified by screening OCT billing data and cross-referencing with patient charts. Clinical and imaging data were collected for each patient and reviewed. RESULTS: Twelve eyes of seven consecutive patients were identified, demonstrating two patterns of posterior ocular involvement: chorioretinal infiltration and superficial retinal/retinal vascular infiltration without choroidal involvement. Six of 12 eyes had follow-up imaging performed after antifungal treatment, which demonstrated decreased size of choroidal and/or retinal infiltrates. CONCLUSIONS: All patients with follow-up imaging had anatomic improvement by OCT of the lesions with treatment. In the future, OCT imaging may provide a method to assess therapeutic response and prognosis for visual recovery in patients with endogenous fungal ocular disease. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:894-901.].