The use of miltefosine in the management of refractory Acanthamoeba keratitis.

Acanthamoeba keratitis (AK) is a sight threatening infection most commonly affecting contact lens wearers. The authors report a case of intractable A.polyphaga and A.castellanii, with extensive intraocular spread, managed using oral miltefosine. A 59-year old male contact lens wearer was referred to the tertiary corneal service at Bristol Eye Hospital. Vision was hand movements on the left and 6/6 on the right. Clinical examination was consistent with left AK (confirmed by corneal scrape). Management included biguanide (polyhexamethylene biguanide (PHMB) 0.02%, later 0.06%) and diamidine (hexamidine 0.1%). Further treatment included imidazole (guttae voriconazole, oral posaconazole) and fortified biguanide (chlorhexidine 0.2%). Therapeutic PKP was performed. Microscopy revealed Acanthamoeba throughout host stroma. Corneal scrape and anterior chamber tap revealed persistent infection with Acanthamoeba. Intracameral voriconazole was administered twice. Clinically there was scleritis, with concerns regarding posterior segment involvement. There was a severe necrotic keratitis with almost complete corneal melt, requiring enucleation. Oral miltefosine was commenced to reduce the risk of transmission of Acanthamoeba beyond ocular structures at the time of the enucleation. Histopathological analysis detected A.polyphaga and A.castellanii in vitreous but not retina, choroid or optic nerve suggesting that infection had not progressed posteriorly through the ocular structures and the central nervous system was not involved. The use of miltefosine as a component of combination anti-parasitic therapy is associated with long-term survival in cases of Acanthamoeba infection of the central nervous system. This case reports its first systemic use in the United Kingdom in a case of severe intractable AK with intraocular spread.

Full-thickness macular hole: a rare complication of Borrelia burgdorferi neuroretinitis.

Borrelia burgdorferi is a known infective cause of neuroretinitis. We present a case of B burgdorferi neuroretinitis complicated by macular hole in a 22-year-old man. The neuroretinitis was managed with early high-dose intravenous corticosteroid and oral antibiotic. The macular hole was managed with macular hole surgery after intraocular inflammation had resolved.

UK Age-Related Macular Degeneration Electronic Medical Record System (AMD EMR) Users Group Report IV: Incidence of Blindness and Sight Impairment in Ranibizumab-Treated Patients.

PURPOSE: To study the incidence of blindness and sight impairment in treatment-naive patients receiving ranibizumab (Lucentis) for neovascular age-related macular degeneration (nAMD) in the United Kingdom (UK) National Health Service. DESIGN: Multicenter nAMD database study. PARTICIPANTS: A total of 11 135 patients who collectively received 92 976 treatment episodes to 12 951 eyes. METHODS: Data were extracted from 14 UK centers using the same electronic medical record system (EMR). The EMR-mandated collection of a data set (defined before first data entry) including: age, Early Treatment Diabetic Retinopathy Study visual acuity letter score (VA) for both eyes at all visits, and injection episodes. Participating centers used overwhelmingly a pro re nata re-treatment posology at intended monthly follow-up visits following a loading phase of 3 monthly injections. MAIN OUTCOME MEASURES: Incidence of blindness and sight impairment (VA in the better-seeing eye <38 letters [≤20/200 Snellen, approximately], and <68 letters [≤20/50 Snellen, approximately] at 2 consecutive visits, or 1 visit if no further follow-up data) in each year after initiating treatment. RESULTS: Information from >300 000 clinic visits (2.8 million data points) collected over 5 years was collated from 14 centers. Mean age at first treatment was 79.7 years (standard deviation = 9.19 years), with a female preponderance (63%). The mean (median) VA at baseline in the better-seeing eye was 67.2 (72.0) letters, 20/40- (20/40+) approximate Snellen conversion. The cumulative incidence of new blindness and sight impairment in patients with treated nAMD in at least 1 eye at years 1 to 4 after first injection were 5.1%, 8.6%, 12% and 15.6% for new blindness and 29.6%, 41.0%, 48.7%, and 53.7% for new sight impairment, but with significant reductions in the rates between year cohorts initiating treatment (blindness [P = 4.72 × 10-08], sight impaired [P = 3.27 × 10-06]). CONCLUSIONS: To the best of our knowledge, this is the first multicenter real-world study on the incidence of blindness and sight impairment based on VA data in patients treated with ranibizumab for nAMD, and its results show low incidences of both blindness and sight impairment, which both declined during the study period.

Diabetic retinopathy: intravitreal vascular endothelial growth factor inhibitors for diabetic macular oedema.

INTRODUCTION: Diabetic retinopathy is the most common microvascular complication of diabetes. It is also the most common cause of blindness in working-age adults in industrialised nations. Older people and those with worse diabetes control, hypertension, and hyperlipidaemia are most at risk. Diabetic macular oedema, which can occur at any stage of diabetic retinopathy, is related to increased vascular permeability and breakdown of the blood retinal barrier, in part related to increased vascular endothelial growth factor (VEGF) levels. About 1% to 3% of people with diabetes suffer vision loss because of diabetic macular oedema. METHODS AND OUTCOMES: We conducted a systematic overview, aiming to answer the following clinical questions: What are the effects of intravitreal VEGF inhibitors versus each other for diabetic macular oedema? What are the effects of intravitreal VEGF inhibitors plus laser therapy versus intravitreal VEGF inhibitors alone for diabetic macular oedema? We searched: Medline, Embase, The Cochrane Library, and other important databases up to September 2014 (Clinical Evidence overviews are updated periodically; please check our website for the most up-to-date version of this overview). RESULTS: At this update, searching of electronic databases retrieved 240 studies. After deduplication and removal of conference abstracts, 149 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 90 studies and the further review of 59 full publications. Of the 59 full articles evaluated, eight systematic reviews and four RCTs were added at this update. We performed a GRADE evaluation for four PICO combinations. CONCLUSIONS: In this systematic overview, we categorised the efficacy for six comparisons based on information about the effectiveness and safety of intravitreal VEGF inhibitors aflibercept, bevacizumab, and ranibizumab, and each of these intravitreal VEGF inhibitors plus laser therapy.

Long-term outcomes of intravitreal ranibizumab for neovascular age-related macular degeneration in a well defined region of the UK.

AIMS: To study long-term, whole population 'real-world' clinical outcomes of ranibizumab therapy in treatment-naïve eyes for neovascular age-related macular degeneration. METHODS: Data collected prospectively from a single centre serving a defined population using an electronic medical record included: demographics, Early Treatment Diabetic Retinopathy Study visual acuity (ETDRS VA) at all visits, injection dates, central 1 mm retinal thickness, and operative and postoperative complications. RESULTS: 1483 eyes from 1278 patients were included in this study. The median age at the time of the patient's first injection was 82.5 years, 64.9% of patients were female, and another ocular pathology was present in 7.3% eyes. The baseline VA was 23-39, 40-54, 55-70 and >70 ETDRS letters for 17.3%, 23.1%, 42.7% and 16.9% of eyes, respectively. The median VA in all baseline VA groups improved after the loading phase but declined back to the baseline level by 2-5 years. The rate of endophthalmitis following intravitreal injection was 1 in 2124 injections. CONCLUSIONS: These long-term real-world data demonstrate that in general VA increases during the loading phase but returns to near baseline levels after 2-5 years of treatment for each baseline VA category. Patients should be identified and treated as early as possible, since presenting VA predicts the VA maintained after 5 years of treatment. National Institute of Health and Care Excellence guidance advising treatment only for eyes with vision below 70 letters does not promote best long-term VA outcomes for patients.