Resolution of Postoperative Cystoid Macular Edema with a Suprachoroidal Triamcinolone Acetonide Injectable Suspension.

AIM: To report a case of significant postoperative cystoid macular edema (CME) in a patient with no prior history of uveitis or systemic inflammatory disease, in which a suprachoroidal (SC) triamcinolone acetonide injectable suspension resulted in complete resolution of CME. DESIGN: Case report. METHODS: An 81-year-old man presented with a complex, dense brunescent cataract, floppy iris, and miotic pupil in the left eye. Six weeks following cataract extraction, the intraocular lens (IOL) was dislocated completely from the visual axis. He underwent a pars plana vitrectomy and IOL exchange with an anterior chamber IOL due to a three-piece IOL dislocation. Following the operation, the patient began treatment with prednisolone acetate and ketorolac. However, 2 weeks later, he was noted to be a steroid responder and glaucoma suspect. Therefore, the decision was made to taper and discontinue topical steroids. At 6 months postoperatively, ranibizumab was injected for persistent CME. However, following injection, there was intraocular pressure (IOP) elevation and increased CME. IOP improved 1 month later with dorzolamide hydrochloride and timolol maleate. At 8 months post-operation, there was persistent CME. The patient was then treated with an SC triamcinolone acetonide injection. There was complete resolution of CME by 14 weeks later, with improvement in visual acuity. Despite the patient's known steroid response with topical steroids, IOP remained within normal limits during the entire follow-up period after injection. CONCLUSION: SC triamcinolone acetonide injection is indicated for macular edema associated with uveitis; however, treatment for postoperative macular edema with this novel suprachoroidal injection may be considered.

[IDIOPATHIC INTRACRANIAL HYPERTENSION IN A PATIENT WITH ULCERATIVE COLITIS AND UVEITIS].

INTRODUCTION: Idiopathic intracranial hypertension (IIH) is a syndrome mostly affecting young, overweight women, which characteristically causes headaches, transient visual obscuration or double vision, tinnitus, nausea and vomiting. Severe disease may cause irreversible visual loss. IIH may be primary, or it may be secondary to various medications and diseases. We hereby present a case study of a patient with ulcerative colitis and uveitis, who presented with blurred vision, headache and tinnitus and was diagnosed as IIH. We discuss the differential diagnosis with relation to her underlying disease and treatments.

The effect of trabeculectomy and glaucoma drainage device implantation on postural intraocular pressure changes in glaucomatous eyes.

PURPOSE: To investigate the effect of trabeculectomy and glaucoma drainage device implantation on posture related intraocular pressure (IOP) changes in glaucomatous eyes. METHODS: Eyes in this prospective study were divided into three groups: those that underwent Ahmed glaucoma valve implantation (Ahmed group), those that underwent trabeculectomy with mitomycin C (trabeculectomy group) and those treated medically (medication group). IOP was measured in the sitting position, and after 15 min in the left lateral decubitus position using a Tonopen XL, and a Goldmann applanation tonometer (GAT). For GAT measurements in the left lateral decubitus position, we used a specialized system comprised of a motorized bed attached to a modified slit-lamp table. RESULTS: 111 eyes of 64 glaucoma patients were included in the analysis: 19 in the Ahmed group, 46 in the trabeculectomy group and 46 in the medication group. The difference in IOP between the sitting and supine positions was significant in the medication (2.23 mmHg) and trabeculectomy (1.48 mmHg) groups, but not in the Ahmed group (0.53 mmHg). This significance was reached with the GAT, but not with the Tonopen. A rise of 5 mmHg or more between the sitting and supine positions was documented in 5.2%, 4.3% and 15.2% of eyes in the Ahmed, trabeculectomy and medication groups, respectively. Intraclass correlation coefficient for IOP measurements in the supine position demonstrated good correlation between the two tonometers. CONCLUSIONS: Ahmed valve surgery significantly reduces postural IOP response as compared with medically treated controls. There was no significant difference between Ahmed valve and trabeculectomy in terms of their effect on the postural IOP change.

Endophthalmitis after intravitreal injections versus cataract surgery: a 15-year cohort.

PURPOSE: To compare the clinical features, visual outcomes and causative organisms between endophthalmitis secondary to cataract surgery or to intravitreal injections (IVI). SETTING: Meir Medical Center, Kfar Saba, Israel. DESIGN: Retrospective, non-randomized comparative chart review. METHODS: Medical records of patients with proven or suspected endophthalmitis admitted to the Ophthalmology Department at Meir Medical Center 2/2002-2/2017 were reviewed. Clinical characteristics including presenting and final visual acuity (VA) outcomes, causative organisms and time to admission were assessed. RESULTS: Among 84 patients in our study, 35 had preceding cataract surgery and 12 had preceding IVI. The post-cataract group showed a significant improvement in VA following treatment with a presenting and final VA (logMar ± SD) of (1.80 ± 0.54 and 1.39 ± 0.65, P < 0.01) as opposed to the post-IVI group (1.72 ± 0.26 and 1.81 ± 0.32, P = 0.692), while most patients in the cataract group exhibited some degree of VA recovery (70.96%). Patients undergoing cataract surgery were divided into two separate groups; those who underwent cataract surgery in a private center and those operated at a public center. Patients undergoing surgery at a private medical center showed improvement in VA outcomes following treatment (1.80 ± 0.57 and 1.13 ± 0.66, P < 0.01) as opposed to those operated on at our public medical center. CONCLUSIONS: Overall, patients with endophthalmitis following cataract surgery had better visual outcomes and were more likely to show a VA improvement following treatment when compared with endophthalmitis following IVI. Final VA outcomes of patients with endophthalmitis after cataract surgery performed in a private center were better than those operated on and treated in a public medical center.

Objective Measurement of Eyelid Force in Ptosis Versus Controls.

Thorough evaluation of the upper eyelid is essential for diagnosis and management planning in blepharoptosis. In a previous study, our group described a novel force gauge for direct assessment of upper lid force in healthy subjects. In this study, the authors apply the same technique for measuring muscle forces in ptotic eyelids.Patients scheduled to undergo surgical repair of aponeurotic blepharoptosis or dermatochalasis, from July 2017 to August 2018, in a tertiary care medical center, were enrolled in this prospective case series. When the eyelid disorder was unilateral, the normal eye was designated as control. The upward force generated by the eyelid was measured directly using a handheld dynamometer noninvasively attached to the upper eyelid. Measurements were conducted with and without fixation of the frontalis muscle, to differentiate between total lid force, levator force, and frontalis contribution.A total of 56 eyes was included in the study: 34 in the ptosis group, 11 in the dermatochalasis group, and 11 as controls. Both the ptosis group and the dermatochalasis group had significantly lower total muscle force and levator force measurements when compared with control (P <0.05). Calculated frontalis force contribution to upgaze did not differ significantly between groups. In the control group, calculated frontalis force contribution to upgaze strongly correlated to marginal reflex distance1 (r = 0.75, P = 0.05)In conclusion, the authors present a simple, inexpensive, new portable force gauge for direct eyelid force measurements in eyelid pathologies. Distinct differences between ptotic and healthy eyelids are demonstrated, suggesting potential applications in patient evaluation and management.

Efficacy of Primary Collagen Cross-Linking with Photoactivated Chromophore (PACK-CXL) for the Treatment of Staphylococcus aureus-Induced Corneal Ulcers.

PURPOSE: To evaluate the efficacy of corneal collagen cross-linking (CXL) with photoactivated riboflavin (PACK-CXL) as primary therapy for Staphylococcus aureus-induced corneal ulcers in a rabbit model. METHODS: The right eye of 40 rabbits was inoculated with S. aureus to induce formation of central corneal ulcers (day 1). The ulcer was examined on day 5, and rabbits were randomly assigned to 4 groups-group A: no treatment (control); group B: topical antibiotic treatment (cefazolin 50 mg/mL, garamycin 14 mg/mL drops, chloramphenicol 5% ointment every 2 hours); group C: PACK-CXL; group D: PACK-CXL + topical antibiotics. Follow-up by biomicroscopy was performed on day 5 and then every week for 1 month. The main outcome measures included infiltrates or the scar diameter, time to healing, time to full epithelialization, and a change in corneal thickness. RESULTS: After 1 month of treatment, group C ulcers had the smallest mean scar diameter (8.8 mm), followed by groups D (11.2 mm), B (13.0 mm), and A (24.5 mm) (P = 0.011). Group C had the shortest mean healing time (15.5 days), followed by groups D (17.2 days), B (19.7 days), and A (21.8 days). Analysis of relative reduction in the infiltrate size from day 5 yielded better results for groups C (P = 0.039) and D (P = 0.034) than those of group B. CONCLUSIONS: We demonstrate a beneficial effect of PACK-CXL as primary treatment, either as stand-alone or as an adjuvant to antimicrobial therapy.

First 100: learning curve for Descemet stripping automated endothelial keratoplasty.

PURPOSE: Endothelial keratoplasty is largely replacing penetrating keratoplasty for the routine treatment of corneal endothelial failure. The aim of the study was to describe the performance, complications, and outcome of the first 100 Descemet stripping automated endothelial keratoplasty (DSAEK) procedures performed at a major medical center, with an emphasis on the learning curve. 
 METHODS: A retrospective, comparative case series study was conducted by a single surgeon at a tertiary, university-affiliated medical center. Data were collected on 100 consecutive DSAEK procedures performed between September 2008, when the technique was introduced in the ophthalmology department, and January 2011. Main outcome measures include best-corrected visual acuity, graft dislocation rate, primary failure rate, and endothelial cell loss. Findings were compared between the first (early group) and last (late group) 50 cases.
 RESULTS: Mean (SD) logMAR best-corrected visual acuity at 1 year improved from 1.02 ± 0.36 to 0.38 ± 0.35 in the early group (p<0.05) and from 0.93 ± 0.48 to 0.25 ± 0.21 in the late group (p<0.05) (n = 86). Although the late group included more complex cases (presence of anterior chamber intraocular lens, need for combination cataract surgery or secondary scleral intraocular lens fixation), graft dislocation was more common in the early group (20% versus 10%, p = 0.26). Primary and late graft failures occurred only in the early group (12% vs 0, p = 0.03). 
 CONCLUSIONS: Rates of primary failure and disc dislocation for DSAEK decrease as surgeons gain experience with the procedure, and the number of functional grafts increases accordingly. Visual outcome improves regardless of surgical experience.