Filtering-Associated Endophthalmitis after Trabeculectomy or Tube-Shunt Implant.

PURPOSE: To determine the rate, clinical features, and outcomes of filtering-associated endophthalmitis in eyes that underwent trabeculectomy or tube-shunt implantation. DESIGN: Retrospective database study with selective chart review. PARTICIPANTS: Eyes that underwent incisional glaucoma surgery at our institution between January 1, 2012, and December 31, 2019. METHODS: An electronic medical record database was used to identify all eyes that underwent trabeculectomy or tube-shunt implantation during the study period. Date of surgery, date of last ophthalmology clinic visit, and filtering-associated endophthalmitis diagnoses were obtained and used to perform a Kaplan-Meier analysis. The log-rank test was used to compare rates of filtering-associated endophthalmitis after trabeculectomy and tube-shunt implantation. Microbiology, management, and clinical outcomes data from patients with filtering-associated endophthalmitis were also collected and analyzed. MAIN OUTCOME MEASURES: Cumulative risk of filtering-associated endophthalmitis as determined by Kaplan-Meier analysis. Visual acuity improvement to within 2 lines of baseline at 3 months of follow-up and globe salvage at last available follow-up in eyes with filtering-associated endophthalmitis. RESULTS: Kaplan-Meier analysis of 1582 eyes that underwent incisional glaucoma surgery yielded a 5-year cumulative incidence for filtering-associated endophthalmitis of 1.32%. No statistically significant differences were found between rate of endophthalmitis after trabeculectomy or tube-shunt implantation (P = 0.761, log-rank test). Seven of 16 cases (43.8%) of filtering-associated endophthalmitis showed positive culture results from either a vitreous sample or explanted tube shunt. Recovery of vision to within 2 lines of pre-endophthalmitis baseline was achieved in 53% of patients at 3 months of follow-up. Rate of globe salvage was 100% at last available follow-up. CONCLUSIONS: Risk of filtering-associated endophthalmitis is persistent and relatively constant for at least 5 years after incisional glaucoma surgery. The overall prognosis of filtering-associated endophthalmitis remains poor; however, good visual and anatomic outcomes can be achieved in some patients with prompt intervention.

Risk Factors and Disease Course for Blood-Brain Barrier Disruption-Associated Maculopathy.

Importance: Blood-brain barrier disruption (BBBD) is a systemic therapy for malignant central nervous system (CNS) tumors that has been linked to poorly understood pigmentary maculopathy. Objectives: To examine the rate of and risk factors for the development of BBBD-associated maculopathy and to assess whether there can be visually significant progression after completion of systemic therapy. Design, Setting, and Participants: In this retrospective case series, data from February 1, 2006, through December 31, 2019, were collected from patients treated with osmotic BBBD at a single tertiary referral center who had subsequent ophthalmic evaluation. Exposures: Treatment with BBBD therapy for any malignant CNS tumor. Main Outcomes and Measures: Rate and potential risk factors for developing BBBD-associated maculopathy and changes in visual acuity and retinal imaging characteristics after completion of BBBD therapy. Results: Of 283 patients treated with BBBD and chemotherapy for a CNS malignant neoplasm, 68 (mean [SD] age, 46.0 [17.9] years; 25 [38.5%] female) had an ophthalmic examination after starting systemic therapy. After excluding 3 patients because of bilateral media opacities, pigmentary maculopathy was present in 32 of 65 patients (49.2%) treated with BBBD. The number of BBBD treatment sessions, but not age, CNS malignant cancer type, or systemic chemotherapy agent, was associated with maculopathy development (odds ratio, 1.30; 95% CI, 1.12-1.50; P = .001). After completion of BBBD therapy, progressive enlargement of geographic atrophy occurred in 5 eyes of 3 patients, and choroidal neovascularization developed in 1 eye. Conclusions and Relevance: In this case series, an association was found between BBBD-related maculopathy and the number of BBBD treatment sessions, suggesting a dose-dependent effect. In some cases, maculopathy progression, including enlargement of geographic atrophy, occurred years after completion of systemic therapy. These findings may have important implications for patient education and ophthalmic monitoring.

Disease Course in Patients With Pentosan Polysulfate Sodium-Associated Maculopathy After Drug Cessation.

Importance: Recent studies have linked a vision-threatening maculopathy with long-term use of pentosan polysulfate sodium (PPS). Objective: To evaluate the disease course in PPS-associated maculopathy after drug cessation. Design, Setting, and Participants: In this retrospective case series, patients diagnosed with PPS-associated maculopathy with at least 6 months of follow-up after drug cessation who were treated at the Emory Eye Center, Atlanta, Georgia, or the Casey Eye Institute, Portland, Oregon, were included. Data were collected from April 2014 through November 2019. Main Outcomes and Measures: Change in visual acuity and retinal imaging characteristics over time. Results: Of the 11 included patients, all were female, and the median (interquartile range [IQR]) age was 53 (44-63) years. Participants had a baseline visit at a median (IQR) of 2 (0-4) months after drug cessation and were subsequently observed for a median (IQR) of 12 (8-26) months. The median (IQR) cumulative PPS exposure was 1.97 (1.55-2.18) kg. No eyes exhibited a demonstrable improvement in disease after discontinuing PPS. A total of 9 of 11 patients (82%) reported worsening visual symptoms at the final visit. The mean (SD) logMAR visual acuity was 0.14 (0.23) and 0.14 (0.34) at the baseline and final visit, respectively. Visual acuity improved by 2 or more Snellen lines in 1 eye (5%) and declined by 2 or more Snellen lines in 2 eyes of 1 patient (9%). There was evolution in the pattern of fundus autofluorescence changes and/or optical coherence tomography findings in all eyes. A total of 17 eyes (77%) exhibited expansion of the area of involved tissue. A total of 7 eyes (32%) had macular retinal pigment epithelium atrophy at the baseline visit, and atrophy enlarged after discontinuation of PPS in all 7 eyes, with a median (IQR) growth rate of 0.32 (0.13-0.38) mm per year. Conclusions and Relevance: These retrospective data among 11 patients suggest PPS-associated maculopathy continues to evolve after drug cessation for at least 10 years. In some cases, progressive retinal pigment epithelium atrophy encroaches on the foveal center and thus may pose a long-term threat to central vision.

Maculopathy Associated With Osmotic Blood- Brain Barrier Disruption and Chemotherapy in Patients With Primary CNS Lymphoma.

BACKGROUND AND OBJECTIVE: To describe the incidence, characteristics, and risk factors of a pigmentary maculopathy in patients with primary central nervous system (CNS) lymphoma treated with blood-brain barrier disruption (BBBD) therapy. PATIENTS AND METHODS: This retrospective chart review included patients with biopsy-proven primary CNS lymphoma treated with or without BBBD therapy who underwent an ophthalmic examination after starting systemic treatment. Clinical data and all available retinal imaging were analyzed. RESULTS: Fifty-eight patients met inclusion criteria. Twenty-one of 36 patients treated with BBBD therapy had a bilateral pigmentary maculopathy. None of the 22 patients treated with conventional chemotherapy had similar changes. Additional findings in patients treated with BBBD included geographic retinal pigment epithelium atrophy, subretinal fluid, and in one case, choroidal neovascularization. Some cases of maculopathy resulted in reduced visual acuity. The presence of a pigmentary maculopathy was associated with a higher number of BBBD treatment sessions (20.1 vs 13.3, P = .016), but not vitreoretinal lymphoma involvement or intravitreal methotrexate injections. CONCLUSION: In this cohort, 58.3% of patients with primary CNS lymphoma treated with BBBD and chemotherapy were found to have a bilateral pigmentary maculopathy. This maculopathy can result in reduced visual acuity and is associated with the number of BBBD treatment sessions. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:S5-S12.].

Culture-Proven Endophthalmitis After Intravitreal Injection: A 10-Year Analysis.

BACKGROUND AND OBJECTIVE: To report on the microbiology, management, and visual outcomes of intravitreal injection (IVI)-associated, culture-proven endophthalmitis. PATIENTS AND METHODS: All patients seen at a tertiary referral center with culture-proven endophthalmitis associated with an IVI between June 2007 and July 2017 were included in this retrospective analysis. RESULTS: Thirty-five patients with culture-positive endophthalmitis following IVI were identified. All gram-positive organisms (34 of 35) were susceptible to vancomycin. Cases due to pathogens associated with oral or respiratory flora were common (31.4%, n = 11), presented earlier (2.0 days vs. 4.6 days, P < .001), were more likely to undergo pars plana vitrectomy (81.8% vs. 25.0%, P = .002) and had worse visual acuity outcomes. CONCLUSION: IVI-associated endophthalmitis pathogens and anti-microbial susceptibilities in the Pacific Northwest are similar to those reported from other geographic locations. Bacteria associated with the oral and respiratory flora are common isolates that result in a more aggressive course and worse visual outcomes. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:33-38.].

Quantitative Analysis of En Face Spectral-Domain Optical Coherence Tomography Imaging in Polypoidal Choroidal Vasculopathy.

BACKGROUND AND OBJECTIVE: Spectral-domain optical coherence tomography (SD-OCT) imaging can be used to visualize polypoidal choroidal vasculopathy (PCV) lesions in the en face plane. Here, the authors describe a novel lesion quantification technique and compare PCV lesion area measurements and morphology before and after anti-vascular endothelial growth factor (VEGF) treatment. PATIENTS AND METHODS: Volumetric SD-OCT scans in eyes with PCV before and after induction anti-VEGF therapy were retrospectively analyzed. En face SD-OCT images were generated and a pixel intensity thresholding process was used to quantify total lesion area. RESULTS: Thirteen eyes with PCV were analyzed. En face SD-OCT PCV lesion area quantification showed good intergrader reliability (intraclass correlation coefficient = 0.944). Total PCV lesion area was significantly reduced after anti-VEGF therapy (2.22 mm2 vs. 2.73 mm2; P = .02). The overall geographic pattern of the branching vascular network was typically preserved. CONCLUSION: PCV lesion area analysis using en face SD-OCT is a reproducible tool that can quantify treatment related changes. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:126-133.].

Fundus Autofluorescence Patterns of Submacular Fluid Resolution Following Repair of Macula-Involving Rhegmatogenous Retinal Detachments.

BACKGROUND AND OBJECTIVE: Submacular fluid (SMF) can persist for months to years following rhegmatogenous retinal detachment (RD) repair. The authors' objective was to describe fundus autofluorescence (FAF) and optical coherence tomography (OCT) findings associated with the absorption of persistent submacular fluid (SMF) following RD repair. PATIENTS AND METHODS: Retrospective review of clinical data and FAF and OCT imaging from sequential postoperative visits in a cohort of patients with persistent SMF following RD repair. RESULTS: In 11 of 13 eyes with persistent SMF, patches of decreased FAF signal corresponded to SMF on OCT. In eight eyes, there was a hypo- to hyperautofluorescence transition at the time of SMF resolution. These areas of increased FAF signal correlated with inner segment/outer segment (IS/OS) junction loss on OCT. CONCLUSION: FAF imaging can be informative when following SMF after RD repair; a hypo- to hyper-FAF signal transition correlates with SMF resolution and photoreceptor loss. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:1020-1029.].

LONGITUDINAL QUANTITATIVE EVALUATION OF PHOTORECEPTOR VOLUME FOLLOWING REPAIR OF MACULA-OFF RETINAL DETACHMENT.

PURPOSE: To quantify photoreceptor volume changes after successful surgical repair of macula-off retinal detachment and to correlate these volumetric changes to postoperative best-corrected visual acuity (BCVA). METHODS: Retrospective study of 15 eyes of 15 patients with macula-off retinal detachment who underwent successful surgical repair. A minimum of 4 optical coherence tomography scans that straddled the foveal center was used to quantify the central photoreceptor volume (central 1 mm). RESULTS: Mean photoreceptor volume at the first postoperative visit was 0.451 mm, increasing to 0.523 mm at the final postoperative visit (P = 0.004). Mean BCVA improved from 1.13 ± 0.59 logarithm of the minimum angle of resolution units (∼20/270) preoperatively to 0.52 ± 0.42 logarithm of the minimum angle of resolution units (∼20/66) at the final postoperative visit (P = 0.001). Mean photoreceptor volume at either the initial or final visit demonstrated significant correlations with final postoperative BCVA (r = -0.670, P = 0.017 and r = -0.753, P = 0.005, respectively). Shorter time interval from diagnosis to surgery was significantly associated with greater mean final postoperative photoreceptor volume (r = -0.588, P = 0.021) and better mean final postoperative BCVA (r = 0.709, P = 0.003). CONCLUSION: We observed a significant increase in photoreceptor volume after successful retinal detachment repair; photoreceptor volume was positively associated with BCVA and time to surgery. Our series emphasizes the importance of prompt surgical repair and shows that photoreceptor recovery and volumetric improvement correlate significantly with BCVA.