HEMORRHAGIC OCCLUSIVE RETINAL VASCULITIS AFTER INTRACAMERAL VANCOMYCIN USE IN CATARACT SURGERY AFTER INTRAVENOUS EXPOSURE.

PURPOSE: To report a case of hemorrhagic occlusive retinal vasculitis after cataract surgery. METHODS: A 74-year-old woman presented with blurry vision and distorted vision, which started 2 days after an uncomplicated cataract surgery in the left eye. Intracameral vancomycin was injected during the case. The patient reported being treated with systemic vancomycin in the past. RESULTS: The visual acuity was 20/80 in the left eye. She had trace cells in the anterior chamber with no hypopyon and intraocular lens implant within the capsular bag in the left eye. Dilated fundus examination revealed no vitritis, There were large patches of peripheral retinal hemorrhages and retinal ischemia. The patient was diagnosed with hemorrhagic occlusive retinal vasculitis likely secondary to hypersensitivity reaction to intracameral vancomycin. The patient was started on oral prednisone, and the topical difluprednate course was escalated. Within 3 weeks, vision improved to 20/30 in the left eye. She underwent pan retinal photocoagulation targeting the ischemic areas in the periphery. CONCLUSION: The patient had previous exposure to systemic vancomycin, which may have sensitized her immune system. Later on, the hypersensitivity reaction took place after exposure to intracameral vancomycin during cataract surgery. Our hemorrhagic occlusive retinal vasculitis case had a favorable visual outcome, and recognition of this entity will ensure that vancomycin will not be used for infection prophylaxis in the fellow eye at the time of cataract surgery.

Macular Hole Following Subretinal Tissue Plasminogen Activator for Submacular Hemorrhage Secondary to Neovascular AMD.

A full-thickness macular hole (FTMH) is a rare sequela to submacular hemorrhage. Herein, the authors report a case of an 80-year-old man actively being treated for neovascular age-related macular degeneration who presented with sudden vision loss in the right eye. Examination with optical coherence tomography (OCT) imaging revealed submacular hemorrhage. The patient underwent vitrectomy with subretinal tissue plasminogen activator (tPA) with no intraoperative complications. Dilated fundus examination and OCT imaging revealed a FTMH at postop week 1. Possible causes for MH development include the submacular hemorrhage itself and subretinal administration of the tPA infusion. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:e257-e259.].

Accidental Globe Perforation During Posterior Sub-Tenon's Injection of Triamcinolone Acetonide.

Complications of posterior sub-Tenon's steroid injections like glaucoma, cataract, sub-conjunctival hemorrhage and ptosis are well known. The authors present this photo essay to highlight a rare but serious complication of globe perforation secondary to posterior sub-Tenon's triamcinolone injection and describe its management. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:466-467.].

Serial Swept-Source Optical Coherence Tomography Features of Gentamicin Macular Toxicity: A Glimpse Into the Injury Cascade.

The early clinical manifestations of macular infarction secondary to subconjunctival gentamicin (Gentak; Akorn, Lake Forest, IL) use in an aphakic eye were documented sequentially on swept-source optical coherence tomography (OCT) and fundus fluorescein angiography. The first recorded event after drug toxicity was macular detachment, along with disorganization of outer retinal layers in about 12 hours. The changes in inner retinal layers occurred after 36 hours had elapsed. OCT-documented initial damage to outer retinal layers could be due to the susceptibility of first order retinal neurons, followed by subsequent inner retinal layer involvement and ischemia. This helps in understanding pathogenesis of a catastrophic complication of subconjunctival gentamicin injection commonly used for endophthalmitis prophylaxis. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:456-459.].

Seeing Floaters: A Case Report and Literature Review of Intraventricular Migration of Silicone Oil Tamponade Material for Retinal Detachment.

BACKGROUND: Intraocular injection of silicone oil is commonly performed during vitrectomy to tamponade the retina in place for treatment of retinal detachment. Although rare, this intravitreal silicone can migrate through the optic nerve and chiasm and enter the cerebral ventricles. CASE DESCRIPTION: Here we present a case report of a patient presenting with headache and intraventricular hyperdensities on a computed tomography (CT) scan, raising a concern for intraventricular hemorrhage. However, the intraventricular hyperdensities were in a nondependent location and moved to a new nondependent location when repeat imaging was performed with the patient in the prone position. We provide a literature review of this phenomenon and discuss the relevant CT and magnetic resonance imaging findings. CONCLUSIONS: Intraocular silicone can rarely migrate into the cerebral ventricular system. Careful review of the clinical history and imaging findings can help distinguish this from other, more dangerous intracranial pathologies.

Development of Retinal Infarct Due to Intracameral Cefuroxime Injection Following Complicated Cataract Surgery

We present the case of a 60-year-old patient who underwent a complicated cataract surgery with cefuroxime injection (1 mg/0.1 mL) into the anterior chamber at the end of surgery. The patient presented to our hospital due to decrease in visual acuity (VA) after surgery. VA was counting fingers (CF) from 4 meters. There was extensive retinal hemorrhages and edema in addition to retinal vascular leakage detected with fluorescein angiography (FA). After negative microbiologic tests, the patient was treated with intravenous pulse and oral corticosteroids. Rheumatologic investigation was also negative. At month 5, VA was CF from 1 meter in addition to disseminated capillary loss in FA and optic nerve atrophy despite corticosteroid treatment. The patient developed retinal infarction due to cefuroxime injection following a complicated cataract surgery. Surgeons and surgical staff should be aware of the possibility of retinal toxicity while using cefuroxime, particularly in complicated cases.

Toxicology Evaluation of Drugs Administered via Uncommon Routes: Intranasal, Intraocular, Intrathecal/Intraspinal, and Intra-Articular.

As the need for nasal, ocular, spinal, and articular therapeutic compounds increases, toxicology assessments of drugs administered via these routes play an important role in human safety. This symposium outlined the local and systemic evaluation to support safety during the development of these drugs in nonclinical models with some case studies. Discussions included selection of appropriate species for the intended route; conducting nonclinical studies that closely mimic the intended use with adequate duration; functional assessment, if deemed necessary; evaluation of local tissues with special histological staining procedure; and evaluations of safety margins based on local and systemic toxicity.

A Case of Serious Eye Injury Caused by a Mistaken Injection of Methylrosaniline Chloride During Vitreous Surgery.

This case involved a 75-year-old female with left-eye epiretinal membrane (ERM) and cataract who developed serious eye disorders during vitreous surgery due to methylrosaniline chloride (MRC) being mistakenly injected and applied to the retina instead of Brilliant Blue G during internal limiting membrane staining. Once realized, MRC was washed out with intraocular infusion solution, and ERM surgery was successfully completed. Postoperatively, a Descemet's fold and corneal edema, marked reduction in corneal endothelial cell density, and inner retina damage and visual field defect extending from the macula toward the temporal side were observed. MRC was found highly toxic to eye tissues. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:1010-1015.].

Vitreous hemorrhage and Rhegmatogenous retinal detachment that developed after botulinum toxin injection to the extraocular muscle: case report.

BACKGROUND: The authors report a case of a rare complication that occurred after botulinum toxin injection to the extraocular muscle, which was easily overlooked and successfully corrected by surgery. CASE PRESENTATION: A 34-year-old female patient visited our clinic for diplopia and ocular motility disorder after removal of an epidermoid tumor of the brain. At her initial visit, her best-corrected visual acuity (BCVA) was 20/20 for both eyes. An alternate cover test showed 45 prism-diopter esotropia and 3 prism-diopter hypertropia in the right eye. Following 6 months of observation, the deviation of the strabismus did not improve, and botulinum toxin was injected into the right medial rectus (RMR). After 6 days, she visited our clinic with decreased visual acuity of her right eye. The BCVA was found to be 20/50 for her right eye. Funduscopic examination presented a retinal tear inferonasal to the optic disc with preretinal hemorrhage. Subretinal fluid nasal to the fovea was seen on optical coherence tomography (OCT). Barrier laser photocoagulation was done around the retinal tear; however, her visual acuity continued to decrease, and vitreous hemorrhage and subretinal fluid at the lesion did not improve. In addition, a newly developed epiretinal membrane was seen on OCT. An alternate cover test presented 30 prism-diopter right esotropia. 19 weeks after RMR botulinum toxin injection, she received pars plana vitrectomy, membranectomy, endolaser barrier photocoagulation, and intravitreal bevacizumab (Avastin®) injection. After 4 months, her visual acuity improved to 20/20, and only 4 prism-diopter of right hypertropia and 3 prism-diopter of exotropia were noted. Vitreous opacity and the epiretinal membrane were completely removed, as confirmed by funduscopic and examination. CONCLUSIONS: Sudden loss of vision after injection of botulinum toxin into the extraocular muscle may suggest a serious complication, and a prompt, thorough ophthalmic examination should be performed. If improvements are not observed, rapid surgical intervention is recommended to prevent additional complications.

Orbital abscess following posterior subtenon injection of triamcinolone acetonide.

Orbital cellulitis is a serious sight threatening and potentially life threatening condition which can be complicated by orbital abscess formation. Posterior subtenon (PST) injection of corticosteroid is commonly used in the treatment of posterior segment inflammation including post-operative macular oedema. We report a case of orbital abscess formation as a late complication of PST triamcinolone acetonide and discuss the presentation, diagnosis and management.

[Treatment of macular edema: Comparison of efficacy and tolerability of subconjunctival triamcinolone injections, sub-tenon's triamcinolone injections and intravitreal dexamethasone implant]. / Traitement des œdèmes maculaires : comparaison de l'efficacité et de la tolérance des injections sous-conjonctivales de triamcinolone, des injections sous-ténoniennes de triamcinolone et des injections intra-vitréennes de l'implant de dexaméthasone.

The area of uveitis is related to numerous pathological entities. One of the main causes of decreased visual acuity in these patients is macular edema. One aspect of the treatment includes cortosteroids used peri- and intra-ocularly. MATERIALS AND METHODS: The goal of our work was to estimate the criteria of efficacy (on improvement in visual acuity and macular edema, as well as time to recurrence) and safety (on intraocular pressure and cataract) of these various routes of administration of corticosteroid after a single injection. We compared patients treated with Ozurdex® versus subconjonctival triamcinolone versus sub-tenon's triamcinolone. This is a retrospective study conducted in 2 tertiary centers, the university medical center of Nantes and La Pitié-Salpêtrière hospital from November, 2011 to November, 2013. RESULTS: At presentation, 25 % of the patients displayed VA better than 5/10. During follow-up, this proportion increased to 45 % at M1, 50 % at M3, 49 % at M6 and 48 % at the end of follow-up. There was no significant difference between the groups with respect to VA gain. The reductions in mean CMT compared with D0 were all statistically significant (improvement of one line in log-OCT). We observed an improvement in macular thickness of 88 % at M1, 86 % at M3, 61 % at M6 and 60 % at the end of follow-up, significant at each time, with no significant difference between the three groups. A comparison of time to anatomic vs. functional recurrence was performed, showing no difference. The largest increase in IOP was observed at M1, statistically different from the other time points. DISCUSSION: Intra- and periocular injections should be considered as an adjuvant therapy, since the majority of the conditions in question require systemic treatment. They allow for increased intravitreal concentrations with fewer systemic effects. CONCLUSION: We demonstrated neither any true superiority of any of the 3 treatments nor any difference in tolerability between the 3 groups.

Intraocular use of bevacizumab in India: An issue resolved?

Bevacizumab is a monoclonal antibody against vascular endothelial growth factor (VEGF), which has been approved for intravenous use in certain cancers. There is evidence of its efficacy and safety as an intravitreal drug compared with ranibizumab and aflibercept. We have, in our practice, found it to be a cost-effective treatment option for ocular diseases, which could save a large amount of public money used in various national health insurance systems. An alert issued by the Drug Controller General of India led to a virtual ban on its intraocular use in India. However, pro-active advocacy and leadership by national ophthalmological societies helped to resolve the issue quickly.

A RARE COMPLICATION OF POSTERIOR SUBTENON INJECTION.

PURPOSE: To report a case of posterior ciliary artery occlusion after posterior subtenon injection. METHODS: Clinical examination and fundus fluorescein angiography was performed to confirm diagnosis. A 49-year-old female who was on treatment for bilateral chronic sclerokeratouveitis was given posterior subtenon injection for cystoid macular edema. RESULTS: Posterior ciliary artery occlusion occurred after posterior subtenon injection. CONCLUSION: Choroidal vascular occlusion is a rare complication of posterior subtenon injection.

[A 23-gauge pars plana vitrectomy after induction of general anesthesia: effect of additional retrobulbar anesthesia on postoperative pain]. / 23-Gauge-Pars-plana-Vitrektomien in Allgemeinanästhesie : Effekt einer additiven Retrobulbäranästhesie auf das postoperative Schmerzempfinden.

PURPOSE: Some studies have shown a significant reduction of postoperative pain by additional regional anesthesia in 20-gauge pars plana vitrectomy (20-G-ppV) with the patient under general anesthesia (AN). This observational study examined whether the advantages of additional retrobulbar anesthesia can also be observed with 23-gauge vitrectomy in AN. MATERIAL AND METHODS: Surgery was performed in 130 patients under AN of which 88 received an additional retrobulbar block (group AN+) and 42 patients were treated without additional injection of retrobulbar anesthesia (group AN) using bupivacaine 0.5 % and mepivacaine 1%. The AN was performed with fentanyl and propofol. Postoperatively, the subjective patient pain was recorded using a numeric scale and the use and amount of analgesic drugs in the postoperative course were monitored. RESULTS: The mean age of the patients was 53.6 ± 16.8 years, 52.6% of the patients were male, 31.5% were staged as American Society of Anesthesiologists (ASA) level I, 52.3% as ASA II and 15.4% as ASA III. At no time did the study show a statistically significant difference in pain frequency, intensity and analgesic consumption. However, the results suggest that patients in the AN+ group tended to experienced delayed and more intense postoperative pain, which is also reflected in the postoperative use of pain relief medications. CONCLUSIONS: This study did not show any advantage by additional retrobulbar anesthesia regarding postoperative analgesia compared to an adequate treatment with peripheral acting analgesics during surgery and the early postoperative period.

Optimizing gene transfer to conventional outflow cells in living mouse eyes.

The mouse eye has physiological and genetic advantages to study conventional outflow function. However, its small size and shallow anterior chamber presents technical challenges to efficient intracameral delivery of genetic material to conventional outflow cells. The goal of this study was to optimize methods to overcome this technical hurdle, without damaging ocular structures or compromising outflow function. Gene targeting was monitored by immunofluorescence microscopy after transduction of adenovirus encoding green fluorescent protein driven by a CMV promoter. Guided by a micromanipulator and stereomicroscope, virus was delivered intracamerally to anesthetized mice by bolus injection using a 33 gauge needle attached to Hamilton syringe or infusion with glass micropipette connected to syringe pump. The total number of particles introduced remained constant, while volume of injected virus solution (3-10 µl) was varied for each method and time of infusion (3-40 min) tested. Outflow facility and intraocular pressure were monitored invasively using established techniques. Unlike bolus injections or slow infusions, introduction of virus intracamerally during rapid infusions (3 min) at any volume tested preferentially targeted trabecular meshwork and Schlemm's canal cells, with minimal transduction of neighboring cells. While infusions resulted in transient intraocular pressure spikes (commensurate with volume infused, Δ40-70 mmHg), eyes typically recovered within 60 min. Transduced eyes displayed normal outflow facility and tissue morphology 3-6 days after infusions. Taken together, fast infusion of virus solution in small volumes intracamerally is a novel and effective method to selectively deliver agents to conventional outflow cells in living mice.