Dual platelet inhibition in cases of severe retrobulbar hemorrhage following retrobulbar and peribulbar anesthesia.

PURPOSE: To evaluate the prevalence of dual platelet inhibition in cases of severe retrobulbar hemorrhage following retrobulbar and peribulbar anesthesia. SETTING: Department of Ophthalmology, Ludwig-Maximilans Universität, München, Germany. DESIGN: Retrospective study. METHODS: Two groups of patients were screened retrospectively over a 5-year period for the inclusion criterion of severe retrobulbar hematoma after retrobulbar or parabulbar injection. The first group consisted of emergency cases referred to the clinic. A second group of patients had received retrobulbar block at the hospital. All cases were collected and screened for the presence of antiplatelet therapy. RESULTS: Among roughly 160 000 patient records screened, 3 patients with grade IV retrobulbar hematoma were identified. Two of these patients were taking dual antiplatelet medications and 2 were on anticoagulation therapy during the time of retrobulbar or peribulbar anesthesia. None of the cases showed single medication platelet inhibition. The visual acuity of all patients stayed low at the 6-month follow-up (1.2 logMAR in 1 patient and no light perception in 2 patients). CONCLUSIONS: Retrobulbar hematoma is a rare but severe complication of retrobulbar anesthesia. With the high prevalence of dual platelet inhibition found in these cases, a prospective controlled trial seems unethical. In these high-risk patients, surgery should be performed under topical anesthesia if possible or general anesthesia if necessary. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Preemptive analgesia with ropivacaine for pars plana vitrectomy: randomized controlled trial on efficacy and required dose.

BACKGROUND: The rationale of preemptive analgesia in ocular surgery is avoiding central sensitization because of nociceptive stimuli. The applicability in clinical practice has been argued because evidence for a relevant effect is missing. The present study attempts to demonstrate a clinically relevant pain reduction by preemptive peribulbar ropivacaine injection. METHODS: Sixty patients scheduled for vitrectomy under general anesthesia between March and June 2007 were randomly assigned to receive 0.75% ropivacaine with 75 IU of hyaluronidase as peribulbar injection of 1, 3, or 5 mL before or 5 mL after surgery. Control subjects were 30 patients without any additional analgesic treatment. Groups were compared regarding procedure duration, consumed amount of analgesics during and after surgery, and pain 1, 3, and 24 hours postoperatively. RESULTS: Postoperative pain was most marked in control subjects and in the group that received the injection after surgery. Before surgery, the dose of 5 mL of ropivacaine was most effective (postoperative pain median = 0), whereas patients who had received 1 mL or 3 mL reported some pain. CONCLUSION: The study highlights the benefit of the concept of preemptive analgesia in general: the peribulbar injection of 5 mL of 0.75% ropivacaine before surgery provides a substantial benefit in terms of analgesic demand and postoperative discomfort.

Coenzyme Q10 prevents human lens epithelial cells from light-induced apoptotic cell death by reducing oxidative stress and stabilizing BAX / Bcl-2 ratio.

BACKGROUND: Cataract is one of the most prevalent eye disease and a major cause for legal blindness in the world. Beside others, cumulative light-exposure and apoptotic cell death are significantly associated with cataract development. In contrast, supplementation with antioxidants has been suggested to prevent premature cataractogenesis. This study investigates possible protective effects of Coenzyme Q10 (CoQ10) regarding light-induced stress and apoptotic cell death in human lens epithelial cells (LEC). METHODS: Human LEC were either pre-incubated with CoQ10 or not and then exposed to white light. After 10-40 min of irradiation viability, induction of intracellular reactive oxygen species (ROS), apoptosis and cell death was determined. Expression of apoptotic BAX and anti-apoptotic Bcl-2 protein and their mRNA were determined by RT-PCR and Western blot analysis. RESULTS: Light exposure decreased LEC viability and Bcl-2 expression and increased intracellular ROS, apoptotic cell death, and BAX expression in a time-of-irradiation-dependent manner. Phototoxic cell death and apoptosis, as well as decrease of Bcl-2 and increase in BAX expression was significantly reduced, when cells were pre-incubated with CoQ10. CONCLUSIONS: In this study, CoQ10 significantly reduced light-induced LEC-damage and attenuated phototoxic effects on BAX and Bcl-2 expression. Therefore, CoQ10 supplementation might also be useful in preventing LEC death and consecutive cataract formation in vivo.

Alkylphosphocholines as a potential pharmacologic prophylaxis for posterior capsule opacification.

PURPOSE: To evaluate the effect of alkylphosphocholines (APCs) on human lens epithelial cell (LEC) proliferation, attachment, and migration in a well-established in vitro model. SETTING: Department of Ophthalmology, Ludwig-Maximilians-University, Munich, Germany. METHODS: The immortalized human LEC line HLE-B3 was incubated for 24 hours with APC in different concentrations in the presence of Eagle's modified essential medium supplemented with fetal calf serum under standard cell-culture conditions. The trypan blue exclusion test and live-dead assay were performed to exclude toxic concentrations. To determine cell proliferation, cells were incubated with APCs at the maximum slope of the growth curve for 24 hours before the tetrazolium dye-reduction assay (MTT test) was performed. After cells were seeded on coated 24-well plates, incubated with APCs, and rinsed with phosphate-buffered saline, cell attachment was assessed by the MTT test. Migration was determined by a modified Boyden chamber method after incubation of LECs with APCs. RESULTS: Alkylphosphocholines were effective inhibitors of human LEC proliferation, attachment, and migration at nontoxic concentrations in vitro. The 50% inhibitory concentration was close to 0.1 mM. An APC concentration of 1.0 mM accounted for the following: inhibition of cell proliferation of more than 80%, reduction in cell attachment to 66.5%, and inhibition of cell migration of more than 90%. All effects were dose dependent. No toxic effects were detected compared with controls. CONCLUSIONS: Alkylphosphocholines might have the potential for topical application as a single-dose agent to prevent posterior capsule opacification formation. However, further studies are needed before a clinical application can be considered.

Efficacy and safety of hyaluronidase 75 IU as an adjuvant to mepivacaine for retrobulbar anesthesia in cataract surgery.

PURPOSE: To evaluate the efficacy and safety of hyaluronidase as an adjuvant to mepivacaine for retrobulbar anesthesia in cataract surgery. SETTING: Department of Ophthalmology, Ludwig-Maximilians-University, Munich, and Eye Center Munich East, Munich-Haar, Germany. METHODS: Eyes having cataract surgery at 1 of the 2 centers were included in this prospective randomized double-blind placebo-controlled clinical trial. Retrobulbar anesthesia was administered by the surgeon using a solution of 5 mL mepivacaine 1% with additional hyaluronidase (Hylase Dessau) 75 IU (40 eyes) or additional placebo (40 eyes). The main target parameter was akinesia 5 minutes after administration of the study medication. Secondary parameters were akinesia at later times, additional injections, ptosis of the upper eyelid, time to reach complete anesthesia, assessment of pain using a visual analog scale, assessment of efficacy and tolerability by the patient and the surgeon, and adverse events. RESULTS: Complete akinesia 5 minutes after retrobulbar injection was reached in significantly more cases in the hyaluronidase group (29) than in the placebo group (13) (P < .001). Additional injections were necessary in 5 placebo-treated eyes. The administration of hyaluronidase yielded significantly better results than the placebo in terms of ptosis, time to reach complete anesthesia, assessment of efficacy, tolerability, and postoperative pain. No adverse events occurred in either group. CONCLUSION: The addition of hyaluronidase to mepivacaine for retrobulbar anesthesia in cataract surgery enhanced the safety of the surgical procedure due to more complete akinesia and quicker onset of complete anesthesia.

In vitro safety of intravitreal moxifloxacin for endophthalmitis treatment.

PURPOSE: To investigate the safety of moxifloxacin for intravitreal application in a cell culture model. SETTING: Department of Ophthalmology, Ludwig-Maximilians-Universität, Munich, Germany. METHODS: Primary human retinal pigment epithelium (RPE) cells, ARPE19 cells, and primary optic nerve head astrocyte (ONHA) cells were treated with concentrations of moxifloxacin ranging from 10 to 750 microg/mL. Possible toxic effects and median inhibitory concentration were evaluated after 24 hours as well as under conditions of oxidative stress. After treating the RPE and ONHA cell lines with tumor necrosis factor-alpha (TNF-alpha; 10 microg/mL), lipopolysaccharides (LPS; 20 microg/mL), and interleukin-6 (IL-6; 20 microg/mL), the effects of moxifloxacin on cellular viability under conditions of inflammation were investigated. Toxicity was evaluated by measuring the inhibition of RPE cell proliferation with the tetrazolium dye-reduction assay (MTT; 3-[4,5-dimethylthiazol- 2-yl]-2,5-diphenyl tetrazolium bromide). Cell viability was quantified by a microscopic live/dead assay. RESULTS: At concentrations higher than 150 microg/mL, moxifloxacin had adverse effects on primary RPE, ARPE19, and ONHA cell proliferation and viability. Lower concentrations did not affect RPE or ONHA cell proliferation and viability when administered for 24 hours. No significant decrease in proliferation and viability was observed after preincubation with TNF-alpha, LPS, and IL-6 for 24 hours and subsequent treatment with moxifloxacin concentrations of 10 to 150 microg/mL for 24 hours. Hydrogen peroxide exposure did not increase cellular toxicity. CONCLUSIONS: No significant toxicity of moxifloxacin was seen on primary RPE cells, ARPE19 cells, or ONHA cells at concentrations up to 150 microg/mL. Intravitreal use of moxifloxacin up to this concentration may be safe and effective for the treatment of endophthalmitis.

Resolution of macular oedema in occult choroidal neovascularization under oral Sorafenib treatment.

PURPOSE: To report on the effect of oral nexavar (Sorafenib) treatment in one patient with neovascular age-related macular degeneration (AMD) and advanced renal cell cancer (RCC). METHODS: After two intravitreal injections of bevacizumab (1.25 mg) for occult choroidal neovascularization (CNV) in AMD, the patient was started on oral Sorafenib (400 mg twice daily) treatment for RCC. RESULTS: Visual acuity (VA) was 20/80 in the left eye and optical coherence tomography (OCT) demonstrated persistent central thickening to 251 microm after bevacizumab. After 6 weeks of oral Sorafenib treatment, VA had increased to 20/70 and a significant decrease in retinal thickness to 208 microm was observed on OCT. The patient remained stable during a further 3 months of follow-up. CONCLUSIONS: Resolution of macular oedema and stabilization of VA under oral treatment with the multikinase inhibitor Sorafenib was observed. This observation warrants further investigation.

Short-term in vivo evaluation of novel vital dyes for intraocular surgery.

PURPOSE: To evaluate the staining characteristics and safety of potential new dyes for intraocular surgery in porcine eyes. METHODS: Four dyes in different solutions (light green SF yellowish [LGSF]: 2%; copper(II) phthalocyanine-tetrasulfonic acid [E68]: 2% and 0.5%; bromophenol blue [BPB]: 2%, 1%, and 0.2%; and Chicago blue [CB]: 2% and 0.5%) were included in this investigation. All dyes were dissolved and diluted using balanced salt solution (BSS plus; Alcon Laboratories, Inc., Fort Worth, TX). After triamcinolone-assisted vitrectomy on 10 porcine eyes in vivo, the dyes were first injected into the air-filled vitreous cavity. After 1 minute, the dye was removed by irrigation with BSS, and the staining effect was graded by two examiners. After vitrectomy, the same dyes and concentrations were injected in the air-filled anterior chamber to stain the lens capsule of the same eye. After surgery, the eyes were enucleated and underwent fixation for light and electron microscopy. The animals were killed by injection of pentobarbital (50 mg/kg). For controls, each BSS plus alone and indocyanine green 0.5% were applied in one eye. RESULTS: On the retinal surface, bright staining of the retinal surface was seen after application of BPB 2% and 1%. The staining effect was less pronounced but still very good using E68 2%, and CB 2% and weak using BPB 0.2%, E68 0.5% and CB 0.5% as well as indocyanine green 0.5%. No staining of the retinal surface but of the vitreous was seen after application of LGSF 2%. The lens capsule stained very well with E68 2%, CB 2% and 0.5%, and BPB 2%, 1%, and 0.2% but not with LGSF. No histologic abnormalities were seen after the application in any eye after dye injection. No dye-related complications occurred during surgery. CONCLUSION: In this study, we identified three dyes with satisfying staining characteristics in both anterior and posterior segments. Because BPB stained the retinal surface and lens capsule at a low concentration (0.2%) with no signs of toxicity, this dye seems to be the most promising candidate for application in humans.

Evaluation of minimally invasive therapies and rationale for a prospective randomized trial to evaluate selective intra-arterial lysis for clinically complete central retinal artery occlusion.

OBJECTIVES: To determine the effect of commonly used minimally invasive treatments for clinically complete nonarteritic central retinal artery occlusion (CRAO) and design a prospective randomized trial to evaluate selective intra-arterial lysis for this condition. METHODS: In this retrospective noncomparative case series, all medical records of patients with a diagnosis of CRAO treated at the Department of Ophthalmology, Ludwig-Maximilians-Universität, Munich, Germany, from 1994 through 1999 were reviewed for treatments administered and course of visual acuity. MAIN OUTCOME MEASURES: Best-corrected visual acuity (BCVA) at initial and last visit. RESULTS: We identified 102 patient medical records; 71 were suitable for further analysis. Forty-four (62%) of the 71 patients included were treated with oral acetylsalicylate; 44 (62%), with oral acetazolamide; 32 (45%), with ocular massage; 22 (31%), with isovolemic hemodilution; 19 (27%), with oral pentoxifylline; 8 (11%), with topical beta-blocker; 6 (8%), with paracentesis of the anterior chamber; 4 (6%), with subcutaneous heparin. A mean +/- SD number of treatments of 2.5 +/- 1.4 was administered per patient, and BCVA increased by a mean +/- SD number of Snellen lines of 0.7 +/- 2.8. The BCVA in 11 patients (15%) increased by 3 or more lines. Multivariate stepwise regression did not reveal any single or combination treatment as a significant factor for improvement in BCVA. Patient age and duration of visual impairment before initial examination were not significant predictors of final BCVA. CONCLUSIONS: Commonly used minimally invasive treatments of CRAO do not improve the natural course of the disease. A prospective trial by the European Assessment Group for Lysis in the Eye is under way to evaluate selective intra-arterial lysis, and in this trial some of these minimally invasive treatments are used in the control group.