Pain during pars plana vitrectomy following sub-Tenon versus peribulbar anesthesia: A randomized trial.

PURPOSE: To compare pain during pars plana vitrectomy (PPV) following topical lidocaine jelly and sub-Tenon anesthesia versus peribulbar anesthesia. METHODS: Prospective, single-center, randomized study. Patients scheduled for PPV for macular hole (MH) or epiretinal membrane (ERM) at the Retina and Vitreous Section of the Department of Ophthalmology, Ribeirão Preto Medical School, University of São Paulo were randomly assigned to one of two groups in a 1:1 allocation ratio. Patients assigned to Group ST received topical anesthesia with 2% lidocaine jelly followed by sub-Tenon anesthesia with 2-4 ml of 1% ropivacaine. Patients assigned to PB received peribulbar anesthesia with 4-6 ml of 1% ropivacaine. After PPV, patients in both groups were asked to rate the level of pain they felt during the entire procedure (including anesthesia administration and PPV) by pointing at a 0-100 Visual Analogue Pain Scale (VAS). Data regarding demographics, patient characteristics and surgical features were also collected. RESULTS: Fifty-four patients were enrolled in the study (26 in Group ST and 28 in Group PB). Baseline characteristics, including age, gender, and presence of comorbidities, were similar in both groups. The surgery performed was PPV alone in 10 and 14 patients in the ST and PB groups, respectively, and combined phacoemulsification and PPV in 16 and 14 patients in the ST and PB groups, respectively (p = 0.39, Pearson). Surgery duration (mean ± SD minutes) was similar in the two groups (62 ± 12 for ST and 70 ± 20 for PB, p = 0.09, t-Test). No patients needed supplemental topical or intravenous anesthesia during surgery. No sight- or life-threatening complication was observed in either group. VAS score was significantly lower in the ST compared to the PB group (median (interquartile range) was 1 (2.25-0) in the ST group compared to 11.5 (29.75-5) in the PB group, p< 0.0001, Wilcoxon). CONCLUSION: In this study of patients who underwent PPV for MH or ERM, topical followed by sub-Tenon anesthesia was more effective in controlling pain during the whole vitrectomy procedure than peribulbar anesthesia. Compared to peribulbar anesthesia which is administered with a sharp needle, sub-Tenon anesthesia administered with a blunt cannula may be associated with a reduced risk of such adverse events as globe perforation, retrobulbar hemorrhage, and inadvertent injection of anesthesia into the optic nerve sheath.

Transzonular Triamcinolone-Moxifloxacin Versus Topical Drops for the Prophylaxis of Postoperative Inflammation After Cataract Surgery.

Purpose: To compare the safety and efficacy of an intraoperative transzonular injection of triamcinolone-moxifloxacin (Imprimis' Tri-Moxi 15 mg/1 mg/mL) to topical drops in patients undergoing cataract surgery. Methods: Between January 2017 and October 2017, patients undergoing phacoemulsification cataract surgery by a single surgeon at the Penn State Eye Center were offered a single intraoperative injection of transzonular triamcinolone-moxifloxacin in lieu of perioperative drops. Between November 2017 and July 2018, the transzonular injection was not offered, and all patients who underwent surgery by the same surgeon received a drop regimen consisting of polymyxin b/trimethoprim and prednisolone acetate 1%. Patients were seen 1 day, 1 week, and 6-9 weeks postoperatively. Outcome measures included incidence of intraoperative complications, postoperative breakthrough inflammation, cystoid macular edema, and infectious sequela. Results: Of the 198 eyes, 99 from 73 patients received the injection and 99 from 82 patients received topical drops. One (1%) intraoperative posterior capsule tear occurred in each group. Eleven (11.1%) eyes in the injection group and 3 (3%) in the drop group experienced symptomatic breakthrough inflammation necessitating treatment (P = 0.0488). One (1%) eye in the injection group and zero (0%) in the drop group developed clinically significant macular edema (P = 1.0). No instances of elevated intraocular pressure or infectious sequela occurred in either group (P = 1.0). Conclusions: Transzonular injection of triamcinolone-moxifloxacin may be associated with an increased incidence of breakthrough inflammation compared to topical drops.

Ocular nutritional supplements: are their ingredients and manufacturers' claims evidence-based?

PURPOSE: To compare ingredients contained in top-selling brands of ocular nutritional supplements with the Age-Related Eye Disease Study (AREDS) and AREDS2 formulae and investigate the validity of claims made by manufacturers of leading brands of ocular nutritional supplements. DESIGN: Descriptive. PARTICIPANTS: None. METHODS: We examined the 5 top-selling brands of ocular nutritional supplements in the United States according to dollar sales tracked by SymphonyIRI (Waltham, MA) from June 2011 to June 2012. We reviewed the ingredients and manufacturer claims of 11 ocular nutritional supplements on the companies' consumer information websites; the ingredients were compared with those contained in the AREDS and AREDS2 formulae. MAIN OUTCOME MEASURES: Proportion of ocular nutritional supplements that contained the same ingredients, in the same doses, as the AREDS or AREDS2 formula; proportion of nutritional supplements with unsubstantiated claims made by the manufacturer. RESULTS: All of the ocular nutritional supplements contained the ingredients from the AREDS or AREDS2 formula; 36% (4/11) of the supplements contained equivalent doses of AREDS or AREDS2 ingredients; 55% (6/11) included some information about the AREDS on their consumer information websites. Product descriptions from 4 of the 11 supplements (36%) stated that the supplements were important to maintain general eye health; none of these supplements duplicated the AREDS or AREDS2 formula. All the individual supplements claimed to "support," "protect," "help," or "promote" vision and eye health, but none specified that there is no proven benefit in using nutritional supplements for primary prevention of eye disease. CONCLUSIONS: The majority of top-selling ocular nutritional supplements did not contain the identical ingredient dosages of the AREDS or AREDS2 formula and had product description claims that lacked level 1 evidence, underscoring the importance of ophthalmologists educating their patients on the evidence-based role of nutritional supplements in the management of eye health.

Mitomycin C versus 5-fluorouracil as an adjunctive treatment for trabeculectomy: a meta-analysis of randomized clinical trials.

Mitomycin C (MMC) and 5-fluorouracil (5-FU) are the most frequently utilized adjuvant therapies in trabeculectomy (TRAB), but there is no general consensus as to the direct comparative efficacy and safety of these two adjuvants. In this study, the authors conducted a meta-analysis to compare the efficacy and safety of augmenting TRAB with MMC or 5-FU. A systematic review with meta-analysis was conducted and five randomized controlled clinical trials comparing MMC versus 5-FU as adjunctive therapies were identified, totaling 416 participants. A lower pooled mean IOP and higher complete and qualified success rates were observed in the MMC arm than in the 5-FU arm. Epithelial corneal defects were the unique complication reported more frequently with 5-FU compared to MMC treatment. Compared to TRAB with 5-FU, TRAB with MMC was associated with higher rates of complete and qualified surgical success and was not associated with increased incidences of postoperative complications.

Adherence to recommendations of the age-related eye disease study in patients with age-related macular degeneration.

PURPOSE: The purposes of this study were to determine the rate of adherence to the recommendations of the Age-Related Eye Disease Study (AREDS) regarding vitamin supplement use among patients with age-related macular degeneration (AMD) at a tertiary retina center and to identify factors associated with adherence. METHODS: Consecutive patients with a history of AMD were administered an in-person survey designed to assess use of vitamin supplementation as well as to investigate factors that may influence supplementation use patterns. A retina specialist performed dilated funduscopic examinations and categorized patients' AMD severity according to the AREDS classification system. The main outcome measure was rate of adherence to AREDS recommendations. RESULTS: Sixty-four patients with AMD completed the survey. Sixty-three percent of patients met AREDS criteria for vitamin supplementation. Of those patients who met the criteria, only 43% reported taking AREDS vitamins in the recommended dosages. Among patients using AREDS vitamins as recommended, 100% were return patients to the tertiary retina center and reported a retina specialist as the primary recommendation source for supplement use. Of patients who met AREDS criteria for vitamin supplementation but were not taking vitamins as per AREDS recommendations, 87% were new patients to the retina service and 75% reported that vitamin supplementation had never been recommended to them. CONCLUSION: Patients with intermediate or advanced AMD in at least one eye show a low adherence rate to the AREDS recommendations for vitamin supplementation.

Comparative study of analgesic effectiveness using three different anesthetic techniques for intravitreal injection of bevacizumab.

BACKGROUND AND OBJECTIVE: To compare the analgesic effectiveness and aesthetic appearance associated with topical, subconjunctival, and peribulbar anesthesia for intravitreal bevacizumab injection. PATIENTS AND METHODS: Sixty consecutive patients undergoing their first intravitreal bevacizumab injection were randomized to receive one of three forms of anesthesia: proxymetacaine eye drops, subconjunctival injection of 2% xylocaine, and peribulbar injection of 2% xylocaine. Pain associated with the intravitreal injection and with the entire procedure (including anesthesia administration) was recorded using a Visual Analog Scale 15 minutes after intravitreal injection. Anterior segment evaluation was performed 24 hours after injection to measure the number of clock hours of subconjunctival hemorrhage. RESULTS: Median injection-related pain score was significantly lower in the peribulbar group compared with the topical and subconjunctival groups (P < .05). Median entire procedure pain score was significantly higher in the peribulbar group compared with the topical and subconjunctival groups (P < .05). The median extent of subconjunctival hemorrhage was significantly lower in the topical group compared with the other groups (P < .05). CONCLUSION: Among the three anesthetic techniques, peribulbar anesthesia was associated with greater effectiveness in controlling injection-related pain but was least effective in controlling entire procedure pain. There was no significant difference in pain scores between the topical and subconjunctival groups, and topical anesthesia was associated with less subconjunctival hemorrhage.

Acute-onset endophthalmitis after cataract surgery (2000-2004): incidence, clinical settings, and visual acuity outcomes after treatment.

PURPOSE: To report the incidence, clinical settings, and visual acuity outcomes of acute-onset endophthalmitis after cataract surgery. DESIGN: Retrospective, observational case series. METHODS: Annual cataract surgery statistics were determined by review of electronic surgical records. The clinical and microbiologic records were reviewed of all patients with clinically diagnosed endophthalmitis within 6 weeks after cataract surgery at a single university-affiliated hospital between January 2000 and November 2004. main outcome measures: Operative technique, intraoperative complications, and visual acuity. RESULTS: The incidence of acute-onset endophthalmitis after cataract surgery was 0.04% (7/15,920) for cataract surgeries of all methods, 0.05% (6/11,462) for cataract surgery by clear cornea phacoemulsification, and 0.02% (1/4,458) for cataract surgery by methods other than clear cornea phacoemulsification (P = .681, Fisher's exact test). Six of seven (86%) cases occurred in the right eye, and all cases were performed by right-handed surgeons through temporal incisions. Five of seven (71%) patients had relative immune compromise. Four of seven (57%) patients had an intraoperative complication: vitreous loss in three patients and iris prolapse in one patient. Two patients had topical placement of lidocaine 2% gel before povidone-iodine preparation. The visual acuity at final follow up was 20/25 or better in four patients and count fingers or worse in three patients. CONCLUSIONS: The incidence of acute-onset endophthalmitis after temporal clear cornea incision phacoemulsification is low (0.05%). Potential risk factors for endophthalmitis may include intraoperative complications, relative immune compromise, application of lidocaine 2% gel before povidone-iodine preparation, and inferior incision location.

Endophthalmitis caused by enterococcus faecalis: antibiotic selection and treatment outcomes.

PURPOSE: To investigate clinical settings, treatment strategies, and visual acuity outcomes of endophthalmitis caused by Enterococcus faecalis and to determine antibiotic sensitivity and resistance patterns. DESIGN: Retrospective, noncomparative, consecutive case series. PARTICIPANTS AND METHODS: Records were reviewed of all patients with culture-positive endophthalmitis caused by E. faecalis evaluated at the Bascom Palmer Eye Institute between January 1, 1990, and December 31, 2001. MAIN OUTCOME MEASURES: Associated prior surgical procedures, clinical features, treatments administered, antibiotic sensitivity and resistance patterns, and final visual outcomes. RESULTS: Endophthalmitis caused by E. faecalis was identified in 29 eyes of 29 patients. The mean follow-up was 17.8 months (range, 0.1-86.7 months). Endophthalmitis caused by E. faecalis was associated with, in order of decreasing frequency, cataract surgery in 12 of 29 eyes (41.4%), trabeculectomy in 8 of 29 eyes (27.6%), penetrating keratoplasty in 4 of 29 eyes (13.8%), combined cataract and trabeculectomy in 3 of 29 eyes (10.3%), seton implantation in 1 of 29 eyes (3.5%), and pupilloplasty in 1 of 29 eyes (3.5%). Resistance patterns among the isolates were the following: vancomycin in 0 of 23 eyes (0.0%), linezolid in 0 of 29 eyes (0.0%), ciprofloxacin in 1 of 14 eyes (7.1%), gentamicin (minimum inhibitory concentration >8 mg/l) in 8 of 16 eyes (50.0%), high-level gentamicin (minimum inhibitory concentration >500 mg/l) in 5 of 29 eyes (17.2%), cefazolin in 7 of 8 eyes (87.5%), and quinupristin and dalfopristin in 29 of 29 eyes (100.0%). Preinfection baseline visual acuities ranged from 20/30 to hand motions. Visual acuities on presentation with endophthalmitis ranged from 2/200 to no light perception. Final visual acuity was better than or equal to 20/50 in two cases (6.9%), 20/60 to 20/400 in three cases (10.3%), 5/200 to hand motions in 10 cases (34.5%), and light perception to no light perception in 14 cases (48.3%). CONCLUSIONS: E. faecalis often is resistant to gentamicin and cephalosporins but was sensitive to vancomycin in all isolates tested. Endophthalmitis caused by E. faecalis usually is associated with poor visual outcomes.

Local anesthesia with intravenous sedation for surgical repair of selected open globe injuries.

PURPOSE: To report factors associated with the use of local anesthesia with intravenous sedation (local anesthesia/sedation) rather than general anesthesia for surgery for open globe injuries in adult reparable eyes. DESIGN: Retrospective, nonrandomized, comparative case series. METHODS: Medical records were reviewed of all patients with open globe injuries repaired at Bascom Palmer Eye Institute between 1995 and 1999. "Adult reparable eyes" (eyes in patients >/=18 years of age, not treated with primary enucleation or evisceration, followed up >/=2 months) were included. RESULTS: In all, 220 eyes of 218 patients met inclusion criteria. General anesthesia was employed in 80 of 200 (36%) and local anesthesia/sedation in 140 of 220 (64%). Patients who had local anesthesia/sedation were significantly more likely to have an intraocular foreign body (31% vs 14%; P =.010, chi-square test), better presenting visual acuity (1.8 logMAR [logarithm of the minimum angle of resolution] units vs 2.5 logMAR units; P <.001, t test), more anterior wound location (75% corneal/limbal vs 65%; P =.003, chi-square), shorter wound length (6.3mm vs 10.8mm; P <.001, t test), and dehiscence of previous surgical wound (26% vs 12%; P =.021, chi-square) and were significantly less likely to have an afferent pupillary defect (22% vs 51%; P <.001, chi-square). There was no anesthesia-related complication in either group. The local anesthesia/sedation group had a shorter mean operating time than did the general anesthesia group (78 minutes vs 117 minutes; P <.001, t test). The general anesthesia group had a longer mean follow-up than the local anesthesia/sedation group (20.2 months vs 13.9 months, respectively; P =.002, t test). Change in visual acuity between the presenting and final examinations was similar for open globe injuries repaired with general anesthesia compared with local anesthesia/sedation (0.94 vs 0.72 logMAR units of visual acuity, respectively; P =.16, t test). CONCLUSIONS: Local anesthesia/sedation is a reasonable alternative to general anesthesia for selected patients with open globe injuries.