Intrasilicone bevacizumab injection for iris neovascularization after vitrectomy for proliferative diabetic retinopathy.

PURPOSE: To evaluate the efficacy and safety of intrasilicone injection of bevacizumab for the treatment of iris neovascularization after vitrectomy for proliferative diabetic retinopathy. METHODS: Bevacizumab 1.25 mg/0.05 ml was injected into silicone oil in 15 eyes of 11 patients with iris neovascularization which had developed 2.5-6 months after vitrectomy and silicone oil tamponade. The main outcome measures were regression of iris neovascularization, intraocular pressure elevation, and visual acuity. RESULTS: In all eyes, iris neovascularization regressed and postinjection intraocular pressure was controlled within 7 days postinjection. Visual acuity improved in 12 eyes. In 4 patients, iris neovascularization recurred within 10 weeks after the injection and they were successfully treated with a second intrasilicone bevacizumab injection of the same dose. CONCLUSION: Intrasilicone injection of bevacizumab is safe and effective in the treatment of patients with iris neovascularization after vitrectomy for advanced proliferative diabetic retinopathy. Further studies on greater numbers of patients and more advanced neovascularization are recommended.

Bilateral Acute Depigmentation of Iris (BADI) and Bilateral Acute Iris Transillumination (BAIT)Following Acute COVID-19 Infection.

PURPOSE: To report the presenting features and outcomes in patients who developed bilateral acute iris transillumination (BAIT) or bilateral acute depigmentation of iris (BADI) following acute COVID-19 infection. METHODS: Thirty two eyes of 16 patients were reviewed retrospectively. The severity of COVID-19 infection, use of antibiotics, time of onset of ocular symptoms; ocular signs, the course and surgical procedures were recorded. RESULTS: 24 eyes of 12 BAIT and eight eyes of four consecutive BADI patients were included. The mean time between infection and onset of ocular symptoms was 2.5±1.1 weeks. Nine patients were treated with oral moxifloxacin for COVID-19 prior to presentation. Trabeculectomy was performed in 7 eyes (21.8%) of 5 BAIT patients; in the postoperative follow-up, IOP was controlled without medication in 6 eyes, with medication in 1 eye. CONCLUSION: BADI and BAIT can also develop after COVID-19 infection. A significant proportion of BAIT patients may require glaucoma surgery.

Correlation between urological alpha1-AR antagonist medication and changed intraoperative iris behavior.

The aim of our study was to report on the incidence, the etiology and the management of intraoperative floppy iris syndrome (IFIS) during phacoemulsification. A non-randomized, observational, prospective study was performed for 1 year, in which 439 eyes of 438 patients (320 men and 118 women) undergoing cataract surgery by the same surgeon were enrolled. The surgeon was blinded to the patients' drug history. The use or non-use of alpha blockers (especially tamsulosin for benign prostatic hyperplasia), duration of the treatment, presence or absence of IFIS, management of IFIS and intraoperative complications were recorded. A 3.2 mm incision was performed on 316 eyes and a 2.4 mm incision on 123 eyes. IFIS occurred in 2.96% of the patients who were taking an alpha1 antagonist. In 5.47% we identified an intraoperative iris behaviour which imitated an incipient IFIS stage called IFI-like syndrome. In cases of insufficiently dilated pupils, diluted intracameral epinephrine as well as irrigation fluid was used. Vertical chop, stability of the anterior chamber by decreasing the corneal wound size, and reducing turbulence into the anterior chamber, enhanced the surgery on eyes with IFIS. There were no intraoperative or postoperative complications. The incidence of IFIS in our study was linked to alpha blocker medication. We postulate that IFIS may be caused by other medication, but this could not be demonstrated statistically. IFIS can be well controlled during surgery, intracameral epinephrine being the main stabilizing factor.

[Complications of intravitreal injections--own experience]. / Powiklania po iniekcjach do komory ciala szklistego--doswiadczenia wlasne.

PURPOSE: Authors present complications associated with intravitreal injection perfomed in Ophthalmic Clinic CMKP MATERIAL AND METHODS: retrospective study, between January 2006 and July 2009 we performed intravitreal injections with triamcinolone acetonide (Kenalog, 4 mg), ranibizumab (Lucentis, 0.5 mg), bevacizumab (Avastin, 1.25 mg) and pegaptanib (Macugen, 0.3 mg). We treated eyes with age-related macular degeneration, diabetic macular edema, after retinal venous occlusion, with uveitis, Irvine-Gass syndrome, idiopathic juxtafoveolar teleangiectasia and central serous retinopathy. RESULTS: 943 eyes received intravitreal injections. The most common ocular complication was subconjunctival hemorrhage which was seen in 36% cases. Temporary elevated intraocular pressure above 21 mmHg was noticed in 18 eyes (5%) after anti-VEGF agents injections and in 30 eyes (23.4%) after Kenalog injection. Anterior uveitis developed in sixteen cases (1.7%) from the Avastin (5 eyes) and Lucentis (3 eyes) group. Anterior-posterior inflammation occurred in 8 eyes (0.8%), including four eyes (0.4%) with sterile endophthalmitis (3 following bevacizumab and 1 following ranibizumab injection), one eye (0.1%) with pseudoendophthalmitis (after triamcinolone). There were three cases of suspected endophthalmitis (2 following bevacizumab and 1 following triamcinolone injection). The infectious endophthalmitis after triamcinolone injection was culture-proven and revealed Staphylococcus epidermidis. Cataract formation or progression was noted in 34 eyes totally. In Kenalog group progression of cataract was seen in 23.4% of eyes (30 cases) during 2-years of follow-up and in anti-VEGF agents group--in two cases (0.6%) and 2 cases of iatrogenic cataract. Three diabetic patients suffered systemic adverse events: one patient developed renal insufficiency, one patient developed cerebrovascular accidents and one suffered a myocardial infarction resulting in death. CONCLUSIONS: Intravitreal injections are associated with a low incidence of serious adverse events. The most common ocular complication was subconjunctival hemorrhage. There was one case of serious complication--the culture-proven infectious endophthalmitis after Kenalog injection. Cataract formation and increase of intraocular pressure were more often observed following intravitreal triamcinolone injection.

Presumed Intraocular Tuberculosis Manifesting as Unilateral Iris Granuloma.

Ocular tuberculosis can manifest in a wide variety of clinical presentations. The prevalence is higher in endemic areas as a cause of granulomatous uveitis. While posterior segment manifestations are well known, anterior segment granulomas alone are relatively rare. We report two cases of unilateral iris granulomata in two young patients who presented with decreased vision and redness and were found to have well-circumscribed iris granulomas. Both underwent systemic evaluation and had a negative Mantoux test. Biopsy pathology of the lesions revealed granulomatous inflammation but were negative for PCR, staining, and culture for TB. One patient turned out to have multiple pulmonary lesions. The ocular condition initially worsened with steroid therapy alone and improved and resolved completely after starting a 9 months course of anti-tubercular therapy (ATT).

Aspergillus iris granuloma: a case report with review of literature.

We report the case of a 25-year-old male patient who presented with complaints of redness, photophobia, and decreased vision in the right eye of a week's duration. Slit-lamp biomicroscopic examination revealed a cream-colored, irregular elevated inferior iris mass, extending on to the anterior lens surface. Differential diagnoses of a fungal granuloma, a medulloepithelioma, and an amelanotic melanoma were considered. An excisional biopsy of the mass was performed through a superior clear corneal incision. Polymerase chain reaction analysis of the aqueous humor showed a positive pan fungal genome. Histopathology of the biopsied mass showed a giant cell granuloma with surrounding numerous branching, septate hyphae. Culture growth revealed Aspergillus fumigatus We report this case because of the rarity of Aspergillus iris granuloma as a primary presentation of endogenous Aspergillosis and review the relevant literature. Absence of a significant systemic history compounded the diagnostic dilemma in our patient. Definitive differentiation of this rare entity from a foreign body, amelanotic melanoma, and other inflammatory conditions such as sarcoidosis and tuberculosis, may be possible only on microbiological and histo-pathological evaluation.

Bilateral acute iris depigmentation and bilateral acute iris transillumination syndrome. / Síndrome de despigmentación aguda bilateral de iris y transiluminación aguda bilateral de iris.

The case is presented of a 32 year-old male who arrived with acute bilateral symptoms with blurred vision, red eye, severe photophobia and severe ocular pain after suffering from a flu-like syndrome. The patient presented with a clinical picture of bilateral involvement characterised by pupils in mid-mydriasis, scarcely reactive to light, iris transillumination, diffuse depigmentation of the iridian stroma, pigment dispersion in the anterior chamber, and ocular hypertension. After the eye examination an inflammatory syndrome and pigmentary glaucoma were ruled out. The patient showed depigmentation characteristics as well as bilateral iris transillumination. Both conditions could form part of the spectrum of the same disease.

Observation of treated iris neovascularization by swept-source-based en-face anterior-segment optical coherence tomography angiography.

We evaluated regression of iris neovascularization (INV) using en-face anterior-segment optical coherence tomography angiography (AS-OCTA) after anti-vascular endothelial growth factor (VEGF) therapy. Seven consecutive eyes with INV were examined before and after anti-VEGF therapy, and all AS-OCTA scans were obtained using a swept-source OCTA system with an anterior-segment lens adapter. Slit-lamp microscopy photography and anterior indocyanine green angiography also were performed. Quantitative analyses of the vascular density, vascular lacunarity, and fractal dimension on AS-OCTA images were performed. AS-OCTA visualized the INV as signals around the pupillary margin, which corresponded to the vasculature confirmed by slit-lamp microscopy. After anti-VEGF drug injection, regression of INV was observed by AS-OCTA in all eyes (100%). The vascular density decreased and vascular lacunarity increased significantly after anti-VEGF therapy. This pilot study demonstrated the ability of AS-OCTA not only to detect but also to evaluate INV. Further study is warranted to improve the algorithm for delineating the iris vasculature to decrease artifacts.

Iris root abscess and necrotizing sclerokeratitis caused by Mycobacterium abscessus and presenting as hemorrhagic anterior uveitis.

PURPOSE: To report a case of an iris abscess and necrotizing sclerokeratitis caused by Mycobacterium abscessus and presenting as hemorrhagic uveitis. METHODS: An 86-year-old white woman was diagnosed with hemorrhagic anterior uveitis and treated with high-frequency topical steroids. The inflammation progressed to involve the cornea and the sclera, and the treatment was changed to intensive antibiotics. There was no improvement. Direct microscopy of a biopsy specimen of the lesion wrongly identified Nocardia as the cause, but antibiotic sensitivity suggested clarithromycin as a suitable therapeutic agent. Therapy was changed but there was continued deterioration. The eye could not be saved and the causative organism was subsequently discovered to be M. abscessus. RESULTS: The eye was enucleated 6 months after initial presentation. CONCLUSIONS: Ocular infection with M. abscessus is an extremely rare cause of necrotizing sclerokeratitis and may present as a hemorrhagic uveitis. There is a high risk of misdiagnosis and late detection, which may have severe consequences.

Fluorescein angiography of iris juvenile xanthogranuloma.

A 3-year-old boy was referred because of the presence of a non-pigmented, highly vascular mass with tapioca appearance involving the superior portion of the left iris. Iris fluorescein angiography revealed early hyperfluorescence of the iris tumor with diffuse, intense late leakage of dye throughout the entire iris, not just in the region of the tumor. Cytopathologic examination revealed Touton giant cells and the presence of histiocytes, confirming the diagnosis of iris juvenile xanthogranuloma. The patient was prescribed topical prednisolone acetate, and the lesion resolved during the next 3 months. Fluorescein angiography may be useful in differentiating iris juvenile xanthogranuloma from malignant or non-inflammatory benign iris lesions.

Active Iris in Retinopathy of Prematurity and Regression Following Intravitreal Ranibizumab Injection.

Classic active iris vasculature in retinopathy of prematurity is shown, as well as regression within 24 hours of off-label ranibizumab injection (0.25 mg) in both eyes. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:643-644.].

Prospective multicenter evaluation of cataract surgery in patients taking tamsulosin (Flomax).

PURPOSE: Intraoperative floppy iris syndrome (IFIS) caused by systemic alpha-blockers has been associated with an increased risk of cataract surgical complications when the surgeon was unaware of the medication history and did not anticipate its occurrence. This study was undertaken to evaluate the surgical outcomes and rate of complications when the ophthalmologist knew the patient was taking tamsulosin (Flomax, Boehringer-Ingelheim Pharmaceuticals, Ridgefield, CT) and used 1 of several strategies to manage IFIS. DESIGN: Prospective multicenter nonrandomized observational series. PARTICIPANTS: A total of 167 consecutive eyes in 135 patients taking tamsulosin and undergoing cataract surgery. METHODS: Phacoemulsification was performed in conjunction with at least 1 of 4 different IFIS management strategies, namely, topical atropine preoperatively, iris retractors, pupil expansion ring, or use of viscoadaptive ophthalmic viscosurgical device with reduced fluidic parameters. MAIN OUTCOME MEASURES: Severity of IFIS, incidence of operative or postoperative complications, and final visual acuity. RESULTS: The IFIS severity was rated as mild in 17%, moderate in 30%, and severe in 43% of the study eyes. No IFIS was noted in 10% of the eyes. The rate of posterior capsule rupture and vitreous loss was 0.6% (1/167; 95% confidence interval, 0%-1.8%). Ninety-five percent of eyes achieved a best-corrected visual acuity of at least 20/40. CONCLUSION: When experienced surgeons could anticipate IFIS and employ compensatory surgical techniques, the complication rate from cataract surgery was low and the visual outcomes were excellent in eyes of patients with a history of tamsulosin use.

Combined preoperative topical atropine sulfate 1% and intracameral nonpreserved epinephrine hydrochloride 1:4000 [corrected] for management of intraoperative floppy-iris syndrome.

We describe a technique combining preoperative atropine sulfate 1% and intraoperative intracameral epinephrine in a 1:2500 dilution for the management of intraoperative floppy-iris syndrome (IFIS) induced by alpha(1A)-blocking agents such as tamsulosin. Patients on alpha(1A)-blocking agents used topical atropine sulfate 1% 3 times a day for 2 days before surgery. In addition to routine topical mydriatics before surgery, they received intracameral epinephrine diluted 1:2500 with BSS. In 19 of 20 eyes, there were no clinical manifestations of IFIS with this regimen. Stimulation of the iris dilator by a direct-acting sympathomimetic (epinephrine) combined with strong pupiloplegia (atropine) provides powerful synergism. Preoperative identification of patients on alpha(1)-blockers is important as complications can be reduced significantly by using appropriate strategies to deal with this condition. It is also important that patients suffering from benign prostatic hyperplasia do not stop using an alpha(1A)-blocker, especially when preoperative atropine is used, as acute urinary retention may ensue.

Anterior uveitis and iris nodules that are associated with Langerhans cell histiocytosis.

PURPOSE: To describe a case of Langerhans cell histiocytosis (LCH) that involved the anterior uveal tract. DESIGN: Interventional case report. METHODS: A retrospective review was conducted on a patient with iris nodules and anterior uveitis in the setting of LCH. Visual acuity and clinical findings that were noted on slit lamp biomicroscopy were extracted. RESULTS: An 18-year-old male patient with unilateral anterior segment inflammation and iris nodules experienced visual improvement from 20/200 to 20/25 after treatment with a 5-day course of topical corticosteroids. Regression of the iris nodules and anterior segment inflammation was also noted. Bone marrow aspirate confirmed recurrent, active LCH. CONCLUSION: The clinician should include LCH in the differential diagnosis when faced with anterior segment inflammation in conjunction with iris nodules. Additionally, LCH can be treated successfully with topical corticosteroid therapy.

Treatment of cystic epithelial downgrowth with intralesional administration of mitomycin C.

PURPOSE: To report a case of postoperative cystic epithelial downgrowth treated with needle aspiration and intralesional administration of mitomycin C. METHODS: Case report. A 60-year-old woman with a history of right cataract surgery 7 years ago presented with decreased vision of 1/60. The reduced vision was diagnosed secondary to a large acquired cystic epithelial downgrowth on the surface of the iris occluding the pupil. RESULTS: The cystic epithelial downgrowth was treated with aspiration and intralesional administration of mitomycin C solution. There was no evidence of recurrence on follow-up 1 year after the procedure. CONCLUSIONS: Treatment of acquired cystic epithelial downgrowth with needle aspiration and intralesional administration of mitomycin C resulted in a satisfactory outcome without undertaking more extensive and invasive surgical treatments.

Bilateral acute iris transillumination (BAIT) initially misdiagnosed as acute iridocyclitis.

Bilateral acute iris transillumination (BAIT) is a relatively new clinical entity characterized by bilateral acute loss of iris pigment epithelium, iris transillumination, pigment dispersion in the anterior chamber, and sphincter paralysis. We report the case of a 30-year-old male who was initially diagnosed with acute iridocyclitis in a different clinic and treated with topical and systemic corticosteroids. He was referred to our clinic to seek another opinion because his symptoms did not improve. An ocular examination revealed bilateral pigment dispersion into the anterior chamber, diffuse iris transillumination, pigment dusting on the anterior lens capsule, atonic and distorted pupils, and increased intraocular pressure, suggesting a diagnosis of BAIT rather than iridocyclitis. Clinicians should be aware of the differential diagnosis of syndromes associated with pigment dispersion from iridocyclitis to avoid aggressive anti-inflammatory therapy and detailed investigation for uveitis.

The differential pupillary response to 2.5% phenylephrine in patients taking tamsulosin.

PURPOSE: To determine if a pharmacological test could be developed to determine iris dilator dysfunction in patients taking tamsulosin. METHODS: Patients taking tamsulosin and controls were recruited from the Urology and Ophthalmology clinics at the Montefiore Medical Center. The patient's right eye (OD) was dilated with phenylephrine hydrochloride 2.5% and tropicamide 1%. The patient's left eye (OS) was dilated with tropicamide 1% alone. Forty minutes after dilation, pupillary diameter was measured in both eyes. RESULTS: Thirty-eight tamsulosin subjects and 43 controls met the inclusion criteria for the study. The tamsulosin-treated patients dilated less with phenylephrine than controls (0.61±0.4 vs. 1.10±0.45 mm, respectively P<0.001). Receiver operating characteristic curves comparing maximal pupillary dilation versus differential pupillary dilation in tamsulosin patients relative to controls shows a greater area under the curve for differential dilation (0.8 vs. 0.6, respectively). A correlation between smooth muscle dysfunction and length of time on tamsulosin was observed. Patients using tamsulosin for <1 month had an average OD-OS difference of 0.85±0.5 mm. Patients who were on tamsulosin for >1 month had an average OD-OS difference of 0.52±0.32 mm (P<0.01, Mann-Whitney). CONCLUSION: Patients treated with tamsulosin demonstrated a significantly decreased iris dilatory response to the selective adrenergic effects of phenylephrine compared to controls. Additionally, it appears that longer duration of exposure to tamsulosin increases the likelihood of dilator dysfunction.