Presentation and outcome of a cluster of patients with endogenous endophthalmitis: a case series.

BACKGROUND: The aim of this study was to investigate the clinical features and visual acuity outcomes associated with endogenous endophthalmitis. MATERIAL AND METHODS: Seven eyes of 6 patients treated at Epsom and St Helier University Hospitals between 2010 and 2013 were reviewed for endogenous endophthalmitis. RESULTS: Patients were followed for a mean of 7 months (range 1 to 13). Positive blood cultures were obtained in 5 patients (83%), including 1 patient with fungal isolates (17%), two patients with Gram-positive isolates and another two with Gram-negative isolates. Five patients (83%) were hospitalized at the time of diagnosis and 2 patients (33%) died within 6 months of diagnosis. Initial treatment included vitreous tap and injection of intravitreal antibiotics. Only in one eye (14%) were positive results from the biopsy obtained. Four eyes (57%) achieved a final visual acuity of >6/60. Patients with a Klebsiella endophthalmitis had worse visual outcome. CONCLUSIONS: Endogenous endophthalmitis is generally associated with high mortality and poor visual acuity outcomes. Gram-negative species are associated with poorer visual acuity. Vitreous biopsy has a weak diagnostic relevance as is it often negative.

Retinal pigment epithelium rips after ranibizumab in neovascular age-related macular degeneration: incidence, risk factors and long-term outcome.

BACKGROUND: Retinal pigment epithelium (RPE) rips after ranibizumab for wet age related macular degeneration (AMD) with a pigment epithelial detachments (PED) are a dreaded complication. Aim of this study was to analyse the incidence, the risk factors and long-term outcome after a PED tear. PATIENTS AND METHODS: 401 patients with wet AMD were analysed. A total of 33 eyes with PED were identified. Mean follow up time was 635 days (SD ± 311). RESULTS: PED tears occurred in 8 (24%) patients. Most RPE rips (40%) occurred within the first three months. Mean visual loss was 13 letters (range -57-9). The PED tear group had a mean PED height of 521 µm. The PED group without a tear had a mean height of 300 µm (p ≤ 0.001). Patients with a PED height over 300 µm had more than twice the risk to develop a RPE rip compared to patients with PED height smaller than 300 µm (p ≤ 0.001). CONCLUSIONS: PED height is a relevant factor for the incidence of RPE rips after treatment with ranibizumab. Owing to the close time relationship with the therapy, this complication must be taken into account before treatment as it may lead to significant vision loss.

Primary intravitreal ranibizumab for myopic choroidial neovascularisation.

Myopic chorodial neovascularisation (mCNV) is an important cause of visual loss in high myopia with almost 10% of eyes with pathological myopia developing mCNV. Intravitreal anti-VEGF agents have recently been documented to be effective in mCNV. However, controversy exists regarding the optimal drug, its dose, and the frequency of administration. We performed a retrospective case review examining patients who had myopia of less than -6D and a chorodial neovascular membrane diagnosed on fundus fluorescein angiography (FFA) that were treated with 3 injections of ranibizumab (Lucentis) 5mg/0.05ml given at monthly intervals. The course was repeated if the ocular coherence tomography (OCT) continued to show intra-retinal oedema at review. We recorded logMAR visual acuities and central foveal thickness (CFT) at baseline and final review. Improvement in visual acuity was significantly improved (p = 0.049) by a mean of 0.24 logMAR (range 0 to 0.74). Every patient achieved at least visual stability. Mean CFT reduction was also significantly improved (p = 0.02) by a mean of 109 microns (range -8 to 198). Our series and current literature seem to support as primary treatment a standard dose of an anti-VEGF agent. Further, larger studies are required to clarify whether any particular injection strategy is clearly superior.

Sequential Descemet's membrane detachments and intraocular lens haze secondary to SF6 or C3F8.

PURPOSE: To report an unusual complication of treatment in the case of a Descemet's membrane detachment. METHODS: Observational case report. RESULTS: A 79-year-old woman presented for elective cataract surgery. Ocular risk factors identified preoperatively included moderately shallow anterior chambers bilaterally, previously treated with bilateral YAG peripheral iridotomies. After a clear corneal section during phacoemulsification, large Descemet's tears on introducing the micro finger and phaco probe were noticed. Conversion to an extracapsular technique was necessary because of poor view. Similar peroperative Descemet's detachments were noticed in the contralateral eye during phacoemulsification by a senior surgeon a year later. Postoperatively, the Descemet's detachments were managed by intracameral SF6 and later C3F8 gas. A few weeks later, a fine haze was noticed under the anterior surface of the intraocular lens (IOL). Corneal edema persisted and corneal decompensation ensued. Both eyes needed penetrating keratoplasties. The right eye needed an IOL exchange due to IOL haze. CONCLUSIONS: In this case the SF6 or C3F8 gas may have produced the unexpected effect of an anterior IOL haze. The mechanism of this phenomenon is unknown. To the knowledge of the authors, this effect has not been observed previously with SF6 or C3F8 gas. This haze was visually significant and required an IOL exchange. To the knowledge of the authors this is the first report of this nature. The authors advise caution when using intracameral SF6 or C3F8 gas for repair of Descemet's membrane detachment with this type of IOL.

Twenty year review of histopathological findings in enucleated/eviscerated eyes.

BACKGROUND/AIMS: To evaluate the need for routine histopathological analysis of enucleated/eviscerated eyes and changes in indications for eye removal. METHODS: Retrospective review of all enucleation/evisceration histopathology reports over 20 years. Clinical history was correlated with pathological findings. Two 10 year periods (1984-93, 1994-2003) were compared to detect changes in indications for eye removal. RESULTS: In total, 285 histopathology results were traced from 1984 to 2003; 161 and 124 were evisceration and enucleation specimens, respectively. Glaucoma, malignant melanoma, trauma, and retinal detachment were the most frequent diagnoses 1984-1993. Ocular trauma was the most frequent diagnosis 1994-2003, followed by phthisis bulbi and endophthalmitis. Three cases were diagnosed as metastatic carcinoma; all were suspected preoperatively. A fourth case was a diagnostic surprise: adenocarcinoma found in an eye removed for pain and phthisis. Comparison of two 10 year periods showed a decrease in the number of enucleations/eviscerations, perhaps reflecting a decrease in the number of specimens sent. A preference for eviscerations was evident over the 20 years. CONCLUSION: The number of eyes removed and histologically analysed decreased in the period 1994 to 2003, perhaps because of better treatment options, allowing globe preservation. There was a significant shift in the diagnosis in the two time periods, and a preference for evisceration in both. Only one diagnostic surprise was discovered (0.35%). This study does not support the need to send all globes/contents for histopathological examination. However, because of the one unexpected finding, it is recommended where the examination is incomplete or the history of visual loss is unclear.

Sequential Descemets membrane detachments and intraocular lens haze secondary to SF6 or C3F8.

PURPOSE: To report an unusual complication of treatment in the case of a Descemets membrane detachment. METHODS: Observational case report. RESULTS: A 79-year-old woman presented for elective cataract surgery. Ocular risk factors identified preoperatively included moderately shallow anterior chambers bilaterally, previously treated with bilateral YAG peripheral iridotomies. After a clear corneal section during phacoemulsification, large Descemets tears on introducing the micro finger and phaco probe were noticed. Conversion to an extracapsular technique was necessary because of poor view. Similar peroperative Descemets detachments were noticed in the contralateral eye during phacoemulsification by a senior surgeon a year later. Postoperatively, the Descemets detachments were managed by intracameral SF6 and later C3F8 gas. A few weeks later, a fine haze was noticed under the anterior surface of the intraocular lens (IOL). Corneal edema persisted and corneal decompensation ensued. Both eyes needed penetrating keratoplasties. The right eye needed an IOL exchange due to IOL haze. CONCLUSIONS: In this case the SF6 or C3F8 gas may have produced the unexpected effect of an anterior IOL haze. The mechanism of this phenomenon is unknown. To the knowledge of the authors, this effect has not been observed previously with SF6 or C3F8 gas. This haze was visually significant and required an IOL exchange. To the knowledge of the authors this is the first report of this nature. The authors advise caution when using intracameral SF6 or C3F8 gas for repair of Descemets membrane detachment with this type of IOL.

Glaucoma monitoring in patients with a 'pseudophakic cataract'.

PURPOSE: To assess potential problems in monitoring glaucoma status in pseudophakic patients in whom the intraocular lens (IOL) has undergone varying degrees of opacification. METHODS: Data was collected by retrospective review of the notes of such patients, who had received a hydrophilic acrylic IOL, SC-60B-0UV, after primary cataract extraction by phacoemulsification. At first, among these, patients with glaucoma were identified and notes were reviewed to identify problems with patients in whom the IOL had undergone varying degrees of opacification. RESULTS: A total of 32 eyes with glaucoma were identified to have received the SC-60B-0UV IOL. Of these, 13 IOLs (40.6%) had undergone varying degrees of opacification. Eyes with the opacified IOLs showed decreased visual acuity (2.5 lines of Snellen acuity on average). For these eyes, visual field performance (as determined on automated field analyzers) and optic disc assessments were adversely affected giving a false impression of advanced glaucomatous field loss. CONCLUSION: In our experience, glaucoma monitoring is made comparatively more difficult in pseudophakic patients with cloudy IOLs. Problems are encountered during assessment of the glaucomatous optic disc due to poor view of the optic disc. On standard static automated visual fields, these opacified IOLs produce artefactual visual field defects making monitoring glaucoma and subsequent management more difficult.

Intralenticular opacification of hydrophilic acrylic intraocular lenses.

PURPOSE: To find out the incidence of intraocular lens (IOL) optic opacification in a suspect IOL. METHODS: Retrospective review of patients' notes 3-4 years postimplant. RESULTS: In all, 56 IOLs showed signs of opacification, resulting in reduced vision out of 181 lenses traced. CONCLUSION: Certain hydrophilic acrylic IOLs like the model in question (SC60B-0UV) show opacification of the IOL, which may impair the vision of pseudophakic patients. However, not all lenses of this variety exhibit this cloudiness. Factors affecting this phenomenon are not yet completely clear but may include changes in the UV absorbant material incorporated in the lens substance itself. We report a series of patients who had received this lens and experienced loss of vision due to opacification of the IOL. In a follow-up ranging from 1 to 4 years postoperatively, a higher incidence of postoperative opacification of this lens emerges, after comparison with existing literature. IOL exchange in such patients is the only option. However, this mode of treatment should not be offered lightly as results may be guarded at best even in the face of a technically satisfactory procedure.