Lens capsular bag irrigation for low-grade endophthalmitis.

PURPOSE: In postoperative low-grade endophthalmitis, microorganisms of low pathogenicity exhibit prolonged survival times by sequestration into the capsular bag. Thus, removal or irrigation of the capsular bag as nidus of the microorganisms is an essential therapeutic step. Correspondingly, guidelines suggest pars plana vitrectomy, capsulectomy and/or intraocular lens removal. Here, we report on capsular bag irrigation alone as an alternative, minimally invasive therapeutic method for postoperative infectious low-grade endophthalmitis. METHODS: Nine patients consecutively presenting with whitish precipitates in the capsular bag, anterior chamber inflammation and mild vitritis 2 weeks to 6 months following uncomplicated cataract surgery were included. Using an irrigation/aspiration cannula, synechiae were opened, the intraocular lens was rotated within the intact capsular bag and irrigated with 30 ml Ringer's solution containing 0.16 mg/ml gentamicin and 0.04 mg/ml vancomycin in topical anaesthesia. RESULTS: In all patients, the inflammation subsided within 2 days to 2 weeks. Visual acuity improved in all patients, mostly to post cataract surgery levels. Visual acuity remained stable during follow-up ranging from 2 to 39 months. No further interventions were required. CONCLUSIONS: The results suggest that capsular bag irrigation as first and single surgical step can be a useful, minimally invasive procedure in the surgical armamentarium for the treatment of infectious low-grade endophthalmitis. It may avoid removal of the intraocular lens and reduce the surgical risks of more complex procedures.

Early intravitreal bevacizumab for non-ischaemic branch retinal vein occlusion.

PURPOSE: To evaluate the effect of early intravitreal bevacizumab application in patients with macular oedema due to non-ischaemic branch retinal vein occlusion (BRVO). PROCEDURES: The study included 21 patients (21 eyes) with macular oedema due to non-ischaemic BRVO. Inclusion criteria were significant macular oedema as measured by optical coherence tomography, loss of visual acuity and leakage in fluorescence angiography. All patients received 3 intravitreal injections of 1.5 mg bevacizumab. The mean follow-up was 6.2 +/- 1.2 months (mean +/- standard deviation). The mean duration of the BRVO prior to treatment was 9.2 +/- 5.4 days. RESULTS: The visual acuity improved significantly from baseline 0.81 +/- 0.53 logMAR to 0.54 +/- 0.47 logMAR (p < 0.001) at 1 month, 0.55 +/- 0.46 (p = 0.001) at 3 months and to 0.55 +/- 0.49 (p = 0.002) at 6 months after the first injection. The mean central retinal thickness decreased significantly (p < 0.001) from 492 +/- 113 microm at baseline to 294 +/- 117 microm at 1 month after the first injection to 325 +/- 127 microm at 3 months (p < 0.001) and to 316 +/- 117 microm at 6 months (p < 0.001) after the first injection. The increase in visual acuity correlated significantly (p < 0.01) with the decrease in macular thickness. CONCLUSIONS: Early intravitreal injection of bevacizumab may decrease macular oedema and improve visual acuity in eyes with non-ischaemic BRVO.

Intravitreal bevacizumab versus triamcinolone acetonide for exudative age-related macular degeneration.

BACKGROUND: To compare an intravitreal high-dose injection of triamcinolone acetonide with an intravitreal injection of bevacizumab for the treatment of progressive exudative age-related macular degeneration (AMD). METHOD: The comparative nonrandomized retrospective clinical interventional study included 305 patients with progressive AMD, divided into a bevacizumab group of 36 patients (1.5 mg bevacizumab) and a triamcinolone group of 269 patients (about 20 mg triamcinolone). All patients were consecutively included, in the first phase of the study for triamcinolone, and in the second phase of the study for bevacizumab. The mean follow-up was 8.5+/-6.8 months (2-35.7 months). RESULTS: In the bevacizumab group, best visual acuity increased significantly (p<0.001) by 3.2+/-3.4 Snellen lines, with 25 (69%) eyes and 21 (58%) eyes, improving by at least 2 and 3 Snellen lines, respectively. In the triamcinolone group, the visual acuity change was not statistically significant for any specific follow-up examination within the first 3 months. The maximal increase in visual acuity, the visual acuity change at 2 months after injection and the percentage of patients with an improvement by at least 2 and 3 Snellen lines were significantly (p<0.001) higher in the bevacizumab group than in the triamcinolone group. Intraocular pressure increased significantly (p<0.001) in the triamcinolone group and did not change significantly (p=0.47) in the bevacizumab group. CONCLUSION: In exudative AMD, intravitreal bevacizumab (1.5 mg) compared with intravitreal triamcinolone acetonide (about 20 mg) results in a higher improvement of visual acuity and does not markedly influence intraocular pressure within 2 months after injection.

Intravitreal bevacizumab for myopic choroidal neovascularization.

BACKGROUND AND OBJECTIVE: To evaluate the effect of intravitreal bevacizumab on visual acuity in patients with myopic choroidal neovascularization. PATIENTS AND METHODS: The retrospective case series study included 13 patients with myopic choroidal neovascularization who received three intravitreal injections of 1.5 mg of bevacizumab. RESULTS: At 1, 3, and 6 months after the first injection, mean visual acuity improved significantly from 0.63 +/- 0.41 logarithm of the minimum angle of resolution units (LogMAR) to 0.39 +/- 0.22 (P< .001), 0.47 +/- 0.49 (P= .002), and 0.52 +/- 0.49 LogMAR (P = 0.009), respectively. The increase in visual acuity was correlated with a significant decrease in central retinal thickness (P = .003) as measured by optical coherence tomography. Mean intraocular pressure did not change significantly (P> .05) during follow-up. CONCLUSION: Intravitreal injections of bevacizumab may be a therapeutic option for exudative myopic macular degeneration.

Intravitreal bevacizumab combined with cataract surgery for treatment of exudative macular degeneration.

PURPOSE: The aim of this study was to report on the combination of an intravitreal injection of bevacizumab and cataract surgery in patients with exudative age-related macular degeneration (AMD). METHODS: The interventional case series study included 11 patients (11 eyes) who received an intravitreal injection of 1.5 mg bevacizumab as treatment of exudative AMD (n = 10) or exudative myopic macular degeneration (n = 1), combined with a routine phacoemulsification and posterior chamber lens implantation for treatment of cataract. RESULTS: Intraoperatively and during the follow-up of 150 +/- 77.5 days, there were no complications related to the intravitreal application of bevacizumab combined with cataract surgery, such as wound dehiscence and leakage, delayed wound healing, corneal edema, dislocation of the pseudophakos, rupture of the posterior lens capsule, or rhegmatogenous retinal detachment. CONCLUSIONS: The results of this pilot study suggest that from a safety point of view, intravitreal injections of bevacizumab may be combined with routine cataract surgery.

Retinal pigment epithelium tear after intravitreal bevacizumab for exudative age-related macular degeneration.

PURPOSE: To report on the development of retinal pigment epithelium tears after intravitreal injections of bevacizumab as treatment of exudative age-related macular degeneration (AMD). DESIGN: Interventional case series. METHODS: The study included 63 patients who received an intravitreal injection of 1.5 mg bevacizumab as treatment of a detachment of the retinal pigment epithelium attributable to AMD and who had a follow-up of at least two months. RESULTS: Four patients (6%) developed a tear of the retinal pigment epithelium in the parafoveal region. Compared with the baseline value, visual acuity at the end of follow-up remained stable in three patients and declined in the fourth patient. CONCLUSIONS: Intravitreal injections of bevacizumab may be followed by a tear of the retinal pigment epithelium in eyes with exudative AMD and a retinal pigment epithelium detachment.

Intravitreal triamcinolone acetonide for diabetic macular edema: a prospective, randomized study.

PURPOSE: The aim of this study was to examine the visual outcome of patients receiving an intravitreal injection of triamcinolone acetonide (TA) as treatment of diffuse diabetic macular edema (DDME). METHODS: This prospective, placebo-controlled, randomized, clinical interventional study included 40 eyes (38 patients) with DDME, with 28 (70%) eyes randomized to treatment and 12 (30%) eyes randomized to receive a placebo injection. Thirty-six (36) (90%) eyes completed the 3-month study visit, and 32 (80%) eyes completed the 6-month study visit. The treatment group received an intravitreal injection of approximately 20 mg of TA. RESULTS: Visual acuity increased significantly (P < 0.001) in the study group by 3.4 +/- 2.5 Snellen lines. In the control group, visual acuity did not change significantly (P = 0.07) during follow-up. Difference in change of best visual acuity was significant (P < 0.001) between both groups. At 3 months after baseline, 11 (11/26; 42%) eyes and 10 (10/26; 39%) eyes, respectively, improved by at least 2 and 3 lines, respectively, in the study group, versus 2 (2/10; 20%) eyes and 1 (1/10; 10%) eye in the control group. At 6 months after baseline, 11 (11/23; 48%) eyes and 9 (9/23; 39%) eyes, respectively, improved by at least 2 and 3 lines, respectively, in the study group, versus 0 (0%) eyes and 0 (0%) eyes in the control group. The difference was significant for the 2-line improvement (P = 0.01) and 3-line improvement (P = 0.03). CONCLUSIONS: Using a dosage of approximately 20 mg of intravitreal TA, visual acuity temporarily increases for 6 months after injection.

Triamcinolone acetonide-induced ocular hypertension.

PURPOSE: The aim of this study is to report on the clinical course of a patient showing markedly increased intraocular pressure (IOP) caused by intravitreal triamcinolone acetonide. METHODS: A 33-year-old patient received an intravitreal injection of approximately 20 mg of triamcinolone acetonide (TA) as treatment of otherwise therapy-resistant uveitis. She experienced an IOP rise to values over 40 mmHg for a period for more than 3 months, despite maximal antiglaucomatous medical therapy. Peak IOP was 55 mmHg. RESULTS: Neither confocal scanning laser tomography nor qualitative assessment of optic disc photographs nor perimetry showed development of glaucomatous changes. Scanning laser polarimetry of the retinal nerve fiber layer suggested a slight loss in the nasal upper fundus quadrant. CONCLUSIONS: Relatively young patients with a pronounced TA-induced rise in IOP, unresponsive to maximal antiglaucomatous medication, may not necessarily undergo antiglaucomatous surgery if the rise in IOP does not last longer than approximately 3 months.

Duration of the effect of intravitreal triamcinolone acetonide in eyes with exudative age-related macular degeneration.

OBJECTIVE: The aim of this study was to evaluate the duration of the effect of an intravitreal injection of approximately 20 mg of triamcinolone acetonide (TA) on visual acuity and intraocular pressure (IOP) in patients with exudative age-related macular degeneration (AMD) with subfoveal choroidal neovascularization. PARTICIPANTS: The prospective, clinical, interventional, case series study included 69 patients (71 eyes) with exudative AMD who showed an increase in visual acuity by at least 2 Snellen lines after an intravitreal injection of approximately 20 mg TA. Mean follow-up was 11.5 +/- 7.4 months (3.3-35.7 months). The main outcome measure was visual acuity. RESULTS: Within the first week after the injection, visual acuity and IOP started to increase significantly (P < 0.001) by reaching a plateau-like maximum at 1-6 months after the injection. Visual acuity and IOP returned to baseline values 7-9 months after the injection. Increase of IOP was statistically (P = 0.72) independent of the change in visual acuity. CONCLUSIONS: In patients with exudative AMD, who have shown an increase of at least 2 Snellen lines in visual acuity, the effect of intravitreal TA (dosage approximately 20 mg) lasts 7-9 months with respect to an increase in visual acuity and IOP.

Triamcinolone acetonide concentration after filtration of the solvent agent.

PURPOSE: To determine the amount of triamcinolone acetonide and the preservative benzyl alcohol after filtration. DESIGN: Laboratory investigation. METHODS: The probes were prepared by two different hospital pharmacies. The probes of the first pharmacy included 20 probes with 25-mg triamcinolone acetonide, unfiltered (n = 5 probes) or filtered (n = 5), or with 4-mg triamcinolone acetonide, filtered (n = 5) or unfiltered (n = 5). The probes for the second pharmacy were filtered (n = 3) probes of 25-mg triamcinolone acetonide. RESULTS: For the probes of the first pharmacy, triamcinolone acetonide dosages were 2.4 +/- 0.8 mg, 3.1 +/- 0.6 mg, 12.8 +/- 0.7 mg, and 23.4 +/- 2.3 mg, respectively, for the filtered 4-mg probes, unfiltered 4-mg probes, filtered 25-mg probes, and unfiltered 25-mg probes, respectively. For the second pharmacy, mean triamcinolone acetonide dosage was 23.8 +/- 0.6 mg for the 25-mg filtered probes and contained benzyl alcohol in a mean concentration of 0.0013 +/- 0.0001 mg/0.1 ml. CONCLUSIONS: Depending on the method employed and the pharmacy, preparation of triamcinolone acetonide including filtration of the solvent agent leads to a marked inter-pharmacy variation and a relatively low intra-pharmacy variation in the reduction of triamcinolone acetonide dosage.

High expression of chemokines Gro-alpha (CXCL-1), IL-8 (CXCL-8), and MCP-1 (CCL-2) in inflamed human corneas in vivo.

OBJECTIVE: To investigate in vivo expression of chemokines in normal and inflamed human corneas, to determine whether chemokines are responsible for the recruitment of inflammatory cells. METHODS: In situ hybridization of the CXC chemokines growth-related oncogene-alpha (Gro-alpha) (CXCL-1), interleukin 8 (CXCL-8), macrophage interferon-gamma inducible gene (CXCL-9), and interferon-gamma inducible protein 10 (CXCL-10) and of the CC chemokines macrophage chemoattractant protein 1 (MCP-1) (CCL-2), macrophage inflammatory protein 1alpha (CCL-3), and regulated on activation, normal T-cell expressed and secreted (CCL-5) was performed to localize chemokine messenger RNA. Immunohistochemistry was used to identify the cellular infiltrate within the cornea. Three normal human eyes were compared with eyes enucleated because of chronic inflammation (n = 10), secondary to perforating injuries. RESULTS: In normal corneas, no chemokine expression was detected. In inflamed lesions, a high intensity of signals from Gro-alpha (CXCL-1) and MCP-1 (CCL-2) messenger RNA was observed in limbal epithelium and from Gro-alpha (CXCL-1), interleukin 8 (CXCL-8), and MCP-1 (CCL-2) in corneal stroma. The Gro-alpha (CXCL-1) was the only chemokine expressed by central corneal epithelium. All other examined chemokines were only moderately expressed in limbus and corneal stroma, or barely detectable. CONCLUSIONS: These cytokines are important agents in the cytokine network and contribute to the cell-specific and spatially restricted recruitment of neutrophils and mononuclear cells in acute inflammatory lesions of the human cornea. Clinical Relevance Understanding the role of chemokines in corneal inflammation may lead to the development of a selective receptor blockage of highly expressed chemokines to inhibit the recruitment of leukocyte subsets.

Early intravitreal bevacizumab for non-ischaemic central retinal vein occlusion.

PURPOSE: To evaluate the effect of early intravitreal bevacizumab injections for the treatment of macular oedema caused by non-ischaemic central retinal vein occlusion (CRVO). METHODS: The study included 25 patients (25 eyes) with macular oedema caused by non-ischaemic central retinal vein occlusion, who received three intravitreal injections of 1.5 mg bevacizumab with an interval of 6 weeks between the injections. Mean duration of central retinal vein occlusion prior to the first injection was 4.2 +/- 3.6 days. All patients were re-examined 1, 3 and 6 months after the first injection. The main outcome parameters were visual acuity and macular thickness, as measured by optical coherence tomography. RESULTS: Mean visual acuity improved significantly from 0.97 +/- 0.40 logMAR at baseline to 0.70 +/- 0.42 logMAR (P = 0.007) at 1 month, 0.69 +/- 0.46 (P = 0.006) 3 months and 0.69 +/- 0.52 (P = 0.015) 6 months after the first injection. Mean central retinal thickness decreased significantly from 530 +/- 152 microm at baseline to 347 +/- 127 microm (P < 0.001) at 1 month, 370 +/- 165 microm (P < 0.001) 3 months and 346 +/- 129 microm (P < 0.001) 6 months (P < 0.001) after the first injection. The increase in visual acuity correlated significantly (P < 0.01) with the decrease in macular thickness. Mean intraocular pressure was 14.2 +/- 3.2 mmHg at baseline and did not differ significantly from the measurement obtained at 1 month (P = 0.59), 3 months (P = 0.88) and 6 months after the first injection (P = 0.65). CONCLUSION: Intravitreal bevacizumab injections given shortly after onset of non-ischaemic central retinal vein occlusion may result in a significant increase in vision and a corresponding decrease in macular oedema.

Visual acuity change after intravitreal bevacizumab for exudative age-related macular degeneration in relation to subfoveal membrane type.

PURPOSE: To examine an association between the subfoveal neovascular membrane type and visual acuity change after intravitreal bevacizumab injection for exudative age-related macular degeneration (AMD). METHODS: We carried out a clinical, retrospective, interventional case-series study including 66 consecutive patients (67 eyes) with exudative AMD who received an intravitreal injection of 1.5 mg bevacizumab. Study subgroups included the occult type without or with minimally classic subfoveal neovascularization (n = 28 eyes, 42%), predominantly or purely classic subfoveal neovascularization (n = 22 eyes, 33%), and eyes with retinal pigment epithelium detachment (n = 17 eyes, 25%). Follow-up was >or= 2 months. RESULTS: The maximal visual acuity (VA) gain (mean +/- standard deviation - 0.07 +/- 0.30 logMAR, 0.5 +/- 2.9 Snellen lines; p = 0.87), and VA gain at 1 month (p = 0.10), 2 months (p = 0.77) and 3 months (p = 0.35) after the injection did not vary significantly between the three study subgroups. Correspondingly, a multivariate analysis did not reveal a statistically significant (p = 0.57) influence of subfoveal lesion type on gain in VA. CONCLUSIONS: Visual improvement after intravitreal bevacizumab does not differ markedly between various types of subfoveal neovascularization in AMD.

Prevalence and geographical distribution of Usher syndrome in Germany.

PURPOSE: To estimate the prevalence of Usher syndrome in Heidelberg and Mannheim and to map its geographical distribution in Germany. METHODS: Usher syndrome patients were ascertained through the databases of the Low Vision Department at the University of Heidelberg, and of the patient support group Pro Retina. Ophthalmic and audiologic examinations and medical records were used to classify patients into one of the subtypes. RESULTS: The database of the University of Heidelberg contains 247 Usher syndrome patients, 63 with Usher syndrome type 1 (USH1) and 184 with Usher syndrome type 2 (USH2). The USH1:USH2 ratio in the Heidelberg database was 1:3. The Pro Retina database includes 248 Usher syndrome patients, 21 with USH1 and 227 with USH2. The total number of Usher syndrome patients was 424, with 75 USH1 and 349 USH2 patients; 71 patients were in both databases. The prevalence of Usher syndrome in Heidelberg and suburbs was calculated to be 6.2 per 100,000 inhabitants. There seems to be a homogeneous distribution in Germany for both subtypes. CONCLUSION: Knowledge of the high prevalence of Usher syndrome, with up to 5,000 patients in Germany, should lead to increased awareness and timely diagnosis by ophthalmologists and otologists. It should also ensure that these patients receive good support through hearing and vision aids.

Testing night vision goggles in a dark outside environment.

BACKGROUND: People with degenerative retinal diseases such as retinitis pigmentosa, may have adequate day vision but suffer from poor night vision. We have tested newly developed night vision goggles (NVG) to help these patients overcome their night blindness, thereby promoting more opportunities for normal activities at night or in the dark. METHODS: A total of 42 subjects with night blindness due to retinitis pigmentosa, choroideremia, cone rod dystrophy, or Bardet Biedl syndrome were recruited and clinically examined (visual acuity, visual field, and contrast sensitivity). Using an experienced mobility trainer, we tested binocular NVG on the subjects in two locations: a dark room and a 1 to 2 h outside course at night that provided different levels of difficulties (i.e., obstacles, brightness, and contrast). The assessment of which patients benefited from the NVG was predominantly based on the subjective evaluation of the mobility trainer, followed by their graded responses on two questionnaires. RESULTS: Based on the evaluation of the mobility trainer, 23 (61%) of the 42 subjects experienced improved mobility and orientation with the NVG outdoors, and 19 (39%) subjects did not. The ophthalmic data demonstrated that a visual acuity better than 20/100 and a visual field > 5 degrees (Goldmann perimetry III4) is necessary to benefit from NVG usage. In addition, subjective responses on increased mobility and independence were positively correlated with successful NVG testing. CONCLUSIONS: Night vision goggles have the ability to improve poor night vision in subjects with visual acuity > 20/100 and a visual field > or = 5 degrees (Goldmann: III4). In so doing, NVG can help overcome the obstacles experienced by many people suffering from night blindness. NVG, therefore, have the potential to greatly improve quality of life.