Case Report: Beyond the Blood-retina Barrier: Intravitreal Caspofungin for Fungal Endophthalmitis.

SIGNIFICANCE: Two fungal endophthalmitis cases demonstrate safety and efficiency of intravitreal caspofungin as a new therapy option in fungal endophthalmitis. PURPOSE: The purpose of this study was to evaluate the intravitreal application of caspofungin for the treatment of fungal endophthalmitis because rising resistance to voriconazole and amphotericin B leads to a need for new antifungal therapy options. CASE REPORT: Initially, both patients with fungal endophthalmitis underwent pars plana vitrectomy. Microbiological analysis revealed Aspergillus terreus and Candida dubliniensis, which both possess atypical resistance patterns. Caspofungin has a low bioavailability in the eye when given systemically. It was injected intravitreally into the eyes affected by fungal endophthalmitis. An injection of 100 µg of caspofungin in a volume 0.1 mL was applied repeatedly. Clinical parameters were recorded. Both eyes were stabilized by the treatment. Finally, the intraocular infections with atypical mycotic agents were eliminated. Visual acuity improved to 0.4 logMAR (20/50 Snellen) in the first case and to 1.0 logMAR (20/200 Snellen) in the second case. During the treatment course, we have not seen any toxic effects or damage of intraocular structures related to the intravitreal administration of caspofungin. CONCLUSIONS: In summary, intravitreal caspofungin was effective and well tolerated in both cases. Therefore, caspofungin seems to be a safe and effective intravitreal alternative to voriconazole and amphotericin B in fungal endophthalmitis.

[Chronic bilateral orbital tumors in IgG4-related disease]. / Beidseitige, chronisch progrediente Orbitatumoren bei IgG4-assoziierter Erkrankung.

BACKGROUND: The IgG4-related disease describes a new multisystem disorder, which can also be manifested in the orbit. This syndrome is characterized by a multifocal chronic fibroinflammation with high levels of plasma cells expressing IgG4. CASE REPORT: This article reports the case of a patient with advanced bilateral tumors of the upper eyelid and orbit. The diagnosis of IgG4-related disease was only revealed after many years and after many biopsies of the tumors had been carried out. The initiation of a systemic steroid therapy led to a rapid reduction of the tumors and an improvement in the general condition of the patient.

Evaluation of interface quality in organ-cultured lamellar corneal transplants.

BACKGROUND: With increasing numbers of lamellar keratoplasties, eye banks are challenged to deliver precut lamellar donor tissue. In Europe, the most common technique of corneal storage is organ culture which requires a deswelling process before surgical processing. The aim of this study was to investigate the influence of different deswelling times on the cutting plane quality after microkeratome-assisted lamellar dissection. METHODS: Eight paired donor corneas (16 specimens) not suitable for transplantation were organ cultured under standard conditions at the Eye Bank of the Ludwig-Maximilians Universität, Munich, Germany. Pairs of corneal buttons were analyzed during the deswelling process in dextrane-containing medium. While one cornea was cut at an early time point during the deswelling process and put back into deswelling medium thereafter, the partner cornea was completely deswollen and dissected after 72 hours. Specimens were then further processed for scanning electron microscopy. Surface quality was assessed both digitally using Scanning Probe Imaging Processing software, and manually by three blinded graders. RESULTS: The corneal buttons processed at the beginning of the deswelling process had a smoother surface when compared to the partner cornea that was cut at the end of the deswelling process. In our setting, no relevant difference was detectable between manual and automated microkeratome dissection. CONCLUSION: For lamellar keratoplasty, organ-cultured corneas should be processed at an early stage during the deswelling process. We interpret the smoother dissection plane during early deswelling as a result of mechanical properties in a highly hydrated cornea.

Intracameral injection of bevacizumab for the treatment of neovascular glaucoma.

PURPOSE: To assess the duration of the effect of intracameral bevacizumab in patients presenting with rubeosis iridis and neovascular glaucoma (NVG). METHODS: Retrospective analysis of 24 consecutive eyes of 24 patients with decompensated NVG (> 21 mm Hg) treated with a single intracameral injection of bevacizumab over a minimum follow-up of 6 months. The endpoint of the study was the need for retreatment due to recurrence of raised intraocular pressure (IOP). Secondary outcome was the course of visual acuity (VA) and IOP over 6 months. RESULTS: A Kaplan-Meier calculation revealed a mean duration of the treatment effect of 23 ± 4.4 days. Compared to mean IOP before treatment (26.3 mm Hg), decreases to 17.5 mm Hg at 1 week after treatment (p < 0.002) and to 17.1 mm Hg (p < 0.005) at 6 months following a single injection were seen. At 6 months, additional treatment was performed in 87.5% (n = 21) of eyes. VA remained stable or improved in 75% (n = 18) of all cases. CONCLUSION: The IOP-lowering effect of intracameral bevacizumab can be seen 1 week after the injection, but is limited to a period of approximately 3 weeks. However, the fast and effective response to intracameral bevacizumab injection opens a time window for additional treatments, which are often necessary.

Functional outcome of indocyanine green-assisted macular surgery: 7-year follow-up.

PURPOSE: To evaluate the long-term functional results after surgery for macular pucker and macular holes with indocyanine green (ICG) staining of the internal limiting membrane. METHODS: Long-term functional and anatomical outcomes of 16 eyes of 16 patients were evaluated for 7.3 years after ICG-assisted macular surgery. Examinations performed included best-corrected visual acuity, Goldmann perimetry, Arden color contrast test, optical coherence tomography, and fundus photography. Ten eyes had undergone surgery for macular holes, and 6 eyes had been treated for macular pucker. Indocyanine green with a concentration of 0.05% and an osmolarity of 275 mOsm had been used to stain the internal limiting membrane. RESULTS: Mean follow-up time was 7.3 years. Eighty-eight percent (14) of the eyes had undergone cataract surgery either in a combined intervention primarily (n = 3) or in the years after the ICG-assisted macular surgery (n = 11). One patient was still phakic with a pronounced cataract at last follow-up. Over all patients, best-corrected visual acuity did not increase significantly from 20/200 (median) before macular surgery to the present 20/70 (median). Large visual field defects (VFDs) were found in 10 of 16 patients after internal limiting membrane staining using ICG. In 8 of these 10 eyes, the VFDs had been diagnosed immediately after vitrectomy and remained unchanged throughout the period of review. In 2 eyes, a VFD was noted at the last follow-up visit despite an unremarkable Goldmann perimetry performed at follow-up visits after 3 months and 6 months. Pathologic color testing was found in 15 of 16 patients when comparing the operated and the fellow eye. A nonglaucomatous optic nerve atrophy was found in 11 of 16 eyes. The optical coherence tomography revealed macular hole closure in all 10 patients. CONCLUSION: Indocyanine green-assisted macular surgery might lead to optic nerve atrophy in the long-term and persistent VFDs. In addition, new VFDs may occur in the postoperative course. An affection of color vision also underlines the potential impact of ICG on visual function. A long-term observation of patients after ICG-assisted vitrectomy seems mandatory to reliably detect functional adverse events.

Corneal architecture of femtosecond laser and microkeratome flaps imaged by anterior segment optical coherence tomography.

PURPOSE: To assess and compare the morphology of laser in situ keratomileusis flaps (LASIK) created by a 60 kHz femtosecond laser and a mechanical microkeratome. SETTING: Department of Ophthalmology, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany. METHODS: Anterior segment optical coherence tomography (AS-OCT) (Visante) was used to assess 1 week postoperatively the morphology of 20 LASIK flaps created with the IntraLase femtosecond laser or the Zyoptix XP microkeratome. The flap diameter and flap thickness were assessed at 20 measuring points across each flap. First, the repeatability of the AS-OCT flap measurement was evaluated. On this basis, the dimensions of femtosecond laser flaps and microkeratome flaps were tested and their regularity, reproducibility, and accuracy compared. RESULTS: The method was approved with a repeatability of maximum 8.9 mum. The femtosecond laser flaps were more regular than the microkeratome flaps (P = .02). The reproducibility of flap morphology was not different in the central 1.0 mm radius area (P = .26); however, the femtosecond laser was significantly more precise than the microkeratome in the peripheral area (P = .001). The mean thickness of the femtosecond laser flap was significantly more accurate than the mean thickness of the microkeratome flap (P = .01), with a mean deviation of +16.9 mum and 40.8 mum, respectively. CONCLUSIONS: The flap architecture created with the femtosecond laser was more regular and accurate than the flap architecture created with the microkeratome.

Anterior optic neuropathy associated with adalimumab.

PURPOSE: Our purpose was to report a case of anterior optic neuropathy with pupillary edema in a patient treated with the TNF-alpha-antagonist adalimumab. METHODS: We report the case of a 60-year-old woman with optic neuropathy in 1 eye after 6 months of treatment with adalimumab. RESULTS: The patient developed decreased visual acuity of the left eye. The ocular findings were left optic disc swelling and bleeding at the rim, superior visual field depression in both eyes and left afferent pupillary defect. Adalimumab was discontinued and the visual acuity recovered slowly. CONCLUSIONS: Like infliximab, the modern TNF-alpha antagonist adalimumab is associated with optic neuropathy. Ophthalmologists should thus be alert when seeing patients treated with adalimumab.

Macular thickness after uneventful cataract surgery determined by optical coherence tomography.

BACKGROUND: Using standardized macular optical coherence tomography (OCT) in the postoperative period, subclinical changes in macular thickness can be detected. With this method, postoperative development of macular thickness in healthy eyes is evaluated. The repeatability of the method and the influence of selected surgical (phaco time and phaco energy) and biometric parameters (axial length and anterior chamber depth) on the results were assessed. METHODS: In a prospective study, 33 patients without macular pathology in both eyes were examined. Phacoemulsification and intraocular lens (IOL) implantation was performed in one eye, and the contralateral eye served as control. OCT (StratusOCT; Zeiss, Dublin, CA, USA), mean minimal foveal thickness (MMFT) and mean foveal thickness (MFT) were measured preoperatively, at 1 day, 1 week and 6 weeks postoperatively. At these visits, the best-corrected visual acuity (BCVA) tests and slit-lamp examination were performed. To assess the influence on foveal thickness ocular axial length, anterior chamber depth, phacotime and energy were documented. Statistical analysis using parametric tests was carried out with standard statistical software (SPSS11, BIAS). RESULTS: MMFT of the operated eyes and the intraindividual difference of MMFT increased significantly at one day (+12.31 +/- 24.2 microm, P < 0.001) and 6 weeks (+6.76 +/- 22.6 microm, P = 0.009). MFT in the operated eyes and intraindividual difference of MFT rose significantly at 1 day, 1 week and 6 weeks (1 day: +10.66 +/- 20.8 microm, P = 0,026; 1 week: +15.23 +/- 19.7 microm; 6 weeks: +17.33 +/- 14.81 microm, P < 0.001). Repeatability was better for MFT in controls (ICR = 0.92) than for MMFT in controls (ICR = 0.77). No clinical cystoid macular edema was diagnosed in this study. No correlation between macular thickening and visual acuity and selected surgical and biometrical parameters could be found. CONCLUSIONS: After cataract surgery, a mild increase of foveal thickness without impact on visual acuity could be observed. This increase may be due to both subclinical changes and to influence of changes in media opacity on the measurement technique. Surgical and biometric parameters such as phacotime and energy and axial length did not correlate to the degree of macular thickening.