Effectiveness of bevacizumab step therapy for neovascular age-related macular degeneration.

OBJECTIVE: To determine the effectiveness of bevacizumab step therapy for neovascular age-related macular degeneration (nAMD) in routine clinical practice. METHODS: In this retrospective case series, eyes initiating treatment for nAMD at an academic medical centre from 2011-2019 were included. Exclusion criteria included previous intravitreal anti-VEGF injections, prior non-cataract intraocular surgery, <1 year of treatment, and not starting on monthly bevacizumab therapy. Of 895 eligible eyes, 548 were excluded, yielding 347 eyes in the study population. These eyes were treated for nAMD under the bevacizumab step therapy protocol with an option to switch to another agent in the event of predefined treatment failure. Treatment failure was defined as losing 15 or more Early Treatment Diabetic Retinopathy Study letters or switching to an alternative anti-VEGF agent. Eyes that did not meet these criteria were deemed treatment successes. Annual change in mean VA from baseline (ΔVA) was the primary outcome. Secondary outcomes included treatment success rate, medication switch rate, and post-switch ΔVA. RESULTS: After 1 year, mean ΔVA was +8.4 letters (95% CI: +6.1 to +10.6 letters). 86% had treatment success, and 6% of eyes had switched to aflibercept. In years 2-7, ΔVA ranged from +7.0 to -0.7 letters, and treatment success rates ranged from 68 to 82%. 11% (n = 38) of eyes were switched to aflibercept. The post-switch ΔVA in these eyes was -7.1 letters (95% CI: -13.3 to -0.1) after a mean of 17.7 ± 12.6 injections over an average of 2.7 ± 2.0 years. CONCLUSION: A bevacizumab step therapy protocol in routine clinical practice is effective for long-term treatment of nAMD.

Microbial flora and resistance in ophthalmology: a review.

Antibiotic resistance in systemic infection is well-researched and well-publicized. Much less information is available on the resistance of normal ocular microbiome and that of ophthalmic infections. An understanding of the distribution of ocular microorganisms may help us in tailoring our empiric treatment, as well as in choosing effective pre-, peri- and postoperative management, to achieve the best results for patients. This study aims to summarize and review the available literature on the subject of normal ocular flora and its resistance, as well as the broader topic of antibiotic resistance in ophthalmology.

Incidence and risk factors for chronic uveitis following cataract surgery.

PURPOSE: To determine the incidence of and associated risk factors for uveitis after cataract surgery. METHODS: A total of 17,757 eyes were identified and records of 42 eyes that developed uveitis and 2320 eyes that did not were reviewed. Postsurgical uveitis was defined as persistent inflammation for ≥ 6 months after surgery. RESULTS: Forty-two eyes of 35 patients developed uveitis (0.24%). Eleven patients underwent consecutive cataract surgery but developed unilateral uveitis, and intraoperative complications occurred in 55% of uveitic eyes compared to 0% in fellow eyes (p < 0.05). Median duration of inflammation was 8 and 11.5 months in eyes with and without vitrectomy (p < 0.05). Intraocular complications occurred in 44 and 8.3% of eyes that did and did not develop uveitis, respectively (p = 0.01). CONCLUSIONS: Postsurgical uveitis developed after approximately 1 in 400 cataract surgeries and occurred more frequently in eyes experiencing intraoperative complications.

Intraocular T-cell lymphoma due to mycosis fungoides and response to intravitreal methotrexate.

PURPOSE: To report a case of mycosis fungoides with subsequent intraocular involvement and good response to intravitreal methotrexate. DESIGN: Case report. METHODS: Retrospective chart review. RESULTS: This is a rare case of intraocular T-cell lymphoma due to mycosis fungoides, which responded to intravitreal methotrexate therapy in a previous vitrectomized eye. CONCLUSIONS: Intraocular T-cell lymphoma is a rare manifestation of mycosis fungoides and should be considered in the differential diagnosis of chronic uveitis in patients with this history. Intravitreal methotrexate may be an effective adjunctive treatment for this condition.

Critical appraisal of ophthalmic ketorolac in treatment of pain and inflammation following cataract surgery.

BACKGROUND: The purpose of this review was to provide a critical appraisal of the literature supporting the efficacy of ophthalmic ketorolac (Acuvail(®)) in the treatment of pain and inflammation after cataract surgery. METHODS: Literature search and expert opinion of the authors. RESULTS: Recent studies indicate greater intraocular drug levels in the anterior chamber and iris-ciliary body after topical application of Acuvail in comparison with older formulations of ketorolac. A large randomized, multicenter, placebo-controlled study demonstrated significantly less inflammation and pain after cataract surgery using Acuvail. CONCLUSION: Acuvail appears to be effective in reducing post-cataract surgery pain and inflammation.

Long-term trends in intraocular pressure after pars plana vitrectomy.

PURPOSE: To evaluate the effect of vitrectomy on intraocular pressure (IOP). METHODS: Retrospective cohort study. Medical records of 101 eyes of 101 patients undergoing nonemergent vitrectomy were reviewed for rates of open-angle glaucoma, increased IOP of >4 mmHg from baseline, change in IOP from baseline, and cataract formation. Preoperative and last measured IOPs were recorded. Baseline risk characteristics including lens status and diabetes were analyzed. Main outcome measures were 1) incidence of open-angle glaucoma; 2) increase in IOP of >4 mmHg; and 3) change in IOP. RESULTS: Mean follow-up was 49 months (range, 12-105 months). Mean baseline IOP was 15.3 mmHg, and mean final IOP was 15.8 mmHg (P = 0.3). At the most recent examination, 35 study eyes had a decrease in IOP from baseline, while 14 eyes had no change and 52 eyes had an increase in IOP. Four study eyes were newly diagnosed with ocular hypertension. No study eye developed open-angle glaucoma or required medical, laser, or surgical treatment for glaucoma. Incidence of increased IOP of >4 was 7% at 4 years and 34% at 8 years. Subgroup analysis of 66 patients comparing study eyes with nonvitrectomized fellow eyes demonstrated no significant difference in rates of increased IOP of >4 (P = 0.85). Neither diabetes nor pseudophakia was associated with significantly increased IOP. CONCLUSION: In this series, vitrectomy does not appear to increase IOP even after removal of the crystalline lens.

Long-term stability and visual outcomes of a single-piece, foldable, acrylic intraocular lens for scleral fixation.

PURPOSE: To report long-term visual outcomes and complications of a new foldable, one-piece, acrylic posterior chamber intraocular lens with closed-loop haptics (C-flex, Rayner, UK) for scleral fixation. STUDY DESIGN: Retrospective interventional case series of 29 eyes of 29 patients who underwent scleral fixation with the C-flex intraocular lens in the absence of capsular support. METHODS: Review of 29 consecutive cases from January 2001 to December 2005 in which scleral fixation was performed with the C-flex intraocular lens. All cases were performed by a single surgeon (S.J.L.) and with an ab externo two-point scleral fixation technique. Preoperative status, intraoperative complications, and postoperative outcomes were analyzed. RESULTS: Mean best corrected visual acuity improved from 20/150 to 20/40 (P < 0.001) at 1 month and to 20/50 (P < 0.001) at mean follow-up of 41 months. Complications included clinically insignificant decentration [1 (3%)], mild intraoperative vitreous hemorrhage [1 (3%)], postoperative hyphema [2 (7%)], and transient elevated intraocular pressure [2 (7%)]. All complications were mild and resolved without the need for reoperation. CONCLUSION: Scleral fixation of the closed-loop, foldable, acrylic C-flex intraocular lens appeared to reduce operative time, was associated with minimal postoperative complications, and resulted in long-term visual improvement.