Scleral Fixated Secondary IOLs: An Outcomes Comparison Between the Yamane and Gore-Tex-Sutured Techniques.

BACKGROUND AND OBJECTIVE: Among secondary intraocular lens (IOL) techniques, scleral fixated IOLs (SFIOLs) offer advantages in cases without capsular support. In this article, we compare outcomes between two types of Gore-Tex scleral sutured IOLs with the Yamane technique. PATIENTS AND METHODS: This study was a retrospective chart review of patients who underwent SFIOL implantation. RESULTS: Analysis revealed a statistically significant improvement in final postoperative visual acuity (VA) for sutured SFIOLs (P < 0.001, Envista (n = 29) 95% CI 0.47 to 1.04, Akreos (n = 23) 95% CI 0.32 to 0.81) with no statistical improvement in the Yamane group (P = 0.44, n = 15, 95% CI -0.33 to 0.71). Outcomes analysis revealed greater incidences of cystoid macular edema (CME) in the Yamane cohort (P < 0.05) and a higher rate of reoperations in the Akreos cohort (P < 0.02). All complications related to suture material (n = 4) and IOL decentration (n = 2) occurred in the sutured SFIOL group. CONCLUSIONS: The sutureless Yamane technique offered fewer subsequent surgeries and suture-specific complications while revealing diminished VA improvement in long-term follow-up compared to the sutured SFIOLs. [Ophthalmic Surg Lasers Imaging Retina 2024;55:384-390.].

Transthyretin proteoforms of intraocular origin in human subretinal fluid.

Understanding the molecular composition of ocular tissues and fluids could inform new approaches to prevalent causes of blindness. Subretinal fluid accumulating between the photoreceptor outer segments and retinal pigment epithelium (RPE) is potentially a rich source of proteins and lipids normally cycling among outer retinal cells and choroid. Herein, intact post-translationally modified proteins (proteoforms) were extracted from subretinal fluids of five patients with rhegmatogenous retinal detachment (RRD), analyzed by tandem mass spectrometry, and compared to published data on these same proteins as synthesized by other organs. Single-nuclei transcriptomic data from non-diseased human retina/RPE were used to identify whether proteins in subretinal fluid were of potential ocular origin. Two human donor eyes with normal maculas were immunoprobed for transthyretin (TTR) with appropriate controls. The three most abundant proteins detected in subretinal fluid were albumin, TTR, and apolipoprotein A-I. Remarkably, TTR relative to the other proteins was more abundant than its serum counterpart, suggestive of TTR being synthesized predominantly locally. Six proteoforms of TTR were detected, with the relative amount of glutathionylated TTR being much higher in the subretinal fluid (12-43%) than values reported for serum (<5%) and cerebrospinal fluid (0.4-13%). Moreover, a putative glycosylated TTR dimer of 32,428 Da was detected as the fourth most abundant protein. The high abundance of TTR and putative TTR dimer in subretinal fluid was supported by analysis of available single-nuclei transcriptomic data, which showed strong and specific signal for TTR in RPE. Immunohistochemistry further showed strong diffuse TTR immunoreactivity in choroidal stroma that contrasted with vertically aligned signal in the outer segment zone of the subretinal space and negligible signal in RPE cell bodies. These results suggest that TTR in the retina is synthesized intraocularly, and glutathionylation is crucial for its normal function. Further studies on the composition, function, and quantities of TTR and other proteoforms in subretinal fluid could inform mechanisms, diagnostic methods, and treatment strategies for age-related macular degeneration, familial amyloidosis, and other retinal diseases involving dysregulation of physiologic lipid transfer and oxidative stress.

Long-term visual outcomes of endophthalmitis and the role of systemic steroids in addition to intravitreal dexamethasone.

BACKGROUND: The purpose of this study was to evaluate the role of systemic steroids in post-procedural endophthalmitis as the role of intravitreal steroids in treatment algorithms of endophthalmitis remain controversial. METHODS: This is a retrospective analysis from a single tertiary referral center of all patients older than 18 years old that developed presumed post-procedure endophthalmitis and were treated at our center from 2009 to 2018. RESULTS: Eighty-three patients were followed after being treated for post-procedural endophthalmitis that either received systemic steroids or did not around the time of diagnosis. Almost 30 % of all patients regained a final visual acuity of 20/40 or better, while 31.2% had poor visual outcomes of count fingers or worse. Non-clearing debris was the most significant long-term complication. Visual improvement plateaued in 67.7% by 1 month after diagnosis and initial treatment in both groups. There was no difference in visual outcomes when comparing the sixteen patients that received systemic steroids and the sixty-seven that did not; however, no enucleation or evisceration was required in patients receiving systemic steroids. Five patients that did not receive systemic steroids required an enucleation or evisceration due to a blind, painful eye. CONCLUSIONS: The use of systemic steroids does not seem to worsen long-term outcomes of endophthalmitis compared to those patients that did not receive them and they may prove beneficial in the most severe cases by reducing the risk of losing the globe altogether.

CLINICOPATHOLOGIC CORRELATION OF GEOGRAPHIC ATROPHY SECONDARY TO AGE-RELATED MACULAR DEGENERATION.

PURPOSE: In an eye with geographic atrophy (GA) secondary to age-related macular degeneration, we correlated ex vivo histologic features with findings recorded in vivo using optical coherence tomography (OCT), near-infrared reflectance imaging, and fundus autofluorescence. METHODS: In the left eye of an 86-year-old white woman, in vivo near-infrared reflectance and eye-tracked OCT B-scans at each of 6 clinic visits and a baseline fundus autofluorescence image were correlated with high-resolution histologic images of the preserved donor eye. RESULTS: Clinical imaging showed a small parafoveal multilobular area of GA, subfoveal soft drusen, refractile drusen, hyperreflective lines near the Bruch membrane, subretinal drusenoid deposit (reticular pseudodrusen), and absence of hyperautofluorescent foci at the GA margin. By histology, soft drusen end-stages included avascular fibrosis with highly reflective cholesterol crystals. These accounted for hyperreflective lines near the Bruch membrane in OCT and plaques in near-infrared reflectance imaging. Subretinal drusenoid deposit was thick, continuous, extracellular, extensive outside the fovea, and associated with distinctive retinal pigment epithelium dysmorphia and photoreceptor degeneration. A hyporeflective wedge corresponded to ordered Henle fibers without cellular infiltration. The external limiting membrane descent, which delimits GA, was best visualized in high-quality OCT B-scans. Retinal pigment epithelium and photoreceptor changes at the external limiting membrane descent were consistent with our recent histologic survey of donor eyes. CONCLUSION: This case informs on the extent, topography, and lifecycle of extracellular deposits. High-quality OCT scans are required to reveal all tissue features relevant to age-related macular degeneration progression to GA, especially the external limiting membrane descent. Histologically validated signatures of structural OCT B-scans can serve as references for other imaging modalities.

Clinicopathologic Correlation of Anti-Vascular Endothelial Growth Factor-Treated Type 3 Neovascularization in Age-Related Macular Degeneration.

PURPOSE: To correlate histologic results with previously recorded multimodal imaging results from a patient with type 3 neovascularization secondary to age-related macular degeneration (AMD). DESIGN: Case study, clinical imaging, laboratory imaging, and eye-tracked clinicopathologic correlation. PARTICIPANT: An 86-year-old white woman with type 3 neovascularization secondary to AMD treated with 6 intravitreal injections of bevacizumab. METHODS: Multimodal retinal imaging at each clinic visit was correlated with ex vivo and high-resolution histologic images of the preserved donor eye. Clinical imaging included serial near-infrared reflectance and eye-tracked spectral-domain OCT. Eye tracking, applied to the donor eye, enabled identification of histologic features corresponding to clinical OCT signatures. MAIN OUTCOME MEASURES: Histologic correlates for clinical OCT signatures were sought, including reflectivity of the vascular complex, intraretinal hyperreflective foci and intraretinal cellularity, analysis of the topography of pathologic features, and evaluation of the sub-retinal pigment epithelium (RPE) plus basal lamina (BL) space. RESULTS: Clinical imaging showed a deep neovascular lesion in close relationship with a mixed serous and drusenoid pigment epithelium detachment (PED), characteristic of type 3 neovascularization. Antiangiogenic therapy achieved a complete resolution of exudation. The PED progressively flattened with each treatment, leaving a persistent triangular hyperreflectivity in the outer retina. This persistent deep lesion histologically correlated with a vascular complex implanted into sub-RPE basal laminar deposit. No connection between the choriocapillaris and the sub-RPE plus BL space was observed. Both RPE-derived and lipid-filled cells were correlated with clinical intraretinal hyperreflective foci. The sub-RPE plus BL space contained macrophages, lymphocytes, Müller cell processes, and subducted RPE. CONCLUSIONS: Clinicopathologic correlation of type 3 neovascularization showed vascular elements of retinal origin accompanied by collagenous material and Müller cell processes implanting into thick sub-RPE basal laminar deposit, which may simulate the appearance of chorioretinal anastomosis. Surrounding RPE-derived and lipid-filled cells thought to be microglia correlated with clinical intraretinal hyperreflective foci.

Shingles as the underlying cause of orbital myositis in an adolescent: A case report.

PURPOSE: Orbital myositis is characterized by pain with eye movements, gaze restriction, diplopia, and enlargement of extraocular muscles on imaging. Varicella zoster virus (VZV) is an extremely rare cause of the disease in the elderly and has never been reported in a patient younger than forty-five years old such as the adolescent described herein. We present this case to raise awareness of an entity that will likely become more prevalent due to current vaccine strategies. OBSERVATION: We present the case of a 13-year-old girl with VZV-associated orbital myositis and meningitis that had a quick and complete recovery following IV acyclovir and oral steroids. CONCLUSIONS AND IMPORTANCE: In conclusion, orbital myositis is an extremely rare complication of facial VZV infections. Our case highlights the importance of prompt detection and treatment in the pediatric population.

VITREORETINAL SURGICAL OUTCOMES PERFORMED BY SUPERVISED RETINAL FELLOWS VERSUS ATTENDING FACULTY SURGEONS.

PURPOSE: To evaluate common vitreoretinal surgeries performed by retinal fellows under direct faculty supervision, compared with experienced faculty members. METHODS: Retrospective study analyzing 592 consecutive eyes undergoing retinal surgery from 2009 to 2011 at Retina Consultants of Alabama/University of Alabama at Birmingham, Department of Ophthalmology. Vitreoretinal surgeries included macular hole, macular pucker, retinal detachment, diabetic vitreous hemorrhage, and diabetic tractional retinal detachment. Three fellows performed 390 cases (divided into first or second year fellows), while 4 faculty members performed 202 cases. All 390 fellow-performed cases were under direct supervision. Chi-square analysis was used to compare outcomes. RESULTS: There were no baseline differences between the groups. The mean postoperative visual improvement was statistically significant and equal in all groups, as well as between each physician (P ≤ 0.0001). Complications occurred in 29/592 cases (4.8%), whereas reoperations occurred in 21/592 cases (3.5%) and were equally distributed across groups. There were no differences in complications and reoperations when comparing first-year with second-year fellows. CONCLUSION: With proper supervision, vitreoretinal fellows can achieve an equally high visual improvement with low complication and reoperation rates compared with experienced faculty. The year of fellowship does not significantly influence outcomes or complications. Quality outcomes after vitreoretinal surgery can be obtained throughout fellowship training.

Ocular neovascularization in eyes with a central retinal artery occlusion or a branch retinal artery occlusion.

PURPOSE: To investigate the ocular neovascularization (ONV) rate in eyes with a branch retinal artery occlusion (BRAO) or a central retinal artery occlusion (CRAO), and to study factors that may influence the ONV rate secondary to CRAO. METHODS: This was a retrospective case series of consecutive patients (286 total eyes: 83 CRAOs and 203 BRAOs) who were diagnosed with a retinal artery occlusion from 1998 to 2013 at the Retina Consultants of Alabama and University of Alabama at Birmingham, Birmingham, AL, USA. Generalized estimating equations were used to evaluate the association between hypothesized risk factors and ONV development. RESULTS: Twelve (14.5%) of the 83 eyes with a CRAO developed ONV. Eleven of 12 eyes (91.7%) had iris neovascularization, ten of 12 eyes (83.3%) had neovascular glaucoma, and two of 12 eyes (16.7%) had neovascularization of the optic disc. The average time for ONV development secondary to CRAO was 30.7 days, ranging from the date of presentation to 137 days. Only two (<1.0%) of the 203 eyes with a BRAO developed iris neovascularization. Diabetes mellitus type 2 was a risk factor for ONV development following a CRAO with an adjusted odds ratio of 5.2 (95% confidence interval: 1.4-19.8) (P=0.02). CONCLUSION: ONV is an important complication of CRAO and is a less-frequent complication of BRAO. Patients with a CRAO, especially those with diabetes mellitus type 2, should be closely monitored for the first 6 months for ONV.

Evaluation of proliferating cell abundance and phenotypes in proliferative diabetic retinopathy.

BACKGROUND: The aim of this work is to evaluate the abundance, origins, and phenotypes of actively proliferating cells in proliferative diabetic retinopathy (PDR). METHODS: Eleven epiretinal membranes from patients undergoing surgery for PDR were evaluated by indirect immunofluorescence for evidence of cell proliferation using the nuclear cell proliferation marker Ki67 and for cell identities using glial fibrillary acidic protein (GFAP), glutamine synthetase, and α-smooth muscle actin (αSMA). RESULTS: Ki67 positivity was consistently rare in PDR epiretinal membranes at 3.02 ± 1.42 % of the total cell population. The majority of the Ki67-positive cells were also positive for GFAP (74.0 %) with lower proportions positive for αSMA (30.7 %) and glutamine synthetase (1.5 %). Co-localization studies using glial and myoid markers revealed that virtually all (92 %) of the αSMA-positive cells are also GFAP positive and thus derive from glia. CONCLUSIONS: Entry into cell cycle and thus cell proliferation appears to be a rare phenomenon in PDR involving only a small percentage of the total cell population. Glia and/or glial-derived myofibroblasts appear to be the predominate cell types in epiretinal scar tissues and also account for the majority of the actively proliferating cells.

Nonsupine positioning is preferred by patients over face-down positioning and provides an equivalent closure rate in 25- and 23-gauge macular hole surgery.

PURPOSE: Strict face-down positioning after macular hole surgery is very difficult for most patients. Our study seeks to determine if alleviated positioning (avoidance of supine positioning) has equivalent successful closure rates when compared with face-down positioning. A patient survey was also performed to determine patient preference. METHODS: A single-center retrospective review of patients undergoing macular hole repair with a questionnaire completed by each patient after air bubble clearance summarizing the two postoperative scenarios. Patients were asked which positioning strategy they would choose if they were having repeat surgery. Eighty-two patients undergoing pars plana vitrectomy with primary full-thickness macular hole repair were identified. Repair was performed with either 3 days of strict face-down positioning (57 of 82 patients) or with the avoidance of supine positioning (25 of 82 patients) but no required face-down positioning. RESULTS: The anatomical success rates were similar between the 2 groups with 96% of final hole closure (55/57) in the face-down group versus 100% (25/25) in the nonsupine group. Macular hole size appeared to be similar between the 2 groups (a mean of 408 µm in face-down group vs. that of 483 µm in nonsupine group, with a median of 400 in both groups). Patient preference was in favor of less stringent nonsupine postoperative requirements. Although 100% (25/25) of the nonsupine group would opt for the same strategy with repeat surgery, only 51% (29/57) of the face-down group would opt for face-down positioning with repeat surgery (P < 0.001). CONCLUSION: This study demonstrates equivalent closure rates among the patients who were assigned nonsupine versus face-down positioning postoperatively for macular hole repair, and that most patients would prefer to avoid strict face-down positioning if reoperated.

Safety, efficacy, and quality of life following sutureless vitrectomy for symptomatic vitreous floaters.

PURPOSE: To determine the safety, efficacy, and quality of life improvement following sutureless 25-gauge pars plana vitrectomy for symptomatic floaters. METHODS: Patients with symptomatic vitreous floaters who underwent sutureless vitrectomy between January 2008 and January 2011 were included. Data were collected regarding baseline preoperative characteristics, postoperative outcomes, complications, and a nine-item quality-of-life survey completed by each patient. RESULTS: One hundred and sixty-eight eyes (143 patients) underwent sutureless 25-gauge pars plana vitrectomy for symptomatic vitreous floaters. Mean Snellen visual acuity was 20/40 preoperatively and improved to 20/25 postoperatively (P < 0.0001). Iatrogenic retinal breaks occurred in 12 of 168 eyes (7.1%). Intraoperative posterior vitreous detachment induction was not found to increase the risk of retinal breaks (P = 1.000). Postoperative complications occurred in three eyes, of which one had transient cystoid macular edema and two had transient vitreous hemorrhage. Approximately 88.8% of patients completed a quality-of-life survey, which revealed that 96% were "satisfied" with the results of the operation, and 94% rated the experience as a "complete success." CONCLUSION: Sutureless 25-gauge pars plana vitrectomy for symptomatic vitreous floaters improved visual acuity, resulted in a high patient satisfaction quality-of-life survey, and had a low rate of postoperative complications. Sutureless pars plana vitrectomy should be considered as a viable means of managing patients with symptomatic vitreous floaters.

Myofibroblast and extracellular matrix origins in proliferative vitreoretinopathy.

BACKGROUND: To evaluate origins of the fibrocontractive cell populations and their relation to collagens I and II in proliferative vitreoretinopathy (PVR). METHODS: Human PVR membranes were evaluated by indirect immunofluorescence for GFAP, cytokeratin-18 (CK-18), α-smooth muscle actin (αSMA), collagens I and II. Collagen expression by porcine Müller and retinal pigment epithelial cells (RPE) was evaluated using RT-PCR of RNA harvested from freshly isolated primary and proliferating cultures. RESULTS: Collagen I was detected in all PVR samples and was widely distributed in the extracellular matrix. In contrast, collagen II was present in only two of the ten samples and was localized to thin, acellular bands near the border of the tissues. Using cell type-specific markers CK-18 and GFAP, RPE and glia were localized to the collagen I-rich matrices. Cells positive for GFAP and CK-18 can also co-express αSMA. Normal and proliferating RPE express collagen I, but Müller cells show no evidence of collagen I expression until they proliferate in culture. In contrast, normal RPE and Müller cells contain message for collagen II which is lost shortly after introduction into culture. CONCLUSIONS: Collagen I appears to be the predominate fibrillar collagen in human PVR membranes and collagen II a comparatively minor component. Müller cells and RPE are physically associated with the collagen I matrix and are capable of expressing this protein suggesting that they are the origin. It also appears that the majority of myofibroblasts in PVR membranes are derived from either RPE or Müller cells suggesting that they play a major role in membrane development.

Comparison of hemorrhagic complications of warfarin and clopidogrel bisulfate in 25-gauge vitrectomy versus a control group.

PURPOSE: To estimate the risk of hemorrhagic complications associated with 25-gauge pars plana vitrectomy (PPV) when warfarin (Coumadin; Bristol-Myers Squibb, New York, NY) or clopidogrel (Plavix; Bristol-Myers Squibb) are continued throughout the surgical period, as compared with a control group. DESIGN: A single-center, retrospective, cohort study of 289 consecutive patients receiving either warfarin therapy or clopidogrel therapy or neither of those therapies who underwent 25-gauge PPV. PARTICIPANTS: Included were 61 patients (64 eyes; 64 PPV procedures) in the warfarin group and 118 (125 eyes; 136 PPV procedures) in the clopidogrel group. Warfarin patients were subdivided into 4 groups by international normalized ratio (INR). A control group included 110 patients (110 eyes; 110 PPV procedures) who were not receiving warfarin or clopidogrel. METHODS: Retrospective chart review for which the criteria included: 25-gauge PPV, minimum age of 19 years, warfarin or clopidogrel use, and, if taking warfarin, an INR obtained within 5 days of surgery. MAIN OUTCOME MEASURES: Incidence of intraoperative and postoperative hemorrhagic complications. RESULTS: The most common indications for anticoagulation therapy included: atrial fibrillation (38%), valvular heart disease (17%), and thromboembolic disease (16%). The most common indications for antiplatelet therapy included: cardiac stent (49%), coronary artery bypass grafting (24%), and history of transient ischemic attack (16%). No patient experienced anesthesia-related hemorrhagic complications resulting from peribulbar or retrobulbar block. Transient vitreous hemorrhage occurred in 1 (1.6%) of 64 PPV procedures in the warfarin group (P = 0.6531), 5 (3.7%) of 136 PPV procedures in the clopidogrel group (P = 1.0), and 4 (3.6%) of 110 PPV procedures in the control group. No choroidal or retrobulbar hemorrhages occurred in any patient. CONCLUSIONS: The rate of 25-gauge PPV hemorrhagic complications in patients who underwent systemic anticoagulation or who were receiving platelet inhibitor therapy is extremely low. Given the risks associated with stopping these therapies, the authors recommend that patients continue their current therapeutic regimen without cessation.

Incidence of hemorrhagic complications after intravitreal bevacizumab (avastin) or ranibizumab (lucentis) injections on systemically anticoagulated patients.

PURPOSE: To assess the risk of hemorrhagic complications when performing intravitreal injections on systemically anticoagulated patients. METHODS: A single-center retrospective case series of 520 consecutive patients (675 eyes) receiving 3,106 antivascular endothelial growth factor injections. Patients on the systemic anticoagulants Coumadin (warfarin sodium) or Plavix (clopidogrel bisulfate) were identified, as well as patients on aspirin. Demographic parameters were recorded, as well as relevant anticoagulant medications, preoperative/postoperative best-corrected visual acuities and intraocular pressures, previous ocular surgery, relative ocular diagnoses, and injection complications. RESULTS: Of all patients, 104 were on Coumadin (134 eyes; 548 injections), 90 were on Plavix (123 eyes; 523 injections), 7 were on both Coumadin and Plavix (8 eyes; 33 injections), and 319 were not anticoagulated (400 eyes; 2002 injections). Also, 1,254 injections were on patients taking aspirin. There were no hemorrhagic complications (choroidal hemorrhage, vitreous hemorrhage, or increased submacular hemorrhage) noted in the Plavix (P = 1.0000; 95% confidence interval = 0.0000-0.0088), Coumadin (P = 1.0000; 95% confidence interval = 0.0000-0.0084), or aspirin (P = 1.0000; 95% confidence interval = 0.0000-0.0037) groups. CONCLUSION: The risk of hemorrhagic complications in systemically anticoagulated patients receiving intravitreal injections is extremely low. Because of the demonstrated thromboembolic risk of stopping anticoagulant therapy, we recommend that patients continue their current regiment without cessation.

Risk factors for severe vision loss immediately after transpupillary thermotherapy for occult subfoveal choroidal neovascularization.

BACKGROUND AND OBJECTIVE: To determine risk factors for immediate severe vision loss in patients with age-related macular degeneration after transpupillary thermotherapy for occult subfoveal choroidal neovascularization. PATIENTS AND METHODS: Retrospective review of 84 consecutive patients with age-related macular degeneration who received transpupillary thermotherapy for occult subfoveal choroidal neovascularization. Seven cases had severe vision loss and 77 were controls. All patients were treated with a diode infrared laser. Follow-up was completed on all patients 1, 3, and 6 months after treatment with transpupillary thermotherapy. RESULTS: Pretreatment visual acuity ranged from 20/40 to 1/200. Seven of 84 consecutive eyes had an immediate visual acuity loss of 6 or more Snellen lines after transpupillary thermotherapy. CONCLUSION: Transpupillary thermotherapy has a small but significant risk of immediate severe vision loss in patients with age-related macular degeneration with occult subfoveal choroidal neovascularization. Statistically significant risk factors include a subretinal hemorrhage 5 disc areas or greater in size, 9 disc areas or greater of subretinal fluid, and a laser power greater than 550 mW.

Incidence of acute onset endophthalmitis following intravitreal bevacizumab (Avastin) injection.

PURPOSE: To report the incidence of acute endophthalmitis as a complication of intravitreal bevacizumab (Avastin) (IVB) injection in a tertiary vitreoretinal group practice. METHODS: A retrospective chart review of 5,233 consecutive eyes that underwent IVB injection at Retina Consultants of Alabama (RCA) from October 1, 2005, to August 31, 2007, was performed to identify cases of acute endophthalmitis. RESULTS: During the 23-month study interval, the overall incidence rate of postinjection endophthalmitis was 0.019% (1/5,233). In the single case of acute endophthalmitis, bacterial cultures revealed coagulase-negative Staphylococcus (CNS) species. Visual acuity after treatment for endophthalmitis was improved (baseline 4/400) to 20/400 at two months after the initial IVB injection. CONCLUSIONS: Acute endophthalmitis is a rare potential complication of IVB. Prophylaxis with topical povidone-iodine and adherence to aseptic technique minimizes the risk of postinjection infection. SUMMARY STATEMENT: A retrospective review of 5,233 consecutive intravitreal injections of bevacizumab (Avastin) revealed only a single case of acute endophthalmitis. Adherence to aseptic technique and the use of povidone-iodine prophylaxis minimizes the risk of postinjection intraocular infection.

Preemptive sub-Tenon's anesthesia for pars plana vitrectomy under general anesthesia: is it effective?

BACKGROUND AND OBJECTIVES: To determine whether irrigation of the sub-Tenon's space with anesthetic agents during pars plana vitrectomy (PPV) involving general anesthesia decreases postoperative pain, analgesic use, or nausea. PATIENTS AND METHODS: A prospective, controlled trial of 46 consecutive patients requesting general anesthesia for PPV who were randomized to receive or not receive a sub-Tenon's space injection prior to surgery. A mixture of 3 mL of 2% lidocaine with hyaluronidase and 3 mL of 0.5% bupivacaine was used to induce local blockade. Pain, postoperative nausea, and analgesia use were evaluated. RESULTS: Local blockade did not significantly alter the proportion of reported pain at 30 minutes and 2, 4, and 24 hours after the operation. The local blockade had no effect on reducing postoperative nausea or the number of patients requiring pain medication. CONCLUSIONS: Local blockade prior to surgery in patients undergoing PPV under general anesthesia does not significantly decrease postoperative pain, analgesic use, or nausea.

Eccentric macular holes after vitrectomy with peeling of epimacular proliferation.

PURPOSE: To describe six patients (six eyes) who developed an eccentric macular hole after surgery for idiopathic epimacular proliferation. METHODS: In a retrospective review of 631 consecutive patients who underwent vitrectomy with peeling of the epimacular proliferation and in most cases the internal limiting membrane (ILM) from May 2001 to May 2005, 6 patients were found to have developed an eccentric macular hole postoperatively. RESULTS: Eccentric macular holes developed 9 days to 8 months (mean, 3.1 months) after epimacular proliferation peeling. The ILM was peeled in addition to the epimacular proliferation in five of the six cases. Of the six eccentric macular holes, four were located temporal to the fovea, one was located superior to the fovea, and one was located nasal to the fovea. Final visual acuities after a mean follow-up period of 17.3 months were 20/20 in 2 eyes, 20/25 in 1 eye, 20/40 in 2 eyes, and 5/200 in 1 eye. The eye with the eccentric macular hole nasal to the fovea had the poorest final visual acuity of 5/200. CONCLUSION: Eccentric macular hole occurring after vitrectomy to remove epimacular proliferation is an uncommon postoperative finding. To our knowledge, this is the largest case series of such patients reported. Various explanations have been suggested for the etiology of these holes, but there remains no consensus.