UVR-B-induced NKR-1 Expression in Ocular Tissues is blocked by Substance P Receptor Antagonist Fosaprepitant in the Exposed as well as Unexposed Partner Eye.

Purpose: To investigate the effect of NKR-1 antagonists in an established UVR-B-induced cataract mouse model. Furthermore, to examine the expression of pro-inflammatory cytokines/chemokines in mouse eyes following unilateral UVR-B exposure.Methods: Mice received intraperitoneally injections of Fosaprepitant and Spantide I, before and after unilateral exposure to UVR-B. After day 3 and 7 post-exposure, ocular tissues were extracted for the detection of NKR-1 protein level by ELISA.Results: Pretreatment with Fosaprepitant decreases NKR-1 expression in exposed ocular tissues as well as in the unexposed lens epithelium compared to the saline group. Spantide I treatment showed a tendency of NKR-1 overexpression in ocular tissues.Conclusion: The clinically approved NKR-1 receptor antagonist Fosaprepitant decreases NKR-1 protein expression effectively not only in the exposed but also in the unexposed partner eye in a UVR-B irradiation mouse model. No effect was seen on the protein concentration of pro-inflammatory cytokines/chemokines in either eye.

Risk factors for retinopathy in hemodialysis patients with type 2 diabetes mellitus.

There is limited knowledge on the prevalence and risk factors of diabetic retinopathy (DR) in dialysis patients. We have investigated the association between diabetes mellitus and lipid-related biomarkers and retinopathy in hemodialysis patients. We reviewed 1,255 hemodialysis patients with type 2 diabetes mellitus (T2DM) who participated in the German Diabetes and Dialysis Study (4D Study). Associations between categorical clinical, biochemical variables and diabetic retinopathy were examined by logistic regression. On average, patients were 66 ± 8 years of age, 54% were male and the HbA1c was 6.7% ± 1.3%. DR, found in 71% of the patients, was significantly and positively associated with fasting glucose, HbA1c, time on dialysis, age, systolic blood pressure, body mass index and the prevalence of other microvascular diseases (e.g. neuropathy). Unexpectedly, DR was associated with high HDL cholesterol and high apolipoproteins AI and AII. Patients with coronary artery disease were less likely to have DR. DR was not associated with gender, smoking, diastolic blood pressure, VLDL cholesterol, triglycerides, and LDL cholesterol. In summary, the prevalence of DR in patients with type 2 diabetes mellitus requiring hemodialysis is higher than in patients suffering from T2DM, who do not receive hemodialysis. DR was positively related to systolic blood pressure (BP), glucometabolic control, and, paradoxically, HDL cholesterol. This data suggests that glucose and blood pressure control may delay the development of DR in patients with diabetes mellitus on dialysis.

Ultraviolet Radiation Exposure of One Eye Stimulates Sympathizing Expression of Neurokinin-1 Receptor but Not Monocyte Chemoattractant Protein-1 in the Partner Eye.

PURPOSE: To investigate the influence of unilateral ultraviolet radiation (UVR) exposure on the unexposed, partner eye in vivo. To characterize the immunological cross-talk between the eyes and verify a sympathizing reaction of the partner eye via a neurokinin-dependent signaling pathway of substance P and its neurokinin-1 receptor (NKR-1) and/or monocyte chemoattractant protein-1 (MCP-1). METHODS: C57BL/6 mice were unilaterally exposed in vivo to UVR-B to a 5-fold cataract threshold equivalent dose of 14.5 kJ/m2 with a UV irradiation Bio-Spectra system. The unexposed contralateral eye was completely shielded during irradiation. After 3 and 7 days post exposure, eyes were stained with fluorescence-coupled antibody for substance P NKR-1. The same was performed in control animals receiving only anesthesia but no UVR-B exposure. NKR-1 and MCP-1 levels in ocular tissue lysates were quantified by enzyme-linked immunosorbent assay. RESULTS: UVR-B induces NKR-1 upregulation after 3 and 7 days in the exposed and in the unexposed, contralateral mouse eye. NKR-1 protein level was upregulated in the exposed and contralateral iris/ciliary body complex, choroidea and in the contralateral retina as well as in the exposed cornea. MCP-1 levels were elevated in the exposed cornea, iris/ciliary body complex, and aqueous humor but not in contralateral ocular tissues. CONCLUSIONS: UVR-B exposure triggers NKR-1 upregulation not only in the exposed but also in the unexposed, partner eye in various ocular tissues. Following UVR-B exposure, MCP-1 protein levels are upregulated in the exposed eye, but the contralateral side remains unaffected.

Comparison of 2-year-results of mitomycin C-augmented trabeculectomy with or without cataract extraction in glaucoma patients.

PURPOSE: Comparison of the 2-year results of phacotrabeculectomy (CET) and trabeculectomy (TE), both augmented with mitomycin C. METHODS: This prospective study enclosed 246 eyes in 246 consecutive patients that had undergone trabeculectomy (n = 85) or phacotrabeculectomy (n = 161, hereof n = 10 phacoretrabeculectomy) augmented by mitomycin C. Endpoints were best corrected visual acuity (BCVA), intraocular pressure (IOP), and number of antiglaucomatous medications at baseline, 3 months, and 2 years postoperatively. Postoperative management involved local steroid application and laser suture lysis according to a standardized protocol. RESULTS: Both interventions reduced IOP statistically significant and stable. In the phacotrabeculectomy group BCVA improved from 0.45 ± 0.47 logMAR units preoperatively to 0.28 ± 0.54 logMAR units at 2 years (p < 0.001) and remained unchanged in the trabeculectomy group. After 2 years IOP reduced from 22.5 ± 7.2 mm Hg preoperatively to 11.5 ± 3.1 mm Hg in the TE group and from 20.0 ± 5.4 mm Hg to 12.5 ± 4.8 mm Hg in the CET group (both p > 0.05). The mean number of antiglaucomatous medications was significantly reduced from 2 ± 1 in both groups to 0.3 in the trabeculectomy group and to 0.4 in the phacotrabeculectomy group. With this standardized surgical procedure and postoperative protocol, there was no need for local postoperative antimetabolites. No Tenon's capsule cysts developed. In the subgroup of patients with phacoretrabeculectomy BCVA and IOP improvements were comparable to the phacotrabeculectomy group outcomes. CONCLUSIONS: Phacotrabeculectomy is comparably as effective as trabeculectomy alone in reducing IOP and the need for antiglaucomatous medication over a time interval of 2 years. We found indications that this favourable therapeutic effect is also true for patients needing phacoretrabeculectomy treatment.

Ultraviolet radiation exposure triggers neurokinin-1 receptor upregulation in ocular tissues in vivo.

The purpose of this study was to investigate the neurokinin receptor-1 (NKR-1) protein expression in ocular tissues before and after supra-cataract threshold ultraviolet radiation (UVR-B peak at 312 nm) exposure in vivo in a mouse model. Six-week-old C57Bl/6 mice were unilaterally exposed to a single (2.9 kJ/m2) and an above 3-fold UVR-B cataract threshold dose (9.4 kJ/m2) of UVR. UVR-exposure (λpeak = 312 nm) was performed in mydriasis using a Bio-Spectra exposure system. After latency periods of 3 and 7 days, eyes were fixed in 4% paraformaldehyde, embedded in paraffin, sectioned and stained with fluorescence coupled antibody for NKR-1 and DAPI for cell nuclei staining. Control animals received only anesthesia but no UVR-exposure. Cataract development was documented with a Leica dark-field microscope and quantified as integrated optical density (IOD). NKR-1 is ubiquitously present in ocular tissues. An above 3-fold cataract threshold dose of UV-radiation induced NKR-1 upregulation after days 3 and 7 in the epithelium and endothelium of the cornea, the endothelial cells of the iris vessels, the pigmented epithelium/stroma of the ciliary body, the lens epithelium, pronounced in the nuclear bow region and the inner plexiform layer of the retina. A significant upregulation of NKR-1 could not be provoked with a single cataract threshold dose (2.9 kJ/m2 UVR-B) ultraviolet irradiation. All exposed eyes developed anterior subcapsular cataracts. Neurokinin-1 receptor is present ubiquitously in ocular tissues including the lens epithelium and the nuclear bow region of the lens. UV-radiation exposure to an above 3-fold UVR-B cataract threshold dose triggers NKR-1 upregulation in the eye in vivo. The involvement of inflammation in ultraviolet radiation induced cataract and the role of neuroinflammatory peptides such as substance P and its receptor, NKR-1, might have been underestimated to date.

Incidence of cystoid macular edema following secondary posterior chamber intraocular lens implantation.

PURPOSE: To investigate the incidence and risk factors for the occurrence of cystoid macular edema (CME) after secondary posterior chamber intraocular lens (PC IOL) fixation. SETTING: Eye Clinic Herzog Carl Theodor, Munich, Germany. DESIGN: Retrospective case series. METHODS: Eyes with secondary PC IOL implantation were included. Eyes in Group 1 were treated because of preexisting aphakia; eyes in Group 2 had reimplantation or refixation of a failed primary PC IOL (Group 2). Patients were followed for at least 12 months with measurement of corrected distance visual acuity (CDVA) and central retinal thickness with optical coherence tomography (OCT). Risk factors for CME occurrence were evaluated with standard statistical procedures. Cutoff points of sensitivity and specificity were calculated for the prediction of CME with the receiver operating characteristic (ROC) method. RESULTS: Forty-two eyes of 40 patients (16 men, 24 women; mean age 75.4 years ± 13.7 [SD]) were included. There were 28 eyes in Group 1 and 14 eyes in Group 2. Seven eyes (16.7%) developed CME with significant impairment of CDVA and an increase in central retinal thickness on OCT. Five eyes in Group 1 and 2 eyes in Group 2 were affected, without a significant difference between groups. The CDVA after surgery had a significant influence, and there was a trend toward patient age as a risk factor. The ROC analysis yielded 83.9 years of age and a CDVA of 0.35 logMAR, respectively, as meaningful cutoff points. CONCLUSIONS: Secondary PC IOL fixation was performed with good results despite the inherent CME risk from the procedure. Advanced age and poor CDVA after surgery might predict CME occurrence. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Bilateral Simultaneous Retinal Detachment in Pseudophakia.

Cataract surgery is the most frequent surgical intervention, with approximately 700,000 operations per year in Germany alone. One of the most serious complications is retinal detachment, with a reported incidence rate of pseudophakic retinal detachment of 0.75-1.65%. We report the case of a patient who suffered from a simultaneous bilateral pseudophakic retinal detachment. Interestingly, the bilateral detachments in the left and the right eye started with only some hours' delay. He had no acute trigger for the retinal detachment and no risk factors besides the cataract surgery performed on both eyes some weeks earlier. Simultaneous bilateral retinal detachments will be more common, due to increasing numbers of cataract surgeries and the demographic development. We conclude that funduscopy should be regularly performed in mydriasis to avoid sight-threatening simultaneous bilateral retinal detachments.

Effect of Viscous Agents on Corneal Density in Dry Eye Disease.

PURPOSE: To investigate the effect of the viscous agents, hydroxypropyl methylcellulose (HPMC), carbomer, povidone, and a combination of HPMC and povidone on corneal density in patients with dry eye disease. METHODS: In total, 98 eyes of 49 patients suffering from dry eye and 65 eyes of 33 healthy age-matched individuals were included in this prospective, randomized study. Corneal morphology was documented with Scheimpflug photography and corneal density was analyzed in 5 anatomical layers (epithelium, bowman membrane, stroma, descemet's membrane, and endothelium). Corneal density was evaluated for the active ingredients HPMC, carbomer, povidone, and a combination of HPMC and povidone as the viscous agents contained in the artificial tear formulations used by the dry eye patients. Data were compared to the age-matched healthy control group without medication. RESULTS: Corneal density in dry eye patients was reduced in all 5 anatomical layers compared to controls. Corneal density was highest and very close to control in patients treated with HPMC containing ocular lubricants. Patients treated with lubricants, including carbomer as the viscous agent displayed a significant reduction of corneal density in layers 1 and 2 compared to control. CONCLUSION: HPMC containing ocular lubricants can help to maintain physiological corneal density and may be beneficial in the treatment of dry eye disease.

Two-year outcome of repeat trabeculectomy with mitomycin C in primary open-angle and PEX glaucoma.

PURPOSE: To evaluate the effectiveness of repeat trabeculectomy with risk factor-adjusted mitomycin C (MMC) application in primary open-angle glaucoma (POAG) and pseudoexfoliation glaucoma (PEXG) over 2 years. METHODS: A total of 58 patients (43 with POAG, 15 with PEXG) who had undergone repeat trabeculectomy with MMC were included in this retrospective study. Exposure time of MMC 0.3 mg/mL was adjusted according to a standardized protocol. Main outcome measures were best-corrected visual acuity (BCVA), intraocular pressure (IOP) reduction, surgical success rate (criteria were defined as A: IOP ≤21 mm Hg and a reduction of IOP ≥20%; B: IOP ≤18 mm Hg and a reduction of IOP of ≥30%; C: IOP ≤15 mm Hg and a reduction of IOP of ≥40% from baseline), and number of medications at baseline, 3 months, and 2 years postoperatively. RESULTS: The BCVA remained stable for 2 years after surgery (0.47 ± 0.47 at baseline, 0.49 ± 0.64 logMAR units after 2 years, respectively). Mean IOP decreased from 22.2 ± 7.0 mm Hg at baseline to 12.7 ± 3.1 mm Hg at 3 months and 12.9 ± 4.3 mm Hg 2 years after surgery. The qualified success rate for criterion A was 75.4%, for criterion B 66.6%, and for criterion C45.6%. Complete success rates were 42.9%, 37.5%, and 32.1%, respectively. Two years after repeat trabeculectomy, the mean IOP was reduced by 38.8%, and the number of medications was reduced significantly. CONCLUSIONS: Repeat trabeculectomy with MMC is successful at lowering IOP in POAG and PEXG and permits a significant and safe reduction of antiglaucomatous medication for at least 2 years after surgery.

Recovery of visual function after administration of dabigatran etexilate.

A 46-year-old Caucasian female underwent pars plana vitrectomy (ppv) for retinal detachment. After the procedure, the patient could only distinguish hand movements; the condition was tentatively diagnosed as nonarteritic anterior ischemic optic neuropathy. Conventional treatment with systemic corticosteroids and acetylsalicylic acid was ineffective and yielded substantial steroid-related side effects. Additional administration of 2 × 110 mg dabigatran etexilate (Pradaxa(®)), a novel direct thrombin inhibitor, resulted in a prompt and marked improvement of visual acuity, which indicated improved blood flow in the central vessels of the optic nerve. Dabigatran etexilate may provide a promising alternative for the treatment of postprocedural vision loss after ppv.

Delayed macular hole closure.

PURPOSE: The presented case raises questions regarding the favorable scheduling of planned postoperative care and the ideal observation interval to decide for reoperations in macular hole surgery. Furthermore a discussion about the use of short- and long-acting gas tamponades in macular hole surgery is encouraged. METHODS: We present an interventional case report and a short review of the pertinent literature. RESULTS: We report a case of spontaneous delayed macular hole closure after vitreoretinal surgery had been performed initially without the expected success. A 73-year-old male Caucasian patient presented at our clinic with a stage 2 macular hole in his left eye. He underwent 23-gauge pars plana vitrectomy and internal limiting membrane peeling with a 20% C2F6-gas tamponade. Sixteen days after the procedure, an OCT scan revealed a persistent stage 2 macular hole, and the patient was scheduled for reoperation. Surprisingly, at the date of planned surgery, which was another 11 days later, the macular hole had resolved spontaneously without any further intervention. CONCLUSIONS: So far no common opinion exists regarding the use of short- or long-acting gas in macular hole surgery. Our case of delayed macular hole closure after complete resorption of the gas tamponade raises questions about the need and duration of strict prone positioning after surgery. Furthermore short-acting gas might be as efficient as long-acting gas. We suggest to wait with a second intervention at least 4 weeks after the initial surgery, since a delayed macular hole closure is possible.

11 Years of experience in vitreoretinal surgery training in Nairobi, Kenya, from 2000 to 2010.

OBJECTIVE: We aim to demonstrate that vitreoretinal surgery can be established in Nairobi, Kenya, by intermittent short visits of experienced surgeons combined with clinical/surgical observerships over a longer period of cooperation. This strategy might be a model for other developing countries. DESIGN: Time series over 11 years. PARTICIPANTS: 685 operations were performed over 11 years. METHODS: After the 1998 al-Qaeda bomb assault on the U.S. embassy in Nairobi, Kenya, the Ludwig-Maximilians-University München (Germany) provided materials for surgery of 42 victims with eye injuries. From the year 2000 onward, this equipment has been used to establish a training unit at the Kenyatta Hospital in Nairobi. In 1 annual "project week," 1 author (C-L.S.) performed vitreoretinal surgery at the University of Nairobi in cooperation with the Kenyatta National Hospital and supervised resident eye surgeons. After 7 years of training in Nairobi, clinical/surgical observerships of vitreoretinal surgeons and operating theatre staff were commenced in Munich by 4- to 12-week visits. The project week in Nairobi was carried on. Number, indications, operating surgeons, kind, difficulty, duration of operations, and preparation were recorded and evaluated. RESULTS: The percentage of operations by resident surgeons increased from 29% (in 2000) via 80% (in 2009) to 73% (in 2010) with a partial failure of the laser device. The learning curve of local surgeons is also reflected by an increase of the operations' difficulty with only a moderate increase in operation time and marked decrease of preparation time. CONCLUSIONS: A vitreoretinal unit has been established in Nairobi using our training model. This unit has the potential to train colleagues from other sub-Saharan countries. This strategy has advantages over long-term aid deployment of foreign physicians such as avoiding financial burden for the surgeons to be trained and improving the home facility, but it requires commitment for long-term cooperation.

Secondary glaucoma after intravitreal dexamethasone 0.7 mg implant in patients with retinal vein occlusion: a one-year follow-up.

PURPOSE: To investigate the rate of secondary glaucoma after intravitreal dexamethasone 0.7 mg (Ozurdex(®)) implantation over a clinical treatment period of 1 year. METHODS: A prospective study of a series of 16 patients (9 males, 7 females; mean age 76 years) suffering from central- or branch retinal vein occlusion treated with dexamethasone 0.7 mg were followed up for 12 months. Main outcome measures were intraocular pressure (IOP) determined with Goldmann applanation tonometry (GAT) and Pascal dynamic contour tonometry (DCT), as well as best-corrected visual acuity (BCVA) and central retinal thickness measured with optical coherence tomography (OCT). RESULTS: BCVA (logMAR) improved in treated patients from mean 0.81 at baseline to a peak of 0.47 after 2 months but declined irrespective of reinjections to 0.87 at 12 months. Central retinal thickness measured with OCT initially decreased but increased again with recurring macular edema. 69% of patients treated with dexamethasone 0.7 mg had an IOP increase of at least 5 mmHg. In total, 50% of patients had an increase of ≥10 mmHg during the studied period. The IOP increase in treated eyes was significant 1, 2, 3, and 8 months after dexamethasone 0.7 mg implantation. CONCLUSION: Secondary glaucoma after intravitreal injection of dexamethasone 0.7 mg might be underestimated in the GENEVA studies. The clinical safety profile reported here calls for thorough identification of suitable patients and frequent IOP control if dexamethasone 0.7 mg (Ozurdex) is applied as a long-term treatment.

Restoration of severely impaired eyesight in an adolescent with down syndrome and bilateral cataract in South Asia.

PURPOSE: To report the recovery of visual function after phacoemulsification in a 16-year-old adolescent with Down syndrome (DS) from Saharsa, India. METHODS: Interventional case report and short review of the pertinent literature. RESULTS: A 16-year-old South Asian male with DS and bilateral cataract underwent successful surgery in both eyes after considerable difficulty for his parents including cross-border travel from India into Nepal. After the operation, the patient responded to visual stimuli (e.g. movement of hands) that had eluded him prior to surgery, and thus the additional obstacle to social participation imposed by the impaired eyesight could be removed. CONCLUSIONS: The establishment of basic ophthalmological surgery in developing countries is feasible and can yield extraordinary benefits for individual patients.

Recurrent endophthalmitis after trabeculectomy for glaucoma: importance of timely filtering bleb coverage for the conjunctiva.

PURPOSE: To report the occurrence of endophthalmitis after trabeculectomy for glaucoma that was treated by vitrectomy without bleb closure and recurred 3 times after an initial clinically inapparent period of about 2 years. METHODS: Interventional case report and short review of the pertinent literature. RESULTS: A 73-year-old Caucasian female underwent trabeculectomy (without mitomycin) for glaucoma. Four years after the trabeculectomy, an endophthalmitis with Staphylococcus epidermidis as the causative organism occurred and was treated with a pars plana vitrectomy (20-gauge) and a combined antibiotic and anti-inflammatory drug regimen. The bleb was not covered during the emergency procedure because the filtering bleb was heavily infected and filled with pus. As the filtering bleb healed nicely and the filtering function was restored, the filtering bleb was left as it was, and best-corrected visual acuity initially recovered to 0.8. After 22 months, the endophthalmitis recurred, this time with Enterococcus faecalis as the causative organism. Its treatment required a total of four further vitrectomies (23-gauge), each accompanied by the same antibiotic and anti-inflammatory drug regimen that had been applied previously. However, the visual acuity could not be preserved, and the eye is blind with defective light projection. CONCLUSIONS: The literature suggests an aggressive surgical approach to endophthalmitis, and the present case report confirms this. Since the visual prognosis of eyes after endophthalmitis is poor, the course of treatment for endophthalmitis after trabeculectomy should emphasize recurrence prophylaxis rather than address glaucoma symptoms and therefore include safe bleb leak coverage.

Preemptive analgesia with ropivacaine for pars plana vitrectomy: randomized controlled trial on efficacy and required dose.

BACKGROUND: The rationale of preemptive analgesia in ocular surgery is avoiding central sensitization because of nociceptive stimuli. The applicability in clinical practice has been argued because evidence for a relevant effect is missing. The present study attempts to demonstrate a clinically relevant pain reduction by preemptive peribulbar ropivacaine injection. METHODS: Sixty patients scheduled for vitrectomy under general anesthesia between March and June 2007 were randomly assigned to receive 0.75% ropivacaine with 75 IU of hyaluronidase as peribulbar injection of 1, 3, or 5 mL before or 5 mL after surgery. Control subjects were 30 patients without any additional analgesic treatment. Groups were compared regarding procedure duration, consumed amount of analgesics during and after surgery, and pain 1, 3, and 24 hours postoperatively. RESULTS: Postoperative pain was most marked in control subjects and in the group that received the injection after surgery. Before surgery, the dose of 5 mL of ropivacaine was most effective (postoperative pain median = 0), whereas patients who had received 1 mL or 3 mL reported some pain. CONCLUSION: The study highlights the benefit of the concept of preemptive analgesia in general: the peribulbar injection of 5 mL of 0.75% ropivacaine before surgery provides a substantial benefit in terms of analgesic demand and postoperative discomfort.

Cystoid Macular Edema after Complicated Cataract Surgery Resolved by an Intravitreal Dexamethasone 0.7-mg Implant.

PURPOSE: To report the effective treatment of cystoid macular edema (CME) following complicated cataract surgery (resulting in Irvine-Gass syndrome) with a dexamethasone 0.7-mg (Ozurdex(®)) intravitreal implant. METHODS: An interventional case report with optical coherence tomography (OCT) scans. RESULTS: An 83-year-old Caucasian woman was suffering from CME following complicated cataract surgery on her left eye. She had undergone 3 intravitreal injections of dexamethasone 0.4 mg in the 3 months following the surgery without any improvement of visual function. Seven months after the cataract surgery, she received a single intravitreal injection of dexamethasone 0.7 mg (Ozurdex). Four weeks following the injection, her best-corrected visual acuity improved from 0.3 to 0.8. CME resolved with a reduction of central retinal thickness from 393 µm pre-Ozurdex injection to 212 µm post-Ozurdex injection, as measured by OCT scan. CONCLUSION: Dexamethasone 0.7 mg (Ozurdex) has proven to be an effective treatment option in retinal vein occlusion and non-infectious uveitis. It can also be considered as off-label treatment in Irvine-Gass syndrome.

Fast Resolution of Recurrent Pronounced Macular Edema following Intravitreal Injection of Dexamethasone 0.7 mg.

PURPOSE: To report the fast resolution of recurrent pronounced macular edema due to central retinal vein occlusion (CRVO) within 72 h following intravitreal injection of dexamethasone 0.7 mg (Ozurdex®). METHODS: An interventional case report with optical coherence tomography scans and fluorescein angiographic pictures. RESULTS: A 69-year-old Caucasian man underwent intravitreal injection of dexamethasone 0.7 mg due to incomplete CRVO. He had previously undergone 6 intravitreal injections of bevacizumab 1.25 mg (Avastin®) and a C-grid laser photocoagulation over an interval of 16 months. After repeated recurrences of macular edema, the injection of dexamethasone reduced the macular edema from 570 µm preoperatively to 246 µm postoperatively within 72 h following the injection. Best-corrected visual acuity improved from 0.1 to 0.6 within the same interval. CONCLUSION: Dexamethasone can lead to a very fast reduction of macular edema in patients with vision loss due to CRVO and may facilitate an immediate visual rehabilitation. Retinal anatomy and visual acuity may be restored even in long-standing, recurrent cases.

Efficacy and safety of hyaluronidase 75 IU as an adjuvant to mepivacaine for retrobulbar anesthesia in cataract surgery.

PURPOSE: To evaluate the efficacy and safety of hyaluronidase as an adjuvant to mepivacaine for retrobulbar anesthesia in cataract surgery. SETTING: Department of Ophthalmology, Ludwig-Maximilians-University, Munich, and Eye Center Munich East, Munich-Haar, Germany. METHODS: Eyes having cataract surgery at 1 of the 2 centers were included in this prospective randomized double-blind placebo-controlled clinical trial. Retrobulbar anesthesia was administered by the surgeon using a solution of 5 mL mepivacaine 1% with additional hyaluronidase (Hylase Dessau) 75 IU (40 eyes) or additional placebo (40 eyes). The main target parameter was akinesia 5 minutes after administration of the study medication. Secondary parameters were akinesia at later times, additional injections, ptosis of the upper eyelid, time to reach complete anesthesia, assessment of pain using a visual analog scale, assessment of efficacy and tolerability by the patient and the surgeon, and adverse events. RESULTS: Complete akinesia 5 minutes after retrobulbar injection was reached in significantly more cases in the hyaluronidase group (29) than in the placebo group (13) (P < .001). Additional injections were necessary in 5 placebo-treated eyes. The administration of hyaluronidase yielded significantly better results than the placebo in terms of ptosis, time to reach complete anesthesia, assessment of efficacy, tolerability, and postoperative pain. No adverse events occurred in either group. CONCLUSION: The addition of hyaluronidase to mepivacaine for retrobulbar anesthesia in cataract surgery enhanced the safety of the surgical procedure due to more complete akinesia and quicker onset of complete anesthesia.