Medical Waste Due to Intravitreal Injection Procedures in a Retina Clinic.

Purpose: Medical waste contributes to health care costs and has a direct negative impact on the environment. The goals of this study are to quantify and categorize the medical waste generated by intravitreal injection procedures and identify opportunities to reduce waste. Methods: This is a prospective observational series. Medical waste from intravitreal injections was collected from 337 consecutive intravitreal injections by a retina specialist over 2 weeks. The waste was sorted, photographed, weighed, and recorded. Results: A total of 65.6 kg of waste was collected across 3 broad categories: (1) shipping waste (cardboard boxes, foam coolers, cold packs, and bubble wrap); (2) waste from administering the intravitreal injection (nitrile gloves, tissues, wipes, and plastic or paper packaging); and (3) biohazard waste (used syringes and needles). Shipping waste contributed 83% of the overall waste, by mass, and varied greatly based on the size of the order and how efficiently shipments were packed. Cold packs, foam coolers, cardboard/paper, and nitrile gloves were the greatest contributors to carbon emissions and landfill. Conclusions: Waste due to shipping of medication is a major opportunity for reducing the environmental impact of intravitreal injections. Buying in bulk is a simple way for retina practices to reduce waste. Manufacturers should consider less bulky packaging for branded intravitreal injections; distributors and outsourcing facilities should consider take-back programs to reuse coolers and cold packs. Improved sustainability in the treatment of retinal disease is achievable but requires awareness and optimization of a clinic's routine.

Posterior Retinotomy vs Perfluorocarbon Liquid to Aid Drainage of Subretinal Fluid During Primary Rhegmatogenous Retinal Detachment Repair (PRO Study Report No. 10).

Purpose: This work compares posterior retinotomy vs perfluorocarbon liquid (PFCL) for subretinal fluid (SRF) drainage during pars plana vitrectomy for primary rhegmatogenous retinal detachment (RRD). Methods: In this large, multicenter, retrospective comparative study, 2620 patients underwent pars plana vitrectomy (with or without scleral buckle) for uncomplicated RRD. Patients for whom SRF was drained via the primary break without retinotomy or PFCL were excluded; those who required both retinotomy and PFCL were similarly excluded. Remaining patients were separated into "retinotomy" and "PFCL" cohorts. Subgroup analysis was conducted for macula-on and macula-off subgroups. Postoperative outcomes were analyzed and compared. Results: A total of 760 eyes (82.7%) had retinotomy and 159 eyes (17.3%) had PFCL for drainage of SRF, and baseline characteristics between the 2 groups were similar. Postoperative analysis showed similar outcomes between the retinotomy and PFCL cohorts, including final visual acuity (P = .19), redetachment rate (P = .30), anatomic success (P = .28), presence of postoperative epiretinal membrane (P = .75), and other macular pathologies (P > .99). Subgroup analysis yielded similar outcomes for macula-on and macula-off subgroups. Postoperative presence of retained PFCL was 2.4%, possibly a factor in the slightly higher number of subsequent surgical procedures (P = .03) in the PFCL cohort. Conclusions: Postoperative outcomes for retinotomy vs PFCL during RRD repair are comparable, aside from slightly greater number of subsequent surgical procedures needed in the PFCL cohort. Our analysis suggests both techniques are reasonable tools in the repair of macula-on or macula-off RRD.

Anterior segment retinoblastoma detectable on magnetic resonance imaging.

PURPOSE: To report a case of retinoblastoma infiltrating the iris and ciliary body detected on magnetic resonance imaging. METHODS: A retrospective case report with clinical evaluation, diagnostic testing, enucleation, and pathologic description. RESULTS: A 2-year-old boy presented with hyphema and was noted to have a fluffy whitish iris mass. Retinoblastoma with anterior chamber extension was suggested on magnetic resonance imaging. T2-weighted images demonstrated a hypointense mass with a superficial layer of focal marked hypointensity, consistent with hemorrhage or calcification. Enucleation was performed, and histopathology confirmed retinoblastoma infiltrating the iris and ciliary body. No further treatment was administered, and the patient remains free of associated disease at age 5 years. CONCLUSION: Retinoblastoma can invade the iris and ciliary body stroma. The use of magnetic resonance imaging in evaluating cases of anterior segment masses can demonstrate findings suggestive of retinoblastoma.

Management of fluocinolone implant dissociation during implant exchange.

Three patients with chronic, noninfectious uveitis requiring immunosuppressive therapy underwent fluocinolone acetonide (FA) implant exchange complicated by dissociation of the medication reservoir from its anchoring strut. In 2 patients, the medication reservoir descended into the vitreous cavity and required pars plana vitrectomy with intraocular foreign body removal techniques for its retrieval. The use of viscoelastic or perfluorocarbon to elevate the device was helpful in the safe removal of the FA implant device. Surgeons performing FA implant exchange should be aware of this potential complication and anticipate the possible need for vitreoretinal instrumentation and personnel. Patients undergoing FA explantation or exchange should be counseled regarding this potential complication prior to surgery.

Current and emerging therapies for the treatment of age-related macular degeneration.

Age-related macular degeneration (AMD) is the leading cause of vision loss in the industrialized world. In the last few decades, the mainstay of treatment for choroidal neovascularization (CNV) due to AMD has been thermal laser photocoagulation. In the last decade, photodynamic therapy with verteporfin extended treatment for more patients. While both of these treatments have prevented further vision loss in a subset of patients, improvement in visual acuity is rare. Anti-vascular endothelial growth factor A (VEGF) therapy has revolutionized the treatment of AMD-related CNV. Pegaptanib, an anti-VEGF aptamer prevents vision loss in CNV, although the performance is similar to that of photodynamic therapy. Ranibizumab, an antibody fragment and bevacizumab, a full-length humanized monoclonal antibody against VEGF have both shown promising results with improvements in visual acuity with either agent. VEGF trap, a modified soluble VEGF receptor analogue, binds VEGF more tightly than all other anti-VEGF agents and has also shown promising results in early trials. Other treatment strategies to decrease the effect of VEGF have used small interfering ribonucleic acid (RNA) to inhibit VEGF production and VEGF receptor production. Steroids, including anecortave acetate in the treatment and prevention of CNV, have shown promise in controlled trials. Receptor tyrosine kinase inhibitors, such as vatalanib, inhibit downstream effects of VEGF, and have been effective in the treatment of CNV in early studies. Squalamine lactate inhibits plasma membrane ion channels with downstream effects on VEGF, and has shown promising results with systemic administration. Other growth factors, including pigment epithelium-derived growth factor that has been administered via an adenoviral vector has shown promising initial results. In some patients ciliary neurotrophic factor is currently being studied for the inhibition of progression of geographic atrophy. Combination therapy has been investigated, and may prove to be more effective in the management of AMD-associated CNV. Ongoing and future studies will be crucial for optimizing the treatment of patients with AMD.

Optical coherence tomography findings during pegaptanib therapy for neovascular age-related macular degeneration.

BACKGROUND: To evaluate macular thickness measured by optical coherence tomography (OCT) during pegaptanib therapy for neovascular age-related macular degeneration (AMD). METHODS: For this prospective, nonrandomized, observational case series, 41 eyes from 41 patients with neovascular AMD received intravitreous pegaptanib (1 mg) injections repeated every 6 weeks. The primary outcome measure was central foveal thickness measured by OCT. Secondary outcomes were fluorescein angiographic leakage and visual acuity. RESULTS: Mean thickness of the central area on OCT decreased from 340 +/- 24 microm to 299 +/- 14 microm after 12 weeks of pegaptanib injections. This represents a reduction in thickening of 32%. Fluorescein angiograms with definite leakage decreased from 100% to 81%, and mean visual acuity decreased from 20/116 to 20/120. CONCLUSIONS: Intravitreal injections of pegaptanib at 6-week intervals result in a moderate reduction of central foveal thickness in eyes with subfoveal neovascular AMD. This presents a modest effect relative to that reported with other anti-angiogenic agents.

Emerging therapies for the treatment of neovascular age-related macular degeneration and diabetic macular edema.

Diabetic macular edema (DME) and choroidal neovascularization (CNV) associated with age-related macular degeneration (AMD) are the leading causes of vision loss in the industrialized world. The mainstay of treatment for both conditions has been thermal laser photocoagulation, while there have been recent advances in the treatment of CNV using photodynamic therapy with verteporfin. While both of these treatments have prevented further vision loss in a subset of patients, vision improvement is rare. Anti-vascular endothelial growth factor (VEGF)-A therapy has revolutionized the treatment of both conditions. Pegaptanib, an anti-VEGF aptamer, prevents vision loss in CNV, although the performance is similar to that of photodynamic therapy. Ranibizumab, an antibody fragment, and bevacizumab, a full-length humanized monoclonal antibody against VEGF, have both shown promising results, with improvements in visual acuity in the treatment of both diseases. VEGF trap, a modified soluble VEGF receptor analog, binds VEGF more tightly than all other anti-VEGF therapies, and has also shown promising results in early trials. Other treatment strategies to decrease the effect of VEGF have used small interfering RNA to inhibit VEGF production and VEGF receptor production. Corticosteroids have shown efficacy in controlled trials, including anacortave acetate in the treatment and prevention of CNV, and intravitreal triamcinolone acetonide and the fluocinolone acetonide implant in the treatment of DME. Receptor tyrosine kinase inhibitors, such as vatalanib, inhibit downstream effects of VEGF, and have been effective in the treatment of CNV in early studies. Squalamine lactate inhibits plasma membrane ion channels with downstream effects on VEGF, and has shown promising results with systemic administration. Initial results are also encouraging for other growth factors, including pigment epithelium-derived factor administered via an adenoviral vector. Ruboxistaurin, which decreases protein kinase C activity, has shown positive results in the prevention of diabetic retinopathy progression, and the resolution of DME. Combination therapy has been investigated, and may prove to be quite effective in the management of both DME and AMD-associated CNV, although ongoing and future studies will be crucial to treatment optimization for each condition.

Ocular autopsy and histopathologic features of child abuse.

PURPOSE: To study the ocular histopathologic features in eyes of children with fatal suspected child abuse. DESIGN: Retrospective case series. PARTICIPANTS: One hundred eighteen autopsy cases of known or suspected child abuse. METHODS: The ocular autopsy and histopathologic features of a cohort of consecutive cases of known or presumed child abuse submitted by Maryland's Office of the Chief Medical Examiner or Johns Hopkins Hospital to the Wilmer Eye Pathology Laboratory were tabulated. MAIN OUTCOME MEASURE: Ocular hemorrhage or structural abnormality. RESULTS: Retinal hemorrhage was present in 44% of cases. Circumferential folds with macular schisis cavities were present in 23% of cases and were bilateral in half of those cases. Peripapillary scleral hemorrhage was present in 38% of cases, and subdural hemorrhage was present in the distal optic nerve in 46% of cases. Hemosiderin was present in 27% of cases. CONCLUSIONS: Intraretinal hemorrhages, circumferential macular folds with schisis cavities, peripapillary scleral hemorrhages, and subdural hemorrhages are common pathologic findings in cases of fatal known or suspected child abuse. Their presence on autopsy should raise the suspicion of shaking or blunt nonaccidental trauma.

Intravitreal bevacizumab (Avastin) treatment of neovascular age-related macular degeneration.

PURPOSE: To report the change in visual acuity and central retinal thickness by optical coherence tomography (OCT) after intravitreal injections of bevacizumab for the treatment of neovascular age-related macular degeneration (AMD). METHODS: A retrospective case series in a university-based practice evaluated patients with subfoveal choroidal neovascularization (CNV) due to AMD. Patients received intravitreal injections (1.25 mg) of bevacizumab and were monitored monthly with determination of best-corrected ETDRS visual acuity and OCT for persistence of retinal thickening. Eyes were retreated on an "as needed" basis, defined by presence of intraretinal or subretinal fluid. Patients were monitored every 2 months to 3 months for persistence of angiographic leakage. RESULTS: Seventy-nine eyes of 74 consecutive patients received the initial injection of bevacizumab between August 1, 2005, and January 30, 2006. Sixty-eight eyes (86%) of 64 patients had at least 3 months of follow-up. Mean central retinal thickness +/- SD decreased from 304 +/- 83 microm at baseline to 237 +/- 105 microm at 3 months (P = 0.00002). Mean ETDRS visual acuity gained 4 letters from 20/100 at baseline to 20/80-1 at 3 months (P = 0.040). Twenty eyes (25%) appeared to have a sustained response to a single injection and did not require further injections through 3 months. Two patients had a potentially drug-related adverse event (ischemic stroke and myocardial infarction). No serious injection-related adverse events occurred. CONCLUSIONS: Intravitreal bevacizumab injection affects a rapid decrease in retinal thickness to normal or near-normal levels and improvement in visual acuity in eyes with CNV due to AMD. The sustainability of changes in retinal thickness and visual acuity in response to bevacizumab treatment warrant further investigation and long-term follow-up.