Incidence of endophthalmitis following intravitreal Bevacizumab injection at a tertiary care hospital in Eastern Province of Saudi Arabia.

The aim of this communication is to report the incidence of endophthalmitis following the use of intravitreal Bevacizumab (IVB) at a tertiary care hospital in the Eastern province of Saudi Arabia. A total of 2769 intravitreal Bevacizumab injections were carried out between January 2009 and April 2014. During this period, one case of endophthalmitis following IVB injection occurred. The overall incidence of clinical endophthalmitis was 0.036% (1/2769; 95% confidence interval: 0.0001-0.002%). This compares favorably with studies reported from other parts of the world.

Randomized controlled trial to evaluate intraocular pressure following sub-Tenon's local anesthesia for cataract surgery: With and without hyaluronidase added to anesthetic solution.

AIM: To evaluate effect on intraocular pressure (IOP) during sub-Tenon's local anesthesia (LA) during cataract surgery with 4 ml of anesthetic injected without and with addition of hyluronidase to anesthetic solution. MATERIALS AND METHODS: This randomized controlled study included 65 eyes of 65 patients undergoing phacoemulsification and lens implant for cataract. The patients were randomized to a standardized procedure of administration of 4 ml of sub-Tenon's LA without and with addition of 15 IU/ml hylaluronidase to 2% lidocaine (control group and intervention group respectively). IOP measurements were carried out immediately prior to and at 2, 5, and 10 and 15 min after sub-Tenon's injection using a hand held tonometer (Tonopen). RESULTS: All patients achieved satisfactory akinesia and complete analgesia during surgery. The mean age of patients in control group was 59.56 ± 14.3 years, and 61.77 ± 11.91 years in intervention group (P = 0.507). The mean preinjection and 15 min IOP was 19.16 ± 4.39 and 20.21 ± 5.49 mm Hg, respectively in control group (P = 0.220); and 19.81 ± 3.8 and 19.68 ± 5.19 mmHg respectively in intervention group (P = 0.911). No statistical difference from baseline was detected between preinjection and at 2, 5, 10, and 15 min after injection in control (P = 0.124, 0.310, 0.804, 0.220, respectively) and intervention group (P = 0.367, 0.879, 0.765, 0.911 respectively). CONCLUSION: No significant rise in IOP occurs following injection of sub-Tenon's LA, when up to 4 ml of anesthetic is injected. The addition of hyaluronidase to 2% lignocaine has no beneficial lowering effect on IOP in sub-Tenon's LA. Hence, the practice of addition of this agent may not be necessary during cataract surgery.

Intravitreal bevacizumab as a primary treatment for idiopathic choroidal neovascularization.

PURPOSE: To report long-term outcomes of the use of intravitreal bevacizumab in subjects with idiopathic choroidal neovascularization (ICNV). MATERIALS AND METHODS: Six consecutive subjects with ICNV were included in this prospective study. All subjects received 1.25 mg intravitreal bevacizumab at diagnosis. A decrease in best corrected visual acuity (BCVA), presence of increased retinal edema or hemorrhage, increased retinal thickness on optical coherence tomography (OCT) or increased leakage documented by fluorescein angiography prompted further injections of bevacizumab. RESULTS: The study cohort was comprised of 3 males and 3 females with a mean age of 31.17 years. Mean follow-up was 13.8 months (range, 8 months to 20 months). Following intravitreal bevacizumab injection, vision improved in 3 subjects, remained stable in 3 subjects and no patient lost visual acuity. The mean BCVA improved to logMAR 0.20 at final follow-up from baseline at 0.950 logMAR (P=0.031). The mean central macular thickness and central foveal thickness at the last postoperative visits were reduced from pre-treatment levels of 374.33 ± 146.52 and 347.16 ± 213.97 to 251.20±35.36 and 215.33 ± 43.94 µm, respectively. (P = 0.99 and P = 0.16, respectively). Four subjects required repeat treatments. The total number of repeat treatments was 4. Two subjects required no repeat injections, 3 subjects had 1 retreatment and one subject required 2 additional treatments. The injections were well tolerated by all the subjects, with no ocular or systemic adverse events. CONCLUSION: Intravitreal injection of 1.25 mg bevacizumab in patients with ICNV is effective in improving and stabilizing vision. Additional studies, particularly determination of optimal protocol for timing of re-injection are required to assess long-term effects.

Infliximab therapy for idiopathic retinal vasculitis, aneurysm, and neuroretinitis syndrome.

PURPOSE: We report our experience in treating 2 patients of idiopathic retinal vasculitis, aneurysm, and neuroretinitis (IRVAN) syndrome with antitumor necrosis factor agent, infliximab, who showed a very favorable response to treatment. METHODS: Two patients with clinical diagnosis of IRVAN syndrome were included in the study. The visual acuity was affected due to ocular inflammation and presence of macular edema due to exudation around the optic nerve. RESULTS: The patients did not respond to initial treatment with oral steroids, and visual acuity continued to deteriorate due to macular exudation. Infliximab therapy resulted in prompt resolution of the inflammatory reaction and retinal exudation, with improvement in visual acuity, that was subsequently maintained with maintenance therapy. The intravenous infliximab infusions were scheduled at 0, 4, 8, and 12 weeks initially, and every 2 months thereafter. Retinal neovasculariztion in each patient was managed by pan retinal photocoagulation. CONCLUSION: Infliximab therapy may be useful in reducing inflammation and leakage from the optic nerve in patients with IRVAN syndrome. This may help preserve or improve visual acuity. However, further studies are required to evaluate the long-term benefits of this therapy.

Role of intravitreal bevacizumab (Avastin) injected at the end of diabetic vitrectomy in preventing postoperative recurrent vitreous hemorrhage.

PURPOSE: The purpose of this study was to evaluate the role of bevacizumab (Avastin), an antivascular endothelial growth factor agent, injected at the end of surgery for preventing postoperative recurrent vitreous hemorrhage in patients undergoing vitrectomy for diabetic eye disease. METHODS: This was a retrospective, comparative, and nonrandomized study on a consecutive series of patients who underwent vitrectomy for diabetic eye disease. Recurrence of postoperative vitreous hemorrhage was compared in patients with and without intravitreal 1.25 mg bevacizumab given at the end of surgery. RESULTS: During the study period, 58 patients had vitrectomy for diabetic disease. In 33 patients (the control group), no intravitreal bevacizumab was injected at the end of surgery, and in 25 patients (the intervention group) intravitreal bevacizumab 1.25 mg/0.05 mL was injected at the end of surgery. Both groups were matched for the number of patients, age, sex, diagnosis, and status of systemic disease. Recurrent postoperative vitreous hemorrhage was noted in 14 patients in the control group (14 of 33, 42.40%) and in 1 patient in the intervention group (1 of 25, 4.0%). The difference in postoperative vitreous hemorrhage between the 2 groups was statistically significant (P = 0.001). There was no statistical difference in the mean postoperative visual acuity between the 2 groups during the follow-up period (P = 0.410). CONCLUSION: Intravitreal injection of 1.25 mg bevacizumab given at the end of vitrectomy appears safe and effective for reducing the incidence of recurrent postoperative vitreous hemorrhage after diabetic vitrectomy. Further randomized studies should be performed to evaluate the potential of this therapy in preventing postoperative recurrent vitreous hemorrhage after diabetic vitrectomy.

Role of residual vitreous cortex removal in prevention of postoperative vitreous hemorrhage in diabetic vitrectomy.

AIM: To evaluate whether residual vitreous cortex removal has a role in the prevention of postoperative vitreous hemorrhage in diabetic vitrectomy. METHODS: Retrospective, comparative, nonrandomized study on a consecutive series of patients who underwent vitrectomy for diabetic eye disease. Recurrence of postoperative vitreous hemorrhage was compared in patients following surgery with and without residual vitreous cortex removal. RESULTS: During the study period, 59 patients had vitrectomy for diabetic disease. In 31 patients (group 1), the residual vitreous cortex was not removed and in 28 patients (group 2) the residual vitreous cortex was removed during surgery. Both groups were matched for number of patients, age, sex, duration of follow-up, and diagnosis. Recurrent postoperative vitreous hemorrhage (RVH) was noted in ten patients in group 1 (10/31, 32.25%) and in two patients in group 2 (2/28, 7.14%). The difference in postoperative vitreous hemorrhage between the two groups was statistically significant (P = 0.017). Logistic regression analysis showed that residual vitreous cortex removal and presence of intravitreal gas tamponade were associated with reduced risk of postoperative vitreous hemorrhage. However, only residual vitreous cortex removal was statistically significant factor in reducing risk of postoperative vitreous hemorrhage [odds ratio = 0.174; confidence interval (CI) = 0.0331-0.919; P = 0.040]. CONCLUSION: Residual vitreous cortex removal may be beneficial in reducing recurrence of postoperative vitreous hemorrhage following diabetic vitrectomy. Further randomized studies should be performed to evaluate the potential of this surgical technique in preventing postoperative recurrent vitreous hemorrhage following diabetic vitrectomy.

Pediatric retinal detachment in the Eastern Province of Saudi Arabia: experience of a tertiary care hospital.

BACKGROUND AND OBJECTIVES: Because no previous studies have addressed the issue, we describe clinical characteristics and surgical outcome of patients with rhegmatogenous retinal detachment (RRD) in a pediatric population of the Eastern province of Saudi Arabia. PATIENTS AND METHODS: We conducted a retrospective review of all consecutive cases of pediatric RRD (0-18 years) patients presenting at Dhahran Eye Specialist Hospital, a tertiary care hospital, in the Eastern Province of Saudi Arabia over a period of 3 years. RESULTS: Twenty patients were included in the study, accounting for 9.4% of all retinal detachment surgery cases performed over a period of 3 years (January 2006 to December 2008). The median age was 11.0 years, (range, birth to 18 years). Trauma, (45%) myopia/vitreoretinal degeneration (10%) and prior ocular surgery (25%) were significant risk factors for RRD. Proliferative vitreoretinopathy (PVR) more than grade C was present in 14/20 (70%) of cases. Most patients (15/20, 75%) were treated with pars plana vitrectomy and placement of an encircling buckle, while silicone oil or gas was used as tamponade in 13/20 (65%) patients. Surgery was successful in 17/20 (85%) cases in achieving retinal re-attachment. Visual acuity improved significantly following surgery (Mean preop 2.146 LogMAR, Mean postop 1.497 LogMAR) ( P= .014). Longer duration of RRD ( P =.007) and macular involvement ( P =.05) were associated with worse anatomical outcomes following surgery. CONCLUSION: Pediatric RRD in the Eastern province is often associated with predisposing pathology. Surgery is successful in achieving anatomical reattachment of the retina in a majority of cases with improvement of visual acuity.

Role of combined cataract surgery and intravitreal bevacizumab injection in preventing progression of diabetic retinopathy: prospective randomized study.

PURPOSE: To evaluate the role of intravitreal bevacizumab, an anti-vascular endothelial growth factor agent, injected at the time of cataract surgery on the postoperative progression of diabetic retinopathy (DR) and diabetic maculopathy. SETTING: Tertiary-care eye specialty hospital, Dhahran, Kingdom of Saudi Arabia. METHODS: Patients were randomized to a standardized procedure of phacoemulsification with intraocular lens implantation alone (control group) or to receive 1.25 mg intravitreal bevacizumab at the end of surgery (intervention group). Diabetic retinopathy and maculopathy were assessed at each postoperative visit during a 6-month follow-up. RESULTS: Sixty-eight eyes (68 patients) with DR and cataract were recruited for this prospective study. Progression of DR occurred in 15 (45.45%) of 33 eyes in the control group and 4 (11.42%) of 35 eyes in the intervention group (P = .002) Progression of diabetic maculopathy occurred in 17 eyes (51.51%) in the control group and 2 eyes (5.71%) in the intervention group (P = .0001). There was no statistically significant difference in postoperative visual acuity between the 2 groups (P = .772). Two eyes in the control group and none in the intervention group progressed to neovascular glaucoma. The mean postoperative central macular thickness and mean macular thickness were not statistically significantly different between the 2 groups (P = .874 and .942, respectively). CONCLUSION: Intravitreal administration of 1.25 mg bevacizumab at the time of cataract surgery was safe and effective in preventing the progression of DR and diabetic maculopathy in patients with cataract and DR.

Triamcinolone acetonide as an adjuvant in the surgical treatment of retinal detachment with proliferative vitreoretinopathy.

BACKGROUND AND OBJECTIVE: To report the efficacy of intravitreal triamcinolone acetonide as an adjuvant in the surgical management of cases with advanced proliferative vitreoretinopathy (PVR). PATIENTS AND METHODS: Patients with complicated rhegmatogenous retinal detachment and PVR grade C2 or greater were recruited for this interventional, noncomparative, prospective study. All patients underwent three-port pars plana vitrectomy, membrane peeling, laser photocoagulation, and silicone oil injection to reattach the retina followed by 0.1 mL (4 mg) of triamcinolone acetonide injected through the pars plana into the silicone oil. All patients had supplemental laser therapy around retinal breaks and retinectomy edges at 1 to 2 weeks postoperatively. RESULTS: Patients included 15 males and 9 females, with an average age of 53.6 years (range: 15 to 84 years) and PVR grade C2 to PVR C9. The mean follow-up period was 11.0 months (range: 3 to 26 months). Twenty-one (87.5%) patients had attached retinas at the final followup visit. Visual acuity improved in all patients following surgery (P < .05). CONCLUSION: Triamcinolone acetonide may have potential as an adjuvant in the treatment of retinal detachment with PVR. Further research is required to evaluate the efficacy of this adjuvant treatment.

Phacoemulsification using iris-hooks for capsular support in high myopic patient with subluxated lens and secondary angle closure glaucoma.

We report an unusual case of angle closure glaucoma in a 78-year-old highly myopic female patient. The patient did not show any preoperative signs of subluxation of lens. However, the capsular bag was noted to be unstable during surgery. The patient was managed with phacoemulsification of lens using a novel method of iris hooks for stabilization of capsular bag during surgery.

Delayed suprachoroidal hemorrhage following viscocanalostomy.

Delayed suprachoroidal hemorrhage is a rare complication of conventional glaucoma surgery. Viscocanalostomy is one of the new surgical techniques used in glaucoma surgery that may theoretically protect against suprachoroidal effusion and hemorrhage due to the nonpenetrating nature of the procedure. Delayed suprachoroidal hemorrhage developed in a 92-year-old white woman following viscocanalostomy. This case demonstrates that the risk of suprachoroidal hemorrhage may not be completely eliminated after a nonpenetrating glaucoma procedure such as viscocanalostomy.

Orbital cellulitis with gas.

Orbital cellulitis due to presumed gas-producing organisms has been associated with poor visual prognosis. We report successful visual recovery in a 14-year-old boy with orbital cellulitis and gas in the orbit on CT scan. The patient was treated with intravenous antibiotics and prompt orbital decompression. Pus from the sinus aspirate and orbital drain grew H. influenzae and Gram-negative bacilli. Repeat orbital surgery with drainage of residual abscess was performed and the patient made a complete recovery.