Sudden Vision Loss.

A 37-year-old woman was referred for evaluation of a retinal detachment in her left eye. Posterior examination results demonstrated a retinal detachment in the posterior pole with shifting fluid and no identifiable retinal break, and there was a thickened choroid with a hyporeflective band on ultrasound biomicroscopy. What would you do next?

Intravitreal triple therapy with vancomycin, ceftazidime, and moxifloxacin for bacterial endophthalmitis: A Twelve-year experience.

PURPOSE: Increasing rates of antibiotic resistance in endophthalmitis have been reported. This study examines outcomes of triple therapy with intravitreal vancomycin, ceftazidime, and moxifloxacin for endophthalmitis. METHODS: Retrospective, consecutive series of all patients treated with abovementioned intravitreal antibiotics from January 2009 to June 2021. Percentages of eyes attaining greater than or equal to 20/200 and 20/50 Snellen visual acuities and adverse events were evaluated. RESULTS: 112 eyes met inclusion criteria. 63 of 112 eyes (56%) achieved a visual acuity of 20/200 during follow-up, with 39 (35%) returning to at least 20/50. In subgroup analysis, 23 of 24 (96%) eyes with post-cataract endophthalmitis obtained ≥ 20/200 acuity and 21 of 24 (88%) obtained ≥ 20/50 acuity during follow-up. There were no cases of macular infarction. CONCLUSIONS: Intravitreal moxifloxacin (160 µg/0.1 mL) was well tolerated as an adjunct to vancomycin and ceftazidime for bacterial endophthalmitis. Use of this novel combination offers several theoretical advantages compared to standard therapy with two antibiotics, including expanded gram-negative coverage and potential synergy, and may be particularly valuable in geographies where the local antibiogram supports empiric use. Further study is merited to verify the safety and efficacy profile.

Arginine and Carnitine Metabolites Are Altered in Diabetic Retinopathy.

Purpose: To determine plasma metabolite and metabolic pathway differences between patients with type 2 diabetes with diabetic retinopathy (DR) and without retinopathy (diabetic controls), and between patients with proliferative DR (PDR) and nonproliferative DR (NPDR). Methods: Using high-resolution mass spectrometry with liquid chromatography, untargeted metabolomics was performed on plasma samples from 83 DR patients and 90 diabetic controls. Discriminatory metabolic features were identified through partial least squares discriminant analysis, and linear regression was used to adjust for age, sex, diabetes duration, and hemoglobin A1c. Pathway analysis was performed using Mummichog 2.0. Results: In the adjusted analysis, 126 metabolic features differed significantly between DR patients and diabetic controls. Pathway analysis revealed alterations in the metabolism of amino acids, leukotrienes, niacin, pyrimidine, and purine. Arginine, citrulline, glutamic γ-semialdehyde, and dehydroxycarnitine were key contributors to these pathway differences. A total of 151 features distinguished PDR patients from NPDR patients, and pathway analysis revealed alterations in the ß-oxidation of saturated fatty acids, fatty acid metabolism, and vitamin D3 metabolism. Carnitine was a major contributor to the pathway differences. Conclusions: This study demonstrates that arginine and citrulline-related pathways are dysregulated in DR, and fatty acid metabolism is altered in PDR patients compared with NPDR patients.

Three-Year Findings on Intraocular Pressure Changes in The Prospective Retinal and Optic Nerve Vitrectomy Evaluation (PROVE) Study.

BACKGROUND AND OBJECTIVE: This paper reports 3-year intraocular pressure (IOP) outcomes of the Prospective Retinal and Optic Nerve Vitrectomy Evaluation (PROVE) study. PATIENTS AND METHODS: The prospective, controlled, observational study included 80 eyes of 40 participants undergoing routine pars plana vitrectomy. Study patients underwent preoperative evaluation and multimodal testing of the study (surgical) and fellow (control) eye. This testing was repeated at 3 months postoperatively and then annually for 3 years. RESULTS: Thirty-two of 40 patients (80%) completed 3-year follow-up. At 3 years postoperatively, there was no difference in IOP measurements in surgical eyes overall from baseline (P = .36). Subgroup analysis of pseudophakic eyes at baseline showed a significant elevation in IOP from 14.3 mm Hg ± 2.9 mm Hg at baseline to 16.8 mm Hg ± 3.2 mm Hg at 3-year follow-up (P < .029). Fellow eyes did not experience a significant change from baseline. CONCLUSION: The authors' 3-year results show that IOP is consistently and significantly elevated in pseudophakic eyes compared to baseline following routine vitrectomy. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:371-376.].

Utility of Ophthalmologic Screening for Patients With Candida Bloodstream Infections: A Systematic Review.

Importance: The Infectious Diseases Society of America recommends ophthalmologic examinations for everyone with positive Candida blood culture results (candidemia) to screen for endophthalmitis, a practice that remains controversial because of multiple concerns for its limited usefulness and potential for harm. Objective: To determine guideline efficacy by reconciling discrepancies in the incidence of endophthalmitis and evaluating outcomes of studies assessing ophthalmologic screening for candidemia. Evidence Review: PubMed literature searches, including the search terms candidemia, fungemia, chorioretinitis, and endophthalmitis, identified longitudinal studies prior to 2018 of patients who underwent ophthalmologic evaluations in the setting of positive fungal blood culture results regardless of symptoms or clinical status. Additional studies not captured by these queries were found by manually scanning references within the articles captured by the queries. Ambiguous studies of patients with concomitant bacterial or viral infections were excluded. Findings: Thirty-eight applicable studies of 7472 patients who underwent ophthalmologic screening for candidemia or fungemia were identified. Criteria were compared with the conventional definition of endophthalmitis based on present (concordant) or absent (discordant) frank vitreous involvement. Concordant (59 of 6693 [0.9%]) and discordant (114 of 779 [14.6%]) endophthalmitis incidence rates differed by 13.8% (95% CI, 11.4%-16.4%; P < .001). Visual acuity for each case was recorded verbatim as subjective report provided by each study, when available. None of the concordant endophthalmitis cases reported direct, intraocular, microscopic evidence of Candida or other fungal organisms. Outcomes were available for 19 patients with concordant endophthalmitis; 6 died within 4 weeks of screening. The rate of substantial vision loss was associated (φ = 0.58; 95% CI, 0.01-0.86; P = .046) with additional invasive intervention (3 of 6 [50.0%]) compared with medical management alone (0 of 6). Conclusions and Relevance: In this systematic review without meta-analysis, inconsistent definitions of endophthalmitis accounted for discrepancies of its incidence and overreporting among patients with candidemia, contributing to bias and resulting in the construction of guidelines. As few as 3 of 7472 patients had potential improvement, while routine examination overall could lead to additional interventions and harm in this population. These findings suggest that indiscriminate screening based on candidemia alone does not appear to be supported by the literature and should be reevaluated for inclusion as a recommendation from the Infectious Diseases Society of America.

The Ophthalmology Surgical Competency Assessment Rubric for Panretinal Photocoagulation.

PURPOSE: To develop an internationally valid skill-based rubric that can be used as a global standardized platform for teaching, training, and evaluation of panretinal photocoagulation (PRP) in training programs. DESIGN: A panel of educators and experts in retinal lasers was assembled to develop a standardized objective skill-based rubric. PARTICIPANTS: Sixteen international educators and retina specialists. METHODS: The steps to performing slit-lamp delivery of PRP was described in detail. A group of 6 authors reviewed and agreed on the steps and assigned descriptors to expectation levels of novice, beginner, advanced beginner, and expert according to a modified Dreyfuss model. The tool then was vetted by an international panel of 10 retina specialists who are involved in training ophthalmologists in other countries. MAIN OUTCOME MEASURES: Final version of the tool agreed on by the international review panel. RESULTS: The consecutive steps to performing PRP were outlined and broken down into preparation, procedure, and postoperative care. Descriptive words explaining what to expect from a novice, beginner, advanced beginner, and expert were listed for each step of PRP. Expert comments were incorporated, establishing face and content validity. CONCLUSIONS: This group of authors clearly defined expectations of a trainee at 4 levels of training according to the modified Dreyfus model, and an international panel of retina specialists agreed to its accuracy. This tool, the International Council of Ophthalmology's Ophthalmology Surgical Competency Assessment Rubric for Panretinal Photocoagulation, has face and content validity. It can be used globally in training programs both to teach and assess this important comprehensive skill in ophthalmic training.

Ocular findings at initial pan retinal photocoagulation for proliferative diabetic retinopathy predict the need for future pars plana vitrectomy.

PURPOSE: To determine the 1-year and 2-year likelihood of vitrectomy in diabetic patients undergoing initial pan retinal photocoagulation (PRP). METHODS: Diabetic eyes receiving initial PRP for proliferative diabetic retinopathy (PDR) were analyzed to determine their risk for vitrectomy based on clinical findings. RESULTS: In total, 374 eyes of 272 patients were analyzed. The percentage of eyes undergoing vitrectomy 1 year and 2 years following initial PRP was 19.1% and 26.2%, respectively. Of the eyes in Group 1 (PDR alone), Group 2 (PDR and vitreous hemorrhage), and Group 3 (PDR and iris neovascularization, vitreous hemorrhage with traction or fibrosis, or fibrosis alone), the percentage receiving pars plana vitrectomy at 1 year and 2 years was 9.73% (18/185) and 15.7% (29/185), 26.9% (43/160) and 34.4% (55/160), and 37.9% (11/29) and 48.3% (14/29), respectively. Eyes in Group 2 had 2.78 times greater likelihood (P < 0.0001) and eyes in Group 3 had 3.54 times higher likelihood (P < 0.0001) of requiring pars plana vitrectomy within 2 years than those with PDR alone. CONCLUSION: Eyes receiving PRP for PDR with associated hemorrhage or traction were more likely to undergo pars plana vitrectomy within 1 year and 2 years following initial PRP compared with eyes with only PDR, providing important prognostic information for PRP-naive patients.

Prospective Retinal and Optic Nerve Vitrectomy Evaluation (PROVE) study: twelve-month findings.

PURPOSE: To report 1-year outcomes of the Prospective Retinal and Optic Nerve Vitrectomy Evaluation study. DESIGN: Prospective, controlled, observational study. PARTICIPANTS: Eighty eyes of 40 participants undergoing pars plana vitrectomy for epiretinal membrane (ERM), macular hole (MH), or vitreous opacities. METHODS: Enrolled participants underwent baseline evaluation of the study (surgical) and fellow (control) eyes by a masked fellowship-trained glaucoma specialist; evaluation included intraocular pressure (IOP; Goldmann applanation and Tono-Pen), central corneal thickness, gonioscopy, and cup-to-disc ratio measurement. Baseline testing included bilateral color fundus and optic disc photography, fundus autofluorescence, automated perimetry, and optical coherence tomography (OCT) of the macula and optic nerve. Evaluations were repeated at 3 months and 1 year after surgery. MAIN OUTCOME MEASURES: The primary outcome measure was changes in peripapillary retinal nerve fiber layer (pRNFL) thickness. Secondary outcomes included changes in macular thickness and IOP. RESULTS: Thirty-eight of 40 patients completed 1 year of follow-up. Mean visual acuity (VA) improved in study eyes from baseline (P = 0.003) but remained worse than fellow eyes (P<0.001). Study eyes had thinner inferior pRNFL thickness (114±16.8 µm) compared with fellow eyes (123±14.7 µm; P = 0.004). Mean IOP difference between study eyes and fellow eyes increased from baseline to 1 year. At 1 year, MH study eyes had higher mean IOP (16.0±3.7 mmHg) compared with fellow eyes (14.8±3.4 mmHg; P = 0.08). Mean IOP for pseudophakic study eyes increased from 14.5±3.2 mmHg at baseline to 16.0±2.8 mmHg at 1 year (P = 0.04). Central subfield thickness (CST) and cube volume decreased in study eyes at 1 year but remained greater than that of fellow eyes (P<0.05). Reduction in CST from baseline correlated with degree of VA improvement (P<0.05). Mean deviation (MD) improved in ERM study eyes at 1 year when compared with baseline (-2.2 vs. -4.0; P = 0.02) but remained worse than fellow eyes (-1.2; P = 0.002). CONCLUSIONS: One year after vitrectomy, VA, CST, and MD improved in study eyes but not to the level of fellow eyes. Inferior pRNFL thickness decreased in study eyes. Reduction in CST from baseline correlated with degree of VA improvement. Pseudophakic study eyes demonstrated increased IOP when compared with baseline.

Prospective Retinal and Optic Nerve Vitrectomy Evaluation (PROVE) study: findings at 3 months.

BACKGROUND: The purpose of this paper is to report the 3-month findings of the Prospective Retinal and Optic Nerve Vitrectomy Evaluation (PROVE) study. METHODS: Eighty eyes of 40 participants undergoing vitrectomy were enrolled. Participants underwent baseline evaluation of the study (surgical) and fellow (control) eye that included: intraocular pressure, central corneal thickness, gonioscopy, cup-to-disc ratio measurement, color fundus and optic disc photography, automated perimetry, and optical coherence tomography of the macula and optic nerve. Evaluation was repeated at 3 months. Main outcome measures were changes in macula and retinal nerve fiber layer (RNFL) thickness and intraocular pressure. RESULTS: All participants completed follow-up. Mean cup-to-disc ratio of study and fellow eyes at baseline was 0.43 ± 0.2 and 0.46 ± 0.2, respectively, and 13% of participants had undiagnosed narrow angles. There was no significant change in intraocular pressure, cup-to-disc ratio, or pattern standard deviation in study eyes compared with baseline or fellow eyes at 3 months. Vision improved in all study eyes at 3 months compared with baseline (P = 0.013), but remained significantly worse than fellow eyes (P < 0.001). Central subfield and temporal peripapillary RNFL thickness were significantly greater in eyes with epiretinal membrane (P < 0.05), and resolution after surgery correlated with visual improvement (P < 0.05). CONCLUSION: The 3-month results do not indicate any increased risk for open-angle glaucoma but suggest that a relatively high percentage of eyes may be at risk of angle closure glaucoma. Temporal RNFL thickness and central subfield were increased in eyes with epiretinal membrane, and resolution correlated with degree of visual recovery.

Intravitreal ketorolac for chronic uveitis and macular edema: a pilot study.

OBJECTIVE: To investigate the adverse ocular effects of intravitreal ketorolac (4 mg) in patients with chronic uveitis and complications of chronic inflammation (macular edema). METHODS: We conducted a prospective phase 1 clinical trial involving 10 eyes of 10 adult patients with chronic inflammation and/or macular edema for whom previous treatment failed or who could not tolerate corticosteroids because of adverse ocular effects. Baseline (day 0) electroretinography, fluorescein angiogram, spectral domain optical coherence tomography (OCT), Goldmann visual field, and complete ophthalmic examination were performed, and then a single intravitreal injection of ketorolac (4 mg) was administered. Another ophthalmic examination with OCT was performed on day 3. Ophthalmic examination with fluorescein angiogram and OCT was repeated on days 7 and 30, and ophthalmic examination with fluorescein angiogram, OCT, electroretinography, and Goldmann visual field was performed on day 90. The study took place from March 1, 2010, through February 28, 2011. RESULTS: On the basis of ophthalmic examination findings, visual field, and electroretinography testing, there were no observed adverse ocular effects of intravitreal ketorolac. In 2 of 2 eyes with active intraocular inflammation, there was early resolution of inflammation, and in 4 of 8 eyes with macular edema, there appeared to be transient reduction in OCT thickness and/or fluorescein angiogram leakage. CONCLUSION: A single intravitreal injection of ketorolac (4 mg) appeared to be well tolerated. CLINICAL RELEVANCE: Intravitreal ketorolac requires further clinical trials to determine whether it is an effective means to treat posterior segment inflammation as a safer alternative to corticosteroids in patients at increased risk of cataract formation and increased intraocular pressure.

Antibiotic resistance of conjunctiva and nasopharynx evaluation study: a prospective study of patients undergoing intravitreal injections.

PURPOSE: To determine the baseline antibiotic susceptibility patterns of conjunctival and nasopharyngeal flora isolated from patients undergoing intravitreal (IVT) injections for choroidal neovascularization (CNV). DESIGN: Prospective, observational study. PARTICIPANTS: Forty-eight eyes of 24 patients undergoing unilateral IVT injections for CNV. METHODS: Bilateral conjunctival and unilateral nasopharyngeal cultures on the treatment side were taken before application of any topical medications. MAIN OUTCOME MEASURES: Bacterial isolates were identified and tested for antibiotic susceptibility to 16 different antibiotics using the Kirby-Bauer disc diffusion technique. RESULTS: A total of 57 bacterial isolates were obtained from the conjunctiva of 48 eyes. Coagulase-negative staphylococci (CNS) accounted for 37 of the 57 isolates (65%). The most common CNS organisms were Staphylococcus epidermidis and Staphylococcus lugdunensis accounting for 73% and 11% of CNS isolates, respectively. More than half of S. epidermidis isolates demonstrated some level of resistance to ofloxacin and levofloxacin, and 33% and 37% of isolates showed some level of resistance against gatifloxacin and moxifloxacin, respectively. Some 60% and 30% of CNS isolates were resistant to ≥ 3 and ≥ 5 antibiotics, respectively. Among the 24 nasopharyngeal cultures, 8 (33%) grew Staphylococcus aureus, and 1 of the 8 isolates (13%) was resistant to all penicillin, cephalosporin, macrolide, and fluoroquinolone antibiotics tested. CONCLUSIONS: Our results demonstrate subtantial levels of resistance to third- and fourth-generation fluoroquinolones and multiresistance among ocular CNS isolated from patients undergoing IVT injections for CNV.