Intravitreal anti-VEGF therapy for neovascular age-related macular degeneration and the risk of stroke.

The purpose of this study was to compare the vascular event rate in AMD patients treated with an intravitreal VEGF inhibitor with a historical control group treated with photodynamic therapy. We reviewed medical records of 83 patients treated with intravitreal anti-VEGF for AMD between 2005-2007, and 60 patients treated with PDT between 2001-2004. Mean follow-up in the anti-VEGF group was 40 months versus 95 months in the PDT group. Mean age (76 +/- 9 years, versus 74 +/- 10 years, p=n.s.) and cardiovascular risk factor profile were similar. Vascular event rates in each group were 2.6 per 100 patient years versus 2.3 per 100 patient years, (p = n.s). Age over 80 years was associated with an increased risk of a vascular event (odds ratio = 1.113, p<0.05). Despite the high prevalence of risk factors in AMD patients, the incidence of vascular events was low and associated with older age rather than therapy received.

Interventions for diabetic macular oedema: a systematic review of the literature.

OBJECTIVES: This review discusses the evolution of the treatment of diabetic macular oedema and gives helpful guidelines in the treatment of diabetic macular oedema based on available evidence to date. METHODS: A literature search of all English articles from the Medline and Cochrane database was performed. The search was limited to only English randomised controlled clinical trials in humans. Overall, 93 articles were cited from 1979 to 2007. Of these, 31 articles corresponded to subject matter. Studies were evaluated on a standardised data extraction form and tabulated for easy review. RESULTS: There is good evidence that laser treatment preserves vision in eyes with diabetic macular oedema (DMO). However, laser is a potentially destructive form of treatment which may be of greater benefit in combination with newer forms of treatment such as intravitreal steroid or intravitreal antiangiogenic agents. Current evidence does not support a clear benefit for surgical intervention in DMO. CONCLUSIONS: Although laser treatment remains the cornerstone of treatment in diabetic macular oedema, the literature is beginning to support combination therapy. Using one or two intravitreal injections to reduce central macular thickness followed by focal or grid laser to give a sustained response may offer an alternative to treatment in DMO.

Intravitreal bevacizumab in the treatment of neovascular age-related macular degeneration, 6- and 9-month results.

PURPOSE: To evaluate 6- and 9-month follow-up data including the effect on vision and anatomic outcome in patients treated with intravitreal bevacizumab for neovascular age-related macular degeneration (AMD). STUDY DESIGN: Interventional consecutive retrospective case series. Patients received intravitreal bevacizumab for the treatment of neovascular AMD including choroidal neovascular membranes, pigment epithelial detachment, and macular haemorrhage. Ophthalmic evaluation included log MAR or Snellen acuity, ophthalmic examination, optical coherence tomography, and fluorescein angiography. Repeat injections were given in the presence of persistent leakage or retinal oedema. Change in vision and foveal thickness from baseline was evaluated using the paired Student's t-test. RESULTS: A total of 112 eyes of 111 patients received injections. Median follow-up was 5 months (range: 1-12 months). Mean log MAR vision pre-injection was 0.84+/-0.03 (n=112); at 3 months was 0.69+/-0.05 (P<0.0001, n=84); at 6 months was 0.74+/-0.06 (P<0.05, n=51); and at 9 months was 0.69+/-0.08 (n=29, P=0.09). Thirteen of 17 patients who received only one injection maintained improved or stable vision at 6 months. Mean baseline foveal thickness was 291+/- 9.72 microm (n=56); at 3 months was 282.7+/-28 (P<0.05, n=31); and at 6 months was 249.7+/-10.3 (P<0.05, n=12). One case of endophthalmitis, three submacular haemorrhages, and three retinal pigment epithelial (RPE) tears occurred. CONCLUSION: Intravitreal bevacizumab is an effective treatment for neovascular AMD, resulting in improved vision and foveal anatomy at 6 months and even up to 9 months. This treatment is well tolerated in the majority of patients but adverse events may include endophthalmitis, RPE tears, and submacular haemorrhage.

Long-term follow-up of ischaemic retinopathy in the antiphospholipid syndrome with lupus-like disease.

PURPOSE: Antiphospholipid syndrome (APS), as an acquired prothrombotic disorder, is increasingly being recognised as an important cause of systemic venous and arterial thrombosis. The defining feature of the condition is the presence of raised levels of antibodies to negatively charged phospholipids in the serum. METHODS: We describe 2 cases of APS with ocular involvement and review the recent literature. Both patients experienced acute visual loss. It was the presenting symptom in one case--a finding that led to the diagnosis of the syndrome. RESULTS: Management with anticoagulation therapy, in which the International Normalised Ratio (INR) has been maintained at or above 3, resulted in reperfusion of the ischaemic retina and stabilisation of the retinopathy in one patient, whilst in the other case, where the INR was less than 3, irreversible visual loss occurred. CONCLUSION: Anticoagulation with warfarin appears to result in reperfusion of ischaemic retina with stabilisation of the neovascular process when the INR is greater than 3.

Removal of lens fragments from the vitreous cavity.

Between March 1993 and September 1994 we treated 25 cases of lenses in the vitreous cavity. Nineteen of the 25 were the result of dislocation during phacoemulsification. During this time, we adopted a single surgical algorithm involving vitrectomy, heavy liquids and ultrasound fragmentation. The aims of this retrospective study were to test the validity of our surgical algorithm and to report on outcomes and complications. The indications for vitreous surgery were raised intraocular pressure, uveitis and poor vision. Vitreous surgery was carried out at a mean of 29 days following phacoemulsification. Six patients required heavy liquids and 5 needed ultrasound fragmentation. Vitreous surgery undertaken less than 17 days after phacoemulsification had an increased likelihood of requiring heavy liquids and/or fragmentation (p < 0.02). The greatest threat to a favourable visual outcome was retinal detachment, which was significantly associated with fragmentation and use of heavy liquids (p < 0.02). The presence of an intraocular lens (IOL) reduced the surgical options for removal of the lens fragments, and IOL should not be inserted where lens matter dislocates. The study suggests that we should avoid fragmentation and, provided the intraocular pressure and uveitis can be controlled, that vitreous surgery should be deferred for 2-3 weeks following phacoemulsification.

Persistent binocular diplopia following cataract surgery: aetiology and management.

We studied all patients referred to the orthoptic department with binocular diplopia following cataract surgery between January 1991 and June 1993. Persistence of diplopia for a minimum of 3 months after cataract surgery was required for inclusion in the study. Eighty-one patients (2% of all patients who underwent cataract surgery during this time) satisfied the entry criteria. The patients fell into two groups: non-traumatic and traumatic cataracts. Horizontal deviations were seen in 24 patients. Vertical deviations were seen in 8 patients and a combined horizontal and vertical deviation was seen in 49 patients. Fresnel prisms were used to manage the diplopia in 58 patients. Of these, 48 patients in the non-traumatic group regained binocular single vision with this prism while 10 in the traumatic group benefited. Mechanical and sensory causes are discussed.

The apparent role of blood transfusions in the development of retinopathy of prematurity.

During a 30-month-period, 184 very low birth weight infants from two Liverpool neonatal intensive care units were screened for evidence of retinopathy of prematurity (ROP). Seventeen clinical variables previously considered relevant to the development of ROP, blood gas and blood pressure data over the first 7 days, and the maximum stage of ROP reached in either eye were recorded, together with the need for cryotherapy and current visual status. Ninety-two infants developed any stage of ROP and 15 required cryotherapy or became blind. Logistic regression showed that only gestational age and frequency of blood transfusion were independently associated both with the risk of occurrence of ROP and its severity.

Assessment of the value of congenital hypertrophy of the retinal pigment epithelium as an ocular marker for familial adenomatous polyposis coli.

The presence of bilateral, multiple patches of congenital hypertrophy of the retinal pigment epithelium (CHRPE) is cited as an early phenotypic marker of the familial adenomatous polyposis coli (FAPC) gene. However, the degree of concordance between CHRPE and the presence of familial adenomatous polyposis (FAP) has not been adequately assessed in individual families. We studied the eyes of 28 members of a single kindred spanning three generations with FAPC; 14 were affected and 14 unaffected but 'at risk'. Six affected and 8 unaffected at risk individuals possessed a total of 34 retinal lesions, 17 in each group. Two affected individuals and 1 at risk individual had the classical pattern of CHRPE associated with FAPC. The sensitivity of CHRPE as an ocular marker for FAPC in this kindred was 14.2%. Our findings have implications for the use of CHRPE for the presymptomatic screening of family members at risk of FAPC. Therefore, ocular examination should not replace colonoscopic screening in an individual at risk of FAPC.

Double-masked three-period crossover investigation of timolol in control of raised intraocular pressure.

Forty patients with an intraocular pressure (IOP) between 30 and 49 mmHg in either eye (57 eyes) were recruited into a trial of timolol 0.25% versus timolol 0.5%. Patients were randomised to receive the two concentrations of drug in the order ABA or BAB. The study period was 12 weeks for each patient, with changes in drug concentration at 4 and 8 weeks. IOPs were measured at the same time every 2 weeks. Mean IOP of both eyes was used, excluding any eyes with initial IOPs of less than 30 mmHg. There was no difference between the 2-week and 4-week pressure readings, which were therefore combined. There was no statistically significant difference in the initial IOPs of the two groups (0.5%, 33.45 mmHg; 0.25%, 32.63 mmHg) nor in the initial fall in IOP with either concentration (0.5%, 12.03 mmHg; 0.25%, 11.31 mmHg). Furthermore, changing from one concentration to the other had no significant effect on IOP. Mean IOPs over the whole study period averaged 21.12 mmHg for timolol 0.25% and 20.75 mmHg for timolol 0.5%. Again these differences were not statistically significant. The statistical power of the study was estimated to exceed 85%. The authors suggest that there is no justification for use of the 0.5% strength, which is more expensive and has no advantages.

Cleft anterior segment with maternal hypervitaminosis A.

We report a case of an 'hourglass' cornea and iris with reduplicated lens in the left eye of an infant girl. An excess of vitamin A products had been taken by the mother during pregnancy. Mechanisms by which vitamin A excess could have caused this are discussed.

Doubled-masked three-period crossover investigation of metipranolol in control of raised intraocular pressure.

Metipranolol is a non-cardioselective beta adrenergic blocking drug used in the treatment of glaucoma. 56 patients with intraocular pressure between 30-49 mm hg were randomised to one of six treatment regimens for a 12 week period. Each patient received each concentration for 4 weeks and intraocular pressures were checked every two weeks. Using a worst and an average eye approach, mean initial intra-ocular pressures were 35.8 and 35.0 mm hg respectively. The mean fall in intra-ocular pressure after 4 weeks treatment ranged from 12.8 (0.1%) to 14.1 mm hg (0.6%) for average eyes (n = 56), and from 13.4 to 16.7 mm hg for worst eyes. These differences were not statistically significant (p greater than 0.05-p greater than 0.5). Increasing the concentration had no significant effect on pressure. Reducing the concentration had no effect except in patients who changed from 0.6% to 0.1%, when there was a mean rise of approximately 2 mm hg, p less than 0.02. The incidence of stinging varied from 19% of attendances on 0.1%, to 63% on 0.6%. We recommend the use of the 0.1% strength since all three significantly lower intra-ocular pressure but the higher concentrations are more expensive, cause more stinging, and are no better at lowering intra-ocular pressure.