Characteristics and Outcomes of Pars Plana Vitrectomy for Proliferative Diabetic Retinopathy Patients in a Limited Resource Tertiary Center over an Eight-Year Period.

PURPOSE: To report characteristics and visual results in patients with PDR-associated complications following pars plana vitrectomy (PPV) in a tertiary center over an eight-year period. METHODS: Medical records of diabetic retinopathy patients receiving PPV between January 2007 and December 2014 for PDR-related complications were reviewed. RESULTS: A total of 890 consecutive PDR patients were included in the study. PPVs were performed for tractional retinal detachment (36.6%), persistent vitreous hemorrhage (VH) (35.4%), combined tractional and rhegmatogenous retinal detachment (14.5%), and vitreoretinal abnormalities (13.5%), respectively. Preoperative intravitreal bevacizumab injection (IVB) within two weeks prior to PPV and 23G vitrectomy systems was found to decrease the risk for intraoperative retinal break development (P=0.045 and P=0.015, respectively). The incidence of early dense postoperative VH decreased significantly with the administration of preoperative or intraoperative IVB at the end of PPV. Postoperative visual results significantly correlated with the initial visual acuity level, intraoperative retinal break development, and retained silicone oil tamponade at the final visit (P < 0.001, P=0.040, and P=0.044, respectively). Administration of adjuvant IVB either before or at the end of PPV had no significant association with the final visual outcomes. CONCLUSIONS: This study reported an improvement in visual acuity in nearly half of patients receiving PPV for PDR-associated complications in a limited resource center. The incidence of intraoperative retinal break and early postoperative VH decreased significantly with the application of IVB injections. Poor final visual outcomes were related to the lower initial visual acuity levels, intraoperative retinal breaks, and postoperative retained silicone oil.

Changes in Central Macular Thickness following Single Session Multispot Panretinal Photocoagulation.

Purpose. To determine changes in central subfield (CSF) macular thickness and best corrected visual acuity (BCVA) following single session, multispot panretinal photocoagulation (PRP). Methods. Forty eyes of 33 patients with newly diagnosed proliferative diabetic retinopathy were treated with single session, 20-millisecond, multispot PRP. Changes in central macular thickness and BCVA at 4- and 12-week follow-up were compared to baseline measurements. Results. Each eye received a mean (SD) of 2,750 (686.7) laser spots. At 4-week follow-up, there was a statistically significant 24.0 µm increase in mean CSF thickness (P = 0.001), with a 17.4 µm increase from baseline at 12-week follow-up (P = 0.002). Mean logMAR BCVA increased by 0.05 logMAR units (P = 0.03) at 4-week follow-up. At 12-week follow-up, BCVA had almost returned to normal with only an increase of 0.02 logMAR units compared to baseline (P = 0.39). Macular edema occurred in 2 eyes (5%) at 12-week follow-up. Conclusions. Macular thickening occurs following single session, 20-millisecond, multispot PRP, with a corresponding, mild change in BCVA. However, the incidence of macular edema appears to be low in these patients. Single session, 20-millisecond, multispot PRP appears to be a safe treatment for patients with proliferative diabetic retinopathy.

Predictive factors of open globe injury in patients requiring vitrectomy.

BACKGROUND: To determine the outcomes and predictive factors of patients with open globe injury requiring pars plana vitrectomy (PPV). METHODS: The medical records of 114 patients age 10 years or older who had undergone PPV due to ocular trauma, with at least 6 months follow up, were retrospectively reviewed. RESULTS: The mean age of the patients was 42 (SD14) years, with males accounting for 89% of the cases. Penetrating eye injury was the most common injury mechanism (43%) with most injuries occurring secondary to work related incidents (54%). After surgical interventions, 78% of the patients had visual improvement of one or more Snellen lines, while no light perception occurred in 10%. Anatomical attachment was achieved in 87% of eyes at the final follow up. Logistic regression analysis showed that the presence of a relative afferent pupillary defect (RAPD) was a significant predictive factor of visual outcome, while initial retinal detachment was a significant predictor of anatomical outcome. CONCLUSIONS: Pupillary reaction is an important presenting ocular sign in estimating the post-vitrectomy poor visual outcome for open globe injury. Vision was restored and improved in more than half of the patients in this study; however, long-term sequelae should be monitored.

The use of intravitreal anti-vascular endothelial growth factor injection and its complications in Chiang Mai University Hospital.

OBJECTIVE: To report the use of intravitreal (IVT) injections of anti-vascular endothelial growth factor agents (anti-VEGF) and its complications. MATERIAL AND METHOD: The authors performed a retrospective review of consecutive patients treated with IVT injection of anti-VEGF between May 2006 and December 2010 at Chiang Mai University Hospital. Demographic data and complications were registered. RESULTS: The present study included 1,006 eyes of 878 patients. Mean age was 60 years (range 1 month to 91 years). Mean follow-up time was 12 months (range 1 month to 54 months). Total injections were 2,077 given as 47, 210, 399, 575, and 846 injection per year between 2006 and 2010, respectively. Anti-VEGF agents were bevacizumab (1,878; 90.42%), ranibizumab (190; 9.15%), and pegaptanib (9; 0.43%). Indications for injection based on primary diagnosis were neovascular macular degeneration (38.5%), diabetic retinopathy (38%), and retinal vein occlusion (15.9%). The incidence of endophthalmitis was 0.048% (1/2,077) for all injections and 0.053% (1/1878)for bevacizumab. CONCLUSION: The use of IVT injections of anti-VEGF is increasing, especially the use of bevacizumab. Incidence of ocular and systemic complications after IVT injection of anti- VEGF was low with no significant difference among the three anti-VEGFs agents.

Spontaneous large serous retinal pigment epithelial tear.

PURPOSE: To report cases of spontaneous retinal pigment epithelial (RPE) tear complicating serous pigment epithelial detachment (PED). METHODS: The records of 3 Asian patients with spontaneous giant RPE tear were reviewed retrospectively by including clinical presentation, angiography, optical coherence tomography, fundus autofluorescence imaging, and visual outcome. RESULTS: Three patients (4 eyes) were included in this study, with a mean age of 48.3 (42-56) years, and a mean follow-up period of 7.75 (4-18) months. Fundus examination in all patients showed giant RPE tear associated with bullous PED. Two cases had a history of prior corticosteroid use, and 1 had no history of medication use. All 3 patients developed spontaneous resolution of subretinal fluid with no treatment. However, in patients who used corticosteroids, initial progression of the tear and subretinal fluid were observed despite ceasing medication. On subsequent follow-up, an incomplete RPE regeneration was demonstrated by fundus autofluorescence imaging, and choroidal neovascularization developed in 1 patient. CONCLUSION: Large PED with RPE tear is a rare manifestation. When the fovea is spared, visual prognosis is favorable. No specific treatment is required, but careful choroidal neovascularization monitoring should be performed.

Macular thickness measured by spectral-domain optical coherence tomography in healthy Thai eyes.

PURPOSE: To describe the macular thickness measured by spectral-domain optical coherence tomography (SD-OCT) in healthy eyes of Thai people. DESIGN: Prospective cross-sectional study. METHODS: Three hundred sixty-eight healthy participants underwent a comprehensive ophthalmic examination, including Spectralis SD-OCT scanning, at Chiang Mai University Hospital. The images were obtained over maculae, using a high-speed volumetric raster scan pattern with lines 240 µm apart. Information was collected from both eyes of each person, with only the right one being used unless it was found to be ineligible (in which case the left eye was studied). A mean retinal thickness was calculated based on nine areas that corresponded to the Early Treatment Diabetic Retinopathy Study by OCT mapping software. The relationships between retinal thickness and sex, age, axial length, and spherical equivalence were analyzed. RESULTS: The mean age of the subjects was 49.17 ± 17.24 years. The mean central retinal thickness was 259.18 ± 19.08 µm, the mean foveal volume was 0.20 ± 0.02, and the mean total macular volume was 8.59 ± 0.37 mm(3). Central subfield (CSF) thickness and foveal volume were significantly greater in men than in women (both P < 0.001). When analyzed for six age groups by ANOVA, the CSF thickness showed no significant difference among the groups, with a P value of 0.280, and foveal volume showed no significant difference among the six groups, with a P value of 0.341. After age adjustment, axial length was correlated positively with the CSF thickness (P < 0.001, Pearson correlation). CONCLUSIONS: The normal macular thickness in Thais is thinner than those reported for other populations when measured using the Spectralis SD-OCT. Male gender and axial length were correlated positively with CSF thickness.

Intravitreal bevacizumab at the end of diabetic vitrectomy for prevention of postoperative vitreous hemorrhage: a comparative study.

OBJECTIVE: To study the role of intravitreal injection of bevacizumab (Avastin) at the end of vitrectomy for prevention of postoperative vitreous hemorrhage in diabetic eye disease. MATERIAL AND METHOD: The authors conducted a retrospective, comparative, nonrandomized study comparing patients with diabetic eye disease who received a 1.25 mg bevacizumab injection at the end of vitrectomy to a group with diabetic eye disease who underwent vitrectomy but did not receive this injection. For statistical analysis, each patient was assigned to one of four groups according to the hemostatic modalities used (group 1, none; group 2, only long acting gas; group 3, only intraoperative intravitreal bevacizumab; group 4, both long acting gas and intraoperative intravitreal bevacizumab). The primary outcome measure was the incidence of early and late postoperative vitreous hemorrhage (POVH). The secondary outcome measure was visual acuity (VA) at 1 and 6 months. RESULTS: The present study included 87 eyes from 78 patients. The 87 eyes were categorized in the four groups described above. The incidence of early postoperative VH was lowest in group 3 (50%), followed by group 1 and group 4 (130%) and group 2 (16%) (p = 0.49). No eyes in group 1 or group 4 had late postoperative VH. Group 3 had the lowest incidence of VA below 20/200 (11%) in the first postoperative month, followed by group 1 (22%), group 4 (33%) and group 2 (50%) (p = 0.44). Group 3 also had the best visual recovery (VA above 20/50) with 38% at the end of six months compared with 13% in group 1, 7% in group 4 and no eyes in group 2 (p = 0.03). CONCLUSION: Patients with intravitreal injection of 1.25 mg bevacizumab at the end of diabetic vitrectomy had the lowest incidence of early postoperative vitreous hemorrhage with no statistical significance. However they had significantly the best visual recovery at the end of six months.

Extra-medullary hematopoiesis causing bilateral optic atrophy in beta thalassemia/Hb E disease.

OBJECTIVE: To report a rare presentation of bilateral optic nerve compression from extra-medullary hematopoiesis in beta thalassemia/Hb E disease. DESIGN: Interventional case report. CLINICAL PRESENTATION: A 13-year-old Thai girl was reported with slowly progressive bilateral visual loss due to optic neuropathy as a result of compression from extra-medullary hematopoiesis. Computed tomography of orbit and brain revealed a homogeneous enhancing midline soft tissue mass originating from the ethmoid and sphenoid sinuses along with extensive involvement of the skull. INTERVENTION: Blood transfusion once every month and low-dose radiotherapy to sphenoid and ethmoid bones with some visual improvement. CONCLUSION: Extra-medullary hematopoiesis in beta thalassemia can involve paranasal sinuses and cause compressive neuropathy. In patients with beta thalassemia that required multiple blood transfusions with progressive visual loss, ectopic marrow compression of optic nerve should be ruled out.

Squamous cell carcinoma of the lacrimal sac: a case report.

Lacrimal sac tumors are rare tumors of the periorbital region. The authors report a case of squamous cell carcinoma of the lacrimal sac in a 47-year-old Thai man. The patient presented with epiphora and a palpable mass in the medial canthal area. The diagnosis was confirmed by the pathological studies. Radical surgery and radiation therapy were given. Early detection and long-term follow-up are necessary.

Intravitreal angiostrongyliasis: report of 2 cases.

Two male patients presented with unilateral blurred vision. A small motile worm was found in the vitreous cavity in both cases. In one case, another dead, disintegrated worm was noted in the inferior portion of the vitreous cavity. On each eye, vitreous surgery was performed and the worm was removed by an aspirator. Both worms were identified as Angiostrongylus cantonensis. Since both patients had no signs of meningitis, lumbar puncture was not done. Long-term follow-up confirmed the benefit and safety of the vitreous surgery. Fluorescein angiography revealed severe pigmentary alteration, probably from inflammation of the choroid and retina due to subretinal migration of the worm prior to access into the vitreous cavity.

Epidemiology of the ocular complications of HIV infection in Chiang Mai.

OBJECTIVE: To identify the magnitude of ocular complications in HIV infection in Chiang Mai, and determine the signs or symptoms that indicate the risk factors for developing ocular complications in HIV-positive patients METHOD: A prospective study was carried out in newly diagnosed HIV-positive patients seen in the Ocular Infectious Disease Clinic of Maharaj Nakorn Chiang Mai Hospital from March 1, 2000 through February 28, 2001. A complete ophthalmic examination was performed on each patient together with a systemic evaluation of present illness and current medications. RESULTS: Three-hundred and ninety-five HIV-positive patients were seen for ophthalmic evaluation. Of these, 90 were in stage A (asymptomatic), 84 were in stage B (symptomatic), and 221 were in stage C (AIDS). Ocular complications were found in 44.6 per cent of the patients. Cytomegalovirus (CMV) retinitis was the most common ophthalmic complication (33%). Other ocular complications included cotton wool spot (8%), uveitis (4%), optic neuropathy (3%), and keratoconjunctivitis sicca (2%). The clinical presenting symptoms, which were the indicators for ocular complications and CMV retinitis, included chronic cough, oral thrush, chronic diarrhea, weight loss, wasting, and skin disorders. Ocular symptoms, which indicated a high risk of developing CMV retinitis, included flashing, floaters, and scotoma. CONCLUSIONS: Ocular complications are common in HIV-positive patients. CMV retinitis, which is a major vision-threatening problem, represented the most common finding. It is recommended that HIV-positive patients should have their eyes examined regularly, particularly when they have the clinical presenting symptoms previously mentioned. The patients should also notice early symptoms of CMV retinitis, which includes flashing, floaters, and scotoma.