Comparison of subretinal versus intravitreal injection of recombinant tissue plasminogen activator with gas for submacular hemorrhage secondary to wet age-related macular degeneration: treatment outcomes and brief literature review.

PURPOSE: Contradictory evidence exists over the best approach for the management of submacular hemorrhage (SMH). In this study, we compared the outcomes of subretinal versus intravitreal injection of recombinant tissue plasminogen activator (r-tPA) and gas in cases of SMH secondary to age-related macular degeneration (AMD). METHODS: Twenty five eyes with SMH were retrospectively divided in 2 groups. Group A underwent vitrectomy, subretinal r-tPA and gas (Vitrectomy group, n = 14), and group B received intravitreal r-tPA and gas (Pneumatic group, n = 11). SMH displacement and change in subfoveal hemorrhage thickness (SFHT) at 1 month post-op were assessed. Additionally, best corrected visual acuity (BCVA) and central retinal thickness (CRT) at the end of the 12 month follow-up (FU) were analyzed. Clinical and epidemiological prognostic factors were tested. RESULTS: Mean duration of SMH prior intervention was 8.2(± 7.3) days. Baseline BCVA was 1.53 ± 0.73 LogMAR, mean extension of SMH was 4.604 ± 2079 µm and mean CRT pre-treatment was 795 ± 365 µm. SMH displacement at 1 month post-treatment was total in 9/14 versus 6/11 and partial in 4/14 versus 2/11 in Group A and Group B, respectively (Fisher's exact test p = 0.38). SFHT reduced by 404 ± 312 µm in Group A versus 376 ± 405 µm in group B (p = 0.86). BCVA improvement and reduction of CRT were highly significant at the end of FU (p = 0.002 and p < 0.001 respectively) but did not differ between the 2 groups. Only baseline BCVA and preoperative CRT proved to be significant prognostic factors for the final functional outcome (p = 0.013 and p = 0.047 respectively). CONCLUSION: Both treatment options proved equal efficacy in displacing SMH in AMD. A multicenter trial may delineate a desirable algorithm of treatment.

Comparison of postoperative refractive outcome in eyes undergoing combined phacovitrectomy vs cataract surgery following vitrectomy.

BACKGROUND: To investigate the accuracy of preoperative biometry in eyes undergoing combined phacovitrectomy and to compare it with eyes having cataract surgery at a later point in time following vitrectomy. METHODS: Patients with epiretinal membrane or macular hole who underwent combined phacovitrectomy (group 1) or phacoemulsification following pars plana vitrectomy (PPV) (group 2) were included in this retrospective, comparative, interventional case series. The primary outcome measures were the intraocular lens power prediction error (PE) and the percentage of eyes with PE > ± 0.5D in the two groups. Secondary outcome measures included the correlation between epidemiological, clinical, or surgical factors and dioptric shift. In addition, the influence of optical coherence tomography characteristics to the PE was investigated. RESULTS: Group 1 and 2 consisted of 55 and 54 eyes, respectively, for a total of 109 eyes included in the study. The mean absolute PE was 0.59 D (range + 1.4 to - 2.5D) in group 1 and 0.35 (range + 1.0 to - 1.45D) in group 2 (p = 0.01). PE greater than 0.5D was observed in 47% of eyes in group 1 as opposed to 16.6% of eyes in group 2 (p = 0.027). The PE was associated with shallower anterior chamber depth (ACD), increased central macular thickness (> 300 µ), and worse baseline best-corrected visual acuity. Photoreceptor ellipsoid zone or external limiting membrane disruption was not associated with significantly greater postoperative refractive deviations. CONCLUSION: Combined phacovitrectomy may result in greater postoperative refractive prediction error compared to phacoemulsification alone following vitrectomy. Patients with worse vision, greater central macular thickness, and shallow anterior chambers require more caution since they are prone to inaccurate preoperative biometry.

The role of internal limiting membrane peeling in epiretinal membrane surgery: a randomised controlled trial.

PURPOSE: To compare the anatomical and functional outcomes after primary idiopathic epiretinal membrane (ERM) peeling with or without internal limiting membrane (ILM) peeling. DESIGN: A two-centre randomised, controlled clinical trial with 12 months of follow-up. METHODS: One hundred and two eyes of 102 patients were included in the analysis and were randomised into two groups (ILM peeling (P) and non-ILM peeling (NP) group). Inclusion criteria were: Idiopathic ERM confirmed on optical coherence tomography, age ≥18 years, binocular distortion, best-corrected visual acuity (BCVA) ≤90 ETDRS letters, intraocular pressure ≤23 mm Hg and informed consent. The primary outcome measure was the mean change in the ETDRS distance BCVA at 12 months' follow-up for each group. RESULTS: The mean change in distance BCVA at 12 months was 0.30±0.24 logMAR (15 ETDRS letters) in the P group and 0.31±0.23 logMAR (14 ETDRS letters) in the NP group, a change that was not statistically significant (p=0.84). No statistically significant differences were observed when comparing the changes in distance BCVA, the changes in metamorphopsia (Amsler grid) and the changes in central retinal thickness between the two groups at any of the time points studied. CONCLUSIONS: Our analysis suggests that ILM peeling in idiopathic ERM surgery does not result in better visual improvement. The more frequent presence of an uninterrupted interdigitation zone in the P group did not result in a better functional outcome of our patients. No recurrent ERMs were noted in either group.

Current Perspectives of Prophylaxis and Management of Acute Infective Endophthalmitis.

Endophthalmitis is an intraocular inflammatory condition which may or may not be caused by infective agents. Noninfectious (sterile) endophthalmitis may be attributable to various causes including postoperative retained soft lens matter or toxicity following introduction of other agents into the eye. Infectious endophthalmitis is further subdivided into endogenous and exogenous. In endogenous endophthalmitis there is hematogenous spread of organisms from a distant source of infection whereas in exogenous endophthalmitis direct microbial inoculation may occur usually following ocular surgery or penetrating eye injury with or without intraocular foreign bodies. Acute infective endophthalmitis is usually exogenous induced by inoculation of pathogens following ocular surgery, open-globe injury and intravitreal injections. More infrequently the infective source is internal and septicemia spreads to the eye resulting in endogenous endophthalmitis. Several risk factors have been implicated including immunosuppression, ocular surface abnormalities, poor surgical wound construction, complicated cataract surgery with vitreous loss and certain types of intraocular lens. Comprehensive guidelines and recommendations on prophylaxis and monitoring of surgical cases have been proposed to minimize the risk of acute endophthalmitis. Early diagnosis and prompt management of infective endophthalmitis employing appropriately selected intravitreal antibiotics are essential to optimize visual outcome.

Anatomic and functional outcomes of retinectomy for the management of complicated retinal detachment with proliferative vitreoretinopathy.

The aim of this study is to report the anatomic and functional outcomes of retinectomy for the management of rhegmatogenous retinal detachment complicated by proliferative vitreoretinopathy (PVR), comparing them with previously reported data and determining prognostic factors. Fifty-one eyes of 51 patients with established PVR grade C in which retinectomy was performed were retrospectively enrolled in the study. Primary outcome measures were anatomic success rate and final visual acuity. Secondary outcome measures were intraoperative complications, number of re-operations, and postoperative hypotony. Prognostic factors in relation to retinal re-attachment and final visual acuity were retrospectively analyzed. The rate of complete retinal re-attachment after one operation was 80% and after two operations it was 84%. At the end of the follow-up, the macula was attached in 96% of the cases. Mean LogMAR best-corrected visual acuity (BCVA) improved significantly from 2.45±0.66 preoperatively to 1.37±0.75 at the end of the follow-up (P<0.001). BCVA improved in 37 eyes (72%), remained the same in eleven eyes (22%) and worsened in three eyes (6%). Postoperative hypotony was observed in 2% of cases. Postoperative BCVA was significantly correlated with preoperative BCVA (P<0.001), extension of PVR (P=0.013), preoperative use of gas instead of silicone oil (SO) (P=0.01), and removal of SO (P=0.05). SO was left in situ in 35% of eyes. In conclusion, retinectomy is a surgical option providing good anatomical and reasonable visual outcomes in complicated retinal detachment with PVR. Better preoperative visual acuity, lesser extension of PVR, and the use of gas tamponade during the primary repair are relevant factors for a successful outcome whereas re-proliferation of epiretinal membranes seems to be the main reason of anatomical failure.

Persistent Subretinal Fluid After Successful Full-Thickness Macular Hole Surgery: Prognostic Factors, Morphological Features and Implications on Functional Recovery.

INTRODUCTION: The present study aimed to identify preoperative factors that predispose the development of subretinal fluid (SRF) following successful macular hole (MH) surgery. METHODS: Thirty-four eyes of 33 consecutive patients that underwent pars plana vitrectomy for idiopathic full-thickness MH surgery were included in this retrospective study. Best corrected visual acuity (BCVA), and spectral domain-optical coherence tomography (OCT) images were evaluated pre- and postoperatively in all cases. Patient's demographic characteristics, stage of MH, measurements of base diameter and minimum aperture diameter of the MH, preoperative foveal vitreomacular traction and selected intra-operative parameters were correlated with the development of postoperative SRF. RESULTS: Postoperative SRF was observed in 15 cases (48%). Total absorption of SRF was observed in 73% of affected eyes and was most commonly seen between the third and the fifth postoperative month. One patient developed lamellar hole leading to full-thickness MH. Postoperative BCVA was similar between the eyes that did and the eyes that did not develop postoperative SRF (0.31 ± 0.2 vs 0.35 ± 0.2; p ≥ 0.05). Development of postoperative SRF was significantly associated with the presence of preoperative foveal vitreomacular traction (p = 0.048), stage II MH (p = 0.017) and smaller size of the closest distance between the MH edges (p = 0.046). CONCLUSIONS: Postoperative SRF is a common occurrence following successful MH surgery. Meticulous evaluation of preoperative clinical and OCT findings may disclose risk factors associated with this condition. Based on our observations, idiopathic holes of early stage appear to be at a higher risk of developing postoperative SRF. This could be a point of interest with the advancing use of enzymatic proteolysis.

Bilateral diffuse iris atrophy after the use of oral clarithromycin.

PURPOSE: To report a newly recognised advert event of clarithromycin. METHODS: Retrospective, case report. RESULTS: A 30-year old female referred to our centre with bilateral diffuse iris atrophy after the use of oral clarithromycin for a pulmonary infection. CONCLUSIONS: Bilateral acute depigmentation of the iris is a new clinical entity. Iris transillumination and sphincter paralysis are recognised adverse effects of oral antibiotic therapy, but to our knowledge no other publication has referred to uveitis-like syndrome due to oral administration of clarithromycin.

Long-term follow-up of inflammatory cystoid macular edema.

PURPOSE: To determine the long-term functional and anatomical outcome of idiopathic uveitic cystoid macular edema (UCME). METHODS: A longitudinal retrospective study was undertaken of the medical records of patients with UCME. All individuals were examined in the uveitis Service at the Moorfields Eye Hospital. The main outcome measures were change in visual acuity and anatomical outcome of UCME at diverse time points. RESULTS: A total of 109 eyes (92 patients) with UCME were included in the analysis. Mean follow-up was 60 ± 45 months (median, 48 months). Mean logarithm of the minimum angle of resolution visual acuity 1 month after the intervention improved significantly (P < 0.001) by 0.21 ± 0.27 and maintained at similar levels throughout the follow-up period. Visual acuity at the final follow-up improved in 75 eyes (69%), was deteriorated in 21 eyes (19%), and remained unchanged in 13 eyes (12%). Younger age and better visual acuity at baseline were associated with more favorable visual outcome (P < 0.001). Optical coherence tomography documentation of improvement or total resolution of UCME was observed in 84 eyes (77%) at the final follow-up. CONCLUSION: Cystoid macular edema is a major complication in uveitis. Current management provides satisfactory long-term results for the majority of those individuals. Visual acuity 1 month after the intervention is usually indicative of the final functional outcome.

Pseudovasculitis associated with vitreoretinal traction.

PURPOSE: The purpose of this study was to report a case of vitreoretinal traction masqueraded as retinal vasculitis. METHODS: An 81-year-old woman with exudative age-related macular degeneration was treated with intravitreal injections of ranibizumab. During routine follow-up, angiographic evidence of focal, segmental, retinal vasculitis, involving both arteries and veins, was noticed in the fellow eye. Clinical examination revealed no sign of ocular inflammation in either eye. RESULTS: Spectralis optical coherence tomography revealed partial posterior vitreous detachment with multiple areas of persisting vitreoretinal adhesion. Focal vasculitis on fluorescein angiography showed absolute correspondence with sites of vitreoretinal traction on optical coherence tomography. Patient was managed by observation and 6 months later, despite persisting fluorescein leak, she was still asymptomatic with no evidence of anterior chamber or vitreous activity. CONCLUSION: This is an exceptional case of pseudovasculitis associated with mechanical traction, representing a variant of vitreomacular traction syndrome. Clinicians should be aware of this unusual manifestation, which may mimic true vasculitis associated with uveitis.

Intraocular pressure control over 24 hours using travoprost and timolol fixed combination administered in the morning or evening in primary open-angle and exfoliative glaucoma.

PURPOSE: To evaluate intraocular pressure (IOP) control over 24 hours using travoprost and timolol fixed combination (TTFC) administered in the morning or evening in primary open-angle and exfoliative glaucoma. METHODS: Patients were randomized to TTFC administered in either the morning or evening for 8 weeks. Previously treated patients underwent an untreated washout period of 4-6 weeks, after which baseline IOP was required to be > 25 mm Hg and < 38 mmHg (in two readings taken at 10.00 +/- 1 hours). During the treatment period, IOP was measured at 10.00, 14.00, 18.00, 22.00, 02.00 and 06.00 hours. Patients were then treated with the opposite dosing regimen for 8 weeks and IOP measurements were repeated. RESULTS: In 32 subjects who completed the study, the untreated baseline IOP following washout was 27.7 +/- 3.5 mmHg. Both dosing regimens reduced IOP from baseline at each time-point and throughout the 24-hour diurnal curve (p < 0.0001). When treatments were compared directly, evening dosing (18.4 +/- 3.3 mmHg) provided a statistically significant lower 24-hour curve than morning dosing (19.2 +/- 3.5 mmHg; p = 0.001). Evening dosing also resulted in a lower 24-hour IOP fluctuation (3.8 +/- 1.6 mmHg) than morning dosing (5.1 +/- 1.6 mmHg; p = 0.0002) and lower peak IOP (p = 0.0003). CONCLUSIONS: Both morning and evening administration of TTFC provide effective 24-hour IOP reduction, but evening dosing demonstrates better 24-hour pressure control.