A prospective multicentre randomized placebo-controlled superiority trial in patients with suspected bacterial endophthalmitis after cataract surgery on the adjuvant use of intravitreal dexamethasone to intravitreal antibiotics.

PURPOSE: We aimed to determine whether intravitreal dexamethasone as an adjuvant to intravitreal antibiotics is beneficial in the treatment of suspected bacterial endophthalmitis after cataract surgery. METHODS: Randomized, placebo-controlled superiority trial in three tertiary referral centres in the Netherlands. Patients with suspected bacterial endophthalmitis within 6 weeks after cataract surgery were eligible. A diagnostic vitreous biopsy was taken for culture, and patients received intravitreal injections of 400 µg dexamethasone (without preservatives) or placebo, in addition to 0.2 mg vancomycin and 0.05 mg gentamicin. The vancomycin and dexamethasone or placebo injections were repeated once at day 3 or 4. Primary outcome measure was best-corrected visual acuity (BCVA) at 1 year. RESULTS: Between 1 November 2004 and 1 March 2014 (excluding two interruptions totalling 20 months), 324 eligible patients presented. A total of 167 patients (81 dexamethasone, 86 placebo) were available for the intention-to-treat analysis. Biopsies of 114 patients (68%) were culture-positive. Final BCVA did not differ between the dexamethasone and the placebo group (logMAR 0.31 ± 0.58 versus 0.27 ± 0.50; p = 0.90), nor did the number of patients with final vision of no light perception (LP, 7 versus 13). Pain, corneal oedema, the absence of a red fundus reflex on presentation, LP on presentation and culture of virulent pathogens from biopsy were statistically significantly associated with an unfavourable visual outcome. CONCLUSION: Intravitreal dexamethasone without preservatives as an adjuvant to intravitreal antibiotics does not improve visual acuity (VA) in patients treated for suspected bacterial endophthalmitis after cataract surgery.

Vitreous base visualisation through trans-scleral illumination with a standard 25-gauge light probe.

PURPOSE: To describe a technique of vitreous base visualisation through trans-scleral illumination using a standard 25-gauge light probe. METHODS: All vitrectomies are performed using 25-gauge+ instruments and valved trocars. A non-contact viewing system is used to visualise the retina. After core vitrectomy and the necessary additional procedures, triamcinolone acetonide (Kenacort) is injected in the vitreous cavity. Then, the standard 25-gauge light pipe is covered with a sleeve obtained from a 20-gauge venflon cannula. The light brightness is increased to 100%, and the light probe used to indent the sclera and trans-illuminate the vitreous base. The vitreous cutter is activated between the crystals of triamcinolone acetonide and the retinal surface. Complete vitreous base shaving is carried out for 360°. RESULTS: Iatrogenic peripheral retinal tears, as a result of vitreous shaving, occurred in 4.1% of cases with this technique. CONCLUSIONS: This method represents a valid and low-cost option to achieve accurate vitreous base shaving.

A case of central serous chorioretinopathy occurring after γ-hydroxybutyric acid (liquid ecstasy) ingestion.

PURPOSE: To describe a patient with acute central serous chorioretinopathy after use of γ-hydroxybutyric acid (GHB), also known as "liquid ecstasy." METHODS: Observational case report of a patient who developed central serous chorioretinopathy a day after use of GHB at a party. RESULTS: A young adult male patient presented at the department complaining of non-improving acute onset of vision loss in the left eye after use of GHB at a party 3 weeks before. Fundus examination, optical coherence tomography, and fluorescein angiography revealed a dome-shaped retinal elevation centered to the macula of the left eye, suggesting the diagnosis of central serous chorioretinopathy. Spontaneous subretinal fluid resolution with improvement of vision was observed a month later. CONCLUSION: γ-hydroxybutyric acid has been reported to induce an acute increase in cortisol secretion after its administration. In addition, a case of Cushing syndrome after chronic abuse of GHB has been described. The acutely increased cortisol levels, induced by GHB, might have been the cause of central serous chorioretinopathy in the patient.

Angiographic evidence for revascularization of an rpe-choroid graft in patients with age-related macular degeneration.

PURPOSE: To study graft perfusion using fluorescein angiography (FA) and indocyanine green angiography (ICG) after the translocation of an autologous retinal pigment epithelium (RPE)-choroid graft in patients with exudative age-related macular degeneration (AMD). METHODS: Retrospective observational case series of 31 patients with AMD who had FA and/or ICG performed after an RPE-choroid graft translocation. The FAs (n = 25) and ICGs (n = 23) were assessed by an independent masked reader for the presence of early fluorescence of the graft in FA, and for perfusion of the choroidal vessels of the graft and recipient bed in ICG. RESULTS: Early fluorescence of the graft was present in 23 of the 25 FAs. Perfusion of the graft vasculature was observed in 12 of the 23 ICGs. The two grafts that lacked early fluorescence in FA also had no signs of choroidal perfusion of the graft and the recipient bed with ICG. CONCLUSION: Revascularization of the RPE-choroid graft was observed in all but 2 of the 31 patients either by early fluorescence of the graft by FA or by identification of perfused choroidal graft vessels with ICG from 1 week up to 3 years after surgery. For assessment of revascularization of the graft evaluation of the early phase of the FA is recommended.

Erosive vitreoretinopathy and wagner disease are caused by intronic mutations in CSPG2/Versican that result in an imbalance of splice variants.

PURPOSE: Linkage intervals for erosive vitreoretinopathy (ERVR) and Wagner disease previously were found to overlap at 5q14.3. In a Japanese family with Wagner disease, a CSPG2/Versican splice site mutation (c.4004-2A-->G) was recently reported that resulted in a 39-nucleotide exon 8 in-frame deletion. We investigated whether CSPG2/Versican was mutated in six Dutch families and one Chinese family with Wagner disease and in a family with ERVR. METHODS: In all families, extensive ophthalmic examinations, haplotype analysis of the 5q14.3 region, and sequence analysis of CSPG2/Versican were performed. The effects of splice site mutations were assessed by reverse transcription-polymerase chain reaction (RT-PCR) and real-time quantitative RT-PCR (QPCR). RESULTS: Three novel intron 7 sequence variants (c.4004-5T-->C, c.4004-5T-->A, c.4004-1G-->A) were identified in seven families. The c.4004-5T-->C variant was identified in four families with Wagner disease and a family with ERVR. The families were shown to carry the same 5q14.3 haplotype, strongly suggesting that this is a common Dutch founder variant. All three changes segregated with the disease in the respective families and were absent in 250 healthy individuals. In patients with the c.4004-5T-->A and c.4004-1G-->A variants, RT-PCR analysis of CSPG2/Versican showed activation of a cryptic splice site resulting in a 39-nt exon 8 in-frame deletion in splice variant V0. QPCR revealed a highly significant (P < 0.0001) and consistent increase of the V2 (>38-fold) and V3 (>12-fold) splice variants in all patients with intron 7 nucleotide changes and in a Chinese Wagner disease family, in which the genetic defect remains to be found. CONCLUSIONS: Wagner disease and ERVR are allelic disorders. Seven of the eight families exhibit a variant in intron 7 of CSPG2/Versican. The conspicuous clustering of sequence variants in the splice acceptor site of intron 7 and the consistent upregulation of the V2 and V3 isoforms strongly suggest that Wagner disease and ERVR may belong to a largely overlooked group of diseases that are caused by mRNA isoform balance shifts, representing a novel disease mechanism.

A novel technique for self-sealing, wedge-shaped pars plana sclerotomies and its features in ultrasound biomicroscopy and clinical outcome.

PURPOSE: To investigate a new type of self-sealing pars plana sclerotomy clinically and by means of ultrasound biomicroscopy and to compare the outcome with conventionally sutured sclerotomies. DESIGN: Prospective, nonrandomized clinical trial. METHODS: Twenty-one patients underwent pars plana vitrectomy either with (control group) or without suturing (study group) at the Institute of Ophthalmology, University Medical Centre Nijmegen, The Netherlands, between January 1 and March 31, 2002. One day and 6 to 8 weeks postoperatively, the sclerotomy sites were studied by clinical examination and ultrasound biomicroscopy. Results were graded according to verbal descriptor scales. RESULTS: The study included 21 patients scheduled for pars plana vitrectomy of one eye. Mean follow-up time was 6.5 weeks (range, 6-8). Three patients were lost to follow-up. Of the remaining patients, 12 had self-sealing wedge-sclerotomies and six were conventionally operated. No intraoperative complications occurred in any participant and no visual loss or postoperative hypotony was observed. On the first day after surgery there was significantly more scleral dehiscence in the control group (P =.012). This divergence disappeared during the follow-up period. All other differences noticed were not statistically significant. CONCLUSIONS: Our novel technique of sutureless wedge-shaped sclerotomy allows the creation of simple, reliable, and self-sealing pars plana openings. Clinical examination and assessment by ultrasound biomicroscopy showed results to be at least as safe as conventionally sutured sclerotomies. This new method allows stable intraoperative ocular pressure conditions and seems promising.

Autologous retinal pigment epithelium and choroid translocation in patients with exudative age-related macular degeneration: short-term follow-up.

PURPOSE: To evaluate the feasibilty of translocating autologous retinal pigment epithelium cells and choroid after the removal of a subfoveal choroidal neovascular membrane in patients with exudative age-related macular degeneration. DESIGN: Interventional case series. METHODS: This was a prospective evaluation of six patients with a follow-up of 7 to 13 months. All patients had large (> 1 disk diameter) subfoveal choroidal membranes, five with subretinal hemorrhage. Preoperative visual acuity ranged from 20/400 to 20/200. After the extraction of the neovascular complex, an autologous peripheral full-thickness patch of retinal pigment epithelium, Bruch membrane, choriocapillary, and choroid was cut out from the midperiphery and repositioned under the macula. Functional tests included Early Treatment Diabetic Retinopathy Study vision testing, fixation testing on a optical coherence tomography monitor, fluorescein and indocyanine green angiography, and scanning laser ophthalmoscopy autofluorescence. RESULTS: The retinal pigment epithelium patch appeared flat and had a brown furry aspect in four patients. Fixation was on the patch in these four patients. Postoperative vision ranged from 20/200 to 20/64, with a 2-line increase in three patients. Revascularization was visible on fluorescein and indocyanide angiography in three patients examined in this manner. Normal retinal pigment epithelium autofluorescence was present over the patch in four patients. CONCLUSIONS: The translocation of a full-thickness patch with autologous peripheral retinal pigment epithelium to the macula after choroidal neovascular membrane extraction was feasible and may result in a surviving and functioning graft for more than 1 year. Longer follow-up to evaluate its long-term benefit is necessary, as well as refinement of the surgery.

Rhegmatogenous retinal detachment and uveitis.

PURPOSE: To evaluate the frequency, high-risk factors, and visual prognosis of rhegmatogenous retinal detachment (RRD) in patients with uveitis. DESIGN: Retrospective case-control study. PARTICIPANTS: We included 1387 consecutive patients with uveitis who consulted our uveitis clinic from January 1990 through December 1997 of whom 43 patients (46 eyes) with RRD were identified. The retinal detachment (RD) controls were 212 consecutive patients with RRD (221 eyes, first occurrence of RD, not associated with uveitis) who were admitted for surgery in the period from April 1999 to April 2000. The uveitis control group consisted of 150 age-matched patients (210 eyes) selected from the entire uveitis series. INTERVENTION: Retrospective analysis of clinical data. MAIN OUTCOME MEASURES: The presence of RRD and eventual risk factors for RRD, such as myopia, retinal lattice degeneration, prior intraocular surgery, anatomic location of uveitis, its specific diagnosis, and clinical manifestations. Furthermore, the surgical and nonsurgical outcomes of RRD, as well as the results of various treatment regimens, were analyzed. RESULTS: RRD was identified in 3.1% of the patients with uveitis. RRD was most frequently associated with panuveitis (6.6%). RRD was associated more frequently with infectious (7.6%) than noninfectious uveitis (2.1%). At the onset of RRD, uveitis was active in most (46%) affected eyes. Proliferative vitreoretinopathy was present in 30% of the uveitic RRD eyes at presentation in contrast to 12% of the RRD control eyes. In uveitic RRD, the retina was reattached in 59% of eyes with a single operation; the final anatomic reattachment rate was 88%. Finally, a visual acuity of less than 20/200 was present in 71% of the uveitic RRD eyes, 10% of which had no light perception. CONCLUSIONS: We discovered a high prevalence of RRD in patients with active panuveitis and infectious uveitis and document that uveitis in itself is a risk factor for the development of RRD. The visual prognosis of RRD in uveitis was poor because of the uveitis itself and the frequent development of proliferative vitreoretinopathy.