Determining the effect of low-dose isotretinoin on proliferative vitreoretinopathy: the DELIVER trial.

PURPOSE: To examine the effect of low-dose, oral isotretinoin in lowering the risk of proliferative vitreoretinopathy (PVR) following rhegmatogenous retinal detachment (RRD) repair. METHODS: Prospective, open label, dual-cohort study with pathology-matched historical controls. The prospective experimental arms included two cohorts, composed of 51 eyes with recurrent PVR-related RRD and 58 eyes with primary RRD associated with high-risk features for developing PVR. Eyes in the experimental arms received 20 mg of isotretinoin by mouth once daily for 12 weeks starting the day after surgical repair. The primary outcome measure was single surgery anatomical success rate at 3 months following the study surgery. RESULTS: The single surgery anatomic success rate was 78.4% versus 70.0% (p=0.358) in eyes with recurrent PVR-related retinal detachment exposed to isotretinoin versus historical controls, respectively. In eyes with RRD at high risk for developing PVR, the single surgery success rate was 84.5% versus 61.1% (p=0.005) for eyes exposed to isotretinoin versus historical controls, respectively. For eyes enrolled in the experimental arms, the most common isotretinoin-related side effects were dry skin/mucus membranes in 106 patients (97.2%), abnormal sleep/dreams in 4 patients (3.7%) and fatigue in 3 patients (2.8%). CONCLUSION: The management and prevention of PVR is challenging and complex. At the dose and duration given in this study, oral istotretinoin may reduce the risk of PVR-associated recurrent retinal detachment in eyes with primary RRD at high risk of developing PVR.

Treat-and-Extend Therapy Using Aflibercept for Neovascular Age-related Macular Degeneration: A Prospective Clinical Trial.

PURPOSE: To determine the efficacy and durability of aflibercept used in a treat-and-extend (TAE) regimen for neovascular age-related macular degeneration (NVAMD). DESIGN: Multicenter, prospective, open label, noncomparative, interventional study. METHODS: Forty eyes of 40 patients with treatment-naïve NVAMD were managed with a TAE regimen of intravitreal aflibercept. The main endpoints were the change in mean and median best-corrected visual acuity from baseline at years 1 and 2. Other endpoints included mean number of annual injections and treatment intervals. RESULTS: Thirty-five (87.5%) and 31 patients (77.5%) completed year 1 and year 2, respectively. The mean letter gain was 7.2 (P < .001) and 2.4 (P = .269) letters at 1 and 2 years, respectively, from a mean baseline of 58.9 letters (20/63 Snellen equivalent). The median visual gain was 11.5 and 7.5 letters at 1 and 2 years, respectively, from a median baseline of 59.0 letters (20/63 Snellen equivalent). The mean number of injections was 8.0 and 6.5 during the first and second year, respectively. Twelve-week or longer treatment intervals were used in 35% and 38% of patients during the first- and second-year time points, respectively. CONCLUSION: Intravitreal aflibercept TAE therapy led to significant visual improvement in eyes with NVAMD at 1 year, with some loss in the visual gains at the end of year 2 that was not related to loss of exudative control. TAE therapy with aflibercept is a rational strategy to reduce treatments and clinic evaluations over 2 years with satisfactory outcomes.

Postinjection Endophthalmitis Rates and Characteristics Following Intravitreal Bevacizumab, Ranibizumab, and Aflibercept.

PURPOSE: To compare the incidence and clinical outcomes of endophthalmitis following intravitreal injections of bevacizumab, ranibizumab, and aflibercept. DESIGN: Multicenter, retrospective cohort study. METHODS: All included patients had received intravitreal injections of bevacizumab, ranibizumab, or aflibercept between January 1, 2009 and September 30, 2013 at 5 retina practices. Billing records were used to identify the total number of anti-vascular endothelial growth factor (VEGF) injections administered. Patients who developed endophthalmitis were ascertained from endophthalmitis logs and billing records. Chart review of these patients was performed to confirm that the endophthalmitis was related to the antecedent anti-VEGF injection. Visual outcomes, causative organisms, and clinical course were also recorded. RESULTS: A total of 503 890 anti-VEGF injections were included, from which 183 cases of presumed endophthalmitis were identified. The rate of endophthalmitis for bevacizumab was 0.039% (60/153 812), which was similar to ranibizumab 0.035% (109/309 722; P = .522) and aflibercept 0.035% (14/40 356; P = .693). Similarly, there was no difference in the rates between ranibizumab and aflibercept (P = .960). The culture-positive rate of the vitreous/aqueous tap was 38% for both bevacizumab and ranibizumab and was 43% for aflibercept. Furthermore, visual acuity remained decreased at 3 months follow-up for bevacizumab (P = .005), ranibizumab (P < .001), and aflibercept (P = .07) compared to vision at causative injection. CONCLUSIONS: Endophthalmitis following intravitreal bevacizumab, ranibizumab, and aflibercept injection appears to occur at similar rates and have comparable visual outcomes. This study suggests that the choice of anti-VEGF agent should be primarily based on efficacy and patient response rather than concern for risk of infection.

IDENTIFICATION OF FLUID ON OPTICAL COHERENCE TOMOGRAPHY BY TREATING OPHTHALMOLOGISTS VERSUS A READING CENTER IN THE COMPARISON OF AGE-RELATED MACULAR DEGENERATION TREATMENTS TRIALS.

PURPOSE: To examine treatment decisions by ophthalmologists versus reading center fluid identification from optical coherence tomography in Comparison of Age-Related Macular Degeneration Treatments Trials (CATT). METHODS: Fluid in 6,210 optical coherence tomography scans (598 patients) in "as needed treatment" arm of CATT Year 1 was compared with ophthalmologist's treatment: positive fluid agreement (PFA, fluid+, treatment+) and positive fluid discrepancy (PFD, fluid+, treatment-), negative fluid agreement (fluid-, treatment-) and negative fluid discrepancy (fluid-, treatment+). For PFDs, fluid location and visual acuity were characterized. RESULTS: Treatment and reading center fluid determination agreed in 72.1% (53.0% PFA, 19.1% negative fluid agreement) and disagreed in 27.9% (25.7% PFD, 2.2% negative fluid discrepancy) of visits, with no discrepancies for 20.9% of patients. Compared with PFA, PFD occurred more commonly with lower total foveal thickness (mean ± SD: 265 ± 103 PFD, 366 ± 151 µm PFA), presence of intraretinal fluid only, smaller fluid areas (PFA areas greater than twice those of PFD, P < 0.001), and greater decrease in retinal and lesion thickness. Mean acuities before, at, and after PFD were 65.8, 66.9, and 66.3 letters. CONCLUSION: Treatment decisions by ophthalmologists matched reading center fluid determination in the majority of visits. More pronounced response to treatment and smaller foci of fluid likely contributed to PFD. Positive fluid discrepancy did not have substantial impact on subsequent visual acuity.

PROSPECTIVE EVALUATION OF VISUAL ACUITY AGREEMENT BETWEEN STANDARD EARLY TREATMENT DIABETIC RETINOPATHY STUDY CHART AND A HANDHELD EQUIVALENT IN EYES WITH RETINAL PATHOLOGY.

PURPOSE: To evaluate the visual acuity agreement between a standard back-illuminated Early Treatment Diabetic Retinopathy Study (ETDRS) chart and a handheld internally illuminated ETDRS chart. METHODS: Two-center prospective study. Seventy patients (134 eyes) with retinal pathology were enrolled between October 2012 and August 2013. Visual acuity was measured using both the ETDRS chart and the handheld device by masked independent examiners after best protocol refraction. Examination was performed in the same room under identical illumination and testing conditions. RESULTS: The mean number of letters seen was 63.0 (standard deviation: 19.8 letters) and 61.2 letters (standard deviation: 19.1 letters) for the ETDRS chart and handheld device, respectively. Mean difference per eye between the ETDRS and handheld device was 1.8 letters. A correlation coefficient (r) of 0.95 demonstrated a positive linear correlation between ETDRS chart and handheld device measured acuities. Intraclass correlation coefficient was performed to assess the reproducibility of the measurements made by different observers measuring the same quantity and was calculated to be 0.95 (95% confidence interval: 0.93-0.96). Agreement was independent of retinal disease. CONCLUSION: The strong correlation between measured visual acuity using the ETDRS and handheld equivalent suggests that they may be used interchangeably, with accurate measurements. Potential benefits of this device include convenience and portability, as well as the ability to assess ETDRS visual acuity without a dedicated testing lane.

A prospective pilot study of intravitreal aflibercept for the treatment of chronic central serous chorioretinopathy: the CONTAIN study.

AIM: To evaluate the role of intravitreal aflibercept injection as a treatment for eyes with chronic central serous chorioretinopathy (CSCR). METHODS: This prospective pilot study enrolled 12 patients with chronic CSCR who received a 6-month treatment regimen of intravitreal aflibercept. Patients were followed with monthly Early Treatment of Diabetic Retinopathy Study (ETDRS) best-corrected visual acuity (BCVA) and spectral domain optical coherence tomography (SD-OCT) with enhanced depth imaging. RESULTS: All patients were men between 29 and 64 years (median 55). Subfoveal fluid was present on OCT for a median duration of 6 months (range 4-29 months) prior to treatment. Baseline BCVA ranged from 20/25 to 20/160 (median 20/50) with a mean of 62 (SD=13) ETDRS letters. No patients experienced serious ocular or systemic adverse events over the course of the study. Post-treatment BCVA ranged from 20/20 to 20/200 (median 20/40), with a mean of 64 (SD=16) ETDRS letters (p=0.56). At baseline, three patients (25%) had BCVA of ≥20/40 versus seven patients (58%) at the conclusion of the study. Two patients gained at least 15 ETDRS letters and no patients lost more than 15 ETDRS letters. Six of 12 patients (50%) had complete resolution of subfoveal fluid. Mean central macular thickness decreased from 400 µm (SD=104 µm) to 306 µm (SD=94 µm) (p=0.03), and mean subfoveal fluid decreased from 159 µm (SD=93 µm) to 49 µm (SD=68 µm) (p=0.02). Mean choroidal thickness decreased from 307 µm (SD=72 µm) to 263 µm (SD=63 µm) (p=0.0003). CONCLUSIONS: Intravitreal aflibercept was well tolerated over a 6-month treatment course for chronic CSCR. No change was observed in visual acuity metrics. Anatomic trends may suggest some morphological activity, but larger controlled trials are needed. TRIAL REGISTRATION NUMBER: NCT01710332.

Neovascular events in eyes with central retinal vein occlusion undergoing serial bevacizumab or ranibizumab intravitreal injections: a retrospective review.

PURPOSE: To characterize the onset and type of neovascular events in eyes with central retinal vein occlusion (CRVO) undergoing serial anti-VEGF therapy. METHODS: Consecutive eyes undergoing serial intravitreal bevacizumab or ranibizumab injections for treatment of CME secondary to CRVO were identified. Pertinent data was retrospectively collected and included type and onset of the neovascular event, and the treatment free interval from last injection until the neovascular event. Kaplan-Meier life table analysis was performed to determine the differential effects of baseline perfusion status, early initiation of anti-VEGF treatment (within 3 months of CRVO onset) versus later treatment, and continuous (1-month±2 weeks) versus discontinuous treatment interval (>1.5 months) on time until neovascular event. RESULTS: Of 31 eligible eyes, 12 (39%) and 19 (61%) presented with perfused and ischemic CRVO, respectively. The mean duration from CRVO until the onset of any neovascular event was 17.0±10.3 months. The mean treatment-free interval prior to any neovascular event was 6.2±7.3 months. On average, 5.3±3.2 anti-VEGF injections were given prior to any neovascular event. Neovascularization of the iris or angle occurred in 18 eyes (58%), vitreous hemorrhage associated with neovascularization was observed in 9 eyes (29%) and neovascularization of the disc developed in 5 eyes (16%). Neovascular events showed a trend towards occurring later in eyes with perfused CRVO at baseline (log rank test, P=0.07). CONCLUSION: Neovascular events occur in eyes with CRVO undergoing serial anti-VEGF therapy, and these events may be delayed compared to the natural history of CRVO-associated neovascularization. Iris neovascularization occurred most frequently.

Postoperative vitreous hemorrhage after diabetic 23-gauge pars plana vitrectomy.

PURPOSE: To report the frequency of postoperative vitreous hemorrhage (VH) in eyes that underwent primary 23-gauge pars plana vitrectomy (PPV) for nonclearing VH resulting from proliferative diabetic retinopathy, as well as associated risk factors. DESIGN: Retrospective, consecutive, interventional case series. SETTING: Institutional (Retina Service of Wills Eye Institute). STUDY POPULATION: One hundred seventy-three eyes of 157 patients. INTERVENTION: Twenty-three-gauge PPV for nonclearing diabetic VH. MAIN OUTCOME MEASURES: Percentage of eyes in which postoperative VH developed, categorized as early, delayed, or severe persistent, as well as percentage requiring reoperation. RESULTS: During a mean follow-up of 32 weeks, 56 (32%) of 173 eyes demonstrated postoperative VH, categorized as early (8 eyes; 5%), delayed (13 eyes; 8%), or severe persistent (35 eyes; 20%). Twenty-two (13%) of 173 eyes required reoperation: 4 (50%) of 8 in the early group, 8 (62%) of 13 in the delayed group, and 10 (29%) of 35 in the severe persistent group. Mean preoperative logarithm of the minimum angle of resolution visual acuity was 1.5 (Snellen equivalent, approximately 20/600); mean postoperative VA was 0.65 (Snellen equivalent, approximately 20/90), a gain of 0.85 (P < .0001). Thirty-four (27%) of 127 eyes with complete scatter photocoagulation before undergoing PPV compared with 22 (48%) of 46 eyes with incomplete scatter photocoagulation before undergoing PPV demonstrated postoperative VH (P = .002). Other factors associated with postoperative VH included younger age (P = .022) and phakia (P = .036). CONCLUSIONS: Postoperative VH was not uncommon after initial 23-gauge PPV for diabetic VH and was associated with incomplete scatter photocoagulation, younger age, and phakia before PPV. However, only a minority of patients required reoperation.

Reading Center Characterization of Central Retinal Vein Occlusion Using Optical Coherence Tomography During the COPERNICUS Trial.

PURPOSE: To determine the impact of segmentation error correction and precision of standardized grading of time domain optical coherence tomography (OCT) scans obtained during an interventional study for macular edema secondary to central retinal vein occlusion (CRVO). METHODS: A reading center team of two readers and a senior reader evaluated 1199 OCT scans. Manual segmentation error correction (SEC) was performed. The frequency of SEC, resulting change in central retinal thickness after SEC, and reproducibility of SEC were quantified. Optical coherence tomography characteristics associated with the need for SECs were determined. Reading center teams graded all scans, and the reproducibility of this evaluation for scan quality at the fovea and cystoid macular edema was determined on 97 scans. RESULTS: Segmentation errors were observed in 360 (30.0%) scans, of which 312 were interpretable. On these 312 scans, the mean machine-generated central subfield thickness (CST) was 507.4 ± 208.5 µm compared to 583.0 ± 266.2 µm after SEC. Segmentation error correction resulted in a mean absolute CST correction of 81.3 ± 162.0 µm from baseline uncorrected CST. Segmentation error correction was highly reproducible (intraclass correlation coefficient [ICC] = 0.99-1.00). Epiretinal membrane (odds ratio [OR] = 2.3, P < 0.0001), subretinal fluid (OR = 2.1, P = 0.0005), and increasing CST (OR = 1.6 per 100-µm increase, P < 0.001) were associated with need for SEC. Reading center teams reproducibly graded scan quality at the fovea (87% agreement, kappa = 0.64, 95% confidence interval [CI] 0.45-0.82) and cystoid macular edema (92% agreement, kappa = 0.84, 95% CI 0.74-0.94). CONCLUSIONS: Optical coherence tomography images obtained during an interventional CRVO treatment trial can be reproducibly graded. Segmentation errors can cause clinically meaningful deviation in central retinal thickness measurements; however, these errors can be corrected reproducibly in a reading center setting. TRANSLATIONAL RELEVANCE: Segmentation errors are common on these images, can cause clinically meaningful errors in central retinal thickness measurement, and can be corrected reproducibly in a reading center setting.

Increased Rates of Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK) Graft Failure and Dislocation in Glaucomatous Eyes with Aqueous Shunts.

PURPOSE: To investigate the rates of Descemet's stripping automated endothelial keratoplasty (DSAEK) graft dislocation and failure in glaucomatous eyes, including eyes with history of trabeculectomy and/or aqueous shunts. METHODS: A retrospective, case-control study on a total of 424 consecutive eyes undergoing DSAEK at an academic setting compared 96 glaucomatous eyes to a control group of 328 eyes. Pre- and post DSAEK procedure data was aggregated for up to 2 years (mean follow-up, 6.5±6.9 months) including rates of graft dislocation and failure. RESULTS: Out of 96 glaucomatous eyes, 20 had undergone trabeculectomy, 27 had received one or more aqueous shunts, 12 had undergone both procedures and 37 were on medical therapy. Complete DSAEK graft dislocation and failure occurred in 2.7% and 3% of non-glaucomatous patients, respectively. Eyes with history of aqueous shunt surgery experienced graft dislocation and failure rates of 26.0% (OR=4.6, 95% CI 1.5-13.7, p=0.0067) and 26.0% (OR=10.3, 95% CI 3.8-27.1, p<0.0001), respectively. In contrast, glaucomatous eyes only on medical therapy (p=0.13) or with history of trabeculectomy (p>0.40) had no significant increase in graft dislocation or failure rates. CONCLUSION: Eyes with medically controlled glaucoma or prior trabeculectomy demonstrated comparable rates of graft dislocation and failure as compared to controls. Aqueous shunt surgery was associated with increased rates of graft dislocation and failure after DSAEK.

Assessment of retinal morphology with spectral and time domain OCT in the phase III trials of enzymatic vitreolysis.

PURPOSE: To determine the relative ability of time domain (TD)-optical coherence tomography (OCT) compared with spectral domain (SD)-OCT to assess vitreoretinal interface abnormalities and pharmacologic treatment of symptomatic vitreomacular adhesion (VMA)/traction (VMT) with or without full-thickness macular hole (FTMH), and the reproducibility of trained readers' evaluation of these images in an interventional phase III program of ocriplasmin. METHODS: Eyes from the MIVI-TRUST program with concurrent SD-OCT and TD-OCT at baseline and day 28 were included. Pairwise intermodality agreement frequency and interreader reproducibility were calculated for baseline OCT features and the study endpoints of VMA resolution and FTMH closure. RESULTS: A total 186 eyes (186 patients) met the inclusion criteria for this study. There was excellent agreement between TD-OCT and SD-OCT for the reader-determined presence or absence of VMA (96.7%), FTMH (97.1%), and all other baseline parameters except epiretinal membrane (84.3%), which was detected at a significantly greater rate with SD-OCT than TD-OCT (44.6% vs. 35.3%, P < 0.001). There was excellent agreement for the study endpoints of VMA resolution (95.4%) and FTMH closure (100%) at day 28. Interreader reproducibility was similar but consistently greater with SD-OCT than TD-OCT to detect baseline VMA (kappa 0.6 vs. 0.52); FTMH (kappa 0.9 vs. 0.78); and epiretinal membrane (kappa 0.65 vs. 0.45). CONCLUSIONS: Readers using SD-OCT or TD-OCT have similar ability to assess vitreoretinal interface abnormalities and outcomes of enzymatic vitreolysis. SD-OCT may be superior for formal clinical trial grading due to greater interreader reproducibility and, therefore, decreased need for arbitration of discrepant values. (ClinicalTrials.gov numbers,NCT00781859, NCT00798317.).

Optical coherence tomography grading reproducibility during the Comparison of Age-related Macular Degeneration Treatments Trials.

OBJECTIVE: To report reading center reproducibility during grading of Stratus optical coherence tomography (OCT) (Carl Zeiss Meditec, Dublin, CA) images obtained during the Comparison of Age-Related Macular Degeneration Treatments Trials (CATT). DESIGN: Prospective, clinical trial. PARTICIPANTS: Independent reading teams reevaluated 270 OCT scans randomly sampled from the first 2 years of CATT enrollment. To assess temporal drift, a cohort of 23 scans submitted during the initial portion of the CATT study was longitudinally followed with serial reproducibility analysis. INTERVENTION: The CATT readers performed standardized grading of OCT images. A reader team, composed of 2 independent readers and a senior reader, evaluated each scan. Grading included the CATT OCT end points of total thickness at the foveal center point and intraretinal fluid (IRF), subretinal fluid (SRF), and subretinal pigment epithelium (RPE) fluid. Independent reading teams masked to the results of initial grading reevaluated scans to determine the reproducibility of qualitative grading and measurements. MAIN OUTCOME MEASURES: Categorical grading agreement was reported using percent agreement and kappa statistic, and measurement agreement was reported using intraclass correlations and paired differences. RESULTS: Reading center teams reproducibly graded IRF (percent agreement = 73%, kappa = 0.48; 95% confidence interval [CI], 0.38-0.58), SRF (percent agreement = 90%; kappa = 0.80; 95% CI, 0.73-0.87), and sub-RPE fluid (percent agreement 88%; kappa = 0.75; 95% CI, 0.67-0.83). For independent reading center team measurements of total thickness at the foveal center point, the intraclass correlation was 0.99 (95% CI, 0.99-0.99), and the mean paired difference between reading center teams was 4 µm (95% limits of agreement, -55 to 47 µm). There was no qualitative or quantitative grading drift. CONCLUSIONS: The standardized protocols used to evaluate OCT scans from the CATT study were reproducible. The methods used are suitable to monitor OCT imaging data from a large, neovascular age-related macular degeneration, interventional, multicenter study. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Characterization of vitreoretinal interface disorders using OCT in the interventional phase 3 trials of ocriplasmin.

PURPOSE: We determined the reproducibility of a novel optical coherence tomography (OCT) protocol designed to evaluate formally vitreoretinal interface abnormalities on scans obtained during two phase 3 studies of intravitreal ocriplasmin to treat symptomatic vitreomacular adhesion with or without macular hole. METHODS: Certified technicians obtained time-domain OCT scans that included a macular thickness map (MTM), Fast MTM, and three high resolution linear scans: one 10 mm horizontal and one 10 mm vertical through the optic nerve head (ONH), and one 10 mm 5-degree-offset through the ONH and fovea. Reading Center teams graded all 3695 scans from 652 study eyes for pre-established quantitative and morphologic features. Grading reproducibility at baseline and follow-up visits was tested for presence of vitreomacular adhesion (VMA), width of vitreous adhesion (focal <1500 µm versus broad >1500 µm), presence and minimum width of full thickness macular hole (FTMH), and presence of epiretinal membrane (ERM). RESULTS: Team grading reproducibility for VMA (kappa 0.91, 95% confidence interval [CI] 0.81-1.00), broad versus focal width of vitreous adhesion (kappa 0.87, 95% CI 0.78-0.95), FTMH (kappa 0.87, 95% CI 0.78-0.95), and ERM (kappa 0.87, 95% CI 0.78-0.95) was high. Percent agreement was 97%, 92%, 95%, and 82% for VMA, vitreous adhesion width, FTMH, and ERM, respectively. For repeated measurements of FTMH width, the intraclass correlation was 0.89 (95% CI 0.85-0.93), and the mean paired difference between grading team measurements was 34.4 µm (95% limits of agreement -149.5-218.2 µm). CONCLUSIONS: Quantitative and morphologic vitreoretinal interface features were assessed reproducibly using a newly developed OCT scan acquisition and grading protocol. This protocol will be useful to evaluate OCT endpoints in future clinical trials, and can facilitate identification of vitreoretinal interface pathology during care of individual patients. (ClinicalTrials.gov number, NCT00781859 and NCT00798317.).

Analysis of resident-performed manual small incision cataract surgery (MSICS): an efficacious approach to mature cataracts.

To examine and improve outcomes of resident-performed manual small incision cataract surgery (MSICS) cases via analysis of visual recovery, intraoperative adverse events, and early postoperative course. Particular focus was directed toward mature cataracts extracted by MSICS. A retrospective review was performed to identify MSICS cases performed by resident surgeons unfamiliar with the technique (initial ten cases) in an academic setting. Preoperative history, intraoperative adverse events, and postoperative course were reviewed. Of 30 cases identified, mean preoperative acuity was 1.8 ± 0.9 logMAR units (Snellen equivalent = 20/1262) improving to 0.20 ± 0.35 logMAR units (20/31) at final follow-up (p < 0.0001). Mean follow-up was 22.1 ± 19.0 days. The most frequent intraoperative adverse events were wound leak requiring intraoperative suturing (33 %), vitreous loss (6.7 %), and capsulorhexis radialization (6.7 %). Transient cornea edema was the most frequent (56.7 %) early postoperative minor complication. Two major complications occurred that required wound revision in one eye and iridoplasty in one eye. Of the 30 eyes undergoing surgery, 19 were noted to have mature cataracts. In this subset, mean acuity was 2.25 ± 0.64 logMAR units (20/3557) improving to 0.28 ± 0.42 logMAR (20/38) at final follow-up (p < 0.0001). Complications were similar in nature and frequency to the entire population in this subgroup. Supervised resident MSICS cataract surgery can result in excellent anatomic and visual outcomes. Appropriate wound construction is a frequently encountered difficulty, so particular attention should be directed to this step by both trainers and trainees.

Intravitreal bevacizumab for macular edema due to central retinal vein occlusion: perfused vs. ischemic and early vs. late treatment.

PURPOSE/AIMS: This study investigates the efficacy of intravitreal bevacizumab (IVB) for cystoid macular edema (CME) secondary to central retinal vein occlusion (CRVO). Subgroup analysis was performed comparing early (within 90 days of CRVO onset) and late treatment (after 90 days) as well as perfused and ischemic subgroups. MATERIALS AND METHODS: Retrospective review of 48 consecutive eyes with CRVO treated with IVB was performed. Data collected at various time points included best corrected visual acuity (BCVA), central foveal thickness (FT) on optical coherence tomography (OCT), perfusion status on fluorescein angiography (FA), and complications. RESULTS: Mean initial BCVA was 20/288 compared to 20/214 at 12 months (p=0.07) and 20/204 (p=0.03) at final follow-up. Initial mean central FT was 591 micrometers compared to 339 micrometers at 12 months (p=0.003). Mean follow-up was 10.5 months, and mean number of injections was 3.7. After IVB, no significant difference in BCVA gain or edema resolution on OCT was noted between the early and late treatment groups or between the perfused and ischemic subgroups. CONCLUSIONS: IVB improves foveal thickness in eyes with CRVO, but this does not always correlate with visual recovery. No difference in efficacy was observed for IVB treatment of perfused versus ischemic CRVO or when used for early versus late treatment.

Intravitreal bevacizumab for macular edema secondary to branch retinal vein occlusion.

PURPOSE: To evaluate the effect of intravitreal bevacizumab on the visual and anatomical outcome in eyes with macular edema secondary to branch retinal vein occlusion. METHODS: A retrospective, consecutive case series identified 53 consecutive patients with a branch retinal vein occlusion treated with intravitreal bevacizumab. Clinical variables were analyzed, including best-corrected visual acuity, angiographic characteristics, central foveal thickness, and complications. RESULTS: Fifty-three eyes were identified with a mean initial best-corrected visual acuity of 20/137 and final best-corrected visual acuity of 20/96 (P = 0.05). The mean final line change was +1.6 lines (95% confidence interval, +0.7 to +2.3; +8 letters [95% confidence interval, +3.5 to 11.5]). At final follow-up, 28% gained ≥ 3 lines, whereas a loss of >3 lines was seen in 6% of eyes. The mean initial central foveal thickness of 425 µm decreased to 289 µm (P < 0.001). Mean number of injections was 2.5, and mean follow-up was 9 months. Eyes treated for ≤ 6 months after the onset of branch retinal vein occlusion showed improved functional outcomes (e.g., final best-corrected visual acuity, mean line change) as compared with those treated with >6 months of symptoms (P < 0.01). CONCLUSION: Intravitreal bevacizumab appears to be an effective treatment for macular edema secondary to branch retinal vein occlusion in many subjects. Eyes treated with intravitreal bevacizumab showed a significant reduction in central foveal thickness and improvement in visual acuity. Early treatment with intravitreal bevacizumab resulted in a greater improvement in visual acuity compared with delayed treatment.

Optimizing diagnosis and management of nocardia keratitis, scleritis, and endophthalmitis: 11-year microbial and clinical overview.

OBJECTIVE: To identify clinical factors and microbiological assays that facilitate a rapid diagnosis of Nocardia keratitis, scleritis, and endophthalmitis, and to determine optimal medical and surgical management strategies. DESIGN: Retrospective, consecutive case series. PARTICIPANTS: A total of 111 cases of keratitis, 11 cases of scleritis, and 16 cases of endophthalmitis, all culture-proven Nocardia infections, were identified between January 1999 and January 2010. INTERVENTION: The keratitis cases underwent intensive medical management, and the scleritis and endophthalmitis cases required concurrent surgical intervention for disease control. Corneal and scleral scrapings, as well as undiluted vitreous sample, were submitted for microbiologic evaluation (direct smear and culture). MAIN OUTCOME MEASURES: Historical points, clinical findings, and microbiologic assays that facilitated a prompt Nocardia diagnosis were identified, and management choices were examined for correlation with final acuity. RESULTS: Ocular exposure to soil or plant matter was a common historical point in cases of Nocardia keratitis (48%) and scleritis (45%), respectively. Nocardia keratitis often (38.7%) presented with "wreath"-shaped anterior stromal infiltrate or infiltrate interspersed with elevated, pinhead-sized, chalky lesions. Most patients with scleritis (63.4%) presented with nodular lesions demonstrating pointed abscesses. Nocardia endophthalmitis typically (75%) presented with endoexudates or nodular exudates surrounding the pupillary border. Gram stain and 1% acid-fast stain enabled prompt diagnosis of Nocardia in 64% and 63% of keratitis cases and 45% and 63% of scleritis cases, respectively. Direct smear was usually not revealing in cases of Nocardia endophthalmitis. Isolates from Nocardia keratitis, scleritis, and endophthalmitis demonstrated 97%, 100%, and 90% susceptibility to amikacin, respectively. Nocardia keratitis resolved with medical therapy alone in 82% of cases. Younger age and better initial acuity correlated with improved final acuity in keratitis cases. Outcomes were poor after Nocardia scleritis and endophthalmitis. CONCLUSIONS: Early appropriate treatment often results in visual recovery in eyes with Nocardia keratitis. Despite aggressive and prompt surgical intervention, the prognosis for Nocardia scleritis and endophthalmitis is more guarded. Nocardia isolated from ocular infections demonstrate high levels of susceptibility to amikacin. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

In vitro fluid dynamics of the Ahmed glaucoma valve modified with expanded polytetrafluoroethylene.

PURPOSE: Long-term intraocular pressure reduction by glaucoma drainage devices (GDDs) is often limited by the fibrotic capsule that forms around them. Prior work demonstrates that modifying a GDD with a porous membrane promotes a vascularized and more permeable capsule. This work examines the in vitro fluid dynamics of the Ahmed valve after enclosing the outflow tract with a porous membrane of expanded polytetrafluoroethylene (ePTFE). MATERIALS AND METHODS: The control and modified Ahmed implants (termed porous retrofitted implant with modified enclosure or PRIME-Ahmed) were submerged in saline and gelatin and perfused in a system that monitored flow (Q) and pressure (P). Flow rates of 1-50 µl/min were applied and steady state pressure recorded. Resistance was calculated by dividing pressure by flow. RESULTS: Modifying the Ahmed valve implant outflow with expanded ePTFE increased pressure and resistance. Pressure at a flow of 2 µl/min was increased in the PRIME-Ahmed (11.6 ± 1.5 mm Hg) relative to the control implant (6.5 ± 1.2 mm Hg). Resistance at a flow of 2 µl/min was increased in the PRIME-Ahmed (5.8 ± 0.8 mm Hg/µl/min) when compared to the control implant (3.2 ± 0.6 mm Hg/µl/min). CONCLUSIONS: Modifying the outflow tract of the Ahmed valve with a porous membrane adds resistance that decreases with increasing flow. The Ahmed valve implant behaves as a variable resistor. It is partially open at low pressures and provides reduced resistance at physiologic flow rates.