A case report of cystoid macular edema, uveitis and vitreomacular traction in a patient taking Anastrozole.

PURPOSE: To report a case of cystoid macular edema, uveitis, and vitreomacular traction in a patient with a history of breast cancer and taking anastrozole. OBSERVATIONS: A 73-year-old female with a history of estrogen receptor-positive breast cancer and treatment with anastrozole presented with bilateral blurry vision, photophobia, and eye soreness. Optical coherence tomography (OCT) of both maculae revealed vitreomacular traction (VMT), an epiretinal membrane, cystoid macular edema (CME) in the right eye, and drusen without subretinal fluid bilaterally. Although later, macular OCT did show evidence of cystoid intraretinal spaces in the left eye as well. Fluorescein angiography showed bilateral petaloid leakage, bilateral slow disc leaking, as well as peripheral leakage in the right eye. Anastrozole was discontinued and, subsequent macular OCT showed release of VMT in the right eye, and eventual resolution of intraretinal cystoid spaces bilaterally. CONCLUSIONS AND IMPORTANCE: Stopping of anastrozole was associated in resolution of refractory CME in a patient on aromatase inhibitor therapy for breast cancer. It is therefore important to consider anastrozole and other aromatase inhibitor drugs as possible factors predisposing patients to the development of CME.

Response to aflibercept after frequent re-treatment with bevacizumab or ranibizumab in eyes with neovascular AMD.

BACKGROUND AND OBJECTIVE: To evaluate the effects of switching to aflibercept in eyes with neovascular age-related macular degeneration (AMD) requiring frequent re-treatment with bevacizumab or ranibizumab. PATIENTS AND METHODS: Retrospective review of 73 eyes of 65 patients with neovascular AMD switched to aflibercept due to persistent or recurrent macular fluid after at least 1 year of intravitreal bevacizumab or ranibizumab with re-treatment at least every 6 weeks. Minimum post-switch follow-up was 6 months. All patients were treated using a treat-and-extend strategy. The treatment intervals immediately after and before the switch were the same. RESULTS: The mean pre-switch anti-VEGF therapy duration was 45 months, and the mean number of injections was 31. In the 6 months after the switch, the average number of injections was reduced by 0.6 compared with the 6 months before the switch (P < .001). Visual acuity was unchanged during this period (P = .78). Central retinal thickness (CRT) decreased by 19 µm after the switch (P < .001). Seventy eyes had vascularized retinal pigment epithelial detachments (PEDs). The decrease in the PED cube-root volume during the 6 months after the switch was statistically significant (-0.07 mm; P = .007). CONCLUSION: The number of injections, CRT, and PED volume decreased significantly after the switch to aflibercept, but visual acuity was unchanged.

Severe bilateral ischemic retinal vasculitis following cataract surgery.

This report describes two cases of severe, bilateral ischemic retinal vasculitis following cataract surgeries at different surgical centers. In both cases, the patient underwent bilateral cataract surgeries, performed 1 week apart for each eye. In the perioperative period following the second of the two surgeries, both patients developed severe, bilateral intraocular inflammation and profound vision loss. The underlying cause of this adverse response remains unknown. The authors suggest that the severe inflammatory reaction could be related to an intraoperative intracameral vancomycin injection.

Pseudocystic foveal cavitation in tamoxifen retinopathy.

PURPOSE: To present 3 cases of tamoxifen-induced foveal cavitation and review previous prospective and cross-sectional studies. DESIGN: Observational case series. METHODS: Retrospective analysis of patients presenting to a single institution with evidence of tamoxifen-induced maculopathy. RESULTS: Three patients presented with pseudocystic foveal cavitation similar in appearance to macular telangiectasia type 2 on spectral-domain optical coherence tomography (SD OCT) imaging. CONCLUSIONS: Tamoxifen maculopathy is characterized by cavitation in the central macula with or without typical cystoid macular edema. Pathogenesis involves toxicity to retinal Müller cells. It can occur with low daily and cumulative doses of the drug, and in the absence of subjective visual complaints or crystalline retinopathy. Prospective research with SD OCT imaging will be required to gain a more accurate estimate of the incidence of tamoxifen retinopathy.

Epiretinal macular edema associated with thick epiretinal membranes.

High-resolution imaging with spectral-domain optical coherence tomography has identified an unusual group of epiretinal membranes (ERMs) in the presence of lamellar macular holes. These ERMs are unusually thick. The authors present the case of a patient with age-related macular degeneration who developed edema within a thickened ERM in both eyes after cataract surgery. The edema resolved with anti-vascular endothelial growth factor (VEGF) therapy. The authors propose that the VEGF-responsive fluid within these thick ERMs arose from fibrovascular tissue derived from the retina. Further studies with histopathology will be required to determine whether neovascular tissue is present in all cases of thickened ERMs with epiretinal edema.

Initial outcomes following intravitreal ocriplasmin for treatment of symptomatic vitreomacular adhesion.

BACKGROUND AND OBJECTIVE: When delivered via a single intravitreal injection, ocriplasmin can effect proteolytic resolution of symptomatic vitreomacular adhesion (VMA). The authors describe their initial clinical experience with ocriplasmin at a large academic center. PATIENTS AND METHODS: Retrospective review of all patients with symptomatic VMA treated with ocriplasmin from January 2013 through May 2013 at a single center. RESULTS: Nineteen patients with symptomatic VMA received intravitreal ocriplasmin. Eight patients (42%) exhibited resolution of VMA. Macular holes in three of six patients (50%) closed after injection. A higher proportion of VMA resolution was observed in patients with the following baseline characteristics: age less than 65 years, focal adhesions less than or equal to 1,500 µm, presence of macular hole, phakic status, and absence of epiretinal membrane. CONCLUSION: Initial clinical outcomes using ocriplasmin in this study are consistent with those reported in the phase 3 clinical trials. Improved clinical results can be achieved with careful case selection based on specific baseline characteristics.

The efficacy of a midfacial seal drape in reducing oculofacial surgical field fire risk.

PURPOSE: To evaluate the efficacy of a midface seal drape in eliminating fire risk oxygen concentrations from nasal cannulated oxygen delivery compared with a standard open oculofacial surgical field. METHODS: Controlled experiment using the SimMan patient simulator and an oxygen detector. Oxygen concentrations were measured at 9 facial surgical locations with nasal cannula flow rates of 2, 4, and 6 l/min of 100% FiO2 in both the draped and undraped conditions. RESULTS: The mean oxygen concentration in the oculofacial surgical field with the seal drape was 21.4% and 26.3% without (p = 0.0002; paired t test, 2-tailed). The draped condition provided safe oxygen concentration levels at all anatomical landmarks at all 3 flow rates, whereas the undraped condition was associated with suprathreshold oxygen concentration levels at 13 of 27 measurements. There was a direct correlation between oxygen flow rate and surgical field oxygen concentration in the undraped condition. CONCLUSIONS: A midfacial seal drape reduced oxygen concentrations from nasal cannula oxygen in the oculofacial surgical field and may reduce fire risk.

Amniotic membrane transplantation with anterior stromal micropuncture for treatment of painful bullous keratopathy in eyes with poor visual potential.

PURPOSE: To report the use of anterior stromal micropuncture and amniotic membrane transplantation in the management of painful bullous keratopathy in patients with poor visual potential. METHODS: Interventional case series. A retrospective review was performed to identify all patients who were treated by one of us (A.J.A.) between January 1, 2003, and June 30, 2005. RESULTS: Five eyes of 5 patients were identified. Conjunctival scarring secondary to glaucoma and retinal surgeries prevented mobilization of the conjunctiva in each of the patients identified. Each eye showed an intact, smooth corneal epithelial surface 1 month after the procedure, and no patients developed recurrent bullae formation during the follow-up period (average follow-up, 21 months; range, 11-34 months). CONCLUSIONS: Anterior stromal micropuncture and amniotic membrane transplantation is an effective technique for the management of bullous keratopathy in patients with poor visual potential. The success rate of this combined procedure may exceed that of either procedure performed alone.

No pathogenic mutations identified in the COL8A1 and COL8A2 genes in familial Fuchs corneal dystrophy.

PURPOSE: To investigate the genetic basis of late-onset, familial Fuchs endothelial corneal dystrophy (FECD) through screening of the COL8A1 and COL8A2 genes, in which mutations have been associated with both early and late-onset, familial and sporadic FECD. METHODS: DNA extraction, PCR amplification, and direct sequencing of the COL8A1 and COL8A2 genes was performed in affected and unaffected members of 15 unrelated families with two or more members with late-onset FECD. RESULTS: Screening of the COL8A1 gene did not reveal sequence variants in any affected individuals from the 15 FECD families. In the COL8A2 gene, the previously identified mutations presumed to play a pathogenic role in cases of familial FECD (Arg155Gln, Leu450Trp, and Gln455Lys) were not discovered in any of the affected patients. A mutation previously considered causative of FECD (Arg434His) was shown not to segregate with the disease in the one family in which it was identified. Two previously identified single-nucleotide polymorphisms (SNPs), Pro575Leu and Pro586Pro, were identified in a single affected individual and three affected individuals (two families), respectively. CONCLUSIONS: The Arg434His mutation in the COL8A2 gene, previously associated with FECD, has been shown not to segregate with the disease phenotype, and thus may not be considered a disease-causing mutation. The absence of pathogenic mutations identified in the COL8A1 or COL8A2 genes in affected members of 15 pedigrees with familial FECD indicates that other genetic factors are involved in the development of this autosomal dominant corneal dystrophy.

Corneal copper deposition associated with chronic lymphocytic leukemia.

PURPOSE: To report a case of corneal copper deposition associated with chronic lymphocytic leukemia (CLL). DESIGN: Case report. METHODS: A 65-year-old woman with a history of CLL was diagnosed with bilateral corneal opacification. Slit-lamp examination revealed dense, central yellow-brown pigmentation of Descemet's membrane in each cornea. The presence of a bilateral pigmented deposition at the level of Descemet's membrane led to a presumptive clinical diagnosis of corneal copper deposition. RESULTS: Serologic investigations revealed a markedly elevated copper (hypercupremia) and IgG levels with a normal ceruloplasmin. Wilson's disease was excluded as a possible cause based on liver function tests and a liver biopsy. Thus, the patient was diagnosed with corneal copper deposition secondary to hypercupremia associated with CLL. CONCLUSIONS: Corneal copper deposition may be associated with systemic malignancy, most commonly myeloproliferative disorders, including CLL. Recognition of the characteristic clinical features associated with corneal copper deposition allows the clinician to confirm the diagnosis with appropriate serologic studies.

Unilateral lattice corneal dystrophy associated with the novel His572del mutation in the TGFBI gene.

PURPOSE: To report a novel mutation in the TGFBI gene, c.1761_1763del (p.His572del), associated with a unilateral variant of lattice corneal dystrophy (LCD). METHODS: A 63-year-old man presenting with the complaint of decreased vision in one eye was noted to have a unilateral lattice corneal dystrophy. Examination of the patient's wife and two sons, ages 20 and 27 years old, failed to reveal the presence of any corneal opacities. Following the collection of DNA from the patient and his family members, the TGFBI gene was screened for mutations previously associated with lattice corneal dystrophy and any novel coding region changes. RESULTS: In the affected patient, none of the mutations previously associated with the classic and variant forms of LCD were identified. However, a novel mutation, c.1761_1763del (p.His572del), was identified in exon 13 of TGFBI in the patient and his sons. This mutation was not identified in the patient's wife or in 200 control chromosomes. CONCLUSIONS: The novel TGFBI gene mutation (p.His572del) is associated with a unilateral, late-onset variant of lattice corneal dystrophy. This case highlights the utility of molecular genetic analysis in differentiating corneal dystrophies associated with an atypical phenotype from nondystrophic conditions.

Clinical outcomes in patients with chronic congestive heart failure who undergo left ventricular assist device implantation.

OBJECTIVE: The use of left ventricular assist devices as a bridge to transplantation for patients with chronic congestive heart failure is well accepted. However, few studies have examined outcomes solely for these patients. This study details one center's left ventricular assist device experience with this population. METHODS: Two hundred one patients received HeartMate left ventricular assist devices (Thoratec Corp, Pleasanton, Calif) from January 1, 1996, to April 30, 2004. Of these, 119 (59.2%) had chronic congestive heart failure (diagnosis >6 months) as the primary indication. Outcome parameters included early mortality after left ventricular assist device placement (<30 days), bridge-to-transplantation rate, and posttransplantation survival. Variables examined included patient demographic data; preoperative pacemaker, internal defibrillator, and balloon pump use; and preoperative laboratory values. RESULTS: Advanced age, female sex, and diabetes were independent predictors of early death (P = .048, odds ratio 1.879 per 10 years of age, 95% confidence interval 1.005-3.515; P = .002, odds ratio 10.029, 95% confidence interval 2.256-44.583; P = .040, odds ratio 3.974, 95% confidence interval 1.063-14.861). Advanced age, female sex, and low preoperative albumin were independent predictors of poor bridge-to-transplantation rate (P = .029, odds ratio 0.135 per 10 years of age, 95% confidence interval 0.022-0.819; P = .002, odds ratio 0.013, 95% confidence interval 0.001-0.197; P = .023, odds ratio 19.178 per 1 g/dL albumin, 95% confidence interval 1.504-244.598). There were no independent predictors of poor posttransplantation survival and prolonged intensive care unit stay. Overall bridge-to-transplantation rate was 81.5%. The 1-, 3-, 5-, and 7-year posttransplantation survivals were 88.4%, 84.5%, 78.4%, and 76.0%. CONCLUSION: Among patients with chronic congestive heart failure, advanced age, female sex, diabetes, and low preoperative albumin predict poor clinical course. Careful risk stratification and comprehensive evaluation by care providers should be performed for candidates who are female, are elderly, and have diabetes, and preoperative nutritional optimization should be encouraged to enhance patient outcomes.

Optimization of Schwann cell adhesion in response to shear stress in an in vitro model for peripheral nerve tissue engineering.

The design of nerve guidance channels (NGCs) is evolving to produce a favorable environment for neural regeneration. We created an in vitro model to evaluate the interactions between three centrally important components of this altered host environment: (1). Schwann cells, (2). substrate, and (3). sustained mechanical stimulus in the form of shear stress with laminar fluid flow. Preconfluent Schwann cells were plated on slides coated either with laminin, poly-D-lysine, type IV collagen, or fibronectin. These slides were placed into custom-designed, parallel-plate, flow chambers and were administered laminar fluid flow at a rate of 15 mL/min for 2 h. Schwann cell adhesion assays demonstrated that laminin (mean, 86.1%; SEM, 4.47%) and fibronectin (mean, 81.7%; SEM, 3.24%) were statistically superior to collagen type IV (mean, 57.7%; SEM, 3.96%) and poly-D-lysine (mean, 58.0%; SEM, 4.97%) (p < 0.001). Fibronectin (mean, 12.20%; SEM, 0.374%) induced statistically greater Schwann cell proliferation than did laminin (mean, 8.14%; SEM, 0.682%) (p < 0.001). Therefore, we recommend that fibronectin should be used as an important component of NGCs with further in vivo studies. As mechanical stress is an integral part of the host environment, our study is the first to incorporate this factor into an in vitro model for peripheral nerve tissue engineering.