ENDOGENOUS ENDOPHTHALMITIS IN THE SETTING OF COVID-19 INFECTION: A Case Series.

PURPOSE: To describe endogenous endophthalmitis in the setting of COVID-19 pneumonia. METHODS: Patients recovering from COVID-19 pneumonia who presented to our department with any or all of the following complaints: pain, watering, redness, and decreased vision were identified. All relevant data were collected for analysis. RESULTS: Three patients with endogenous endophthalmitis were identified. All patients had been treated for COVID-19 pneumonia and therefore had received remdesivir and systemic steroids; 2 of the 3 patients received tocilizumab. All patients received vitreous biopsy, vitrectomy, and intraocular antibiotic injection. Patient 1 demonstrated Klebsiella pneumoniae in blood culture, K. pneumoniae and Escherichia coli in urine culture, and K. pneumoniae in vitreous fluid, whereas Patients 2 and 3 demonstrated Stenotrophomonas maltophilia and methicillin-resistant Staphylococcus aureus in the blood and nasopharyngeal culture, respectively. Correspondingly, the same organism was cultured from vitreous in Patients 2 and 3. The visual acuity at the last follow-up in Patients 1 to 3 was 20/100, 20/80, and 20/40, respectively. The probable source of infection was identified in each as renal calculi, dental caries, and the pharynx, respectively. Real-time polymerase chain reaction demonstrated the presence of Severe Acute Respiratory Syndrome Coronavirus 2 in the vitreous fluid of Patient 1. CONCLUSION: We report good outcomes of early intervention for endogenous endophthalmitis in the setting of COVID-19 infection. We also document the presence of SARS-CoV-2 in vitreous.

FLATTENING OF A TREATMENT-RESISTANT RETINAL PIGMENT EPITHELIAL DETACHMENT AFTER A SINGLE INTRAVITREAL INJECTION OF ZIV-AFLIBERCEPT.

PURPOSE: To report flattening of a treatment-resistant retinal pigment epithelial detachment (PED) due to neovascular age-related macular degeneration after a single intravitreal injection of ziv-aflibercept (Zaltrap). METHODS: A 67-year-old woman with a neovascular age-related macular degeneration-related PED was treated with intravitreal injections of bevacizumab and ranibizumab, and in combination with verteporfin photodynamic therapy, before receiving a single intravitreal injection of ziv-aflibercept (1.25 mg/0.05 mL). RESULTS: The patient presented with a visual acuity of 20/30 in the right eye, a PED height of 581 µm, and a central macular thickness of 381 µm. She received eight intravitreal injections of bevacizumab and ranibizumab, one in combination with photodynamic therapy. The height of the PED and the central macular thickness varied over time, but 3 years later, they measured 382 µm and 418 µm, respectively. A single intravitreal injection of ziv-aflibercept resulted in a dramatic reduction in PED height to 140 µm, which was maintained 2 months later. The visual acuity remained stable, and there were no clinical signs of toxicity. CONCLUSION: Intravitreal ziv-aflibercept safely and effectively improved a treatment-resistant PED. Intravitreal ziv-aflibercept could become a treatment option for neovascular age-related macular degeneration in countries where aflibercept (Eylea) is not available or its cost is prohibitive, but further studies are necessary to establish efficacy and safety.

Three-month outcome of ziv-aflibercept for exudative age-related macular degeneration.

PURPOSE: In vitro and in vivo studies did not detect toxicity to the retinal pigment epithelium cells using intravitreal ziv-aflibercept. Our purpose is to ascertain the 3-month safety and efficacy in wet age-related macular degeneration (AMD) treated with intravitreal ziv-aflibercept. METHODS: Prospectively, consecutive patients with wet AMD underwent ziv-aflibercept intravitreal injection (1.25 mg/0.05 mL) from March 2015 to November 2015. Monitoring of best-corrected visual acuity, intraocular inflammation, cataract progression and by spectral domain optical coherence tomography were carried out at baseline day 1, 1 week, 1 month, 2 months and 3 months after injections. RESULTS: 30 eyes were treated (22 Caucasians, 8 Indians; 16 men, 14 women; 14 right eyes and 16 left eyes) with mean age of 74.3 years with 11 treatment-naïve cases and 19 having had treatment-non-naïve. Best-corrected visual acuity improved from baseline logMAR 1.08-0.74 at 1 week, 0.72 at 1 month, 0.67 at 2 months and 0.71 at 3 months (p<0.001 for all time periods). Central macular thickness in microns decreased from 332.8 to 302.0 at 1 week, 244.8 at 1 month, 229.0 at 2 months and 208.2 at 3 months (p<0.001 for all time periods). There were no signs of intraocular inflammation, or change in lens status or increase in intraocular pressure throughout the study. CONCLUSIONS: Off label use of ziv-aflibercept improves visual acuity, without detectable ocular toxicity and offers a cheaper alternative to the same molecule aflibercept, especially in low/middle-income countries and in countries where aflibercept (Eylea) is not available. TRIAL REGISTRATION NUMBER: NCT02486484.

SHORT-TERM SAFETY PROFILE OF INTRAVITREAL ZIV-AFLIBERCEPT.

AIM: To evaluate the safety of intravitreal ziv-aflibercept (Zaltrap) in the treatment choroidal neovascularization secondary to age-related macular degeneration. METHODS: Eligible eyes with choroidal neovascularization secondary to age-related macular degeneration each received a single intravitreal injection of ziv-aflibercept. Comprehensive ophthalmic examinations and detailed systemic evaluations were performed at baseline and Days 1, 7, and 30 after injection, and International Society for Clinical Electrophysiology of Vision standard electroretinography was performed at baseline and Day 30. Primary outcome measures were safety parameters that included signs of clinical and electroretinographic toxicity. Secondary outcome measures included changes in best-corrected visual acuity and central subfield thickness. RESULTS: Twelve eyes of 12 patients were treated. None of the patients complained of blurred vision, ocular pain, or bulbar injection at any of the follow-up visits, nor was intraocular inflammation noted. There were no significant differences in implicit times, "a" and "b" wave amplitudes, or b/a ratios at 1 month when compared with baseline (P = 0.4). None of the patients experienced serious ocular or systemic adverse events. Mean best-corrected visual acuity improved only slightly at 30 days (LogMAR 0.45 ± 0.31 [Snellen equivalent: 20/60]) compared with baseline (LogMAR 0.37 ± 0.24 [Snellen equivalent: 20/50]; P = 0.51). CONCLUSION: Single intravitreal injections of ziv-aflibercept into eyes with neovascular age-related macular degeneration appear to be safe through 1 month. Ziv-aflibercept could become a safe, low-cost therapy for macular diseases in developing countries and in those where intravitreal aflibercept (Eylea) is not available.

ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY FOR NAIVE IDIOPATHIC CHOROIDAL NEOVASCULARIZATION: A Comparative Study.

PURPOSE: To determine the clinical characteristics of patients with idiopathic choroidal neovascularization and to compare outcomes between intravitreal bevacizumab (IVB) and ranibizumab as therapy. METHODS: Retrospective analysis included demographics, the corrected distance visual acuity, details of the ocular examination, imaging, treatment, outcomes, and adverse events. Patients with minimum of 1-year follow-up were included in the study. Primary outcome measure was change in corrected distance visual acuity at the final visit compared with baseline. Secondary outcome measures were change in central macular thickness and subretinal fluid (if present) with treatment and adverse events. RESULTS: This study included 47 eyes of 45 patients with 30 males. Intravitreal bevacizumab group included 29 eyes (27 patients; with a median age of 39.4 ± 7.3 years). Intravitreal ranibizumab group included 18 eyes (18 patients; median age: 36.8 ± 9.3 years). Median baseline corrected distance visual acuity (logMAR) improved from 0.59 ± 0.38 to 0.2 ± 0.18 (P = 0.03) in intravitreal ranibizumab group and from 0.62 ± 0.41 to 0.18 ± 0.15 logMAR (P = 0.023) in intravitreal bevacizumab group. Median central macular thickness (in micrometers) improved from 315.11 ± 75.24 to 228.24 ± 67 (P = 0.036) in intravitreal bevacizumab group and from 327.24 ± 61.56 to 208 ± 53.42 (P = 0.031) in intravitreal ranibizumab group. There was no significant difference between groups in final corrected distance visual acuity (P = 0.31) or central macular thickness (P = 0.51). No adverse events were noted. CONCLUSION: Both intravitreal ranibizumab and intravitreal bevacizumab seem equally effective in treating idiopathic choroidal neovascularization with a good safety profile without recurrence.

Apophysomyces elegans: a novel cause of endogenous endophthalmitis in an immunocompetent individual.

A 20-year-old male presented with sudden onset redness, pain, and decreased vision in his left eye. Best-corrected visual acuity in the left eye was noted to be perception of light positive with inaccurate projection. On clinical examination, he was diagnosed to have left eye endogenous endophthalmitis. Smear and culture of vitreous biopsy were positive for Apophysomyces elegans, a fungus known to cause extensive soft tissue infections systemically characteristically in immunocompetent individual. The patient was treated aggressively with topical, systemic, and intravitreal antifungals but had a poor visual and anatomical outcome. This is a first known report of endogenous endophthalmitis due to Apophysomyces elegans.

Epidemiology and intermediate-term outcomes of open- and closed-globe injuries in traumatic childhood cataract.

PURPOSE: To study epidemiology and intermediate-term outcomes of open- and closed-globe injuries (CGI) in traumatic childhood cataract. METHODS: In this retrospective interventional case series, demographic parameters and history including type of injury of 57 children younger than 16 years with traumatic cataract were recorded; ocular examination included best-corrected visual acuity (BCVA), slit-lamp biomicroscopy, and posterior segment evaluation. Patients underwent cataract surgery with or without intraocular lens (IOL) implantation. Main surgical outcomes at 6 months comprised BCVA, residual refractive spherical error (SE), and postoperative complications, namely visual axis opacification (VAO) and amblyopia. RESULTS: Bow and arrow was the most common causal agent. Open-globe injury (OGI) was 3 times more frequent than CGI. There was a significant visual gain from baseline in both groups after cataract surgery (p<0.001); residual SE was greater in OGI (1.6 ± 0.95 SD) compared to blunt trauma (0.8 ± 0.55 SD; p = 0.001). Incidence of corneal scarring, iris distortion, posterior synechiae, and intraoperative posterior capsular tear was greater with OGI (p<0.05). A total of 86% of patients were rehabilitated with a primary/secondary IOL. Single-piece IOL implantation rate (p = 0.004) was significantly greater in CGI, with no statistical difference for in-the-bag IOL (p = 0.053) and IOL implantation rate (p = 0.16). Final BCVA was significantly better for in-the-bag IOL implantation compared to sulcus fixation. Postoperative complications included amblyopia (51%) and VAO (12%). CONCLUSIONS: Bow and arrow injury caused the maximum cases of traumatic cataract; cataract extraction resulted in significant visual improvement; and CGI tended to have better prognosis in pediatric traumatic cataracts.

Prevalence and causes of patient dropout after glaucoma surgery.

PURPOSE: To determine the prevalence of patient dropout after glaucoma surgery and reasons for the same based on patient attitudes and beliefs. DESIGN: A hospital-based retrospective case-control study. METHODS: Clinical and demographic data of patients who failed to attend follow-up within 12 months of their last scheduled appointment after glaucoma surgery were analyzed. These patients were issued recall letters and those who returned were interviewed to establish the reasons for their dropout. A structured interview was conducted to assess the educational and socioeconomic status of the patients, their knowledge and belief regarding glaucoma, their attitude towards surgery and the specific reason for their inability to follow up post-operatively. Control subjects who were regularly followed-up post-operatively were also interviewed. RESULTS: Of 312 patients operated on from 2004-2006, only 92 (30%) patients maintained a 5-year follow-up. Of patients who dropped out, 43 patients responded to the recall letters and were interviewed along with 45 control patients. The demographic profile of those who dropped out was statistically similar to the controls; however, the controls had a significantly better awareness of glaucoma and higher monthly income (p < 0.001 and p = 0.01, respectively). Among those who dropped out, 38 (88%) believed surgery was the cure to the disease in comparison to 12 (46%) controls (p < 0.001). CONCLUSIONS: Dropout after glaucoma surgery is high among patients from lower socioeconomic strata. Misconceptions regarding surgery as a cure to glaucoma and situational factors are the most common reasons for patient dropout in this population.