UNITED KINGDOM DATABASE STUDY OF INTRAVITREAL DEXAMETHASONE IMPLANT (OZURDEX) FOR MACULAR EDEMA RELATED TO RETINAL VEIN OCCLUSION.

PURPOSE: To study the treatment patterns, visual outcomes and safety profile of intravitreal dexamethasone implant (IDI) used for the treatment of macular edema secondary to retinal vein occlusion. METHODS: Up to 2 years of routinely collected anonymized data within electronic medical record systems were remotely extracted from 16 centers. The outcome measures include visual outcome, number of injections, and safety measures, including the rate of intraocular pressure (IOP) rise, frequency of IOP-lowering medication usage, and cataract surgery rates. RESULTS: The study included 688 eyes (44.4%) with central retinal vein occlusion and 862 eyes (55.6%) with branch retinal vein occlusion; 1,250 eyes (80.6%) were treatment naive and 28% (275/989) had high IOP or were on IOP-lowering medications before IDI use. It was found that 31% (476) of eyes received two injections, and 11.7% (182) and 3.7% (58) of eyes received three and four injections, respectively. The mean baseline Snellen visual acuity improved from 20/125 to 20/40 after the first injection. The probability of cataract surgery was 15% at 24 months. The proportion of eyes with ≥10 mmHg change from baseline was higher in phakic (14.2%) compared with pseudophakic eyes (5.4%, P = 0.004). Three eyes required IOP filtering surgery (0.2%). CONCLUSION: The visual results of IDI in eyes with macular edema secondary to retinal vein occlusion in the real world are comparable to those of clinical trial setting. Increased IOP in eyes with preexisting ocular hypertension or glaucoma can be controlled with additional medical treatment. Intraocular pressure rise with IDI may be more frequent in phakic than in pseudophakic eyes.

Individualizing Therapy for Neovascular Age-Related Macular Degeneration with Aflibercept (VITAL): A Two-Year Prospective, Interventional Single-Centre Trial.

AIMS: To report the mean change in Early Treatment Diabetic Retinopathy Study (ETDRS) best-corrected visual acuity (BCVA) and reading performance (reading acuity and maximum reading speed (MRS) using the MNREAD test) between baseline and 24 months in treatment-naïve patients with neovascular age-related macular degeneration (nAMD) treated with intravitreal aflibercept injections. METHODS: A prospective, open-label, interventional non-randomised case series with 24 months' duration. Patients were recruited to the study from medical retina clinics at Moorfields Eye Hospital. Intravitreal injections of 2.0 mg aflibercept in the study eye were administered using a fixed dosing regimen during the first year and a treat-and-extend treatment regimen during the second year of treatment. RESULTS: Fifty patients were enrolled with a mean age (SD) of 78.7 (7.6) years; a mean BCVA of 62.8 ETDRS letters; mean reading acuity of 0.52 logMAR; mean maximum reading speed (MRS) of 141.3 words per minute and a central macular thickness of 322.6 µm at baseline. The mean improvement in BCVA was 6.4 letters for the 44 patients (88%) for whom data was available at 2 years. The mean improvement in reading acuity was 0.13 logMAR with an improvement in MRS of 2.9 words per minute. The mean reduction in CRT from baseline was 104.8 µm. CONCLUSIONS: Aflibercept treatment of nAMD using fixed dosing in year 1 and treat and extend in year 2 leads to improvements in reading ability, visual acuity and retinal morphology which were maintained to 2 years of treatment. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT02441816, the VITAL study.

Intraocular Lens Opacification following Intracameral Injection of Recombinant Tissue Plasminogen Activator to Treat Inflammatory Membranes after Cataract Surgery.

Purpose. To report 7 cases of intraocular lens (IOL) opacification following treatment of postoperative anterior chamber fibrin with recombinant tissue plasminogen activator (rtPA) after cataract surgery. Methods. Retrospective case series of 7 eyes in 7 patients who developed IOL opacification after receiving rtPA for anterior chamber inflammatory membrane formation resulting from phacoemulsification cataract surgery. Three explanted IOLs were investigated with light microscopy, histochemical analysis, scanning electron microscopy, and X-ray spectrometry. Results. All patients underwent uncomplicated cataract surgery and posterior chamber hydrophilic IOL implantation. Anterior chamber inflammatory membranes developed between 1 and 4 weeks of surgery and were treated with intracameral rtPA. IOL opacification was noted between 4 weeks and 6 years after rtPA treatment with reduced visual acuity, and IOL exchange was carried out in 3 patients. Light microscopy evaluation revealed diffuse fine granular deposits on the anterior surface/subsurface of IOL optic that stained positive for calcium salts. Scanning electron microscopy (SEM) and energy-dispersive X-ray spectrometry (EDS) confirmed the presence of calcium and phosphate on the IOL. Conclusions. Intracameral rtPA, though rapidly effective in the treatment of anterior chamber inflammatory membranes following cataract surgery, may be associated with IOL opacification.

Patterns of non-embolic transient monocular visual field loss.

The aim of this study was to systematically describe the semiology of non-embolic transient monocular visual field loss (neTMVL). We conducted a retrospective case note analysis of patients from Moorfields Eye Hospital (1995-2007). The variables analysed were age, age of onset, gender, past medical history or family history of migraine, eye affected, onset, duration and offset, perception (pattern, positive and negative symptoms), associated headache and autonomic symptoms, attack frequency, and treatment response to nifedipine. We identified 77 patients (28 male and 49 female). Mean age of onset was 37 years (range 14-77 years). The neTMVL was limited to the right eye in 36 % to the left in 47 % and occurred independently in either eye in 5 % of cases. A past medical history of migraine was present in 12 % and a family history in 8 %. Headache followed neTMVL in 14 % and was associated with autonomic features in 3 %. The neTMB was perceived as grey in 35 %, white in 21 %, black in 16 % and as phosphenes in 9 %. Most frequently neTMVL was patchy 20 %. Recovery of vision frequently resembled attack onset in reverse. In 3 patients without associated headache the loss of vision was permanent. Treatment with nifedipine was initiated in 13 patients with an attack frequency of more than one per week and reduced the attack frequency in all. In conclusion, this large series of patients with neTMVL permits classification into five types of reversible visual field loss (grey, white, black, phosphenes, patchy). Treatment response to nifidipine suggests some attacks to be caused by vasospasm.

Embolic and nonembolic transient monocular visual field loss: a clinicopathologic review.

Transient monocular blindness and amaurosis fugax are umbrella terms describing a range of patterns of transient monocular visual field loss (TMVL). The incidence rises from ≈1.5/100,000 in the third decade of life to ≈32/100,000 in the seventh decade of life. We review the vascular supply of the retina that provides an anatomical basis for the types of TMVL and discuss the importance of collaterals between the external and internal carotid artery territories and related blood flow phenomena. Next, we address the semiology of TMVL, focusing on onset, pattern, trigger factors, duration, recovery, frequency-associated features such as headaches, and on tests that help with the important differential between embolic and non-embolic etiologies.

Uveitis (acute anterior).

INTRODUCTION: Anterior uveitis is rare, with an annual incidence of 12/100,000 population, although it is more common in Finland (annual incidence of 23/100,000), probably because of genetic factors, such as high frequency of HLA-B27 in the population. It is often self-limiting, but can, in some cases, lead to complications such as posterior synechiae, cataract, glaucoma, and chronic uveitis. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical question: What are the effects of anti-inflammatory eye drops on acute anterior uveitis? We searched: Medline, Embase, The Cochrane Library and other important databases up to November 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found six systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review we present information relating to the effectiveness and safety of the following interventions: corticosteroids, mydriatics, and non-steroidal anti-inflammatory drug eye drops.

Uveitis (acute anterior).

INTRODUCTION: Anterior uveitis is rare, with an annual incidence of 12/100,000 population, although it is more common in Finland (annual incidence of 23/100,000), probably because of genetic factors, such as high frequency of HLA-B27 in the population. It is often self-limiting, but can, in some cases, lead to complications such as posterior synechiae, cataract, glaucoma, and chronic uveitis. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical question: What are the effects of anti-inflammatory eye drops on acute anterior uveitis? We searched: Medline, Embase, The Cochrane Library and other important databases up to February 2007 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found six systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review we present information relating to the effectiveness and safety of the following interventions: corticosteroids, mydriatics, and non-steroidal anti-inflammatory drug eye drops.

Inert intraocular eyelash foreign body following phacoemulsification cataract surgery.

INTRODUCTION: We describe the first reported case of tolerated eyelash inoculation following phacoemulsification surgery, with 4 years follow-up, that did not result in endophthalmitis or low grade chronic uveitis. CASE REPORT: A 79-year-old man with bilateral cataracts underwent phacoemulsification and posterior chamber intraocular lens implantation in the right eye. Three months later, he was found to have an eyelash within the right anterior chamber. The patient opted to leave his asymptomatic right eye alone. Four years later, he was referred to our hospital for review of his intraocular foreign body. He had remained asymptomatic with bilateral 6/6 vision, and without pain, photophobia or monocular diplopia. He declined surgery to remove the foreign body and opted for annual review. DISCUSSION: Intraocular implantation of cilia is a rare surgical complication following cataract surgery. The reaction of the eye to cilia has been reported to be variable and unpredictable, varying from absolute lack of reaction to endophthalmitis. Careful preoperative preparation can prevent similar incidents with potential complications. The position of the cilium is an important consideration. In contrast to other organic materials, a cilium is relatively inert and is rarely associated with infection. Acute inflammation most commonly occurs within days or after a few months, although the eye can tolerate the cilium for many years. Some ophthalmologists prefer observation, particularly when there is no inflammation present. We believe that each patient should be considered on an individual basis. The decision to remove an intraocular eyelash remains controversial and should be considered at the onset of inflammatory or infective clinical signs.

Orbital varices, cranial defects, and encephaloceles: an unrecognized association.

PURPOSE: To highlight an apparently unreported association between orbital varices and malformations of the cranial skeleton with or without abnormalities of the underlying cerebral parenchyma. DESIGN: Retrospective, noncomparative review of case notes and radiologic imaging. PARTICIPANTS: Three hundred ten patients attending the Orbital Clinic at Moorfields Eye Hospital, London, with a diagnosis of low-pressure, low-flow orbital venous anomalies. METHODS: All available orbital imaging for patients with orbital venous anomalies was examined. For those with defects of the cranial base, the radiologic characteristics were noted and the clinical details were reviewed. MAIN OUTCOME MEASURES: The presence and type of orbital roof or medial wall defects and associated nasal or other cranial anomalies. RESULTS: Imaging was adequate for review in 222 of 310 patients (72%), and anomalies of the neighboring cranium or cerebral structure were found in 10 of 222 patients (4.5%). In the group with cranial anomalies, the proportion of men (7/10; 70%) did not significantly differ from that in the group with varices but without cranial anomalies (93/212; 44%; P = 0.19, Fisher exact test). Orbital varices were associated with 3 types of cranial anomaly: major midline encephaloceles (type I anomaly; 4 cases), large superomedial defects of the orbital wall (type II; 3 cases), or defects of the greater wing of the sphenoid (type III; 3 cases). CONCLUSIONS: Clinicians should be aware of the possibility of significant cranio-orbital or cranionasal anomalies in patients with orbital venous anomalies; these anomalies can vary from minor defects in the cranial base to large encephalomeningoceles. This rare association should not be overlooked when orbital varices become markedly inflamed, because intranasal encephaloceles are a known predisposition to recurrent meningitis.