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ABSTRACT: PURPOSE: To describe the clinical characteristics of and risk factors for the development of optic neuropathy after pars plana vitrectomy (PPV) for macula-sparing primary rhegmatogenous retinal detachment (RRD) repair. DESIGN: Retrospective case-control study. PARTICIPANTS: Seven patients who underwent PPV for macula-sparing primary RRD with subsequent development of optic neuropathy and 42 age- and gender-matched control patients undergoing PPV for macula-sparing primary RRD. METHODS: Retrospective chart review of medical and surgical records. MAIN OUTCOME MEASURES: Clinical features of patients who developed optic neuropathy after PPV for macula-sparing RRD and analysis of potential risk factors (age, gender, medical history, surgical technique, intraoperative ocular perfusion pressure [OPP], and operative time). RESULTS: At last follow-up, all 7 patients with optic neuropathy had visual acuity less than 20/200, relative afferent pupillary defects, optic nerve pallor, and visual field defects. A total of 5 of 7 patients (71%) demonstrated intraoperative reduced OPP with associated systemic hypotension compared with 7 of 42 patients (17%) in the control cohort (P = 0.01). CONCLUSIONS: Optic neuropathy after PPV for macula-sparing primary RRD is a rare but potentially devastating complication. Although the cause is often unclear, reduced ocular perfusion due to intraoperative systemic hypotension may be a contributing risk factor in some eyes. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.
Ophthalmology 07/2012; · 5.45 Impact Factor
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Ophthalmology 08/2011; 118(8):1696, 1696.e1; author reply 1697. · 5.45 Impact Factor
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ABSTRACT: To examine the usefulness of 23-gauge pars plana vitrectomy (PPV) in removing retained lens fragments and to determine which cases require 20-gauge ultrasonic fragmentation.
Retrospective comparative case series.
Twenty eyes in 20 consecutive patients who had 23-gauge PPV for retained lens fragments after complicated cataract surgery at Wills Eye Institute were retrospectively reviewed. Retained lens fragments were graded based on percentage of total nuclear size. Every surgical case started with 23-gauge PPV, but 1 sclerotomy was enlarged to facilitate 20-gauge ultrasonic fragmentation if all lens material could not be adequately removed.
Twelve patients (60%) were successfully managed with 23-gauge PPV alone while 8 patients (40%) required 20-gauge ultrasonic fragmentation. The 23-gauge cases had a lower percentage of retained lens fragments (median 10%, range 0% to 75%) compared to the 20-gauge cases (median 90%, range 10% to 100%).
23-Gauge PPV is a feasible approach in the surgical management of select cases of retained lens fragments.
American journal of ophthalmology 07/2011; 152(4):624-7. · 3.83 Impact Factor
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ABSTRACT: To describe outcomes of and risk factors for endophthalmitis after intravitreal anti-vascular endothelial growth factor (VEGF) injection.
Single-center, consecutive, case series and retrospective case-control study.
Between January 1, 2009, and May 31, 2010, 16 vitreoretinal surgeons administered a total of 27 736 injections. During this period, 23 cases of presumed infectious endophthalmitis occurred. Each surgeon used his own preferred injection technique.
Vitreous or aqueous tap, or both, with intravitreal antibiotic injection and subsequent topical antibiotic and steroid drops.
Visual acuity, bladed lid speculum use, conjunctival displacement, hemisphere of injection, bevacizumab versus ranibizumab, and infectious organism.
Seven of 23 cases had positive culture results; 3 grew coagulase-negative Staphylococcus. All cases had pain and vitritis on average 3.4 days (range, 1-6 days) after injection, with no difference between culture-positive and culture-negative groups. Eighteen (78%) of 23 cases had a hypopyon. Fifteen of 23 cases returned to baseline vision (±2 lines) within 3 months. Neither lid speculum use (0.10% vs. 0.066% in the no-use group; P = 0.27), conjunctival displacement (0.11% vs. 0.076% in the no-displacement group; P = 0.43), hemisphere of injection (0.11% superior vs. 0.079% inferior; P = 0.56), or bevacizumab versus ranibizumab (0.11% vs. 0.066%; P = 0.21) affected risk. Analysis of only culture-positive results yielded similar results. There was no statistically significant difference between the proportion of culture-negative cases after bevacizumab injection (83%) versus ranibizumab injection (55%; P = 0.13).
Most patients in whom presumed infectious endophthalmitis develop after anti-VEGF injection regained baseline vision after treatment. Bladed lid speculum use, conjunctival displacement, hemisphere of injection, and type of anti-VEGF agent did not affect risk. No difference in culture-negative endophthalmitis rates was detected after bevacizumab versus ranibizumab injection. Neither the presence of pain, vitritis, decreased vision, hypopyon, nor the interval between injection and development of symptoms differentiate culture-positive from culture-negative cases. Because a subgroup of patients had poor outcomes, a low threshold for vitreous tap with intravitreal antibiotic injection may be warranted.
The author(s) have no proprietary or commercial interest in any materials discussed in this article.
Ophthalmology 06/2011; 118(10):2028-34. · 5.45 Impact Factor
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ABSTRACT: To investigate the short-term outcomes of 25-gauge pars plana vitrectomy (PPV) in 18 cases of complicated retinal detachment requiring silicone oil tamponade.
In this retrospective noncomparative review, the primary outcome measures included postoperative anatomical status, preoperative and postoperative visual acuity and intraocular pressure (IOP), cataract progression, development of keratopathy, and other complications. The average follow-up was 5 months (142 days).
Thirteen (72.2%) of 18 patients had attachment postoperatively. There was no difference between preoperative visual acuity and visual acuity at the end of follow-up (P = 0.851). One patient (5.6%) who underwent concomitant penetrating keratoplasty had hypotony (IOP, <6 mmHg) postoperatively and until the end of follow-up. Ocular hypertension in two patients was controlled with antiglaucoma drops. Five (55.6%) of 9 patients who were initially phakic underwent cataract extraction or had documented cataract progression. There were no cases of keratopathy or endophthalmitis. Four patients had intraocular or retinal hemorrhage. Two patients developed significant macular epiretinal membranes, and one developed a parafoveal hole.
Sutureless 25-gauge PPV with silicone oil is a relatively safe and comparable alternative to 20-gauge PPV with silicone oil for repair of complicated retinal detachment.
Retina 06/2008; 28(5):723-8. · 2.81 Impact Factor
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ABSTRACT: To describe the effects of intravitreal bevacizumab in eyes with macular edema resulting from central retinal vein occlusions (CRVO).
Retrospective consecutive case series of patients diagnosed with macular edema from CRVO who received intravitreal bevacizumab.
Thirty eyes of 29 patients with an average age of 72 years (range, 54-87 years) had intravitreal bevacizumab injections. Mean follow-up was 18.1 weeks. Initial mean visual acuity was 20/394. At the 1- and 2-month follow-up, mean visual acuity improved to 20/237 (n = 26, P = 0.04) and 20/187 (n = 21, P = 0.008), respectively. At the 3- and 4-month follow-up, visual acuity improved from 20/228 to 20/157 (n = 15, P = 0.05) and from 20/313 to 20/213 (n = 11, P = 0.03), respectively. No significant changes in visual acuity were found after 4 months though the number of patients in this group was small. Duration of treatment effect following an injection appears to be limited to 2 months for most patients. No ocular or systemic adverse reactions were noted.
The visual benefits of intravitreal bevacizumab for macular edema due to CRVO are apparent early but are not sustained without repeated injections. Larger clinical studies with long-term follow-up will be necessary to better elicit the best regimen for this therapy.
Retina 11/2007; 27(8):1013-9. · 2.81 Impact Factor
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ABSTRACT: Purpose: To describe a case of cytomegalovirus (CMV) retinitis following intravitreal triamcinolone acetonide (IVTA) in an immunocompetent patient.
Methods: A 77-year-old man with a history of diabetes mellitus developed retinal whitening with a vasculitis 6 weeks after receiving IVTA in the left eye. A vitreous biopsy was performed.
Results: Polymerase chain reaction was positive for CMV (419,000 copies/mL). A complete medical evaluation, including a negative test for human immunodeficiency virus, showed no systemic evidence of immunosuppression except for a highly elevated hemoglobin A1C level.
Conclusion: CMV retinitis may be a rare complication of IVTA, possibly due to local ocular immunosuppression from the steroid medication. Poorly controlled diabetes mellitus may have contributed to this development.
Retinal Cases & Brief Reports 12/2006; 1(4):208-210.
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ABSTRACT: To evaluate pars plana vitrectomy (PPV) versus a combined PPV and scleral buckle (PPV/SB) for repair of noncomplex, pseudophakic retinal detachment.
Retrospective, nonrandomized, comparative interventional study.
One hundred fifty-two eyes of 152 patients followed up for a mean of 10 months. The case series included 68 consecutive patients who underwent PPV and 84 consecutive patients who underwent a PPV/SB for primary repair of primary pseudophakic retinal detachment at Wills Eye Hospital between 2002 and 2004.
All primary PPV cases were performed by 2 surgeons who perform primary vitrectomy without regard to location of detachment, number and location of break(s), refractive error, or macula status. All primary PPV/SB were performed by a group of surgeons who solely perform PPV/SB on pseudophakic retinal detachments. All eyes underwent a standard 3-port 20-gauge PPV under wide-field viewing and scleral depression. Endolaser photocoagulation was applied either around the retinal tears or 360 degrees to the vitreous base region followed by gas tamponade. Patients with proliferative vitreoretinopathy grade C or worse were excluded from the study.
(1) Single surgery anatomic success rates, (2) preoperative and postoperative visual acuity, and (3) complications.
The single surgery anatomic success rate in the primary PPV group was 63 of 68 eyes (92.6%; 95% confidence interval [CI], 84%-98%) and in the primary PPV/SB group was 79 of 84 eyes (94.0%; 95% CI, 87%-98%). Both groups obtained 100% final reattachment rate. There was no statistically significant difference between the success rates (P = 0.75, Fisher exact test). The PPV group's best-corrected postoperative visual acuity demonstrated a +0.10 logarithm of the minimum angle of resolution improvement over the PPV/SB group (P = 0.07). The PPV group had a smaller incidence of postoperative complications (13/68 patients [19.1%] vs. 27/84 patients [32.1%]; P = 0.10, Fisher exact test).
Primary PPV and PPV/SB seem to have similar efficacy in the repair of a matched group of patients with primary noncomplex pseudophakic retinal detachment. There was no statistically significant difference in complication rate between the 2 groups.
Ophthalmology 12/2006; 113(11):2033-40. · 5.45 Impact Factor
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ABSTRACT: To assess the number of laser burns applied to the peripheral retina to treat retinopathy of prematurity (ROP) in a recent population of patients and to compare that number with historical data.
The authors performed a retrospective chart review of all patients treated for ROP within a single practice from 2002-2004. There were 183 eyes from 93 patients. Sufficient data for analysis were available on 112 eyes from 57 patients. Data from these patients were compared to those of patients reported upon in 1991.
The average number of laser burns applied to the 112 eyes was 2163. Eyes with zone 1 disease had an average of 3077 spots and those with zone 2 disease had an average of 2072 spots. Greater than three months follow-up was available on 42 eyes from 21 patients. Of those eyes, 90% had complete regression of ROP. In an initial report of laser treatment for ROP by several of the same authors in 1991, the average number of laser burns applied for treatment of ROP was 816. There was a 265% increase in the average number of laser applications from the early study to the present.
The data indicate that there has been a trend towards more confluent laser treatment to the avascular zone in ROP.
Retina 10/2006; 26(7 Suppl):S16-7. · 2.81 Impact Factor
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Archives of Ophthalmology 04/2005; 123(3):406-7; discussion 409-10. · 3.71 Impact Factor
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ABSTRACT: To assess visual and structural outcomes after laser photocoagulation and transscleral cryotherapy for threshold retinopathy of prematurity (ROP) after 10 years.
Extended follow-up of a randomized controlled clinical trial.
One hundred eighteen eyes from 66 patients were randomly assigned to receive either cryotherapy or laser photocoagulation for threshold ROP. Forty-four eyes from 25 patients were examined for 10-year follow-up evaluations.
Early Treatment of Diabetic Retinopathy Study (ETDRS) visual acuity, slit-lamp, and fundus examination; fundus photography; and B-scans (eyes with retinal detachments) were performed. Patients' histories were taken to elicit past amblyopia therapy. Based on fundus photographs, independent observers graded the degree of retinal dragging as none, mild, moderate, or severe. MAIN AND SECONDARY OUTCOME MEASURES: Best-corrected ETDRS visual acuity (BCVA). The degree of dragging was determined clinically and photographically. In addition, the presence of strabismus or amblyopia and/or any history of treatment for amblyopia were noted accordingly.
Eyes treated with laser had a mean BCVA of 20/66 (Snellen equivalent), whereas cryotherapy-treated eyes had a mean BCVA of 20/182 (Snellen equivalent) (P = 0.015, n = 42). Compared with eyes treated with cryotherapy, eyes treated with laser photocoagulation were 5.2 times more likely to have a 20/50 or better BCVA (95% confidence interval, 1.37-19.8, n = 42). Eyes treated with cryotherapy were 7.2 times (95% confidence interval, 1.54-33.6, n = 33) more likely to develop retinal dragging compared with laser treatment. By linear regression analysis, ETDRS visual acuity was inversely proportionate to the degree of retinal dragging in both laser (r = -0.637, P = 0.006) and cryotherapy (r = -0.517, P = 0.040) treated eyes. Among the 21 patients with favorable outcomes in both eyes, 13 had strabismus (62%) and 6 had received amblyopia therapy (29%). Ptosis, loss of cilia, and cortical cataract were among probable treatment-related complications that were noted in this study.
Overall, laser-treated eyes had better structural and functional outcome compared with eyes treated with cryotherapy.
Ophthalmology 06/2002; 109(5):928-34; discussion 935. · 5.45 Impact Factor
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ABSTRACT: To compare the refractive outcome of eyes treated with cryotherapy for threshold retinopathy of prematurity (ROP) with eyes treated with laser photocoagulation.
Extended follow-up of a randomized controlled clinical trial.
One hundred eighteen eyes from 66 patients were randomly assigned to receive either cryotherapy or laser photocoagulation for threshold ROP. Twenty-five patients (44 eyes treated) were available for follow-up examination 10 years later.
Cycloplegic autorefraction or retinoscopy was performed. Immersion ultrasound biometry (A-scan) was also performed, and an autokeratometer was used for keratometry. If an A-scan could not be tolerated or the patient was not cooperative, a B-scan through-the-lid biometry was performed. Corneal thickness was measured using optical coherence tomography. MAIN AND SECONDARY OUTCOME MEASURES: Refractive error. In addition, anterior chamber depth, lens thickness, and axial length were measured. Central corneal thickness measurements and keratometric readings were also obtained.
Eyes treated with cryotherapy were significantly more myopic than those treated with laser photocoagulation. When comparing patients with bilateral treatment, the mean spherical equivalent (SE) of eyes treated with laser was -4.48 diopters (D) compared with a mean SE of -7.65 D for eyes treated with cryotherapy (n = 15 pairs of eyes, P = 0.019). Cryotherapy-treated eyes had a mean axial length of 21.7 mm versus 22.9 mm for laser-treated eyes (P = 0.024, n = 12 pairs of eyes). The anterior chamber depth and lens thickness averaged 2.86 mm and 4.33 mm, respectively, in the cryotherapy-treated eyes compared with 3.42 mm and 3.95 mm in the laser-treated eyes (P < 0.001, n = 12 pairs for both measurements). There were no statistical differences in anterior corneal curvature and central corneal thickness between the two treatment modalities. Crystalline lens power bore the strongest correlation to refractive outcomes in both laser-treated (r = 0.885, P < 0.001) and cryotherapy-treated eyes (r = 0.591, P = 0.026). Although keratometric readings were higher than normal values in these eyes, there was no correlation to the degree of myopia.
Laser-treated eyes were significantly less myopic than cyrotherapy-treated eyes. Lens power seemed to be the predominant factor contributing to the excess myopia.
Ophthalmology 05/2002; 109(5):936-41. · 5.45 Impact Factor
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ABSTRACT: Purpose: To assess the value of patient-initiated second medical opinions (SMO).
Methods: The authors prospectively collected demographic data from 100 consecutive patients. The authors recorded major changes in the patients' care, such as inappropriate surgery recommended, inadequate treatment performed, and appropriate treatment not recommended. The authors also recorded costs incurred or saved by the patients and the third-party payers.
Results: In nearly 15 of the cases, the authors had major disagreements with the initial diagnosis or management. Surgery had been recommended in 28 cases. They advised against it in nine. In 72 cases, no surgery had been recommended. They advised and performed it in five. The management of five other patients was not in accordance with that recommended by large clinical trials or was inadequately done. Including the consultation fees, surgery performed or advised against, retinal angiography, and ultrasonography, the 100 SMO cost third-party payers $12,426. If the authors subtract the cost of noncontroversial surgery they recommended and if the patients had paid the consultation fee and had brought along their fluorescein angiograms, third-party payers would have saved $4,079.
Conclusion: The savings SMO generated by eliminating unnecessary surgery resulted in improved patient care at minimal cost to third-party payers.
Retina 11/2001; 21(6):633-638. · 2.81 Impact Factor
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ABSTRACT: New medications targeting vascular endothelial growth factor show promise in the treatment of wet macular degeneration. This study describes the clinical response and optical coherence tomography (OCT) findings for patients with refractory pigment epithelial detachment (PED) and occult choroidal neovascular membranes (CNVMs) who were treated with intravitreal bevacizumab.
A retrospective analysis of data for 10 patients with fibrovascular PEDs, initially treated with intravitreal pegaptanib, thermal laser, or photodynamic therapy with or without triamcinolone acetonide administration, was performed. All patients were refractory to previous treatment. They received monthly injections of bevacizumab and were followed by clinical examination, angiography, and OCT.
Nine of 10 patients had stable or improved vision. Angiogram findings showed resolution of leakage from CNVMs. OCT demonstrated resolution of the subretinal or intraretinal fluid but persistence of the PED itself. Vision improvement was correlated with OCT changes.
Intravitreal bevacizumab may be a viable option in treating patients with fibrovascular PEDs. OCT findings suggest that visual improvement is secondary to resolution of subretinal and intraretinal edema without resolution of the PED.
Retina 27(4):445-50. · 2.81 Impact Factor
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ABSTRACT: To assess the safety and efficacy of ranibizumab in patients who had inadequate response to pegaptanib or bevacizumab.
In this single-center study, 19 patients with subfoveal choroidal neovascularization secondary to age-related macular degeneration (AMD) previously treated with pegaptanib (n = 1), bevacizumab (n = 13), or both (n = 5) received 12 monthly ranibizumab injections (0.5 mg). Outcomes were measured from start of previous therapy (baseline) to start of ranibizumab treatment (day 0) through 12 months.
No drug- or injection-related adverse events and no serious adverse events were reported. At 6 and 12 months, 4 and 5 patients gained 3 or more lines of VA, respectively; 3 patients lost less than 3 lines of VA at 6 months, and 6 patients lost less than 3 lines at 12 months. At 6 and 12 months, VA increased by a mean (± standard error of the mean) of 2.06 ± 1.23 and 1.17 ± 0.62 lines, respectively. Central retinal thickness decreased by a mean of 62.65 ± 22.46 and 62.16 ± 29.20 μm at months 6 and 12, respectively. When stratified by pigment epithelial detachment (PED) status, patients without PED had better visual and anatomical outcomes than patients with PED.
Ranibizumab has favorable safety and efficacy profiles for patients with AMD without previous response to pegaptanib or bevacizumab.
Ophthalmic Surgery Lasers and Imaging 43(1):13-9. · 0.62 Impact Factor
