Assessing Deep Retinal Capillary Ischemia in Paracentral Acute Middle Maculopathy by Optical Coherence Tomography Angiography.

PURPOSE: To assess microvascular blood flow of the deep retinal capillary plexus in eyes with paracentral acute middle maculopathy using optical coherence tomography (OCT) angiography. DESIGN: Retrospective, multicenter observational case series. METHODS: Clinical and multimodal imaging findings from 8 patients with paracentral acute middle maculopathy were reviewed and analyzed. OCT angiography scans were analyzed and processed, and vessel density was calculated. RESULTS: Eight patients (7 male, 1 female, aged 9-82 years) were included. OCT angiography was obtained at either the acute (4 cases) or old stage (4 cases). Scans of the deep capillary plexus showed preservation of perfusion in acute lesions and capillary attenuation in old cases. Cases of central retinal artery occlusion showed marked loss of the deep capillary plexus. The mean vessel density of the superficial capillary plexus in normal fellow eyes was 12.8 ± 1.8 mm(-1) vs 12.1 ± 1.9 mm(-1) in eyes with paracentral acute middle maculopathy (reduction -6.0%, P = .08). The mean vessel density of the deep capillary plexus in normal fellow eyes was 17.5 ± 1.4 mm(-1) vs 14.7 ± 3.5 mm(-1) in eyes with paracentral acute middle maculopathy (reduction -19.4%, P = .04). This significant difference was representative of the eyes with old lesions. CONCLUSION: Paracentral acute middle maculopathy lesions correspond to preservation of perfusion in focal acute lesions and to pruning of the plexus in old cases. Cases of central retinal artery occlusion demonstrate marked hypoperfusion of the deep capillary plexus. Our study further supports an ischemic pathogenesis of this retinal vasculopathy.

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.

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 spectrum of postoperative scleral necrosis.

An otherwise healthy 62-year-old woman developed necrotizing scleritis 23 years following pterygium excision with adjunctive beta-radiation. Surgically induced necrotizing scleritis (SINS) was diagnosed, but the scleritis progressed despite anti-inflammatory therapy, and 10 weeks after presentation the patient developed a hypopyon and decreased vision. After cultures revealed no growth at 72 hours, immunosuppressive therapy was escalated, with a subsequent deterioration in the patient's clinical course. Scedosporium superinfection was eventually cultured and found on histological examination of the enucleated globe. In reported cases, infectious scleral necrosis occurs most commonly following pterygium (71.4%) and scleral buckling (97.2%) surgery. Hypopyon is uncommon (10.0%) in patients with postoperative scleral necrosis, but when present is a strong predictor of infection (odds ratio, 21.2; 95% confidence interval, 2.9-157.5). Rates of underlying autoimmune disease are generally low (0.0-12.5%) except following cataract and lens procedures, where the occurence of SINS heralds systemic illness in 42.9% of cases.

Reducing oral flora contamination of intravitreal injections with face mask or silence.

PURPOSE: To provide experimental evidence to support or refute the proposition that the use of surgical face masks and/or avoidance of talking can decrease the dispersion of respiratory flora during an intravitreal injection. METHODS: Ten surgeons recited a 30-second standardized script with blood agar plates positioned 30 cm below their mouths. The plates were divided into 4 groups, with 10 plates per group. In Group 1, participants did not wear a face mask. In Group 2, participants wore a standard surgical mask. In Group 3, no mask was worn, but plates were pretreated with 5% povidone-iodine. In Group 4, no mask was worn, and participants remained silent for 30 seconds. The plates were then incubated at 37°C for 24 hours, and the number of colony-forming units (CFUs) was determined. RESULTS: Mean bacterial growth were as follows: Group 1, 8.6 CFUs per subject; Group 2, 1.1 CFUs per subject; Group 3, 0.1 CFUs per subject; and Group 4, 2.4 CFUs per subject. Differences between the groups were statistically significant (P < 0.05), with the exception of Group 2 versus Group 4 (P = 0.115). CONCLUSION: The use of a face mask and avoidance of talking each significantly decreased the dispersion of bacteria. Even without these interventions, plates pretreated with povidone-iodine demonstrated the least bacterial growth.

Endogenous Candida albicans endophthalmitis following spontaneous abortion and IUD removal.

The authors report a rare case of a 32-year-old woman who developed endogenous Candida albicans endophthalmitis following spontaneous abortion and removal of a contraceptive intrauterine device. Considerations regarding diagnosis and management are presented based on a review of the literature.

Intravitreal injection technique.

As the intravitreal injection of therapeutic medication plays an increasingly large role in ophthalmology, its implementation continues to be modified and refined. Variations in injection technique are discussed, and the authors combine their clinical and research experience with a review of the literature to propose a recommended intravitreal injection protocol.

Povidone-iodine before lidocaine gel anesthesia achieves surface antisepsis.

BACKGROUND AND OBJECTIVE: Viscous lidocaine interferes with ocular surface antisepsis. The current study was designed to evaluate the impact on surface antisepsis of different application sequences with lidocaine gel and povidone-iodine solution. MATERIALS AND METHODS: Blood agar plates inoculated with Staphylococcus epidermidis were treated with varying sequences of 2% lidocaine gel and 5% povidone-iodine solution. The plates were then incubated at 37°C for 24 hours and bacterial growth was determined. RESULTS: Plates on which povidone-iodine was applied alone or prior to lidocaine gel demonstrated no bacterial growth regardless of whether the antiseptic was retained on the plate for 5 seconds or for 30 seconds. There was no statistically significant difference between bacterial growth on plates not treated with povidone-iodine and on plates treated with lidocaine gel alone or prior to povidone-iodine (P = .553 and P = .485, respectively). CONCLUSION: Povidone-iodine effectively reduces bacterial counts when applied alone or prior to lidocaine gel. Lidocaine gel was confirmed to be a barrier to antisepsis when administered prior to povidone-iodine.

Evaluating exaggerated, prolonged, or delayed postoperative intraocular inflammation.

PURPOSE: To provide a diagnostic approach for the evaluation of patients with exaggerated, prolonged, or delayed postoperative intraocular inflammation. DESIGN: Perspective. METHODS: Selected articles on normal and abnormal postoperative intraocular inflammation were reviewed and interpreted in the context of the authors' clinical and research experience. RESULTS: In addition to infectious endophthalmitis, a number of noninfectious conditions characterized by exaggerated, prolonged, or delayed postoperative inflammation have been described. Heuristically, increased postsurgical inflammation may be categorized by time from surgery to first recognition using the following general guidelines: as immediate and occurring within 2 days after surgery; as early and occurring after 2 days, but within the first 2 weeks, after surgery; and as delayed and occurring more than 2 weeks after surgery. CONCLUSIONS: Although infectious endophthalmitis always must be excluded as a cause of increased postoperative intraocular inflammation, potential noninfectious causes also exist. We review both infectious and noninfectious causes of increased postoperative inflammation and provide a diagnostic framework for evaluating such patients.

Long-term variability of GDx VCC retinal nerve fiber layer thickness measurements.

PURPOSE: To evaluate the long-term variability of GDx VCC retinal nerve fiber layer (RNFL) thickness measurements. METHODS: The study enrolled a cohort of glaucoma suspects who did not develop any evidence of visual field damage or change in the appearance of the optic nerve during an average follow-up of 9.1+/-3.2 years. Subjects underwent ocular imaging using the commercially available GDx VCC scanning laser polarimeter. At each visit, each eye was imaged 3 times. Subjects underwent repeated testing with GDx VCC at approximately 12-month intervals during their follow-up. In total, 255 examinations were obtained in 31 eyes of 31 individuals during an average GDx VCC follow-up time of 26.0+/-8.9 months. A random effects analysis of variance model was used to estimate intraclass correlation coefficients and long-term and short-term variability estimates. RESULTS: Intraclass correlation coefficients ranged from 0.77 to 0.86 for GDx VCC parameters. Short-term variability estimates ranged from 2.45 to 3.89 microm for RNFL thickness parameters, whereas the short-term variability estimate for the parameter Nerve Fiber Indicator was 3.71. Long-term variability was slightly higher than short-term variability for all parameters. For RNFL thickness parameters, long-term variability estimates ranged from 3.21 to 4.97 microm, whereas for the parameter Nerve Fiber Indicator the long-term variability estimate was 4.93. CONCLUSIONS: RNFL measurements obtained with the GDx VCC were found to be highly reproducible in a long-term test-retest situation, supporting the use of this instrument for longitudinal assessment of the RNFL.

Generalized cognitive impairments, ability to perform everyday tasks, and level of independence in community living situations of older patients with psychosis.

OBJECTIVE: This study examined the relationship between performance of instrumental activities of daily living, as measured with the University of California, San Diego, Performance-Based Skills Assessment (UPSA), and measures of cognitive functioning and independence in the community living situation of older outpatients with psychotic disorders. METHOD: One hundred eleven middle-aged and elderly outpatients with primary psychotic disorders were administered the UPSA, the Mattis Dementia Rating Scale, and standardized measures of psychopathology. Independence in the community living situation was rated on a scale from 1 to 5, with 5 representing the highest level of independence, such as living alone in an apartment or house. Ability in seven domains of neuropsychological functioning was assessed in 67 participants. RESULTS: Total scores on the University of California, San Diego, Performance-Based Skills Assessment were significantly correlated with total and subscale scores on the Mattis Dementia Rating Scale, level of independence in the community living situation, and scores on the neuropsychological measures in the subset of patients who underwent neuropsychological testing. Lower scores on the Mattis Dementia Rating Scale memory subscale and more severe negative symptoms were significantly associated with worse performance on the skills assessment. Performance on the skills assessment contributed uniquely to prediction of independence in the community living situation. CONCLUSIONS: Generalized cognitive abilities are associated with everyday functioning capacity in older patients with psychosis. Reduction of cognitive deficits and negative symptoms may improve patients' ability to function independently in the community.