VITREORETINAL SURGICAL OUTCOMES PERFORMED BY SUPERVISED RETINAL FELLOWS VERSUS ATTENDING FACULTY SURGEONS.

PURPOSE: To evaluate common vitreoretinal surgeries performed by retinal fellows under direct faculty supervision, compared with experienced faculty members. METHODS: Retrospective study analyzing 592 consecutive eyes undergoing retinal surgery from 2009 to 2011 at Retina Consultants of Alabama/University of Alabama at Birmingham, Department of Ophthalmology. Vitreoretinal surgeries included macular hole, macular pucker, retinal detachment, diabetic vitreous hemorrhage, and diabetic tractional retinal detachment. Three fellows performed 390 cases (divided into first or second year fellows), while 4 faculty members performed 202 cases. All 390 fellow-performed cases were under direct supervision. Chi-square analysis was used to compare outcomes. RESULTS: There were no baseline differences between the groups. The mean postoperative visual improvement was statistically significant and equal in all groups, as well as between each physician (P ≤ 0.0001). Complications occurred in 29/592 cases (4.8%), whereas reoperations occurred in 21/592 cases (3.5%) and were equally distributed across groups. There were no differences in complications and reoperations when comparing first-year with second-year fellows. CONCLUSION: With proper supervision, vitreoretinal fellows can achieve an equally high visual improvement with low complication and reoperation rates compared with experienced faculty. The year of fellowship does not significantly influence outcomes or complications. Quality outcomes after vitreoretinal surgery can be obtained throughout fellowship training.

Needle contamination in the setting of intravitreal injections.

BACKGROUND/PURPOSE: To evaluate the risk of intravitreal needle contamination through speaking versus breathing in an office setting. METHODS: This was a prospective sampling assay. Participants held a sterile 30-gauge half-inch needle 25 cm from their mouth for 30 seconds under 2 conditions: (1) while speaking and (2) while breathing silently. Needles were then cultured and assayed after 6 days of incubation. Absolute colony-forming units were compared between conditions and against control sterile needles and oral swab cultures. RESULTS: Ten physicians were sampled with 15 samples per physician. Participants grew an average of 0.21 colonies (median = 1 CFU) from their talking samples and 0.07 colonies (median = 1 CFU) from their silent breathing samples. Oral swab plates grew an average of 373.4 colonies. None of the control needle plates grew colony-forming units. A nominal regression analysis showed no significant difference between talking and silent samples (P = 0.457). CONCLUSION: No significant difference in needle contamination was found between talking and breathing. Compared with oral swab plates, a significant difference exists between the amount of flora colonizing the oropharynx and that which was found on the needle cultures (P < 0.0001). These findings suggest that speaking versus remaining silent makes no difference in regard to needle contamination with oral flora during intravitreal injection.

Safety, efficacy, and quality of life following sutureless vitrectomy for symptomatic vitreous floaters.

PURPOSE: To determine the safety, efficacy, and quality of life improvement following sutureless 25-gauge pars plana vitrectomy for symptomatic floaters. METHODS: Patients with symptomatic vitreous floaters who underwent sutureless vitrectomy between January 2008 and January 2011 were included. Data were collected regarding baseline preoperative characteristics, postoperative outcomes, complications, and a nine-item quality-of-life survey completed by each patient. RESULTS: One hundred and sixty-eight eyes (143 patients) underwent sutureless 25-gauge pars plana vitrectomy for symptomatic vitreous floaters. Mean Snellen visual acuity was 20/40 preoperatively and improved to 20/25 postoperatively (P < 0.0001). Iatrogenic retinal breaks occurred in 12 of 168 eyes (7.1%). Intraoperative posterior vitreous detachment induction was not found to increase the risk of retinal breaks (P = 1.000). Postoperative complications occurred in three eyes, of which one had transient cystoid macular edema and two had transient vitreous hemorrhage. Approximately 88.8% of patients completed a quality-of-life survey, which revealed that 96% were "satisfied" with the results of the operation, and 94% rated the experience as a "complete success." CONCLUSION: Sutureless 25-gauge pars plana vitrectomy for symptomatic vitreous floaters improved visual acuity, resulted in a high patient satisfaction quality-of-life survey, and had a low rate of postoperative complications. Sutureless pars plana vitrectomy should be considered as a viable means of managing patients with symptomatic vitreous floaters.

Povidone-iodine contact time and lid speculum use during intravitreal injection.

PURPOSE: To determine the time necessary for 5% povidone-iodine (PI) to cause a significant reduction in colony-forming units and whether a lid speculum increases the conjunctival flora. METHODS: This was a prospective randomized study of 131 eyes undergoing intravitreal injection. Conjunctival samples were collected in a prospective protocol at three points before intravitreal injection: (1) no intervention (baseline), (2) after placement of a lid speculum, and (3) after treatment with 5% PI. Participants were randomized into three different PI exposure intervals. Cultures were incubated for 6 days, and the resulting colony-forming units were tallied for each intervention. RESULTS: Use of 5% PI caused significant decrease in the number of colony-forming units (P < 0.0001). Exposure to PI for 15 seconds did not cause a significant reduction in conjunctival bacteria (P = 0.08), but a significant reduction was observed after 30 seconds of exposure and beyond (P = 0.0003). Placement of a lid speculum did not result in a significant increase or decrease in the number of colony-forming units when compared with baseline (P = 0.47). CONCLUSION: The use of 5% PI causes a significant reduction in bacterial colonies, and 30 seconds of exposure appears to be an adequate time to decrease conjunctival bacterial counts. Lid speculum use before intravitreal injection does not affect the overall conjunctival flora.

Quantification of fluorescein-stained drusen associated with age-related macular degeneration.

BACKGROUND: Previous studies of age-related macular degeneration have not quantified the number of drusen that accumulate fluorescein. Histopathologic studies have demonstrated druse subregions with different degrees of hydrophobicity, and these subregions might potentially exhibit different degrees of fluorescein uptake. METHODS: We evaluated macular drusen from 35 age-related macular degeneration patients by measuring druse area in color digital images and fluorescein angiograms, using 2 morphometric methods. RESULTS: Of 828 drusen evaluated, 405 had a corresponding fluorescein angiogram signal. About half of all drusen per eye (49.57%) stained in each participant. Among fluorescein-stained drusen, druse size measured in color images did not differ significantly from the sizes measured in corresponding fluorescein images (P = 0.8105), across the range of druse sizes. CONCLUSION: These findings indicate that our understanding of drusen subregion staining may not directly correlate to in vivo observations of macular drusen in age-related macular degeneration.

Apolipoprotein E epsilon4 offers protection against age-related macular degeneration.

BACKGROUND: In many previous studies, age-related macular degeneration (ARMD) has been linked to a variety of different risk factors. The publications have debated whether apolipoprotein E (apoE) epsilon4 serves as a potential protective factor in the development of the disease. Other studies have classified the behavior of this protein in different pathologies, including Alzheimer's disease (AD) and cardiovascular disease. The general behavior of the epsilon4 isoform of ApoE is different than the predominant epsilon3 isoform. HYPOTHESIS: We propose that the general characteristics and molecular behavior of apoE epsilon4 cause it to be a protective factor against the development of ARMD by preventing cumulative effects of oxidative retinal damage. EVALUATION OF HYPOTHESIS: Review of the literature related to ARMD and ApoE, using OVID as our main database, led to the development of several theories regarding ApoE epsilon4's behavior compared to epsilon3 and potential explanation of its protective characteristics. CONSEQUENCES OF HYPOTHESIS: We relate these theories to the potential behavior of ApoE epsilon4 in other situations including choroidal neovascularization, Alzheimer's Disease (AD), cardiovascular disease, herpes simplex virus infection, and smoking. DISCUSSION: The potential implications of this theory could be used as a branching point for further studies that examine the role of the different apoE isoforms, in relation to the other risk factors for ARMD.