Late-Onset Retinal Findings and Complications in Untreated Retinopathy of Prematurity.

PURPOSE: To investigate late retinal findings and complications of eyes with a history of retinopathy of prematurity (ROP) that did not meet treatment criteria and did not receive treatment during infancy. DESIGN: Retrospective, nonconsecutive, noncomparative, multicenter case series. PARTICIPANTS: Three hundred sixty-three eyes of 186 patients. METHODS: Data were requested from multiple providers on premature patients with a history of ROP and no treatment during infancy who demonstrated late retinal findings or complications and included age, gender, gestational age and weight, zone and stage at infancy, visual acuity, current retina vascularization status, vitreous character, presence of peripheral retinal findings such as lattice retinal tears and detachments (RDs), retinoschisis, and fluorescein findings. MAIN OUTCOME MEASURES: Rate of RDs and factors conferring a higher risk of RDs. RESULTS: The average age was 34.5 years (range, 7-76 years), average gestational age was 26.6 weeks (range, 23-34 weeks), and average birth weight was 875 g (range, 425-1590 g). Findings included lattice in 196 eyes (54.0%), atrophic holes in 126 eyes (34.7%), retinal tears in 111 eyes (30.6%), RDs in 140 eyes (38.6 %), tractional retinoschisis in 44 eyes (11.9%), and visible vitreous condensation ridge-like interface in 112 eyes (30.5%). Fluorescein angiography (FA) was performed in 113 eyes, of which 59 eyes (52.2%) showed leakage and 16 eyes (14.2%) showed neovascularization. Incomplete vascularization posterior to zone 3 was common (71.6% of eyes). Retinal detachments were more likely in patients with a gestational age of 29 weeks or less (P < 0.05) and in eyes with furthest vascularization to posterior zone 2 eyes compared with zone 3 eyes (P = 0.009). CONCLUSIONS: Eyes with ROP not meeting the treatment threshold during infancy showed various late retinal findings and complications, of which RDs were the most concerning. Complications were seen in all age groups, including patients born after the Early Treatment for Retinopathy of Prematurity Study. Contributing factors to RDs included atrophic holes within peripheral avascular retina, visible vitreous condensation ridge-like interface with residual traction, and premature vitreous syneresis. We recommend regular examinations and consideration of ultra-widefield FA examinations. Prospective studies are needed to explore the frequency of complications and benefit of prophylactic treatment and if eyes treated with anti-vascular endothelial growth factor therapy are at risk of similar findings and complications.

THE SPECTRUM OF AMALRIC TRIANGULAR CHOROIDAL INFARCTION.

PURPOSE: To describe the multimodal imaging findings, including optical coherence tomography angiography analysis, and spectrum of etiologies associated with Amalric triangular choroidal infarction. METHODS: This study is a multicenter, retrospective, observational case series review of the clinical and multimodal imaging findings for six patients with Amalric triangular choroidal infarction. RESULTS: Six patients (10 eyes) with Amalric triangular choroidal infarction were enrolled. Patients' ages ranged from 7 years to 90 years (mean 54 years, median 60 years). Wedge-shaped or triangular areas of choroidal ischemia were evident with fluorescein angiography in all patients and with indocyanine green angiography in one patient. Optical coherence tomography angiography demonstrated choriocapillaris flow reduction that colocalized with outer retinal structural abnormalities with en face optical coherence tomography and corresponded with the triangular zones of choroidal infarction identified with fluorescein angiography in one patient. Etiologies included giant cell arteritis in three cases: traumatic carotid dissection, traumatic retrobulbar hemorrhage, and malignant hypertension secondary to lupus-associated nephropathy. CONCLUSION: The Amalric triangular syndrome of choroidal infarction can occur as a result of a spectrum of etiologies, especially giant cell arteritis. Infarction is evident on traditional angiography in all cases. Optical coherence tomography angiography may provide a simple noninvasive tool to evaluate choroidal ischemia.

Long-term visual outcomes following lens-sparing vitrectomy for retinopathy of prematurity.

AIM: To describe the long-term outcomes of lens-sparing vitrectomy (LSV) for retinopathy of prematurity (ROP). METHODS: Single-centre retrospective case series of eyes that underwent LSV for ROP between 1998 and 2005 and had a follow-up of at least 5 years. The primary outcome was the mean visual acuity, and secondary outcomes were the proportion of eyes without functional vision, proportion of eyes with anatomic success, proportion of Stage 4A eyes with vision better than 20/400, proportion of Stage 4B eyes with vision better than 20/800. RESULTS: Thirty-seven eyes of 30 patients (mean age at last follow-up: 7.1 years) were included in the study, while an additional 23 patients had been lost to follow-up and were not included in the study. Of eyes that underwent LSV for Stage 4A or 4B: 63% had measurable visual acuity (mean logMAR 0.92 for Stage 4A, 1.63 for Stage 4B), 19% had form vision, but neurological comorbidities precluded visual acuity measurement, and the remaining 18% had light perception or no light perception. CONCLUSIONS: While most eyes that underwent LSV for Stage 4A or 4B ROP maintain useful vision with long-term follow-up, approximately one-fifth of eyes had no functional vision, and in a further fifth, vision could not be measured due to severe neurological impairment.

Regression of serous macular detachment due to peripheral exudative hemorrhagic chorioretinopathy following intravitreal bevacizumab.

PURPOSE: To describe a case of exudative macular detachment secondary to peripheral exudative chorioretinopathy with a favorable anatomic and visual outcome following treatment with intravitreal bevacizumab. METHODS: The medical records of a patient with peripheral exudative chorioretinopathy were reviewed. RESULTS: Macular reattachment was achieved with a corresponding visual acuity improvement that was maintained over an uncomplicated 17-month clinical course. CONCLUSIONS: Bevacizumab may be an effective treatment option for exudative macular detachment secondary to peripheral exudative hemorrhagic chorioretinopathy.

Long-term observation of exposed scleral exoplant without topical antibiotic prophylaxis.

PURPOSE: The purpose of this study was to describe a case of long-term observation without topical antibiotic prophylaxis for asymptomatic scleral exoplant exposure. METHODS: The medical records of a patient with long-term observation for asymptomatic scleral exoplant exposure were reviewed. RESULTS: No complications or clinical changes were noted throughout a 36-month course of observation for exoplant exposurei. CONCLUSION: Simple observation of asymptomatic scleral exoplant exposure is an alternative to observation with topical antibiotic prophylaxis if exoplant removal is deferred.

Refractive outcomes of lens-sparing vitrectomy for retinopathy of prematurity.

OBJECTIVE: To evaluate the refractive outcomes of 3-port lens-sparing vitrectomy (LSV) for subtotal retinal detachments owing to retinopathy of prematurity. METHODS: The study included 9 infants who had undergone complete ablative laser treatment for threshold retinopathy of prematurity in both eyes, subsequently developed stage 4A retinal detachment in 1 eye for which they underwent LSV, and maintained complete retinal attachment bilaterally. Eyes that underwent LSV were compared with fellow eyes. Cycloplegic refraction was performed, and corneal curvature, axial length, lens thickness, lens position, and anterior chamber depth were measured. RESULTS: Significantly less myopia was present in eyes that had undergone LSV compared with control eyes (mean spherical equivalent, -6.78 vs -10.33 diopter [D]; P < .001). The reduced myopia in LSV eyes was predominantly owing to increased anterior chamber depth (mean, 3.81 vs 2.96 mm; P < .001) and a more posterior position of the lens (mean, 5.58 vs 4.63 mm; P < .001). There was a minor contribution from reduced corneal power in LSV eyes (mean, 43.90 vs 44.20 D; P = .02). There was no significant difference in axial length, lens thickness, or lens power between LSV and control eyes. CONCLUSIONS: Infant eyes undergoing 3-port LSV for stage 4A retinopathy of prematurity develop less myopia than fellow eyes treated with ablative laser alone. The difference is owing to posterior displacement of the lens, with a smaller contribution from reduced corneal power. The reduction in myopia may explain the excellent functional outcomes following 3-port LSV for stage 4A retinopathy of prematurity.

Evaluating retinal toxicity of intravitreal caspofungin in the mouse eye.

PURPOSE: Caspofungin is a synthetic echinocandin antifungal agent that inhibits the synthesis of ß(1,3)-D-glucan, an essential component of the cell wall of susceptible Aspergillus and Candida species. In this study, retinal toxicity was determined after intravitreal injection of caspofungin in a mouse model to assess its safety profile for the treatment of fungal endophthalmitis. METHODS: Caspofungin acetate was injected intravitreally in the left eyes of male C57BL/6 mice, with final vitreal concentrations corresponding to 0.41, 1.2, 2.5, 4.1, and 41 µM (five mice per cohort). A total of 25 age-matched male C57BL/6 mice injected with balanced salt solution were used as control subjects (five for each of the five different caspofungin acetate concentrations). Electroretinograms (ERGs) were recorded 7 weeks after the injections, and the injected eyes were examined histologically. RESULTS: Mice injected with caspofungin at vitreal concentrations from 0.41 to 4.1 µM did not have significant alterations in their ERG waveforms, and their retinas had no detectable morphologic changes or loss of cells. At the vitreal concentration of 41 µM, caspofungin reduced the amplitudes of the a-waves, b-waves, and scotopic threshold responses of the ERG and also produced a decrease in the number of cells in the ganglion cell layer. CONCLUSIONS: Caspofungin is a safe antifungal agent at vitreal concentrations of 0.41 to 4.1 µM in mice and consequently shows promise for the treatment of fungal endophthalmitis in humans. Much higher doses produce toxicity and should not be used.

Refractive outcomes of three-port lens-sparing vitrectomy for retinopathy of prematurity (An AOS Thesis).

PURPOSE: To study the refractive outcomes of 3-port lens-sparing vitrectomy (LSV) for subtotal retinal detachments due to retinopathy of prematurity (ROP). Lens-sparing vitrectomy may provide superior refractive outcomes by limiting induced myopia of prematurity. METHODS: This is a retrospective, consecutive, nonrandomized, comparative (paired eye) study. Entrance criteria were previous complete ablative laser for threshold ROP in both eyes, followed by LSV in one eye for stage 4A traction retinal detachment. Both eyes then maintained complete retinal attachment. Main outcome variables were cycloplegic refraction, keratometry, and biometric values for axial length, lens thickness, and anterior chamber depth. RESULTS: Nine patients met inclusion criteria. Lens-sparing vitrectomy eyes were significantly less myopic than control eyes (-6.78 D vs -10.33 D, P < .005). The reduction in myopia in LSV eyes was predominantly due to increased anterior chamber depth (3.81 mm +/- 0.217 vs 2.96 mm +/- 0.232, P < .005). There was a minor contribution from reduced corneal power in LSV eyes (43.89 D +/- 0.253 vs 44.20 D +/- 0.265, P < .005). There was a minor negative impact from increased lens thickness in LSV eyes (3.85 +/- 0.32 mm vs 3.74 +/- 0.31, P < .005). There was no significant difference in axial length or lens power between the LSV and control groups. CONCLUSIONS: The data demonstrate that infant eyes undergoing 3-port LSV for stage 4A ROP develop less myopia than fellow eyes treated with laser alone. The difference is due to posterior displacement of the lens-iris diaphragm with a smaller contribution from reduced corneal power. The reduction in myopia may improve functional outcomes following 3-port LSV for stage 4A ROP.

Chorioretinitis and panuveitis in an infant with systemic langerhans cell histiocytosis.

BACKGROUND: Panuveitis and chorioretinitis in infants with Langerhans cell histiocytosis are rare and fundus photographic documentation is lacking in the literature. METHODS: Case report with fundus photography. RESULTS: The authors report a case of an infant with disseminated Langerhans cell histiocytosis who presented with panuveitis in the right eye and chorioretinitis in left eye. Treatment with chemotherapy led to resolution of chorioretinal lesions; however, the visual prognosis remained guarded because of the macular involvement and amblyopia. CONCLUSION: The authors recommend examination of infants with Langerhans cell histiocytosis for chorioretinal involvement.

Bacillus cereus endophthalmitis following intravitreous bevacizumab injection.

The first case of Bacillus cereus endophthalmitis following an intravitreous injection of bevacizumab is described. A 77-year-old man presented to a retina specialist with an active choroidal neovascularization related to age-related macular degeneration for which he received intravitreous bevacizumab (1.25 mg) and post-injection topical gatifloxacin. Eight hours later, the patient woke up with excruciating pain and a decline in vision associated with nausea and vomiting. A vitreous biopsy was performed that revealed B. cereus. Despite intravitreous injections of vancomycin and ceftazidime on day 1 and pars plana vitrectomy with repeat intravitreous injections on day 3, the eye did not recover light perception.

Iris-sutured intraocular lenses for ectopia lentis in children.

PURPOSE: To compare outcomes and complications of pars plana lensectomy-vitrectomy (PPL-PPV) for the management of ectopia lentis in children with and without a foldable iris-sutured intraocular lens (IOL). SETTING: Department of Ophthalmology, Baylor College of Medicine, Houston, Texas, USA. METHODS: This study comprised 22 eyes of 12 consecutive pediatric patients with ectopia lentis who had PPL-PPV by the same vitreoretinal surgeon with (12 eyes; Group L) or without (10 eyes; Group A) insertion of a foldable iris-sutured IOL between June 1998 and October 2006. Outcome measures included the proportion of eyes achieving visual acuity of 20/40 or better, mean logMAR visual acuity, and complications. RESULTS: There was no statistically significant difference between the 2 groups in the proportion of eyes achieving a visual acuity of 20/40 or better (Group A: 5/10; Group L: 10/12) (P = .17) or the mean postoperative best corrected logMAR visual acuity (Group A: 0.41 [20/52]; Group L: 0.24 [20/35]) (P = .18). Complications included IOL dislocation in 4 (33%) of 12 eyes in Group L (95% confidence interval, 11%-65%). Eyes with dislocated IOLs had retrieval with resuturing of the IOL to the iris and had a mean visual acuity of 20/27 at the last follow-up. No retinal detachment was observed. CONCLUSION: Pars plana lensectomy-vitrectomy with iris-fixation of a foldable IOL for the management of ectopia lentis yielded visual outcomes as least as good as those of optically corrected aphakia with a significant risk for dislocation.

Safety and pharmokinetics of triamcinolone hexacetonide in rabbit eyes.

PURPOSE: The aim of this study was to evaluate whether intravitreal triamcinolone hexacetonide (TH) is a safe, longer lasting alternative to intravitreal triamcinolone acetonide (TA) in the rabbit eye. METHODS: Three groups, each comprising of 15 Dutch-belted rabbits, received a unilateral injection of 0.1 mL of drug and 0.1 mL of physiologic salt solution in the fellow eye. Group I received TA, group II received commercially available TH, and group III received reformulated iso-osmolar triamcinolone hexacetonide (rTH). Simultaneous bilateral dark-adapted electroretinography was performed following the injection. Retinal morphology was assessed by using histopathology in each group enucleated 12 weeks after injection. High-performance liquid chromatography of vitreous isolated from the enucleated eyes was used to determine drug concentrations. RESULTS: A significant reduction in saturated a-wave and maximal scotopic b-wave was observed in the group II eyes relative to the fellow control eyes at both 2 and 12 weeks postinjection (P < 0.001 for each comparison) but not in the other groups. Histopathology showed no differences between drug-injected eyes and fellow control eyes in groups I and III, but in group II there was severe degeneration of all retina layers. In group I, the drug half-life was 17.7 +/- 1.7 days, group II 44 +/- 13 days, and group III 12.8 +/- 2.3 days. CONCLUSIONS: The half-life of commercially available TH in the vitreous is double that of TA, but the former is toxic to the retina in this rabbit model. Reformulated iso-osmolar TH showed no evidence of deleterious effects to retina function or structure but had a similar half-life to TA.

25-gauge vitrectomy using sulfur hexafluoride and no prone positioning for repair of macular holes.

PURPOSE: To report on the outcomes of 25-gauge pars plana vitrectomy using sulfur hexafluoride and no prone positioning for repair of macular holes. METHODS: Retrospective case series of 44 consecutive patients who underwent pars plana vitrectomy with internal limiting membrane peeling for repair of stages 2 to 4 idiopathic macular holes using 20% to 30% sulfur hexafluoride. No postoperative prone positioning or gas augmentation was used. RESULTS: The macular hole closure rate was 88.6%. There were no differences in the macular hole closure rates between phakic and pseudophakic patients (21 of 23 vs. 17 of 21, respectively) or among stages 2, 3, and 4 macular holes (12 of 13, 20 of 23, and 7 of 8, respectively). In eyes successfully operated on, visual acuity improved from 0.61 logarithm of the minimal angle of resolution (logMAR) (20 of 82) preoperatively to 0.483 logMAR (20 of 61) at 1 month and 0.396 logMAR (20 of 50) at a mean final follow-up of 10.8 months. Adverse effects were elevation of intraocular pressure to >30 mmHg in 7 (13.6%) of 44 patients on the first postoperative day, postoperative retinal detachments in 2 (4.5%) of 44 patients, and progression of cataract requiring cataract surgery in 7 (30.4%) of 23 phakic patients during follow-up. CONCLUSIONS: Macular hole closure rates similar to those achieved using pars plana vitrectomy with perfluoropropane and prone positioning can be achieved using sutureless 25-gauge vitrectomy with sulfur hexafluoride tamponade and no prone positioning for both phakic and pseudophakic patients.

Photodynamic therapy for bilateral subfoveal choroidal neovascularization complicating stargardt macular dystrophy.

PURPOSE: To report the outcome of repeated photodynamic therapy (PDT) for a patient with choroidal neovascularization complicating Stargardt disease. METHODS: Interventional case report. RESULTS: A 41-year-old patient with Stargardt disease developed unilateral choroidal neovascularization treated multiple times with PDT over 2.5 years. At that time, she developed choroidal neovascularization in the fellow eye also treated with PDT. Despite poor interim vision, after >4 years of follow-up, final visual outcome was excellent. CONCLUSION: Our case provides further evidence that repeated PDT may be used for the treatment of choroidal neovascular membrane complicating Stargardt disease without deleterious effects up to 4 years after treatment.

Symptomatic posterior vitreous detachment and the incidence of delayed retinal breaks: case series and meta-analysis.

PURPOSE: To establish the necessity for an early follow-up examination after an initial funduscopic examination with negative results for patients with acute, symptomatic posterior vitreous detachment (PVD). DESIGN: Retrospective case-control study and meta-analysis. METHODS: Records were reviewed of patients seeking treatment over a 4.5-year period who were diagnosed with an acute, symptomatic PVD. A MEDLINE search to identify all published observational case studies reporting vitreoretinal pathologic features after acute, symptomatic PVD. RESULTS: The incidence of retinal tears in eyes with a symptomatic PVD was 8.2%. The overall rate of retinal break in the meta-analysis portion of the study was 21.7%. In total, 1.8% of patients had retinal tears that were not seen on initial examination. Of the 29 patients with delayed-onset retinal breaks, 24 (82.8%) had at least one of the following: vitreous hemorrhage at initial examination, hemorrhage in the peripheral retina at initial examination, or new symptoms. CONCLUSIONS: If the results of an initial examination of a patient with an acute, symptomatic PVD are negative for retinal tears, the necessity of early follow-up may be best determined by the presence of pigmented cells in the vitreous, vitreous hemorrhage, or retinal hemorrhage. Most patients with symptomatic PVD may not need an early follow-up examination.

Long-term retinal toxicity of intravitreal commercially available preserved triamcinolone acetonide (Kenalog) in rabbit eyes.

PURPOSE: To investigate whether intravitreal Kenalog (IVTK; Bristol Meyers Squibb Company, Princeton, NJ) produces histologic or electroretinographic changes in the rabbit retina up to 3 months after injection. METHODS: Ten Dutch-belted rabbits were injected with 4 mg/0.1 mL Kenalog in one eye and 0.1 mL physiologic salt solution (PSS) in the fellow eye. Simultaneous bilateral dark-adapted electroretinography was performed 2 weeks and 12 weeks after injection in 10 and 6 rabbits, respectively. Saturated a-wave amplitude, maximal scotopic b-wave amplitude, and individual a-wave and b-wave amplitudes of IVTK-injected and control eyes were compared at 2 and 12 weeks after injection. Light microscopy was performed on both eyes of three animals 3 months after injection. Immunohistochemistry was performed with antibodies recognizing vimentin and human alveolar macrophage (HAM)-56, markers of glial cells and macrophages, respectively. RESULTS: No significant difference was observed in the saturated a-wave or maximal scotopic b-wave amplitudes between the PSS-injected eyes and the IVTK-injected eyes at 2 weeks (P = 0.95 and P = 0.56, respectively) and 12 weeks (P = 0.82 and P = 0.17) after injection. Light microscopy and immunohistochemistry disclosed only rare macrophages in the vitreous of IVTK-injected eyes. Retinal layers, retinal pigment epithelium, and choriocapillaris in treatment and control eyes were unremarkable. CONCLUSIONS: No demonstrable electroretinographic or histologic changes occurred to suggest immediate or delayed widespread retinal toxicity of IVTK.

Etanercept monotherapy induces complete resolution of cystoid macular edema in a patient with intermediate uveitis.

BACKGROUND: There is controversy on whether etanercept, an anti-tissue necrosis factor agent, shares infliximab's purported efficacy in the treatment of intermediate uveitis and, in particular, intermediate uveitis-associated cystoid macular edema. METHODS: Interventional case report. RESULTS: A 29-year-old patient with decreased vision bilaterally secondary to cystoid macular edema complicating chronic idiopathic intermediate uveitis refractory to oral corticosteroids, methotrexate (17.5 mg weekly), and cyclosporine (100 mg daily) started etanercept monotherapy with rapid and complete resolution of cystoid macular edema and dramatic improvement in visual acuity. CONCLUSION: Etanercept may have a role in the treatment of refractory intermediate uveitis and intermediate uveitis-associated cystoid macular edema.