Comparison of hemorrhagic complications of warfarin and clopidogrel bisulfate in 25-gauge vitrectomy versus a control group.

PURPOSE: To estimate the risk of hemorrhagic complications associated with 25-gauge pars plana vitrectomy (PPV) when warfarin (Coumadin; Bristol-Myers Squibb, New York, NY) or clopidogrel (Plavix; Bristol-Myers Squibb) are continued throughout the surgical period, as compared with a control group. DESIGN: A single-center, retrospective, cohort study of 289 consecutive patients receiving either warfarin therapy or clopidogrel therapy or neither of those therapies who underwent 25-gauge PPV. PARTICIPANTS: Included were 61 patients (64 eyes; 64 PPV procedures) in the warfarin group and 118 (125 eyes; 136 PPV procedures) in the clopidogrel group. Warfarin patients were subdivided into 4 groups by international normalized ratio (INR). A control group included 110 patients (110 eyes; 110 PPV procedures) who were not receiving warfarin or clopidogrel. METHODS: Retrospective chart review for which the criteria included: 25-gauge PPV, minimum age of 19 years, warfarin or clopidogrel use, and, if taking warfarin, an INR obtained within 5 days of surgery. MAIN OUTCOME MEASURES: Incidence of intraoperative and postoperative hemorrhagic complications. RESULTS: The most common indications for anticoagulation therapy included: atrial fibrillation (38%), valvular heart disease (17%), and thromboembolic disease (16%). The most common indications for antiplatelet therapy included: cardiac stent (49%), coronary artery bypass grafting (24%), and history of transient ischemic attack (16%). No patient experienced anesthesia-related hemorrhagic complications resulting from peribulbar or retrobulbar block. Transient vitreous hemorrhage occurred in 1 (1.6%) of 64 PPV procedures in the warfarin group (P = 0.6531), 5 (3.7%) of 136 PPV procedures in the clopidogrel group (P = 1.0), and 4 (3.6%) of 110 PPV procedures in the control group. No choroidal or retrobulbar hemorrhages occurred in any patient. CONCLUSIONS: The rate of 25-gauge PPV hemorrhagic complications in patients who underwent systemic anticoagulation or who were receiving platelet inhibitor therapy is extremely low. Given the risks associated with stopping these therapies, the authors recommend that patients continue their current therapeutic regimen without cessation.

Macular hole closure following intraoperative choroidal hemorrhage.

This interventional case report retrospectively reviews the outcome of a 56-year-old woman who suffered an intraoperative choroidal hemorrhage at commencement of macular hole surgery. Due to the early intraoperative choroidal hemorrhage, vitrectomy was not performed. One month postoperatively, the macular hole was noted to be closed and remained closed 2 years later, leaving the patient with a good visual outcome. The authors postulate that the temporal location of the choroidal hemorrhage may have exerted mechanical displacement of the retina toward the macular hole margins, resulting in closure. Macular hole closure directly following intraoperative choroidal hemorrhage is possible.

Proliferative retinopathy as a complication of dyskeratosis congenita.

OBJECTIVES: To describe a patient with dyskeratosis congenita (DC) who developed retinal neovascularization (RNV) and discuss this novel association. METHODS: A 10-year-old boy with DC was referred for evaluation of possible retinal vascular disease. He underwent ophthalmologic examination, as well as fluorescein angiography. RESULTS: Fluorescein angiography demonstrated proliferative retinopathy with capillary nonperfusion in the temporal retina of both eyes. The patient underwent further evaluation with an examination with anesthesia and indirect ophthalmoscopic laser photocoagulation to areas of capillary nonperfusion. CONCLUSION: Although various ocular complications of both acquired aplastic anemia and inherited aplastic anemia due to DC have been previously described, to the authors' knowledge, this is the first reported case of either disease to exhibit RNV consistent with proliferative retinopathy. Ophthalmologists need to be aware of this potential complication in DC that could threaten vision, to provide prompt laser photocoagulation therapy.

Risk factors for severe vision loss immediately after transpupillary thermotherapy for occult subfoveal choroidal neovascularization.

BACKGROUND AND OBJECTIVE: To determine risk factors for immediate severe vision loss in patients with age-related macular degeneration after transpupillary thermotherapy for occult subfoveal choroidal neovascularization. PATIENTS AND METHODS: Retrospective review of 84 consecutive patients with age-related macular degeneration who received transpupillary thermotherapy for occult subfoveal choroidal neovascularization. Seven cases had severe vision loss and 77 were controls. All patients were treated with a diode infrared laser. Follow-up was completed on all patients 1, 3, and 6 months after treatment with transpupillary thermotherapy. RESULTS: Pretreatment visual acuity ranged from 20/40 to 1/200. Seven of 84 consecutive eyes had an immediate visual acuity loss of 6 or more Snellen lines after transpupillary thermotherapy. CONCLUSION: Transpupillary thermotherapy has a small but significant risk of immediate severe vision loss in patients with age-related macular degeneration with occult subfoveal choroidal neovascularization. Statistically significant risk factors include a subretinal hemorrhage 5 disc areas or greater in size, 9 disc areas or greater of subretinal fluid, and a laser power greater than 550 mW.

Macular holes associated with diabetic tractional retinal detachments.

BACKGROUND AND OBJECTIVE: Evaluation of surgical treatment of full-thickness macular holes secondary to diabetic tractional retinal detachments was conducted. PATIENTS AND METHODS: A retrospective review of medical records, fluorescein angiograms, fundus photographs, optical coherence tomography images, and operative findings of six consecutive patients with full-thickness macular holes and diabetic tractional retinal detachments was completed. Each eye was treated with pars plana vitrectomy, tractional retinal detachment repair, membranectomy, indocyanine green-assisted internal limiting membrane peeling, and intraocular gas tamponade. RESULTS: Surgical intervention resulted in the closure of all full-thickness macular holes. Mean best-corrected visual acuity was 20/250 preoperatively and 20/100 postoperatively, with all patients having improvement after a mean follow-up of 10 months. CONCLUSION: Closure of tractional retinal detachments related to full-thickness macular holes can be achieved via pars plana vitrectomy, complete membranectomy, and intraocular gas. Vitrectomy with dissection of proliferative membranes helps to relieve the tractional forces responsible for full-thickness macular hole formation, enabling successful closure of the diabetic full-thickness macular holes and resulting in visual acuity improvement.

Branch retinal artery occlusion: visual prognosis.

PURPOSE: To evaluate the visual prognosis in eyes with branch retinal artery occlusion (BRAO). DESIGN: Retrospective, observational, consecutive case series. METHODS: Retrospective medical record review of 52 consecutive eyes of 52 patients with BRAO seen at two vitreoretinal practices in Birmingham, Alabama. Only eyes with decreased central macular perfusion on fluorescein angiography (FA) were included. Eyes with anterior segment or optic nerve disease, lack of retinal whitening or a delay in arterial filling on FA, central retinal artery occlusion, and cilioretinal artery occlusion were excluded. The main outcome measure was presenting best-corrected visual acuity (BCVA) and its relationship to final BCVA. RESULTS: On presentation, 54% of eyes with BRAO had BCVA of 20/40 or better. At the mean 14-month visit, 60% of all eyes had visual acuity (VA) of 20/40 or better. VAs of 20/40 or better were retained by 89% of eyes with baseline BCVA of 20/40 or better. Only 14% of eyes with 20/100 or worse BCVA improved to 20/40 or better. Neither visible emboli (P > or = .244) nor the region of macular involvement (P = .142) were significant with respect to visual improvement. CONCLUSIONS: Visual prognosis after BRAO seems to be correlated to presenting VA. Eyes with initial VA of 20/40 or better usually remained at 20/40 or better. Individuals with poor VA of 20/100 or worse generally did not show the significant improvement reported in previous studies.

Incidence of acute onset endophthalmitis following intravitreal bevacizumab (Avastin) injection.

PURPOSE: To report the incidence of acute endophthalmitis as a complication of intravitreal bevacizumab (Avastin) (IVB) injection in a tertiary vitreoretinal group practice. METHODS: A retrospective chart review of 5,233 consecutive eyes that underwent IVB injection at Retina Consultants of Alabama (RCA) from October 1, 2005, to August 31, 2007, was performed to identify cases of acute endophthalmitis. RESULTS: During the 23-month study interval, the overall incidence rate of postinjection endophthalmitis was 0.019% (1/5,233). In the single case of acute endophthalmitis, bacterial cultures revealed coagulase-negative Staphylococcus (CNS) species. Visual acuity after treatment for endophthalmitis was improved (baseline 4/400) to 20/400 at two months after the initial IVB injection. CONCLUSIONS: Acute endophthalmitis is a rare potential complication of IVB. Prophylaxis with topical povidone-iodine and adherence to aseptic technique minimizes the risk of postinjection infection. SUMMARY STATEMENT: A retrospective review of 5,233 consecutive intravitreal injections of bevacizumab (Avastin) revealed only a single case of acute endophthalmitis. Adherence to aseptic technique and the use of povidone-iodine prophylaxis minimizes the risk of postinjection intraocular infection.

Intravitreal bevacizumab treatment for radiation macular edema after plaque radiotherapy for choroidal melanoma.

PURPOSE: To evaluate the effect of intravitreal bevacizumab treatment on patients with macular edema (ME) due to radiation retinopathy after plaque radiotherapy for choroidal melanoma. METHODS: In this retrospective case series, 10 consecutive patients with ME due to radiation retinopathy after plaque radiotherapy for choroidal melanoma were treated with a single intravitreal injection of bevacizumab. Postinjection best-corrected visual acuity (BCVA) and mean foveal thickness measured by ocular coherence tomography were the primary outcome measures. RESULTS: The mean BCVA at the time of the diagnosis of choroidal melanoma was 20/25 (range, 20/20 to 20/40). The mean radiation dose to the foveola was 4,323 cGy (range, 1,908-7,975 cGy). Radiation ME developed at a mean of 26 months (range, 17-44 months) after plaque radiotherapy. Choroidal melanoma regressed in all patients, and there were no neovascular sequelae. At the time of radiation ME diagnosis, the mean BCVA was 20/100 (range, 20/40 to 20/200). After bevacizumab injection, the mean BCVA was 20/86 at 6 weeks and 20/95 at 4 months. Mean foveal thickness measured by ocular coherence tomography was 482 microm before injection, 284 microm 6 weeks after injection, and 449 mum 4 months after injection. CONCLUSIONS: Intravitreal bevacizumab injection decreases mean foveal thickness while only modestly improving BCVA on a short-term basis in patients with radiation-induced ME.

Preemptive sub-Tenon's anesthesia for pars plana vitrectomy under general anesthesia: is it effective?

BACKGROUND AND OBJECTIVES: To determine whether irrigation of the sub-Tenon's space with anesthetic agents during pars plana vitrectomy (PPV) involving general anesthesia decreases postoperative pain, analgesic use, or nausea. PATIENTS AND METHODS: A prospective, controlled trial of 46 consecutive patients requesting general anesthesia for PPV who were randomized to receive or not receive a sub-Tenon's space injection prior to surgery. A mixture of 3 mL of 2% lidocaine with hyaluronidase and 3 mL of 0.5% bupivacaine was used to induce local blockade. Pain, postoperative nausea, and analgesia use were evaluated. RESULTS: Local blockade did not significantly alter the proportion of reported pain at 30 minutes and 2, 4, and 24 hours after the operation. The local blockade had no effect on reducing postoperative nausea or the number of patients requiring pain medication. CONCLUSIONS: Local blockade prior to surgery in patients undergoing PPV under general anesthesia does not significantly decrease postoperative pain, analgesic use, or nausea.