High-Dose Aflibercept for Neovascular AMD and DME in Suboptimal Responders to Standard-Dose Aflibercept.

Purpose: To assess the effect of higher dose (HD) aflibercept on visual acuity (VA), optical coherence tomography outcomes, and injection burden in eyes with neovascular age-related macular degeneration (nAMD) or diabetic macular edema (DME) that responded suboptimally to standard-dose aflibercept. Methods: This retrospective analysis included eyes with clinically significant disease activity on monthly therapy (AMT) (injection interval ≤35 days) or clinically significant increased activity on extension (IAE) (injection interval >36 days) that were switched from aflibercept 2 mg to aflibercept HD (3 mg to 4 mg). Outcomes were assessed at baseline, after injections 1 through 4, and at 6, 9, and 12 months. Results: Overall, 318 eyes of 288 adult patients were analyzed (eyes with nAMD: 59 AMT, 147 IAE; eyes with DME: 50 AMT, 62 IAE). Most of the study cohort received aflibercept HD 3 mg (nAMD: 73% AMT and 58% IAE; DME: 49% AMT and 68% IAE); the remainder received 4 mg. The mean best VA improved significantly with AMT and was maintained with IAE. In all groups, the central subfield thickness decreased significantly and the mean injection intervals increased or remained stable. No new safety signals were observed. Conclusions: Aflibercept HD might improve outcomes while decreasing treatment burden for eyes that respond suboptimally to standard dosing.

Intravitreal injection analysis at the Bascom Palmer Eye Institute: evaluation of clinical indications for the treatment and incidence rates of endophthalmitis.

OBJECTIVE: To report the incidence of endophthalmitis, in addition to its clinical and microbiological aspects, after intravitreal injection of vascular-targeting agents. METHODS: A retrospective review of a consecutive series of 10,142 intravitreal injections of vascular targeting agents (bevacizumab, ranibizumab, triamcinolone acetonide, and preservative-free triamcinolone acetonide) between June 1, 2007 and January 31, 2010, performed by a single service (TGM) at the Bascom Palmer Eye Institute. RESULTS: One case of clinically-suspected endophthalmitis was identified out of a total of 10,142 injections (0.009%), presenting within three days of injection of bevacizumab. The case was culture-positive for Staphylococcus epidermidis. Final visual acuity was 20/40 after pars plana vitrectomy surgery. CONCLUSIONS: In this series, the incidence of culture-positive endophthalmitis after intravitreal injection of vascular agents in an outpatient setting was very low. We believe that following a standardized injection protocol, adherence to sterile techniques and proper patient follow-up are determining factors for low incidence rates.

Ocular trauma and visual outcome secondary to paintball projectiles.

PURPOSE: To describe ocular injuries attributable to paintball-related trauma and their management and results. DESIGN: Retrospective, interventional case series. METHODS: setting: University practice and emergency department. patient population: Thirty-six eyes of 36 patients who sustained ocular injuries secondary to paintballs between July 1, 1998 and January 1, 2005. observation procedure: Age, gender, laterality, setting, eye protection, best-corrected visual acuity (BCVA), and initial diagnosis were documented. main outcome measures: Medical and surgical intervention within the first three days postinjury and further treatment after this time period were recorded. BCVA at the initial and final clinical visit were compared. RESULTS: The mean follow-up interval was 11.7 months (one to 40). Mean age was 21 years (three to 64), 31 (86%) were male, 34 (97%) were not wearing eye-protection device when injured, and initial BCVA was worse than 20/200 in 28 eyes (78%). The most common ocular finding was hyphema in 29 eyes (81%). Initially, 20 eyes (56%) were managed medically and nine eyes (25%) required primary repair of a ruptured globe. Ultimately, 29 eyes (81%) had surgical intervention including eight eyes (22%) enucleations. Final visual acuity was 20/40 or better in 13 eyes (36%), whereas 18 eyes (50%) were worse than 20/200. Visual acuity (VA) at initial presentation correlated strongly with final VA (r = 0.64; P < .001). CONCLUSIONS: Paintball-related ocular injuries are frequently severe and visually devastating. The compulsive use of protective eyewear may have eliminated 97% of injuries in this series and continues to need emphasis to paintball users.

Cartilage thickness in cadaveric ankles: measurement with double-contrast multi-detector row CT arthrography versus MR imaging.

PURPOSE: To test the accuracy of double-contrast multi-detector row computed tomographic (CT) arthrography for measurement of cartilage thickness in cadaveric ankles and to compare this technique with three-dimensional (3D) fat-suppressed spoiled gradient-echo in the steady state (FS-SPGR) magnetic resonance (MR) imaging. MATERIALS AND METHODS: Five cadaveric ankles were used. In the ankle specimens, five to nine 1.5-mm-diameter holes were drilled across the joint traversing the tibial subchondral bone, tibial articular cartilage, talar dome cartilage, and talar subchondral bone. The ankle specimens were obtained and used according to institutional policies. Each ankle specimen was imaged first by using 3D FS-SPGR MR imaging with a 1.5-T magnet and then by using double-contrast arthrography followed by CT with a four-detector row scanner (ie, double-contrast multi-detector row CT arthrography). The section thickness used for CT scanning was 1.0 mm reconstructed in 0.5-mm intervals. The MR and CT images obtained in the five specimens were then downloaded to a workstation, where a measurement tool was used to measure the cartilage thickness at each hole. The physical measurement of cartilage thickness at each hole was used as the reference standard with which the MR imaging and CT measurements were compared. Linear regression and correlation analyses were performed by using a statistical computer program. RESULTS: Double-contrast arthrography followed by multi-detector row CT, as compared with 3D FS-SPGR MR imaging, enabled more accurate measurement of the physical cartilage thickness in the ankle (P < .001). CONCLUSION: In this study of five cadaveric ankles, multi-detector row CT arthrography was more accurate than 3D FS-SPGR MR imaging for measurement of articular cartilage thickness in the ankle.

The Agility total ankle arthroplasty. Seven to sixteen-year follow-up.

BACKGROUND: We previously reported the intermediate-term results with the early version of the Agility total ankle replacement, a unique design that takes advantage of arthrodesis of the tibiofibular syndesmosis for tibial component support. The purpose of this study was to report longer-term results of this procedure in the treatment of disabling ankle arthritis. METHODS: We conducted an independent review of all Agility total ankle replacements performed by a single surgeon between 1984 and 1994. Follow-up evaluation consisted of completion of a validated ankle osteoarthritis scale and a short questionnaire and a review of the radiographs. All radiographs were evaluated for evidence of the development of progressive hindfoot arthritis, nonunion of the tibiofibular syndesmosis, progressive radiolucent lines, osteolysis, and component subsidence. RESULTS: One hundred and thirty-two arthroplasties were performed in 126 patients. After a mean follow-up period of nine years, thirty-three patients (thirty-six implants) had died, fourteen patients (11%) had a revision of the implant or an ankle arthrodesis, and one had the leg amputated because of an unrelated cause. Of the remaining seventy-eight patients (eighty-one ankles), sixty-seven (sixty-nine ankles) were followed clinically. More than 90% of them reported that they had decreased pain and were satisfied with the outcome of the surgery. We found modest differences in a comparison of the pain and disability scores with those of age-matched controls. Of the 117 ankles that had been followed radiographically for a minimum of two years, twenty-two (19%) had progressive subtalar arthritis, seventeen (15%) had progressive talonavicular arthritis, and nine (8%) had a syndesmosis nonunion. Eighty-nine (76%) of the 117 ankles had some evidence of peri-implant radiolucency. CONCLUSIONS: Arthrodesis of the tibiofibular syndesmosis impacts the radiographic and clinical outcomes with the Agility total ankle replacement. The relatively low rates of radiographic hindfoot arthritis and revision procedures at an average of nine years after the arthroplasty are encouraging. Agility total ankle replacement is a viable and durable option for the treatment of ankle arthritis in selected patients.