Short-term safety of 23-gauge single-step transconjunctival vitrectomy surgery.

PURPOSE: The purpose of this study was to report the safety profile of the Alcon 23-gauge single-step preloaded transconjunctival vitrectomy system. METHODS: This was a retrospective case series examining 118 eyes of 114 patients that underwent 23-gauge vitrectomy between July and November 2007. Patients were observed postoperatively for a minimum of 6 weeks. Main outcome measures were postoperative intraocular pressure (IOP), intraoperative complications, and postoperative adverse events. RESULTS: The mean postoperative Day 1 IOP was 14.3 +/- 6.6 mmHg (median, 13 mmHg; range, 2-38 mmHg) and Month 1 IOP was 15.8 +/- 5.9 mmHg (median, 15 mmHg; range, 6-52 mmHg). Two eyes (1.7%) developed choroidal effusions. Four eyes (3.4%) developed intraoperative horseshoe tears. No retinal detachments or endophthalmitis occurred. Four eyes (3.4%) had postoperative hypotony. Intraoperative wound leak after cannula removal requiring a sclerotomy suture occurred in 38% of patients: 35 eyes requiring closure of 1 cannula site (29.6%), 8 eyes (6.8%) requiring closure of 2 cannula sites, and 2 eyes (1.7%) requiring closure of all 3 cannula sites. CONCLUSION: The Alcon 23-gauge single step preloaded transconjunctival vitrectomy system has few safety issues. Sclerotomy leaks after cannula removal are common, with 38% of eyes requiring suture closure of at least 1 cannula site.

Central and pericentral retinal sensitivity after macular translocation surgery.

PURPOSE: To evaluate the separate contribution of the retina versus retinal pigment epithelium (RPE)-choriocapillaris to visual function after treatment of neovascular age-related macular degeneration by measuring retinal sensitivity across three areas after macular translocation surgery. METHODS: Using the Nidek microperimeter-1, we tested retinal sensitivity across three areas in 35 patients after macular translocation surgery. Microperimetry scores ranged from -2 (no response to brightest stimulus) to 20 (response with 20 dB neutral density filtering). Median retinal sensitivity score (MRSS) for the central 10-degrees (Area 1, fovea translocated over healthier RPE) was compared with acuity, reading speed and MRSS of adjacent areas: Area 2, retina over site of choroidal neovascularization removal and Area 3, retina over undisturbed RPE. RESULTS: In 27 of 35 eyes in this study (77%), the MRSS for Area 1, was greater than Area 2. Area 1 was a median of 3.0 decibels (dB) greater in sensitivity (range, 16 greater-2 lower) than Area 2 (P < or = 0.001), and 5.0 dB lower (range, 2 greater-12 lower) than Area 3 (P < or = 0.001). The median of the MRSS (25th/75th percentile) for Areas 1, 2 and 3 were 2.0 (0.0/6.0), -2.0 (-2.0/-2.0) and 9 (4.0/12.0), respectively. The MRSS for Area 1 correlated with reading speed more than with acuity. CONCLUSIONS: Sensitivity of the translocated macula was significantly greater than in Area 2, retina over abnormal RPE-choriocapillaris, suggesting that disturbed RPE-choriocapillaris significantly limits retinal function. Area 1 sensitivity was lower than in retina unaffected by age-related macular degeneration over undisturbed RPE, suggesting that persisting retinal dysfunction can limit vision recovery.

Combined fluocinolone acetonide intraocular delivery system insertion, phacoemulsification, and intraocular lens implantation for severe uveitis.

PURPOSE: To determine whether a three-year fluocinolone acetonide sustained drug delivery system can be implanted safely at the same time that phacoemulsification and intraocular lens (IOL) implantation are performed for a visually significant cataract in eyes with uveitis. DESIGN: Retrospective, single-center case series. METHODS: All consecutive patients treated from April 1998 through September 2006 at an academic clinical practice with intermediate uveitis, posterior uveitis, or panuveitis requiring immunosuppressive therapy, periocular corticosteroid injections, or both. Phacoemulsification, IOL implantation, and fluocinolone acetonide implant insertion were performed during a single surgical session. The main outcome measures were preoperative and postoperative ocular inflammation, visual acuity (VA), intraoperative complications, anti-inflammatory medication use, IOP, and postoperative adverse events. RESULTS: Twenty-four eyes of 21 patients were studied. Mean follow-up duration was 27 months (range, six to 60 months). No patients had intraoperative complications. The mean Snellen VA at baseline was 20/316, which improved significantly to 20/75 at 12 months. The average number of recurrences in the 12 months before implantation was 2.2 episodes per eye. Only one eye experienced a recurrence at seven months after implantation. Topical corticosteroids, posterior sub-Tenon capsule injections, and systemic anti-inflammatory medications were reduced significantly at 12 months. Average IOP was unchanged after surgery compared with preoperative IOP; 15% underwent glaucoma filtering surgery. CONCLUSIONS: A fluocinolone acetonide implant insertion can be combined safely with phacoemulsification plus IOL implantation during the same surgical session in eyes with uveitis. VA generally was improved, uveitis recurrences decreased, and the need for immunosuppression decreased. The most common side effect was increased IOP.

Intravitreal triamcinolone acetonide for diabetic macular edema.

PURPOSE: Intravitreal injection of triamcinolone acetonide has been advocated to treat exudative diabetic macular edema. The purpose of the study was to evaluate the clinical outcome of an intravitreal injection of triamcinolone acetonide as treatment for diffuse diabetic macular edema. METHODS: This study was a retrospective, interventional, clinical case series examining 210 eyes of 174 patients who received an intravitreal injection of 1 or 4 mg of triamcinolone acetonide for treatment of diffuse diabetic macular edema. Inclusion criteria were clinically significant macular edema, visual acuity loss, and leakage shown by fluorescein angiography. Main outcome measures were visual acuity and intraocular pressure. Mean follow-up time +/- SD was 6.6 +/- 3.1 months. RESULTS: In the study group, visual acuity improved significantly (P < 0.001) from a median of 20/200 (mean logMAR, 0.92) at baseline to 20/80 (mean logMAR, 0.82) at 6 months. Mean intraocular pressure +/- SD increased from 15.4 +/- 3.4 mmHg (median, 16 mmHg; range, 6-26 mmHg) to a maximal value of 20.4 +/- 6.2 mmHg (median, 19 mmHg; range, 12-51 mmHg) during the follow-up period. Complications included culture-negative sterile endophthalmitis in six cases and cataract extraction in five eyes. CONCLUSIONS: Intravitreal injection of 1 to 4 mg of triamcinolone acetonide may benefit patients by improving visual acuity in eyes with clinically significant diabetic macular edema. This study did not provide significant evidence to justify its routine use in clinical practice for all patients with diabetic macular edema. A randomized clinical trial on this issue would provide more conclusive evidence and help identify those patients most likely to benefit from intravitreal triamcinolone acetonide.

The effects of iridotomy size and position on symptoms following laser peripheral iridotomy.

PURPOSE: To evaluate visual disturbances following laser peripheral iridotomy (LPI). Patients sometimes note visual disturbances following laser peripheral iridotomy. The purpose of this study was to provide what we believe to be the first systematic evaluation of these visual disturbances, including a determination of whether or not they are associated with characteristics of a primary patent laser peripheral iridotomy, such as lid position and size of the iridotomy. PATIENTS AND METHODS: This was a case series of 93 consecutive (172 eyes) glaucoma patients who had had an Nd: YAG laser peripheral iridotomy. Patients returning for a follow-up visit after laser peripheral iridotomy were selected. A standardized questionnaire was prospectively administered to the study patients at least 1 month after their laser peripheral iridotomy had been performed, inquiring if they experienced any of the following either before or after the iridotomy: halo, lines, crescent, ghost image, glare, spots, shadows, blurring, or other unlisted visual disturbances. On the same visit when they answered the questionnaire, the patients were examined at the slit lamp to assess the location, lid coverage status, and size of the laser peripheral iridotomy. Selection for the performance of the LPI was not prospective. A series of 93 consecutive patients served as controls. RESULTS: Seven (4%) of the 172 study eyes had postoperative visual symptoms of shadows, ghost images, crescents, or lines. Ninety (52.3%) of the laser peripheral iridotomies were covered by the upper lid, 40 (23%) were completely exposed, and 42 (24%) were partially exposed. Visual disturbances (those listed above plus glare, blurring, haloes, spots, and miscellaneous) occurred in 8 of the 90 (8.9%) eyes with completely covered laser peripheral iridotomies, in 11 of the 42 (26%) with partially covered laser peripheral iridotomies, and in 7 of the 40 (17.5%) with fully exposed LPIs. CONCLUSION: Visual symptoms following laser peripheral iridotomy are more likely to occur in patients who have partially or fully exposed laser iridotomies than in those in whom the iridotomy is completely covered by the lid.

Noninfectious endophthalmitis associated with intravitreal triamcinolone injection.

BACKGROUND: Intravitreal injection of triamcinolone has been advocated to treat exudative macular diseases such as macular edema and choroidal neovascularization. OBJECTIVE: To describe 7 patients who developed a clinical picture simulating endophthalmitis after intravitreal triamcinolone injection. METHODS: Intravitreal triamcinolone injections were performed to treat refractory cystoid macular edema or diffuse macular edema associated with diabetic retinopathy, macular pucker, branch retinal vein occlusion, or pseudophakia. One patient received an injection in an attempt to treat exudation associated with occult choroidal neovascularization. RESULTS: Preinjection visual acuity ranged from 20/50 to 20/400. An extensive inflammatory response developed 1 to 2 days after injection in all 7 eyes. Five eyes had previously undergone vitrectomy. Four eyes had a layered hypopyon. All 7 eyes had an anterior chamber cellular reaction and vitritis. Visual acuity ranged from 20/400 to hand movements. The first 6 patients were treated for presumed endophthalmitis with vitreous cultures and intravitreal injections of antibiotics. All 6 cultures were negative for any organisms, and the eyes resolved their inflammatory response, with recovery to preinjection visual acuity or better. The seventh patient was treated with topical prednisolone without antibiotic therapy, and the inflammation resolved, with resolution of the macular edema seen before the intravitreal triamcinolone injection. CONCLUSION: It may be appropriate to closely observe noninfectious, toxic endophthalmitis in patients treated with intravitreal triamcinolone before assuming it to be infectious, especially in the absence of eye pain.

Multiple isolated aneurysms in a case of "burned out" Takayasu aortitis.

Takayasu aortitis (TA) is a chronic inflammatory disease predominantly seen in young Asian women. The disease is idiopathic and largely affects the aorta and its major branches. The basic pathologic changes in TA are fibrosis and subsequent occlusion of the large arteries. TA is classically termed "pulseless" disease, with manifestations during the occlusive stage including limb ischemia, renovascular hypertension, and heart failure. Arterial dilation and aneurysm are largely unappreciated manifestations of TA, but they occur in as many as 32% of affected patients. We report chronic "burned out" TA in a 23-year-old Hispanic woman with isolated aneurysms of the descending thoracic aorta, abdominal aorta, and common iliac arteries, without occlusive disease.