Long-Term Follow-Up of Retinal Detachment Repair in Patients With Stickler Syndrome.

BACKGROUND AND OBJECTIVE: To report the long-term anatomic and visual outcomes of patients with Stickler syndrome undergoing retinal detachment (RD) surgery. PATIENTS AND METHODS: Retrospective, interventional, consecutive case series of patients with Stickler syndrome undergoing RD repair from 1999 to 2017 at the Long Island Vitreoretinal Consultants, New York. Retinal attachment status and visual acuity (VA) at 1-year and last follow-up were assessed. RESULTS: Successful reattachment was achieved in 28 of 29 eyes (97%) with an average of 2.3 surgeries (including silicone oil removal surgeries). Redetachment after the first surgery occurred in 13 eyes (45%). Mean Snellen VA at initial presentation, 1-year follow-up, and last follow-up were 20/289, 20/118 (P = .012), and 20/103 (P = .022), respectively. CONCLUSIONS: Anatomic success can be achieved in most eyes. However, redetachments are common, and multiple surgeries are often required. Reasonable visual recovery is possible in many eyes. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:612-616.].

Early initial clinical experience with intravitreal aflibercept for wet age-related macular degeneration.

BACKGROUND: Age-related macular degeneration (AMD) is a degenerative process that leads to severe vision loss. Wet AMD is defined by choroidal neovascularisation, leading to the accumulation of subretinal fluid (SRF), macular oedema (ME), and pigment epithelium detachments (PED). Purpose To evaluate the initial clinical experience of conversion from bevacizumab or ranibizumab to aflibercept in wet AMD patients. METHODS: Records of 250 consecutive wet AMD patients were retrospectively reviewed. Of 250 patients, 29 were naive (with no previous treatment), and 221 were previously treated with bevacizumab (1/3) or ranibizumab (2/3). On average, converted patients received 14 injections every 6 weeks on a treat-and-extend regimen with Avastin or Lucentis before being converted to aflibercept every 7 weeks on average (no loading dose) for three doses. For the purposes of this study, we concentrated on the patients converted to aflibercept since the number of naive patients was too small to draw any conclusion from. Snellen (as logMar) visual acuities, and optical coherence tomography (OCT) were compared predrug and postdrug conversion. RESULTS: Converted patients did not show a significant difference in visual acuity or average OCT thickness from preconversion values; however, small improvements in ME (p=0.0001), SRF (p=0.0001), and PED (p=0.008) grading were noted on average after conversion to aflibercept. CONCLUSIONS: No significant difference in visual outcome or average OCT thickness was observed when switched from bevacizumab or ranibizumab q6 week to aflibercept 7-week dosing, on average. Mild anatomic improvements did occur in converted patients with regard to ME, SRF and PED improvement, on average, after conversion to aflibercept, and aflibercept was injected less frequently. No serious adverse reactions, including ocular infections or inflammation, as well as ocular and systemic effects were noted.

Pars plana vitrectomy in the management of patients diagnosed with endophthalmitis following intravitreal anti-vascular endothelial growth factor injection.

PURPOSE: To evaluate the possible benefit of pars plana vitrectomy in the treatment of patients with endophthalmitis following antivascular endothelial growth factor (VEGF) injection. METHOD: The authors retrospectively reviewed the medical records of all patients in their practice with a diagnosis of endophthalmitis from January 1, 2007, through December 31, 2011. Only those with a clinical presentation consistent with endophthalmitis after intravitreal anti-VEGF injection were included. Clinical data that were collected and recorded included visual acuities and the method of initial and subsequent treatment of endophthalmitis following anti-VEGF injection: tap and injection of intravitreal antibiotics (TAP) and tap and inject with subsequent pars plana vitrectomy (VIT). RESULTS: The authors identified 23 patients meeting criteria. Nineteen patients had received bevacizumab and four patients had received ranibizumab. The median time from last injection to presentation was 4 days (range, 1-18 days) with a median follow-up of 15 months (range, 5-48 months) after being diagnosed of endophthalmitis. Nine patients had positive cultures. The median baseline visual acuity (preendophthalmitis) was 20/70 (range, 20/25 to counting fingers at 2 ft) with a median presenting visual acuity of counting fingers at 1 ft (range, 20/50 to light perception vision). Overall, 90% (9/10) of the patients in TAP only group regained visual acuity within 1 line or better of baseline versus 46% (6 of 13) in the TAP and VIT group. Only one of the patients treated with TAP alone suffered more than one line of visual acuity loss. CONCLUSION: Patients diagnosed with endophthalmitis after anti-VEGF intravitreal injection who underwent TAP regained baseline visual acuity more often than those who underwent TAP and VIT. This study did not support a benefit for VIT in all patients, rather only in those cases who warranted it because of worsening clinical course. The study suggests that TAP is a viable primary intervention for endophthalmitis after anti-VEGF injection.

Retinal pigment epithelium tears after intravitreal injection of bevacizumab (avastin) for neovascular age-related macular degeneration.

BACKGROUND: Intravitreal bevacizumab (Avastin, Genentech, Inc., South San Francisco, CA) treatment of neovascular age-related macular degeneration (AMD) has become an important part of clinical retinal practice. We describe retinal pigment epithelium (RPE) tears that were noted after intravitreal injection of bevacizumab. METHODS: In this multimember, retrospective case series, data on eyes that developed RPE tears after intravitreal bevacizumab injection were collected and analyzed. Previous treatments, type of lesion, time to tear, and preinjection and final visual acuities were all compared. The total numbers of bevacizumab injections were available from all four institutions and compiled to estimate the incidence rate. RESULTS: Four retina centers administered a total of 1,455 intravitreal 1.25-mg bevacizumab injections for neovascular AMD during the 9-month study period. Twelve patients presented with RPE tears within 4 days to 8 weeks of injection (mean +/- SD, 24.3 +/- 15.2 days from injection to tear). In each case, the RPE tear was preceded by an RPE detachment, and all had a component of serous sub-RPE fluid. On the basis of our collective data, we estimate an incidence rate of approximately 0.8%. CONCLUSIONS: RPE tears can occur after intravitreal injection of bevacizumab. The low incidence of this adverse event should not preclude anti-vascular endothelial growth factor therapy counseling for patients with neovascular AMD, but eyes with serous RPE detachments appear to be most vulnerable to this adverse event.

Visual improvement following intravitreal bevacizumab (Avastin) in exudative age-related macular degeneration.

PURPOSE: To study the visual and anatomic outcome of intravitreal bevacizumab injection in the treatment of exudative age-related macular degeneration (AMD). METHODS: Retrospective review of patients who received one or more intravitreal bevacizumab injections for exudative AMD. Outcome measures include standardized visual acuity, optical coherence tomography (OCT), macular thickness and volume, intraocular pressure, and blood pressure at 24 or more weeks follow-up. RESULTS: Fifty eyes of 48 patients were identified. Patients were observed for a median length of follow-up of 34 weeks (range, 24-50 weeks). Thirty-six eyes (72%) had prior treatment with pegaptanib (Macugen) and/or photodynamic therapy (PDT) and 14 eyes (28%) were treatment-naive. Mean visual acuity increased by 6.5 letters (P < 0.01) at 4 weeks and 5.3 letters (P < 0.01) at 24 weeks after initial bevacizumab injection. At 24 weeks, naive eyes had a mean increase of 14.2 letters (P < 0.001) and previously treated eyes had a mean increase of 2.8 letters (P = 0.06). Overall, mean OCT macular thickness and volume decreased by 73 micro m (P < 0.001) and 1.0 mm3 (P < 0.001) respectively at last follow-up. At last follow-up, all eyes received an average of 3.5 injections and experienced an average of 1.08 recurrences. There was no incidence of severe vision loss or adverse effect. CONCLUSION: Intravitreal bevacizumab has the potential for improvement in vision in both naive and previously treated eyes for at least 6 months. The benefit is more pronounced in eyes without prior pegaptanib and/or PDT.

Acute endophthalmitis in eyes treated prophylactically with gatifloxacin and moxifloxacin.

PURPOSE: To study the use of prophylactic fourth-generation fluoroquinolone antibiotics, gatifloxacin and moxifloxacin, and bacterial sensitivity in cases of acute postoperative endophthalmitis following cataract surgery. DESIGN: Retrospective, consecutive, observational case series. METHODS: Forty-two eyes of 42 patients with acute endophthalmitis occurring within six weeks after cataract surgery were identified. All patients were seen in a referral vitreoretinal practice over a two-year time interval. The number of patients using prophylactic gatifloxacin or moxifloxacin and results of bacterial culture and sensitivity to all fluoroquinolone antibiotics were recorded. RESULTS: Thirty-one of 42 eyes (74%) were treated with perioperative gatifloxacin or moxifloxacin and 24 eyes (57%) were continuously taking one of these antibiotics at the time of diagnosis. Nineteen eyes (45%) had a positive bacterial culture. The most frequent organism isolated was coagulase-negative Staphylococcus. Sensitivities were performed for 14 gram-positive organisms, and sensitivities to ciprofloxacin (50%), ofloxacin (44%), levofloxacin (46%), gatifloxacin (38%), and moxifloxacin (38%) were noted. Five organisms were resistant to gatifloxacin and moxifloxacin with a minimum inhibitory concentration of 8 microg/ml. All gram-positive organisms were sensitive to vancomycin. Median visual acuity improved from hand motions to 20/40 at last follow-up. CONCLUSION: Acute endophthalmitis can develop after cataract surgery despite the prophylactic use of fourth-generation fluoroquinolone antibiotics. Gram-positive organisms causing acute endophthalmitis are frequently resistant to all fluoroquinolones, including a significant number of cases resistant to gatifloxacin and moxifloxacin.

Retinal tears and retinal detachment as factors affecting visual outcome after cataract extraction complicated by posteriorly dislocated lens material.

PURPOSE: To evaluate the incidence and effect on visual acuity of complicating factors such as retinal tears (RTs) and rhegmatogenous retinal detachment (RRD) in eyes with posteriorly dislocated lens fragments after cataract extraction. METHODS: Retrospective consecutive series of patients presenting at a referral vitreoretinal practice with posteriorly dislocated lens material after cataract extraction over a period of 8 years. The presence of RT, RRD, endophthalmitis, and choroidal hemorrhage was noted, and their effect on visual outcome was studied. RESULTS: A total of 307 eyes with posteriorly dislocated lens material after cataract extraction were identified. Fifty-eight eyes (19%) were managed medically (Group I), whereas the other 249 eyes (81%) underwent pars plana vitrectomy for removal of the lens material (Group II). Indications for surgical management included uncontrolled inflammation, elevated intraocular pressure, and large lens fragments. No eyes in Group I developed RT or RRD. Of the 249 Group II eyes, 13 (5%) were found to have RT, and 25 (10%) developed RRD. In Group II, choroidal hemorrhage and endophthalmitis were noted in 12 (5%) and 4 (2%) eyes, respectively. Fifty-one (88%) of 58 eyes in Group I and 138 (55%) of 249 eyes in Group II achieved a final visual acuity of 20/40 or better. Seven (54%) of the 13 eyes with RT and 9 (36%) of the 25 eyes with RRD achieved a final visual acuity of 20/40 or better. In the RRD group, 9 (56%) of the 16 macula-on eyes achieved a final visual acuity of 20/40 or better, whereas none of the 9 macula-off eyes had a final visual acuity of 20/40 or better. None of the 4 eyes with endophthalmitis and only 1 (8%) of the 12 eyes with choroidal hemorrhage had a final visual acuity of 20/40 or better. Five (62%) of eight eyes with retinal detachment treated with pneumatic retinopexy needed further treatment with scleral buckle to achieve anatomical reattachment. CONCLUSION: A good visual outcome (20/40 or better) is possible in eyes with posteriorly dislocated lens fragments after cataract extraction, even when retinal tears or macula-on retinal detachment is present. The presence of a macula-off retinal detachment, however, has a significant adverse effect on the visual outcome. Pneumatic retinopexy is not associated with retinal reattachment in many cases and is not preferred.

Management of macular holes that develop after retinal detachment repair.

PURPOSE: To study the characteristics and management of macular holes that develop after prior rhegmatogenous retinal detachment (RD) repair. DESIGN: Retrospective, interventional, consecutive case series. METHODS: The setting was a clinical practice. The case records of all of our patients (n = 12) who developed a new full-thickness macular hole after prior RD repair over an 8-year period were examined. Patients who developed a macular hole after prior RD repair were offered either surgical repair of the macular hole or continued observation. For eyes that underwent macular hole repair, main outcome measures included macular attachment status and postoperative visual acuity. RESULTS: Twelve full-thickness macular holes were detected in a series of 2,380 eyes (0.5% prevalence), which had undergone surgery for prior primary RD. Ten macular holes developed after scleral buckling surgery, two after pneumatic retinopexy, and none were seen after primary vitrectomy. The fovea had been detached in 11 of the 12 eyes at the time of RD. The median time to macular hole diagnosis after RD repair was 3.4 months (range, 0.3-161 months). Eight of the eight eyes (100%) undergoing surgical repair achieved macular reattachment with a median of 3.5 lines of visual improvement at a median of 14.8 months of follow-up. Seven of these eight eyes had an improvement in visual acuity of at least 3 Snellen lines, and four of the eight had at least 20/40 visual acuity postoperatively. Four eyes with macular holes were observed. CONCLUSIONS: Macular holes developed in less than 1% of eyes that had previously undergone repair of rhegmatogenous RD. In our series, these atypical holes were seen predominantly after macula-off detachments, most commonly occurring after scleral buckling procedures. They were effectively repaired using conventional pars plana vitrectomy with long-acting gas tamponade and a variety of adjuvant therapies. A good visual outcome is possible with this approach.