Treatment of dry age-related macular degeneration: A review.

Age-related macular degeneration is a global disease with a significant societal impact. The advent of anti-vascular endothelial growth factor therapy (anti-VEGF) has revolutionised the treatment of neovascular age-related macular degeneration (nAMD). Dry age-related macular degeneration (dAMD) is being investigated for possible therapeutic options. The therapeutic categories undergoing clinical trials include complement pathway inhibitors, visual cycle modulators, reduction of toxic byproducts, antioxidative therapy, neuroprotective agents, laser therapy, surgical options, gene therapy, stem cell therapy, and miscellaneous treatments. Two intravitreal anti-complement factors (pegcetacoplan and avacincaptad pegol) have recently shown phase 3 clinical trial evidence of a reduction in the growth of geographic atrophy. In this review, we provide an update on treatment options currently undergoing clinical research trials for the management of dAMD and preventing the progression of Geographic Atrophy (GA).

360-Degree laser retinopexy in primary vitrectomy for rhegmatogenous retinal detachment: factors associated with its use and impact on surgical outcomes.

BACKGROUND: To determine patient and surgical factors associated with the use of 360-degree laser retinopexy during primary pars plana vitrectomy (PPV) ± scleral buckle (SB) for rhegmatogenous retinal detachment (RRD) and its impact on surgical outcomes. METHODS: Patients who underwent PPV ± SB for repair of non-complex RRD at a single centre were included in this retrospective study. The primary outcome was single surgery anatomical success (SSAS). Secondary outcomes included visual acuity, epiretinal membrane formation, the presence of cystoid macular oedema, tonic pupil and corneal epithelial defects. Multiple logistic regression and multivariate regression was used. RESULTS: The study included 192 cases, of which 130 received 360-degree laser. Worse preoperative logMAR visual acuity (P = 0.009), male sex (P = 0.060), higher PVR grades, supplemental SB (P = 0.0468) and silicone oil/C3F8 tamponade (P < 0.0001) were associated with 360-degree laser use. No significant associations between 360-degree laser and SSAS (P = 0.079), final logMAR visual acuity (P = 0.0623), ERM development (P = 0.8208), postoperative CMO (P = 0.5946), tonic pupil (P > 0.9999) or corneal epithelial defects (P = N/A) were found. CONCLUSIONS: 360-degree laser retinopexy during primary PPV ± SB for RRD was associated with more complex cases and more extensive operations. Even when accounting for this, there was no difference in surgical outcomes or complication rates.

Ocular causes of visual distortions.

BACKGROUND: Patients with complaints of visual distortions may first present to their general practitioners (GPs) for assessment. Visual distortions can present in various forms, from blurred images to aberrations of colour. It is important to clarify any complaints of distortion to uncover potentially vision-threatening pathology. This can be achieved through a directed history and examination. OBJECTIVE: The aim of this article is to provide a guide to clarifying complaints of visual distortions, outlining the common ocular causes, with a focus on macular pathologies. DISCUSSION: Targeted clues in the cause of visual distortions can be obtained through a directed history. Simple office-based examination techniques such as visual acuity, the use of Amsler's grid and fundoscopy are useful to identify pathology responsible for visual distortions. A basic assessment and knowledge of macular pathologies can assist GPs' appropriate assessment, treatment and referral of patients who present with visual distortions.

Managing corneal foreign bodies in office-based general practice.

BACKGROUND: Patients with a corneal foreign body may first present to their general practitioner (GP). Safe and efficacious management of these presentations avoids sight-threatening and eye-threatening complications. Removal of a simple, superficial foreign body without a slit lamp is within The Royal Australian College of General Practitioners' (RACGP's) curriculum and scope of practice. Knowing the rele-vant procedural skills and indications for referral is equally important. OBJECTIVE: The objective of this article is to provide an evidence-based and expert-based guide to the management of corneal foreign bodies in the GP's office. DISCUSSION: History is key to identifying patient characteristics and mechanisms of ocular injury that are red flags for referral. Examination tech-niques and methods of superficial foreign body removal without a slit lamp are outlined, as well as the procedural threshold for referral to an ophthalmologist.

Anatomical and Functional Outcomes of Pars Plana Vitrectomy for Lamellar Macular Defects.

PURPOSE: The aim of this study is to investigate the anatomical and functional outcomes of surgical management of lamellar macular defects. DESIGN: This study is a retrospective observational case series. METHODS: Overall, the records of 89 eyes of 78 consecutive patients with a clinical diagnosis of either lamellar macular hole, macular pseudohole, or foveal pseudocyst were reviewed. Twenty-one (23.6%) of the 89 eyes underwent pars plana vitrectomy by a single ophthalmologist. Preoperative and postoperative visual acuities (VAs) were compared, and the anatomical outcome of vitrectomy was examined by studying the restoration of the foveal contour on optical coherence tomography (OCT) scans. Comparisons of visual acuity and OCT measurements between vitrectomized and nonvitrectomized eyes were made. Comparisons were also made between the 3 different types of lamellar macular defects. RESULTS: Anatomical closure of the lamellar macular holes was achieved with a single surgical procedure in all vitrectomized eyes as confirmed by OCT. Visual acuity improved in 15 eyes (71%), from 0.39 ± 0.30 logMAR preoperatively to 0.26 ± 0.19 logMAR postoperatively (t20 = 2.425; P = 0.025). Macular pseudohole was associated with better presenting VA (F2,86 = 8.524; P < 0.001) and postoperative VA (F2,18 = 8.920; P = 0.002) than the other types of lamellar defects. Better postoperative VA was significantly correlated with better preoperative VA (r = 0.579; P = 0.006) and greater preoperative central foveal thickness (r = -0.535; P = 0.012). CONCLUSIONS: Pars plana vitrectomy provided a high success rate of anatomical and functional improvement for eyes with all types of lamellar macular defects.

Characteristics of Patients Who Drop Out From Ranibizumab Therapy.

PURPOSE: Anti-vascular endothelial growth factor therapy is a first-line treatment for age-related macular degeneration, but frequent visits and injections can be a burden for patients. This study aimed to estimate the dropout rate and tolerability of ranibizumab therapy in a clinical setting. DESIGN: A retrospective case-control study. METHODS: We investigated 250 eyes with choroidal neovascular membranes who underwent anti-vascular endothelial growth factor therapy in a single practice from July 1, 2008, to June 30, 2010. Clinical characteristics of patients who dropped out of treatment (n = 85) were recorded and compared with patients who continued with follow-up (n = 165). RESULTS: The dropout rate from follow-up was 34.5%. The dropout rate was not significantly different between age groups, but there was a trend increasing dropout with increasing age. Dropout rate did not differ between sexes. Dropout rate was significantly higher (50.0%) in those living farther than 100 km from the clinic, compared with those who lived within 100 km (28.0%; odds ratio, 2.48). Patients with no other systemic diseases were also seen to drop out at a significantly higher rate (48.7%; P < 0.04). Financial status did not appear to affect dropout rate. CONCLUSIONS: Dropout of ranibizumab therapy was higher among patients who lived far from the clinic, those referred with a diagnosis of age-related macular degeneration, and patients with other health problems. The dropout rate from this clinic was 34.5%. These findings have implications in the planning of interventions to improve the follow-up of patients with blinding eye disease.

Anti-VEGF treatment for subfoveal idiopathic (type II) choroidal neovascular membranes.

Two cases of subfoveal choroidal neovascular membranes (CNVM) in the absence of other pathology are described in two young patients who were successfully treated with anti-vascular endothelial growth factor (anti-VEGF) agents. The natural history of idiopathic CNVM and factors influencing the decision to treat using various options are discussed. Current experience with use of anti-VEGF is also outlined. Lastly, the importance of timely referral for thorough investigations to exclude underlying aetiology and consideration for treatment is highlighted.

Modified cow-hitch suture fixation of transscleral sutured posterior chamber intraocular lenses: long-term safety and efficacy.

PURPOSE: To evaluate the long-term safety and efficacy of a new technique using a modified cow-hitch knot for transscleral suture fixation of posterior chamber intraocular lenses (PC IOLs). SETTING: Public hospital in Brisbane, Australia. METHODS: A retrospective chart review was conducted of consecutive patients who had transscleral sutured PC IOL implantation from March 2000 to June 2006 using the new technique, which was modified to eliminate free suture ends and minimize the risk for knot slippage. Data collected included demographic data, ocular history, preoperative and final best corrected visual acuities (BCVAs), preoperative and postoperative intraocular pressure (IOP), and postoperative complications. RESULTS: Eighty-two eyes of 79 patients (51 men, 28 women) with a mean age of 62.5 years+/-18.9 (SD) were included in the study. The mean follow-up was 22.9+/-21.2 months (range 5 to 76 months). The BCVA was 20/40 or better in 45 eyes (54.9%) and 20/200 or worse in 10 eyes (12.2%). The final BCVA was largely determined by the preoperative underlying ocular pathology. Postoperative complications included temporary increased IOP in 14 eyes (17.1%), escalated glaucoma in 7 eyes (8.5%), temporary hypotony in 7 eyes (8.5%), and retinal detachment, hyphema, and irregular astigmatism in 1 eye (1.2%) each. The PC IOLs remained well centered and without tilt in all eyes. CONCLUSIONS: The technique provided excellent PC IOL centration in the presence of no adequate capsule support. It was effective and safe for transscleral suturing of PC IOLs.

Microcannula breakage in 25-gauge transconjunctival sutureless vitrectomy.

PURPOSE: To report the first case of intraoperative breakage of a microcannula during 25-gauge transconjunctival sutureless vitrectomy. METHOD: Case report. CONCLUSION: Surgeons should be aware of the potential complications of broken microcannulae during 25-gauge transconjunctival sutureless vitrectomy and react promptly to prevent further complications.

Rate of microbiological contamination in vials of bevacizumab used for multiple intravitreal injections.

PURPOSE: A prospective pilot study was undertaken to determine the rate (if any) of microbiological contamination in vials of bevacizumab (Avastin; Genentech, Inc., South San Francisco, CA) being accessed for multiple intravitreal injections. METHODS: Twenty-one unfractionated, 100-mg (4 mL) vials of bevacizumab were used for 321 intravitreal injections. Each vial was accessed multiple times under sterile conditions. Upon completion of each vial, the residual contents were stored for a further 2 weeks before being sent for microbiological contamination studies. RESULTS: No evidence of microbiological contamination was detected in 21 vials sent for assessment. Of 321 intravitreal injections performed, none was associated with any sign of endophthalmitis. CONCLUSIONS: Using the same vial multiple times for intravitreal injections (stored for up to 4 weeks after opening) is a reasonable alternative to other methods of administering bevacizumab. Larger studies are required to determine the safety and efficacy of this practice.

Late-onset post-traumatic Phaeoacremonium parasiticum endophthalmitis.

This is the first documented case of Phaeoacremonium parasiticum endophthalmitis to the authors' knowledge. P. parasiticum has been described in the literature causing various skin, subcutaneous and joint infections and one case of infective endocarditis, but has never been documented as an ocular infectious agent. The most likely source of inoculation in this case was a penetrating injury caused by a stick 5 years prior to the presentation. An enucleation was avoided through treatment with intravitreal antibiotics and amphotericin and oral voriconazole, and the patient's vision stabilized at 6/18. Microbiological studies were delayed but confirmed the mould's sensitivity to amphotericin B and voriconazole.

Retinopathy associated with photodynamic therapy for treatment of idiopathic choroidal neovascularization.

A case of retinopathy with retinal pigment epithelial alterations due to photodynamic therapy for the treatment of idiopathic choroidal neovascularization is reported. The possible mechanisms are discussed.

Perfluoro-n-octane as a postoperative vitreoretinal tamponade in the management of giant retinal tears.

BACKGROUND: Despite recent advances in giant retinal tear repair, retinal redetachment remains an issue. This may be due to inadequate retinal tamponade with silicone oil or perfluorocarbon gas that allows fluid to seep back under the edge of the tear. We propose short-term postoperative retinal tamponade with perfluoro-n-octane liquid to overcome this problem. Theoretical advantages include the reduced likelihood of proliferative vitreoretinopathy. It is easier to remove than silicone oil due to its lower viscosity, and supine posturing is more manageable from a patient perspective. METHODS: A retrospective case series of 16 giant retinal tear repairs without significant proliferative vitreoretinopathy is presented. Lens-sparing vitrectomy was performed with endolaser to the edge of the tear and the entire retinal periphery. Scleral buckling was not utilized. Perfluoro-n-octane was used as a postoperative tamponade for a mean of 16.4 days (range, 6-50 days). RESULTS: The retina was reattached at the end of the procedure in all 16 cases. Redetachment occurred in only 1 (6.3%) of 16 cases. CONCLUSION: Postoperative tamponade with perfluoro-n-octane may decrease the rate of redetachment in giant retinal tear repair compared with silicone oil or perfluorocarbon gas alone. We found no adverse effects directly attributable to perfluoro-n-octane.

Central serous chorioretinopathy and bullous retinal detachment: a rare association.

While idiopathic central serous retinopathy (ICSC) is a common ocular condition, bullous exudative retinal detachment associated with ICSC is a relatively rare finding. Bullous retinal detachment has been described as a severe variant of ICSC, characterised by multiple leaking pigment epithelial detachments and the presence of shifting neuro-sensory sub-retinal fluid. The peculiar clinical findings may present a diagnostic dilemma and lead to inappropriate treatment. Here, we describe the atypical presentation of ICSC with bullous retinal detachment and the effect of focal laser treatment on resolution of the retinal detachment. Despite ICSC being a self-limiting condition in the majority of cases, recognition of this atypical form of ICSC is important. Failure to differentiate this condition from inflammatory disease of the retina and choroid may result in inappropriate use of corticosteroids, leading to exacerbation of the condition and permanent visual loss.

Suicide-related perforating injury of globe with nail gun.

A case is reported of nail gun injury due to suicide attempt involving both orbits, frontal lobe and abdomen, which resulted in an unusual posterior perforation of the left globe. Injury was inflicted with a total of eight nails. Three nails entered the left orbit, one of which perforated the posterior aspect of the left globe. One nail entered the right orbit involving the optic nerve and crossed the midline to finish in the left sphenoid sinus. Three nails entered the frontal lobe near the midline and the final nail pierced the left lobe of the liver. The left eye underwent primary repair, lensectomy and vitrectomy with silicone oil and achieved a visual acuity of 6/60, 3 months post removal of oil with sutured posterior chamber intraocular lens. The right eye suffered traumatic optic neuropathy and currently has a visual acuity of 6/36 due to senile cataract formation. No other serious sequelae resulted from the other injuries and the patient has recovered from his episode of depression.