Diabetic macular edema outcomes in eyes treated with fluocinolone acetonide 0.2 µg/d intravitreal implant: real-world UK experience.

PURPOSE: To conduct an observational, multicenter study to evaluate real-world clinical efficacy and safety of the 0.2 µg/day fluocinolone acetonide (FAc) implant in the treatment of patients with chronic diabetic macular edema (DME) in 3 large hospital ophthalmology departments in the United Kingdom. METHODS: Fluocinolone acetonide implants were inserted into the study eyes following a suitable washout period; phakic eyes received FAc implant following cataract surgery. Follow-up visits took place 2-4 weeks postinjection and then at 3, 6, and 12 months; change in central macular thickness (CMT) from baseline was measured by optical coherence tomography and best-corrected visual acuity (BCVA) was also assessed. Adverse events and changes in intraocular pressure (IOP) were recorded in order to evaluate the safety profile for the FAc implant. RESULTS: Improvements in BCVA and CMT were observed from 3 months and sustained for the duration of observation. At 12 months, the overall mean change from baseline CMT was -126 µm and mean increase in BCVA from baseline was 5.1 letters. Increases in IOP following FAc implant were easily managed with IOP-lowering medication. Implant migration into the anterior chamber occurred in 2 eyes where prior vitrectomy had resulted in a posterior capsule defect; this was rectified and resolved. CONCLUSIONS: The results of this study provide further efficacy and safety profile data for FAc implant treatment of chronic DME in a real-world clinical setting; the FAc implant appears to be a valuable therapeutic approach for patients with chronic DME who have suboptimal response to other treatment options.

Efficacy of transscleral diode laser cyclophotocoagulation in patients with good visual acuity.

PURPOSE: To study the effect on central vision of transscleral diode laser cyclophotocoagulation (TSDLC) for the reduction of intraocular pressure (IOP) in patients with visual acuity (VA) better than 6/18. METHODS: Retrospective chart review was conducted of patients undergoing cyclophotocoagulation between 2000 and 2008. Patients who underwent TSDLC with VA of 6/18 or better and at least 24 months follow-up were included. Primary outcome was decrease of 2 or more lines at 24 months. Secondary outcome was IOP control with or without treatment. RESULTS: A total of 46 eyes of 44 patients were included with VA ranging from 6/18 to 6/5 (median VA 6/12). Mean IOP was 24 mm Hg (range 12-35). A mean of 1.3 treatments were given per eye, with 12 eyes (26%) requiring retreatment. At 24 months, the median VA was 6/18 (range light perception-6/5). Eighteen eyes (39.1%) retained the same VA, 35 eyes (76.1%) retained VA of 6/18 or better, in 7 eyes (19.4%) VA was <6/60. Loss of ≥2 lines was recorded in 11 eyes (23.9%), and loss of 1 line in 13 eyes (28.3%). Mean IOP at 24 months was 17.2 mm Hg (range 12-28). Thirty-nine (84.8%) patients had IOP ≤21 mm Hg. CONCLUSIONS: This study suggests a role of TSDLC as an effective, safe, and rapid method of treatment in patients with good vision over a 24-month period. The loss of VA in some patients is similar to previously reported studies in patients having cyclodiode, trabeculectomy, or tube surgery.

Displacement of submacular hemorrhage associated with age-related macular degeneration using vitrectomy and submacular tPA injection followed by intravitreal ranibizumab.

BACKGROUND/AIMS: To evaluate retrospectively the clinical outcomes of patients presenting with submacular hemorrhage (SMH) secondary to neovascular age-related macular degeneration (nAMD), treated by vitrectomy, submacular tissue plasminogen activator (tPA) injection and pneumatic displacement of SMH with air followed by postoperative intravitreal ranibizumab (RZB). METHODS: Patients with SMH and nAMD had 25-guage vitrectomy and subretinal tPA (12.5 micrograms/0.1 mL) with fluid/air exchange. Intravitreal RZB was administered postoperatively to patients eligible for National Health Service (NHS) funded treatment. RESULTS: Of the total of 16 patients, 11 (68.7%) had complete displacement of SMH. The remaining five had residual SMH, mainly subretinal pigment epithelium in location. Three of the four patients who previously had a failed expansile gas pneumatic displacement were successfully displaced with vitrectomy surgery. At presentation 5/16 (31.3%) patients were eligible for NHS funded intravitreal RZB. This increased to 12 patients after the vitrectomy procedure (75.0%). At 6 months postoperatively all improved by >/=1 line. Ten of the 16 patients (63%) improved by >/=2 lines, with 10 of the 12 patients (83%) treated with RZB improving by >/=2 lines. CONCLUSION: Vitrectomy/subretinal tPA/air to displace SMH followed by intravitreal RZB injection can stabilize/improve vision in patients with nAMD. This technique displaces hemorrhage not displaced by attempted expansile gas techniques.

Optical biometry in combined phacovitrectomy.

PURPOSE: To assess the accuracy of intraocular lens (IOL) power calculation using optical biometry in patients having combined phacovitrectomy for macular hole and macular pucker. SETTING: Sunderland Eye Infirmary, North East England, United Kingdom. METHODS: This single-surgeon retrospective case series review comprised eyes having combined narrow-gauge phacovitrectomy for macular hole or macular pucker. Intraocular lens power was calculated using the results of optical biometry and the Haigis formula. Achieved and planned refraction were compared to calculate the mean postoperative refractive prediction error (ME) and the mean absolute postoperative prediction error (MAE) and the percentage of eyes with an achieved refraction within +/-0.50 diopter (D) and +/-1.00 D of the planned refraction. The results were compared with those in a series of 42 eyes that had phacoemulsification after previous vitrectomy surgery and a series of 60 nonvitrectomized eyes that had uneventful phacoemulsification. RESULTS: Of the of 59 having combined phacovitrectomy, 39 had macular hole and 20 had macular pucker. There was no statistically significant difference in refractive outcomes between the phacovitrectomy group (ME -0.02, MAE 0.39) and the sequential phacoemulsification group (ME -0.10, MAE 0.38) (P = .82). There was a statistically significant difference between the phacovitrectomy group and the phacoemulsification-only group (ME 0.08, MAE 0.26) (P<.001). CONCLUSIONS: The use of optical noncontact biometry with the Haigis formula achieved a high degree of accuracy of IOL power estimation in patients having phacovitrectomy. There was no tendency toward a myopic shift, as has been reported using ultrasound axial length measurement.

Cataract surgery management in patients taking tamsulosin staged approach.

PURPOSE: To demonstrate a progressive approach to the problems of intraoperative floppy-iris syndrome (IFIS) in cataract surgery caused by tamsulosin. SETTING: Cataract Treatment Center, Sunderland Eye Infirmary, Sunderland, United Kingdom. METHODS: Thirty-two eyes of 20 patients who were using tamsulosin had cataract surgery by the same surgeon using the same technique. Patients received standard preoperative eyedrops consisting of topical cyclopentolate, phenylephrine, and diclofenac. When necessary, intracameral phenylephrine, iris hooks, or both were used. All cases were videotaped and analyzed for surgical complications. RESULTS: The degree of IFIS manifested varied widely in the patients: Seventeen of 32 eyes (53%) had good mydriasis preoperatively (type 1 and type 2 pupils); however, in 7 of the 17 eyes (43%), the pupils constricted later during surgery (type 2 pupils). Twelve eyes (38%) had a mid-dilated pupil that sometimes constricted later (type 3 pupils), and 3 eyes (9%) had poor dilation at the beginning of surgery (type 4 pupils). There were no surgical complications attributed to IFIS. Full IFIS manifestation varied between eyes of the same patient. Some eyes required no intervention. Intraoperative pupil constriction was reversed with intracameral phenylephrine, which also prevented iris prolapse and billowing and further pupil constriction in patients who had medium to small pupils preoperatively. CONCLUSION: A staged approach in managing pupils in IFIS and using phenylephrine intracamerally when necessary effectively prevented serious intraoperative complications.