Aqueous Chlorhexidine Compared with Povidone-Iodine as Ocular Antisepsis before Intravitreal Injection: A Randomized Clinical Trial.

PURPOSE: Topical povidone-iodine (PI) is widely used as an ocular surface antiseptic for intravitreal injections (IVIs). Although PI is generally well tolerated, it can be associated with significant ocular irritation. Aqueous chlorhexidine (AqCHX) has been described as a possibly better tolerated antimicrobial for ophthalmic procedures. We compared patient pain scores, ocular surface characteristics, and antimicrobial efficacy between PI 5% and AqCHX 0.1% during IVIs. DESIGN: Prospective single-center, randomized clinical trial. PARTICIPANTS: Patients receiving same-day bilateral intravitreal anti-vascular endothelial growth factor (VEGF) injections. METHODS: Each patient had 1 eye randomized to PI or AqCHX, and the second eye received the other agent. Both eyes received topical proparacaine 0.5%. MAIN OUTCOME MEASURES: After IVIs, participants rated their pain (Wong-Baker, scale 0-10) for each eye 1 minute after PI or AqCHX instillation and 1 day after the procedure. Each eye was assessed using a standardized quantitative grading system of corneal epitheliopathy (ocular staining score). Microbial swab cultures of the conjunctiva both before instillation of topical antisepsis and 10 minutes after IVIs were given. RESULTS: A total of 100 eyes of 50 patients were included. The mean patient age was 68 years (range, 39-92), and 30 of 50 (60%) were male. Compared with AqCHX, eyes receiving PI had a greater mean pain score immediately after injection (1.44 vs. 0.44, P < 0.001) but not on postprocedure day 1 (1.04 vs. 0.48, P = 0.06). Eyes that received PI had a higher ocular staining score indicating worse corneal epitheliopathy (4.22 vs. 3.10, P < 0.001). There was no difference in rates of positive microbial cultures between groups. There was no difference in rates of adverse events between groups (P = 0.99), and no cases of endophthalmitis occurred. CONCLUSIONS: Povidone-iodine demonstrated greater ocular surface discomfort and corneal epitheliopathy compared with AqCHX during same-day bilateral IVIs. The 2 agents otherwise demonstrated no difference in positive microbial cultures or adverse events. Aqueous chlorhexidine may be a better tolerated alternative to PI for antimicrobial prophylaxis during IVIs for some patients.

Endogenous Bacterial Endophthalmitis: A Five-Year Retrospective Review at a Tertiary Care Academic Center.

PURPOSE: To better characterize the demographics and outcomes of endogenous bacterial endophthalmitis (EBE). METHODS: Retrospective observational case series of 49 eyes of 41 patients with EBE evaluated at a single academic center. RESULTS: Gram stain (p = .395), symptom duration prior to treatment (p = .483), and number of intravitreal antimicrobial injections (p = .421) did not correlate with mean change in VA. There was no significant difference between mean LogMAR VA at initial evaluation (1.7 ± 0.9) and last available follow up (1.4 ± 1.1, p = .15). Patients with bilateral EBE had 7.25 times greater odds of having cancer (95% CI 1.28, 41.14; p = .025). CONCLUSION: EBE in a North American population showed poor visual recovery despite treatment. It was most commonly due to gram-positive bacteria with the most common infectious source being endocarditis. Malignancy should be considered in patients with bilateral EBE.

Secondary Vitreoretinal Lymphoma Masquerading as Acute Retinal Necrosis.

Intraocular lymphoma is considered a uveitis masquerade syndrome and may rarely present with features resembling a necrotizing viral retinitis. The authors report a secondary vitreoretinal lymphoma presenting in this fashion, which was treated with a unique combination of intravitreal methotrexate and rituximab.

Comparison Among Methods of Retinopathy Assessment (CAMRA) Study: Smartphone, Nonmydriatic, and Mydriatic Photography.

PURPOSE: We compared smartphone fundus photography, nonmydriatic fundus photography, and 7-field mydriatic fundus photography for their abilities to detect and grade diabetic retinopathy (DR). DESIGN: This was a prospective, comparative study of 3 photography modalities. PARTICIPANTS: Diabetic patients (n = 300) were recruited at the ophthalmology clinic of a tertiary diabetes care center in Chennai, India. METHODS: Patients underwent photography by all 3 modalities, and photographs were evaluated by 2 retina specialists. MAIN OUTCOME MEASURES: The sensitivity and specificity in the detection of DR for both smartphone and nonmydriatic photography were determined by comparison with the standard method, 7-field mydriatic fundus photography. RESULTS: The sensitivity and specificity of smartphone fundus photography, compared with 7-field mydriatic fundus photography, for the detection of any DR were 50% (95% confidence interval [CI], 43-56) and 94% (95% CI, 92-97), respectively, and of nonmydriatic fundus photography were 81% (95% CI, 75-86) and 94% (95% CI, 92-96%), respectively. The sensitivity and specificity of smartphone fundus photography for the detection of vision-threatening DR were 59% (95% CI, 46-72) and 100% (95% CI, 99-100), respectively, and of nonmydriatic fundus photography were 54% (95% CI, 40-67) and 99% (95% CI, 98-100), respectively. CONCLUSIONS: Smartphone and nonmydriatic fundus photography are each able to detect DR and sight-threatening disease. However, the nonmydriatic camera is more sensitive at detecting DR than the smartphone. At this time, the benefits of the smartphone (connectivity, portability, and reduced cost) are not offset by the lack of sufficient sensitivity for detection of DR in most clinical circumstances.