Nanosecond Laser Cataract Surgery in LOCS III Grade 4 and 5: A Case Series.

PURPOSE: A major obstacle to the widespread implementation of nanosecond laser cataract removal has been its limited efficacy in cases when the cataract is harder than Lens Opacities Classification System III (LOCS III ) grade 3. The latest technological modifications seem to have overcome this obstacle. DESIGN: A case series. METHODS: This study presents a case series of 17 consecutive patients with a cataract classified as harder than LOCS III grade 3 who underwent nanolaser cataract surgery. The basic surgical procedure included administration of topical or local anesthesia, capsulorhexis, hydrodissection, cataract removal with a nanosecond laser, cortical cleanup, intraocular lens implantation, and clear corneal incision closure with physiological solution. RESULTS: The nanosecond laser system effectively removed the cataract in all patients. This result was statistically significant (P < 0.000001) compared with an expected conversion rate to ultrasound phacoemulsification of 100%. CONCLUSIONS: Harder cataracts should no longer be considered a limitation for the use of nanosecond laser in cataract surgery.

Visual acuity change after intravitreal bevacizumab for exudative age-related macular degeneration in relation to subfoveal membrane type.

PURPOSE: To examine an association between the subfoveal neovascular membrane type and visual acuity change after intravitreal bevacizumab injection for exudative age-related macular degeneration (AMD). METHODS: We carried out a clinical, retrospective, interventional case-series study including 66 consecutive patients (67 eyes) with exudative AMD who received an intravitreal injection of 1.5 mg bevacizumab. Study subgroups included the occult type without or with minimally classic subfoveal neovascularization (n = 28 eyes, 42%), predominantly or purely classic subfoveal neovascularization (n = 22 eyes, 33%), and eyes with retinal pigment epithelium detachment (n = 17 eyes, 25%). Follow-up was >or= 2 months. RESULTS: The maximal visual acuity (VA) gain (mean +/- standard deviation - 0.07 +/- 0.30 logMAR, 0.5 +/- 2.9 Snellen lines; p = 0.87), and VA gain at 1 month (p = 0.10), 2 months (p = 0.77) and 3 months (p = 0.35) after the injection did not vary significantly between the three study subgroups. Correspondingly, a multivariate analysis did not reveal a statistically significant (p = 0.57) influence of subfoveal lesion type on gain in VA. CONCLUSIONS: Visual improvement after intravitreal bevacizumab does not differ markedly between various types of subfoveal neovascularization in AMD.

Effect of uncomplicated phacoemulsification on the central retina in diabetic and non-diabetic subjects.

BACKGROUND: The purpose of this study was to evaluate the subclinical influence of uncomplicated cataract surgery on foveal thickness and volume in the early postoperative period. METHODS: In a prospective study, 108 eyes were assessed by optical coherence tomography preoperatively and 1 day, 1 week and 4 weeks after uncomplicated small incisional phacoemulsification with endocapsular intraocular lens (IOL) implantation under topical anesthesia. The study included 24 eyes of diabetic patients. Eyes with diseases predisposing them for postoperative macular edema, preexisting macular edema, and eyes that developed cystoid macular edema during follow-up were excluded. Main outcome measures were minimal foveal thickness (MFT) and foveal volume. Secondary outcome measure was VA. RESULTS: Visual acuity (LogMAR) increased significantly (p<0.001) from 0.43+/-0.21 to 0.11+/-0.15 4 weeks after surgery, with a significantly (p=0.001) higher increase in VA for nondiabetic subjects. MFT increased from 183+/-27 mum preoperatively to 191+/-37 mum 4 weeks after surgery (p=0.001), with diabetic patients showing a tendency toward a more pronounced increase in minimal retinal thickness than nondiabetic subjects (p=0.058). One day and 1 week after surgery, MFT measurements were not significantly different from preoperative results. Foveal volume showed a significant increase at 1 week and 4 weeks after surgery (p<0.001), independent of the presence of diabetes (p=0.565). The proportion of patients exhibiting subclinical macular swelling was about 1/5 in the nondiabetic group and 1/3 in the diabetic group. Mean duration of surgery was 11.5+/-6.6 min. CONCLUSION: Foveal thickness and foveal volume demonstrate a subclinical increase within 4 weeks after uncomplicated cataract surgery in up to 1/3 of the patients. The amount and frequency of early postoperative subclinical retinal thickening was higher than expected.

Intravitreal triamcinolone acetonide for treatment of acute nonarteritic anterior ischemic optic neuropathy.

PURPOSE: To report on the use of intravitreal triamcinolone acetonide as treatment for nonarteritic anterior ischemic optic neuropathy (NAION). METHODS: The interventional clinical case series included three patients with acute NAION who received an intravitreal injection of about 20 mg triamcinolone acetonide. RESULTS: At the end of follow-up at 3 months, 3.5 months and at 5 months after the injection, visual acuity had changed from 0.10 at baseline to 0.20 in the first patient, from 0.50 to 0.20 in the second patient, and from 0.16 to 0.20 in the third patient. One eye developed triamcinolone-induced ocular hypertension which was treated by topical antiglaucomatous medication. CONCLUSIONS: The clinical courses of all three patients presented suggest that an intravitreal high-dosage injection of triamcinolone acetonide may not be markedly effective in increasing visual acuity after acute NAION.

Triamcinolone acetonide-induced ocular hypertension.

PURPOSE: The aim of this study is to report on the clinical course of a patient showing markedly increased intraocular pressure (IOP) caused by intravitreal triamcinolone acetonide. METHODS: A 33-year-old patient received an intravitreal injection of approximately 20 mg of triamcinolone acetonide (TA) as treatment of otherwise therapy-resistant uveitis. She experienced an IOP rise to values over 40 mmHg for a period for more than 3 months, despite maximal antiglaucomatous medical therapy. Peak IOP was 55 mmHg. RESULTS: Neither confocal scanning laser tomography nor qualitative assessment of optic disc photographs nor perimetry showed development of glaucomatous changes. Scanning laser polarimetry of the retinal nerve fiber layer suggested a slight loss in the nasal upper fundus quadrant. CONCLUSIONS: Relatively young patients with a pronounced TA-induced rise in IOP, unresponsive to maximal antiglaucomatous medication, may not necessarily undergo antiglaucomatous surgery if the rise in IOP does not last longer than approximately 3 months.

Intravitreal triamcinolone acetonide for diabetic macular edema: a prospective, randomized study.

PURPOSE: The aim of this study was to examine the visual outcome of patients receiving an intravitreal injection of triamcinolone acetonide (TA) as treatment of diffuse diabetic macular edema (DDME). METHODS: This prospective, placebo-controlled, randomized, clinical interventional study included 40 eyes (38 patients) with DDME, with 28 (70%) eyes randomized to treatment and 12 (30%) eyes randomized to receive a placebo injection. Thirty-six (36) (90%) eyes completed the 3-month study visit, and 32 (80%) eyes completed the 6-month study visit. The treatment group received an intravitreal injection of approximately 20 mg of TA. RESULTS: Visual acuity increased significantly (P < 0.001) in the study group by 3.4 +/- 2.5 Snellen lines. In the control group, visual acuity did not change significantly (P = 0.07) during follow-up. Difference in change of best visual acuity was significant (P < 0.001) between both groups. At 3 months after baseline, 11 (11/26; 42%) eyes and 10 (10/26; 39%) eyes, respectively, improved by at least 2 and 3 lines, respectively, in the study group, versus 2 (2/10; 20%) eyes and 1 (1/10; 10%) eye in the control group. At 6 months after baseline, 11 (11/23; 48%) eyes and 9 (9/23; 39%) eyes, respectively, improved by at least 2 and 3 lines, respectively, in the study group, versus 0 (0%) eyes and 0 (0%) eyes in the control group. The difference was significant for the 2-line improvement (P = 0.01) and 3-line improvement (P = 0.03). CONCLUSIONS: Using a dosage of approximately 20 mg of intravitreal TA, visual acuity temporarily increases for 6 months after injection.

Retrobulbar catheter anesthesia as a routine technique for retinal and vitreoretinal surgery.

To ascertain the safety of the retrobulbar catheter technique for intraoperative local anesthesia and titratable postoperative analgesia, 1,423 consecutive retinal or vitreoretinal surgeries were reviewed. Using a commercially available retrobulbar needle, a 28-gauge flexible catheter was introduced into the retrobulbar space before surgery and was removed the next morning. When pain occurred, a local anesthetic was re-injected intraoperatively or postoperatively through the catheter. None of the patients had intraoperative or postoperative complications. The retrobulbar catheter anesthesia may be a relatively safe procedure for prolonged intraoperative anesthesia and titratable postoperative analgesia in retinal and vitreoretinal surgery.

Limbal stem cell deficiency after subconjunctival mitomycin C injection for trabeculectomy.

PURPOSE: To report on severe limbus cell insufficiency after trabeculectomy with subconjunctival injection of mitomycin C. DESIGN: Interventional small case-series. METHODS: Seven consecutive Caucasian patients (seven eyes) underwent penetrating trabeculectomy that included subconjunctival injection of 0.1 to 0.2 ml of mitomycin C (0.2 mg/ml) at the 12 o'clock position. RESULTS: All patients with a follow-up time of >1.5 years (n = 3 eyes; 43%) experienced marked ocular surface problems that included corneal thinning (n = 1) and scleral melting (n = 2). Four patients (57%) with a follow-up time of <14 months did not show complications that were attributable to the subconjunctival application of mitomycin. CONCLUSIONS: Because limbal stem cell deficiency may be a late complication of subconjunctival mitomycin C injection, subconjunctival injection of mitomycin C may be avoided in routine antiglaucomatous filtering surgery.

Repeated intravitreal high-dosage injections of triamcinolone acetonide for diffuse diabetic macular edema.

OBJECTIVE: To report the results of repeated intravitreal injections of triamcinolone acetonide for treatment of diffuse diabetic macular edema. DESIGN: Retrospective interventional comparative study. PARTICIPANTS: The investigation included a study group (the responders) of 19 patients (22 eyes) with diffuse diabetic macular edema, who showed an improvement in visual acuity after an intravitreal injection of approximately 20 mg triamcinolone acetonide, and who received a second intravitreal injection 10.0+/-3.8 months after the first injection. A control group consisted of 31 patients with diffuse diabetic macular edema without treatment during follow-up. METHODS: Intravitreal injection of approximately 20 mg triamcinolone acetonide. MAIN OUTCOME MEASURES: Visual acuity and intraocular pressure. RESULTS: Follow-up after the second injection was 9.1+/-4.9 months. Four patients received a third injection at 9.7+/-3.7 months after the second injection, with a follow-up after the third injection that was at 7.9+/-11.5 months. After the second and third injections, visual acuity increased significantly (P = 0.002 and P = 0.068, respectively) by 1.8+/-2.1 and 4.0+/-2.6 Snellen lines, respectively. Eleven eyes (50%) showed an improvement in visual acuity by at least 2 Snellen lines after the second injection, and 3 patients (75%) experienced a gain in visual acuity by at least 2 Snellen lines after the third injection. Intraocular pressure increased significantly (P<0.01) after each injection, and returned to baseline values before each reinjection. Visual acuity improvement (P>0.05) and intraocular pressure rise did not differ significantly (P>0.55) between the various injections. Improvement in visual acuity and rise of intraocular pressure lasted approximately 6 to 8 months after each injection. CONCLUSIONS: Intravitreal injection of approximately 20 mg triamcinolone acetonide may repeatedly lead to an improvement in visual acuity and a rise of intraocular pressure in patients with diffuse diabetic macular edema. The duration of the effect after each injection is approximately 6 to 8 months. Tachyphylaxis in visual acuity or intraocular pressure outcomes were not observed.

Vitreous prolapse and IOL dislocation during intravitreal injection of triamcinolone acetonide.

BACKGROUND: To report on procedure-related anterior segment complications during intravitreal injections. METHODS: In a prospective interventional case series, 614 eyes received a total of 723 intravitreal injections of about 20 mg triamcinolone acetonide (in 0.2 ml) after paracentesis and aqueous humor drainage for various indications. RESULTS: In three eyes (0.49% of all eyes) a vitreous prolapse occurred during the injection. In one eye, the vitreous prolapse was combined with dislocation of the intraocular lens (IOL). All three eyes were pseudophakic, showing an posterior capsule defect, and the IOL located in the ciliary sulcus. They were treated by translimbal vitrectomy, and one eye with reposition of the IOL. No other procedure-related postoperative complications were observed during injection or follow-up (7.8+/-7.1 months). CONCLUSIONS: Intravitreal injections may cause a vitreous prolapse into the anterior chamber with or without IOL decentration or dislocation in predisposed eyes. Ophthalmologists should be aware of this possible complication and inform patients at risk.

Topical anesthesia for transpupillary silicone oil removal combined with cataract surgery.

PURPOSE: To assess safety of topical anesthesia for transpupillary silicone oil removal in combination with cataract surgery. SETTING: Department of Ophthalmology Mannheim, University of Heidelberg, Mannheim, Germany. METHODS: The clinical interventional study included 37 consecutive patients having transpupillary silicone oil removal combined with cataract surgery. Without exception, surgery was carried out in topical anesthesia for all patients. During the study period, there were no patients having transpupillary silicone oil removal in another type of local anesthesia than topical anesthesia. Topical anesthesia was achieved with oxybuprocaine 0.4% eyedrops installed 4 to 5 times prior to surgery. Cataract surgery was performed using the clear cornea technique with implantation of a foldable intraocular posterior chamber lens. Silicone oil was released through a planned posterior capsulotomy during cataract surgery prior to implantation of the intraocular lens (IOL). RESULTS: For all patients, surgery could be carried out in topical anesthesia without switching to peribulbar or any other type of anesthesia. None of the patients complained about severe pain intraoperatively or postoperatively. No severe complications such as expulsive hemorrhage, luxation of the IOL, or iris incarceration were encountered in any of the surgeries. CONCLUSION: Transpupillary silicone oil through a planned posterior capsulotomy during cataract surgery may be performed in topical surgery.

Phototoxic maculopathy after secondary intraocular lens implantation.

We report phototoxic maculopathy in 2 aphakic patients after secondary, scleral-sutured intraocular lens implantation. This rare complication may have been triggered by drugs that increased the photosensitivity of the tissue. Careful preoperative assessment is necessary to question the receipts of photosensitizing drugs and identify diseases that predispose patients to phototoxic injuries.

[Grid laser photocoagulation in diffuse diabetic macular edema]. / Grid-Laserkoagulation bei diffusem diabetischen Makulaödem.

BACKGROUND: To evaluate the clinical outcome of macular grid laser photocoagulation in the treatment of diffuse diabetic macular oedema. PATIENTS AND METHOD: The retrospective study included 30 consecutive patients (41 eyes) who were treated by macular argon green grid laser photocoagulation for diffuse diabetic macular oedema. Follow-up time was 31.4 +/- 19.6 weeks. RESULTS: Visual acuity decreased from 0.25 +/- 0.18 (range, 0.03 - 0.8) to 0.20 +/- 0.18 (range, 0.02 - 0.8) (P = 0.045), representing a change of - 0.9 +/- 2,32 lines. 5 (12.2 %) eyes gained in visual acuity, visual acuity remained unchanged for 23 (56.1 %) eyes, and 13 (31.7 %) eyes showed a visual loss of more than one line. In eyes with a baseline visual acuity > or = 0.2 (N = 24) visual acuity dropped from 0.36 +/- 0.15 (0.2 - 0.8; median 0.3) to 0.29 +/- 0.19 (0.05 - 0.8; median 0.2) (p = 0.038). 3 eyes (12.5 %) gained > or = 2 lines, 11 eyes (45.8 %) lost > or = 2 lines, 10 eyes (41.7 %) remained stable. Mean loss was - 1.63 +/- 2.53 lines. Eyes with a baseline visual acuity < or = 0.2 did not change significantly. CONCLUSION: In the present study mean visual acuity decreased in the whole population and especially in the subgroup with a baseline visual acuity of > or = 0.2 after macular grid laser photocoagulation for diffuse diabetic macular oedema. Mean visual loss was just below the predefined 2 lines. In view of these results and upcoming new pharmacological and surgical treatment modalities, the significance of grid laser photocoagulation should be re-discussed.

Topical versus peribulbar anaesthesia for cataract surgery.

BACKGROUND: To assess and compare the efficacy and safety of topical versus peribulbar anaesthesia in patients undergoing routine cataract surgery. METHODS: The unicentre, prospective, randomized, clinical interventional trial included 140 consecutive patients undergoing routine cataract surgery performed by one of two surgeons. The patients were randomly distributed to either peribulbar anaesthesia or topical anaesthesia. To assess intraoperative pain, each patient was asked immediately after surgery to quantitate his/her pain using a 10-point pain rating scale. RESULTS: The study groups did not differ significantly in pain score (p=0.54), duration of surgery (p=0.52), anaesthesia-related intraoperative difficulties (p=0.17), postoperative visual acuity (p=0.94), overall intraoperative surgical complication rate, blood pressure rise (p=0.16) or blood oxygen saturation (p=0.74) CONCLUSIONS: Patient comfort and surgery-related complications did not differ between topical anaesthesia and peribulbar anaesthesia. As there are no significant differences between the two techniques in terms of subjective pain experienced by patients, intraoperative complications and postoperative visual outcome, and in view of the minimally invasive character of topical anaesthesia compared to peribulbar anaesthesia, the present study suggests the use of topical anaesthesia for routine cataract surgery.

Topical anesthesia for penetrating trabeculectomy.

PURPOSE: To evaluate the efficacy and clinical practicability of topical anesthesia in comparison with retrobulbar anesthesia for penetrating trabeculectomy. METHODS: The prospective single-surgeon clinical interventional trial included 20 consecutive patients, who were randomly distributed into a topical anesthesia group ( n=10) and a retrobulbar anesthesia group ( n=10). In the topical anesthesia group, patients received preoperatively oxybuprocaine 0.4% eye drops and cocaine hydrochloride eye drops 10%. The patients of the retrobulbar group received 5 ml mepivacaine 2% injected into the retrobulbar space. To assess intraoperative pain, each patient was asked immediately after surgery to quantitate his/her pain using a 10-point pain rating scale. RESULTS: The topical anesthesia group and the retrobulbar anesthesia study group did not vary significantly in duration of surgery (21.5+/-3.37 min vs 20.2+/-4.46 min, P=0.31), preoperative intraocular pressure (32.2+/-14.62 mmHg vs 30.6+/-12.33 mmHg, P=0.22), postoperative intraocular pressure (8.0+/-4.47 mmHg vs 9.12+/-3.13 mmHg, P=0.64), subjective pain score by the patient (2.25+/-1.23 relative units vs 2.33+/-1.08 relative units ( P= 0.71), and practicability score by the surgeon (2.24+/-1.76 vs 2.56+/-1.58, P=0.82). CONCLUSIONS: In view of its clinical feasibility and its minimally invasive character, topical anesthesia may be an option for penetrating trabeculectomy.