Association between retinal thickness measured by spectral-domain optical coherence tomography (OCT) and rod-mediated dark adaptation in non-exudative age-related maculopathy.

AIM: To examine associations between retinal thickness and rod-mediated dark adaptation in older adults with non-exudative age-related maculopathy (ARM) or normal macular health. METHODS: A cross-sectional study was conducted with 74 adults ≥ 50 years old from the comprehensive ophthalmology and retina services of an academic eye centre. ARM presence and disease severity in the enrolment eye was defined by the masked grading of stereofundus photos using the Clinical Age-Related Maculopathy grading system. High-definition, spectral-domain optical coherence tomography was used to estimate retinal thickness in a grid of regions in the macula. Rod-mediated dark adaptation, recovery of light sensitivity after a photo-bleach, was measured over a 20-min period for a 500 nm target presented at 5° on the inferior vertical meridian. Main outcomes of interest were retinal thickness in the macula (µm) and parameters of rod-mediated dark adaptation (second slope, third slope, average sensitivity, final sensitivity). RESULTS: In non-exudative disease retinal thickness was decreased in greater disease severity; thinner retina was associated with reductions in average and final rod-mediated sensitivity even after adjustment for age and visual acuity. CONCLUSIONS: Impairment in rod-mediated dark adaptation in non-exudative ARM is associated with macular thinning.

Comparison of hemorrhagic complications of warfarin and clopidogrel bisulfate in 25-gauge vitrectomy versus a control group.

PURPOSE: To estimate the risk of hemorrhagic complications associated with 25-gauge pars plana vitrectomy (PPV) when warfarin (Coumadin; Bristol-Myers Squibb, New York, NY) or clopidogrel (Plavix; Bristol-Myers Squibb) are continued throughout the surgical period, as compared with a control group. DESIGN: A single-center, retrospective, cohort study of 289 consecutive patients receiving either warfarin therapy or clopidogrel therapy or neither of those therapies who underwent 25-gauge PPV. PARTICIPANTS: Included were 61 patients (64 eyes; 64 PPV procedures) in the warfarin group and 118 (125 eyes; 136 PPV procedures) in the clopidogrel group. Warfarin patients were subdivided into 4 groups by international normalized ratio (INR). A control group included 110 patients (110 eyes; 110 PPV procedures) who were not receiving warfarin or clopidogrel. METHODS: Retrospective chart review for which the criteria included: 25-gauge PPV, minimum age of 19 years, warfarin or clopidogrel use, and, if taking warfarin, an INR obtained within 5 days of surgery. MAIN OUTCOME MEASURES: Incidence of intraoperative and postoperative hemorrhagic complications. RESULTS: The most common indications for anticoagulation therapy included: atrial fibrillation (38%), valvular heart disease (17%), and thromboembolic disease (16%). The most common indications for antiplatelet therapy included: cardiac stent (49%), coronary artery bypass grafting (24%), and history of transient ischemic attack (16%). No patient experienced anesthesia-related hemorrhagic complications resulting from peribulbar or retrobulbar block. Transient vitreous hemorrhage occurred in 1 (1.6%) of 64 PPV procedures in the warfarin group (P = 0.6531), 5 (3.7%) of 136 PPV procedures in the clopidogrel group (P = 1.0), and 4 (3.6%) of 110 PPV procedures in the control group. No choroidal or retrobulbar hemorrhages occurred in any patient. CONCLUSIONS: The rate of 25-gauge PPV hemorrhagic complications in patients who underwent systemic anticoagulation or who were receiving platelet inhibitor therapy is extremely low. Given the risks associated with stopping these therapies, the authors recommend that patients continue their current therapeutic regimen without cessation.

Incidence of hemorrhagic complications after intravitreal bevacizumab (avastin) or ranibizumab (lucentis) injections on systemically anticoagulated patients.

PURPOSE: To assess the risk of hemorrhagic complications when performing intravitreal injections on systemically anticoagulated patients. METHODS: A single-center retrospective case series of 520 consecutive patients (675 eyes) receiving 3,106 antivascular endothelial growth factor injections. Patients on the systemic anticoagulants Coumadin (warfarin sodium) or Plavix (clopidogrel bisulfate) were identified, as well as patients on aspirin. Demographic parameters were recorded, as well as relevant anticoagulant medications, preoperative/postoperative best-corrected visual acuities and intraocular pressures, previous ocular surgery, relative ocular diagnoses, and injection complications. RESULTS: Of all patients, 104 were on Coumadin (134 eyes; 548 injections), 90 were on Plavix (123 eyes; 523 injections), 7 were on both Coumadin and Plavix (8 eyes; 33 injections), and 319 were not anticoagulated (400 eyes; 2002 injections). Also, 1,254 injections were on patients taking aspirin. There were no hemorrhagic complications (choroidal hemorrhage, vitreous hemorrhage, or increased submacular hemorrhage) noted in the Plavix (P = 1.0000; 95% confidence interval = 0.0000-0.0088), Coumadin (P = 1.0000; 95% confidence interval = 0.0000-0.0084), or aspirin (P = 1.0000; 95% confidence interval = 0.0000-0.0037) groups. CONCLUSION: The risk of hemorrhagic complications in systemically anticoagulated patients receiving intravitreal injections is extremely low. Because of the demonstrated thromboembolic risk of stopping anticoagulant therapy, we recommend that patients continue their current regiment without cessation.

Risk factors for severe vision loss immediately after transpupillary thermotherapy for occult subfoveal choroidal neovascularization.

BACKGROUND AND OBJECTIVE: To determine risk factors for immediate severe vision loss in patients with age-related macular degeneration after transpupillary thermotherapy for occult subfoveal choroidal neovascularization. PATIENTS AND METHODS: Retrospective review of 84 consecutive patients with age-related macular degeneration who received transpupillary thermotherapy for occult subfoveal choroidal neovascularization. Seven cases had severe vision loss and 77 were controls. All patients were treated with a diode infrared laser. Follow-up was completed on all patients 1, 3, and 6 months after treatment with transpupillary thermotherapy. RESULTS: Pretreatment visual acuity ranged from 20/40 to 1/200. Seven of 84 consecutive eyes had an immediate visual acuity loss of 6 or more Snellen lines after transpupillary thermotherapy. CONCLUSION: Transpupillary thermotherapy has a small but significant risk of immediate severe vision loss in patients with age-related macular degeneration with occult subfoveal choroidal neovascularization. Statistically significant risk factors include a subretinal hemorrhage 5 disc areas or greater in size, 9 disc areas or greater of subretinal fluid, and a laser power greater than 550 mW.

Macular holes associated with diabetic tractional retinal detachments.

BACKGROUND AND OBJECTIVE: Evaluation of surgical treatment of full-thickness macular holes secondary to diabetic tractional retinal detachments was conducted. PATIENTS AND METHODS: A retrospective review of medical records, fluorescein angiograms, fundus photographs, optical coherence tomography images, and operative findings of six consecutive patients with full-thickness macular holes and diabetic tractional retinal detachments was completed. Each eye was treated with pars plana vitrectomy, tractional retinal detachment repair, membranectomy, indocyanine green-assisted internal limiting membrane peeling, and intraocular gas tamponade. RESULTS: Surgical intervention resulted in the closure of all full-thickness macular holes. Mean best-corrected visual acuity was 20/250 preoperatively and 20/100 postoperatively, with all patients having improvement after a mean follow-up of 10 months. CONCLUSION: Closure of tractional retinal detachments related to full-thickness macular holes can be achieved via pars plana vitrectomy, complete membranectomy, and intraocular gas. Vitrectomy with dissection of proliferative membranes helps to relieve the tractional forces responsible for full-thickness macular hole formation, enabling successful closure of the diabetic full-thickness macular holes and resulting in visual acuity improvement.

Incidence of acute onset endophthalmitis following intravitreal bevacizumab (Avastin) injection.

PURPOSE: To report the incidence of acute endophthalmitis as a complication of intravitreal bevacizumab (Avastin) (IVB) injection in a tertiary vitreoretinal group practice. METHODS: A retrospective chart review of 5,233 consecutive eyes that underwent IVB injection at Retina Consultants of Alabama (RCA) from October 1, 2005, to August 31, 2007, was performed to identify cases of acute endophthalmitis. RESULTS: During the 23-month study interval, the overall incidence rate of postinjection endophthalmitis was 0.019% (1/5,233). In the single case of acute endophthalmitis, bacterial cultures revealed coagulase-negative Staphylococcus (CNS) species. Visual acuity after treatment for endophthalmitis was improved (baseline 4/400) to 20/400 at two months after the initial IVB injection. CONCLUSIONS: Acute endophthalmitis is a rare potential complication of IVB. Prophylaxis with topical povidone-iodine and adherence to aseptic technique minimizes the risk of postinjection infection. SUMMARY STATEMENT: A retrospective review of 5,233 consecutive intravitreal injections of bevacizumab (Avastin) revealed only a single case of acute endophthalmitis. Adherence to aseptic technique and the use of povidone-iodine prophylaxis minimizes the risk of postinjection intraocular infection.

Intravitreal injection of bevacizumab (Avastin) as adjunctive treatment of proliferative diabetic retinopathy.

PURPOSE: To report the use of intravitreal bevacizumab (Avastin) as an adjunctive treatment for proliferative diabetic retinopathy (PDR). DESIGN: Retrospective case review. METHODS: Institutional review board approval to review patient data was obtained for this retrospective study. Three patients underwent intravitreal injection of bevacizumab as part of their treatment for PDR after informed consent was signed. Each patient also underwent fundus photographs before the bevacizumab injection and then one to three weeks after. RESULTS: All three patients showed complete regression of their neovascularization elsewhere (NVE) and neovascularization of the disk (NVD) between one and three weeks after injection. CONCLUSIONS: The speed and degree of neovascular regression after the injection of intravitreal bevacizumab may make this procedure an important adjunctive treatment in the management of selected cases with severe PDR.

Effect of short-term, high-dose retinol on dark adaptation in aging and early age-related maculopathy.

PURPOSE: To examine the effect of a short course of high-dose retinol (preformed vitamin A) on dark adaptation in older adults with normal retinal health or early age-related maculopathy (ARM). METHODS: The study design was a randomized, double-masked, placebo-controlled experiment. Adults > or = 50 years of age whose fundus photographs for the eye to be tested psychophysically fell within steps 1 to 9 of the Age-Related Eye Disease Study (AREDS) Grading System were randomly assigned to a 30-day course of 50,000 IU oral retinol or a placebo. At baseline and 30-day follow-up, dark adaptation was tested and the Low Luminance Questionnaire (LLQ), an instrument for assessing difficulty with vision in reduced lighting, was administered. Primary outcomes of interest were rod- and cone-mediated parameters of dark adaptation, with scores on the LLQ's six subscales as secondary outcomes. RESULTS: The sample consisted of 104 participants with 52 each in the intervention and placebo groups. There were no group differences in baseline variables. At 30-days, the dark-adaptation parameters of cone time-constant, cone threshold, rod-cone break, and rod threshold did not differ. The retinol intervention group had significantly larger (i.e., steeper) rod slopes, indicating faster sensitivity recovery, than did the placebo group (P = 0.0419). There were no group differences in scores on the LLQ subscales driving, extreme lighting, emotional distress, general lighting, or peripheral vision. The retinol group had a higher score by five points on the mobility subscale compared with the placebo group (P = 0.0141). Those who had the most self-reported change on the mobility subscale at day 30 were more likely to have greater change in the speed of dark adaptation, as indicated by the rod slope parameter (r = 0.24, P = 0.0141). CONCLUSIONS: A short-term, high-dose course of retinol increased the rate of rod-mediated dark adaptation in older adults who were in the early phases of ARM or were exhibiting normal retinal aging. These results are consistent with the hypothesis that depositions and other structural changes in the retinal pigment epithelium and Bruch's membrane in aging and early ARM cause a localized retinoid deficiency.

Visual outcome and risk factors for light perception and no light perception vision after vitrectomy for diabetic retinopathy.

PURPOSE: To assess the visual outcome following vitrectomy for diabetic retinopathy compared with previous studies; to evaluate risk factors for light perception (LP) and no light perception (NLP) vision after diabetic vitrectomy. DESIGN: Retrospective medical record review. METHODS: The charts of 100 consecutive patients who underwent vitrectomy for proliferative diabetic retinopathy between November 1, 1997, and November 30, 1998, were reviewed. Surgical technique included standard pars plana vitrectomy with combination of delamination and segmentation of gliotic tractional membranes using bimanual techniques. All patients had post-operative follow-up of at least 12 months. Several factors were analyzed for their effect on poor visual outcome (LP and NLP) using Fisher's exact test. RESULTS: Post-vitrectomy, 73% of diabetic patients had stable or improved vision; 16% had worsened but functional vision, defined as worse but still >or= 20/400; 4% had worsened but ambulatory vision, defined as worse but still count fingers (CF) or hand motion (HM); and 7% had poor visual outcome, LP or NLP. Resultant visual acuity was >or=20/40 in 38% of patients, 20/50 to 20/100 in 34%, 20/120 to CF in 18%, HM in 3%, LP in 4%, and NLP in 3%. Risk factors for eyes with LP and NLP vision included pre-operative iris neovascularization (INV), P = .05, post-operative INV, P = .02, post-operative macular ischemia, P = .0001, and post-operative vitreous hemorrhage (VH), P = .02. CONCLUSIONS: Pre-operative and post-operative INV, post-operative macular ischemia, and post-operative VH appear to be risk factors for LP and NLP vision following diabetic vitrectomy, whereas overall improvements in surgical technique and visual outcome continue to be reported.

An association between central serous chorioretinopathy and gastroesophageal reflux disease.

PURPOSE: To explore a clinically observed association between central serous chorioretinopathy (CSC) and gastroesophageal reflux disease (GERD) DESIGN: A retrospective case-control study. PARTICIPANTS AND CONTROLS: Sixty-nine consecutive patients diagnosed with CSC were compared with a control group of 55 non-CSC patients. METHODS: The records of 69 patients with CSC were retrospectively reviewed and compared with the records of 55 controls. All patients and controls were examined in a referral setting. RESULTS: Patients with CSC were significantly more likely to have GERD compared with controls (odds ratio 6.05; 95% confidence interval 2.14-17.11; P =.0003). Central serous chorioretinopathy patients were also more likely than controls to have used oral corticosteroid medications (odds ratio 16.30; 95% confidence interval 2.09-127.33; P =.0006) and antacid/antireflux medications (odds ratio 15.00; 95% confidence interval 1.91-117.58; P =.001). CONCLUSIONS: This study identifies an association between CSC and GERD. There are biochemical factors common to both diseases that support this association, giving further insight into the pathogenesis of CSC.

Retinochoroidal collateral veins protect against anterior segment neovascularization after central retinal vein occlusion.

OBJECTIVE: To test the hypothesis that retinochoroidal collateral veins (RCVs), or alternatively, retinociliary or optociliary shunts/collaterals/veins or opticociliary anastomoses, act protectively against the development of anterior segment neovascularization (ASN) following central retinal vein occlusion (CRVO). DESIGN: Case-control retrospective medical record review of patients with CRVO. PATIENTS: We identified 107 patients with CRVO, of whom 34 had developed ASN, by reviewing their medical records. After applying exclusion criteria, a case group and an age-, sex-, and visual acuity-matched control group were selected. We analyzed these groups for the presence or absence of RCVs and noted the time course involved in their development. MAIN OUTCOME MEASURES: Anterior segment neovascularization (including neovascularization of the iris and/or anterior chamber angle), neovascular glaucoma, and RCV development. RESULTS: Only 1 (5.4%) of 19 individuals who developed ASN did so in the presence of RCVs. In contrast, 11 (57.9%) of 19 individuals in the control group developed RCVs. Statistical analysis revealed that patients who developed ASN were roughly 25 times less likely to have had RCVs than individuals who never developed ASN (odds ratio = 24.74; P =.001). CONCLUSION: Retinochoroidal collateral veins are negatively associated with ASN post-CRVO and may function in a protective manner against such an outcome.

Ocular trauma from paintball-pellet war games.

BACKGROUND: We studied ocular injuries and visual outcome after blunt trauma from paintball pellets. METHODS: We retrospectively reviewed cases of ocular injury from paintball pellets occurring over 32 months. RESULTS: Ten cases of ocular injury from paintball pellets were recorded. Most patients (9) were injured at home or at a friend's home; only 1 was injured at a war game facility. Six patients had surgery. Final visual acuity was 20/25 or better in 6 patients, 20/30 to 20/50 in 2 patients, 20/60 to 20/100 in 2 patients, and 20/200 in 1 patient. Traumatic maculopathy and epiretinal membrane formation were determinants of worse final visual acuity. CONCLUSIONS: Paintball pellet ocular injuries occur more frequently at home than at war game facilities. Advanced surgical techniques offer decreased ocular morbidity and improved visual acuity. Decreasing visual morbidity from paintball pellets requires public education, proper product labeling, and packaging of eye protection with all paintball-related products.