a clinical observation of vascular complications after ocular surgery

Background. Ocular vascular occlusions following intraocular procedures are a rare complication. We report a case series of patients with retinal vascular occlusions or anterior ischemic optic neuropathy (AION) after anterior and posterior segment surgery and demonstrate possible risk factors. Methods. Observational case series. Results. In ten patients, vascular occlusions were observed within ten weeks after intraocular surgery: branch retinal arterial occlusion (BRAO) (n = 2), central retinal artery occlusion (CRAO) (n = 2), central retinal vein occlusion (CRVO) (n = 1), branch retinal vein occlusion (BRVO) (n = 1), anterior ischemic optic neuropathy (AION) (n = 3), and combined central artery and vein occlusion (n = 1). AION occurred later (27–69 d) than arterial occlusions (14–60 d) or venous occlusions (1-2 d). In all cases, either specific surgical manipulations or general vascular disorders were identified as risk factors. In addition to general cardiovascular risk factors (arterial hypertension n = 6, diabetes mellitus n = 4), internal workup disclosed bilateral stenosis of the carotid arteries (n = 1) and myeloproliferative syndrome (n = 1). Conclusion. Vascular occlusions after surgical ocular procedures seem to be more frequent when cardiovascular diseases coexist. Surgical maneuvers and intra- or postoperative pressure changes may act as a triggering mechanism in patients with underlying systemic cardiovascular disorders. Affected patients should undergo thorough internal examination to identify possible underlying diseases

Real-world management of macular edema secondary to retinal vein occlusion with intravitreal aflibercept: 24-month results from the AURIGA observational study

Introduction: AURIGA is the largest real-world study to date to evaluate intravitreal aflibercept (IVT-AFL) treatment of diabetic macular edema or macular edema secondary to retinal vein occlusion (RVO) in routine clinical practice. Here, we report the 24-month outcomes in the RVO cohort from France, Germany, Italy, and Taiwan.MethodsAURIGA (NCT03161912) was a prospective observational study. Eligible patients with RVO were enrolled for whom the decision to treat with IVT-AFL had already been made by the attending physician. Patients were treated with IVT-AFL for up to 24 months at physician discretion according to local practice. The primary endpoint was mean change in visual acuity (VA; Early Treatment Diabetic Retinopathy Study [ETDRS] letters) from baseline to month (M) 12. All statistical analyses were descriptive.ResultsIn 554 treatment-naive and 65 previously treated patients with RVO, the respective mean (95% confidence interval) change in VA from baseline was + 12.5 (10.8, 14.3) and + 7.9 (3.3, 12.6) letters by M12 and + 11.4 (9.4, 13.3) and + 4.4 (- 0.6, 9.5) letters by M24 (baseline mean +/- standard deviation: 51.0 +/- 21.9 and 51.9 +/- 20.4 letters); 44.0% of treatment-naive and 27.9% of previously treated patients reported >= 15-letter gains by M24. By M24, the mean change in central retinal thickness from baseline was - 247 (- 267, - 227) mu m in treatment-naive patients and - 147 (- 192, - 102) mu m in previously treated patients. From baseline to M6, M12, and M24, treatment-naive patients received a total of 4.0 +/- 1.3, 5.5 +/- 2.5, and 6.9 +/- 4.2 injections, respectively, and previously treated patients received 3.8 +/- 1.5, 5.0 +/- 2.2, and 6.3 +/- 3.7 injections, respectively. The safety profile of IVT-AFL was consistent with that of previous studies.ConclusionsIn AURIGA, patients with RVO experienced clinically relevant functional and anatomic improvements following IVT-AFL treatment in routine clinical practice. These improvements were largely maintained in treatment-naive patients over the 24-month study despite the decreasing treatment frequency, suggesting long-term durability of IVT-AFL treatment outcomes. Infographic available for this article.Trial RegistrationClinicalTrials.gov Identifier: NCT03161912 (May 19, 2017)

Risk factors for severe bleeding complications in glaucoma surgery and the role of antiplatelet or anticoagulant agents

PURPOSE: To evaluate the influences and risk factors for severe bleeding complications during glaucoma surgery, and to investigate the role of antiplatelet (AP) and anticoagulant (AC) agents. METHODS: This prospective study enrolled patients undergoing trabeculectomy, trabeculotomy (with Trabectome® or Kahook Dual Blade®), viscocanaloplasty and Ahmed or Baerveldt implants. Bleeding severity was graded on an ordinal scale ranging from 0 to 5. Immediately after surgery and one day later, the incidence and severity of bleeding events was documented on a standardized form. A grade ≥3 was defined as severe bleeding. The influence of known systemic disorders, the type of anesthesia, surgical procedure, intraoperative blood pressure, and the use of or change in AP or AC agents on intraoperative bleeding were analyzed. RESULTS: Data from 89 eyes undergoing glaucoma procedures were included (age 71.3y ± 10.5). We observed severe intraoperative bleeding in 8 eyes (9%) and found that concomitant diseases such as the history of a deep vein thrombosis or peripheral arterial occlusive disease, and the type of surgical procedure (trabeculectomy and viscocanaloplasty) were significantly associated with severe bleeding events. By contrast, the use of AP/ AC agents had no significant influence on severe intraoperative bleeding events. CONCLUSION: According to the results of our study cohort, glaucoma procedures entailing scleral manipulations (trabeculectomy and viscocanaloplasty) and concomitant diseases such as the history of a deep vein thrombosis or peripheral arterial occlusive disease influence the risk of severe intraoperative bleeding events, we detected no increased risk related to concomitant antiplatelet and/ or anticoagulant medication use

Vascular Occlusions following Ocular Surgical Procedures: A Clinical Observation of Vascular Complications after Ocular Surgery

Background. Ocular vascular occlusions following intraocular procedures are a rare complication. We report a case series of patients with retinal vascular occlusions or anterior ischemic optic neuropathy (AION) after anterior and posterior segment surgery and demonstrate possible risk factors. Methods. Observational case series. Results. In ten patients, vascular occlusions were observed within ten weeks after intraocular surgery: branch retinal arterial occlusion (BRAO) (n=2), central retinal artery occlusion (CRAO) (n=2), central retinal vein occlusion (CRVO) (n=1), branch retinal vein occlusion (BRVO) (n=1), anterior ischemic optic neuropathy (AION) (n=3), and combined central artery and vein occlusion (n=1). AION occurred later (27–69 d) than arterial occlusions (14–60 d) or venous occlusions (1-2 d). In all cases, either specific surgical manipulations or general vascular disorders were identified as risk factors. In addition to general cardiovascular risk factors (arterial hypertension n=6, diabetes mellitus n=4), internal workup disclosed bilateral stenosis of the carotid arteries (n=1) and myeloproliferative syndrome (n=1). Conclusion. Vascular occlusions after surgical ocular procedures seem to be more frequent when cardiovascular diseases coexist. Surgical maneuvers and intra- or postoperative pressure changes may act as a triggering mechanism in patients with underlying systemic cardiovascular disorders. Affected patients should undergo thorough internal examination to identify possible underlying diseases

Intravitreal Aflibercept for the treatment of diabetic macular edema in routine clinical practice: results from the 24-Month AURIGA observational study

Introduction AURIGA is the largest real-world study to date to evaluate intravitreal aflibercept (IVT-AFL) in the treatment of diabetic macular edema (DME) or macular edema secondary to retinal vein occlusion in routine clinical practice. The 24-month outcomes in the DME cohort from across 11 participating countries are reported here.MethodsAURIGA (NCT03161912) was a prospective observational study. The study enrolled eligible patients with DME for whom the decision to treat with IVT-AFL had previously been made by the attending physician. Patients were treated with IVT-AFL for up to 24 months at physician discretion according to local practice. The primary endpoint was mean change in visual acuity (VA; Early Treatment Diabetic Retinopathy Study [ETDRS] letters) from baseline to month 12 (M12). All statistical analyses were descriptive.ResultsIn 1478 treatment-naive and 384 previously treated patients with DME, the mean (95% confidence interval) change in VA from baseline was +6.7 (5.7, 7.6) and +7.4 (5.5, 9.4) letters by M12 and +5.9 (4.9, 6.9) and +8.1 (6.1, 10.1) letters by M24 (baseline [mean +/- standard deviation]: 56.0 +/- 19.8 and 50.8 +/- 19.5 letters), respectively; 25.9% of treatment-naive and 32.8% of previously treated patients achieved >= 15-letter gains by M24. The mean change in central retinal thickness from baseline to M24 was -110 (-119, -102) mu m in treatment-naive patients and -169 (-188, -151) mu m in previously treated patients. By M6, M12, and M24, treatment-naive patients had received 3.8 +/- 1.7, 4.9 +/- 2.8, and 5.7 +/- 3.9 injections, respectively, and previously treated patients had received 3.9 +/- 1.5, 4.9 +/- 2.4, and 6.2 +/- 3.6 injections, respectively. The safety profile of IVT-AFL was consistent with previous studies.ConclusionIn AURIGA, treatment-naive and previously treated patients with DME achieved clinically relevant functional and anatomic improvements following IVT-AFL treatment for up to 24 months in routine clinical practice. Even with the decreasing injection frequency observed, these gains were largely maintained throughout the study, suggesting long-term durability of the positive effects of IVT-AFL treatment. Infographic available for this article.Trial RegistrationClinicalTrials.gov Identifier: NCT03161912 (May 19, 2017)

Pars plana vitrectomy for diabetic macular edema. Internal limiting membrane delamination vs posterior hyaloid removal. A prospective randomized trial

To access publisher full text version of this article. Please click on the hyperlink in Additional Links field.BACKGROUND: Diabetes mellitus, as well as subsequent ocular complications such as cystoid macular edema (CME), are of fundametal socio-economic relevance. Therefore, we evaluated the influence of internal limiting membrane (ILM) removal on longterm morphological and functional outcome in patients with diabetes mellitus (DM) type 2 and chronic CME without evident vitreomacular traction. METHOD: Forty eyes with attached posterior hyaloid were included in this prospective trial and randomized intraoperatively. Prior focal (n = 31) or panretinal (n = 25) laser coagulation was permitted. Group I (n = 19 patients) underwent surgical induction of posterior vitreous detachment (PVD), group II (n = 20 patients) PVD and removal of the ILM. Eleven patients with detached posterior hyaloid (group III) were not randomized, and ILM removal was performed. One eye had to be excluded from further analysis. Examinations included ETDRS best-corrected visual acuity (BCVA), fluorescein angiography (FLA) and OCT at baseline, 3 and 6 months postoperatively. Main outcome measure was BCVA at 6 months, secondary was foveal thickness. RESULTS: Mean BCVA over 6 months remained unchanged in 85% of patients of group II, and decreased in 53% of patients of group I. Results were not statistically significant different [group I: mean decrease log MAR 95% CI (0.06; 0.32), group II: (-0.02; 0.11)]. OCT revealed a significantly greater reduction of foveal thickness following PVD with ILM removal [group I: mean change: 95% CI (-208.95 μm; -78.05 μm), group II: (-80.90 μm: +59.17 μm)]. CONCLUSION: Vitrectomy, PVD with or without ILM removal does not improve vision in patients with DM type 2 and cystoid diabetic macular edema without evident vitreoretinal traction. ILM delamination shows improved morphological results, and appears to be beneficial in eyes with preexisting PVD

Case report of a secondary macular hole closure after intravitreal bevacizumab therapy in a patient with retinal pigment epithelial detachment

We describe a case of macular hole (MH) closure after intravitreal bevacizumab therapy for an underlying pigment epithelial detachment (PED) due to exudative age-related macular degeneration (AMD). The 73-year-old Caucasian female presented with reduced visual acuity (20/80) of the left eye and metamorphopsia for approximately 6 months. Spectral domain optical coherence tomography revealed a subfoveal PED due to AMD with an associated MH. To treat the exudative component of the pathology, we started intravitreal bevacizumab therapy, consecutively leading to reduction of the height of PED and allowing closure of the MH. Detachment recurred during further follow-up, but the MH remained closed. MHs and exudative AMD are common diseases, which rarely occur simultaneously. To the best of our knowledge (search via PubMed for “MH,” “PED,” “age-related macular degeneration”), no other case with the persistent closure of an MH associated with PED during intravitreal antivascular endothelial growth factor therapy and despite recurrent PED has been published to date

Optical coherence tomography findings in patients prior to cataract surgery regarded as unremarkable with ophthalmoscopy.

PurposeTo investigate the feasibility and diagnostic benefit of routinely performed preoperative macular spectral-domain (SD-) optical coherence tomography (OCT) for the detection of macular pathology in patients with normal biomicroscopic funduscopy prior to cataract surgery.MethodsProspective, single center study. A total of 162 eyes of 123 consecutive patients referred for cataract surgery with a visual acuity better than 20/100, absence of macular symptoms such as metamorphopsia, no history of previous intravitreal procedures and a normal funduscopic appearance on biomicroscopy underwent an additional SD-OCT-examination prior to cataract surgery. OCT-scans were classified in three categories: normal, degenerative vitreous changes without impact on visual outcome or pathological with potential impact on visual outcome.Results80 eyes (49.38%) showed normal OCT-scans. 69 eyes (42.59%) were classified as degenerative vitreous changes without impact on visual outcome and 20 eyes (12.35%) as pathological with potential impact on visual outcome. The indication of cataract surgery or the therapeutic strategy remained unchanged in all patients. In patients with pathological alterations further follow-up examinations were recommended.ConclusionsRoutine SD-OCT-imaging of the macular region in patients prior to cataract surgery was feasible to detect macular pathologies in a considerable number of patients, which remained undiagnosed on biomicroscopic funduscopy. Although OCT-findings did not impact therapeutic strategy in this study, preoperative judgement of the expected visual outcome and patient´s informed consent can improve