Early Pars Plana Vitrectomy for Treatment of Acute Infective Endophthalmitis

Purpose: To evaluate the efficacy and safety of early pars plana vitrectomy (PPV) for the treatment of acute infective endophthalmitis, and identify prognostic factors for better visual outcome. Design: Retrospective cohort study. Methods: Consecutive patients who underwent early PPV within 72 hours of presentation for the treatment of acute infective bacterial endophthalmitis and presented to a large tertiary referral center in New South Wales, Australia, between January 2009 and December 2013 were included. Changes in best-corrected visual acuity (VA) from baseline to 1 year were examined. Results: A total of 64 patients were included. The inciting events were cataract surgery (53%), intravitreal injection (36%), trabeculectomy (3%), and endogenous (3%). The mean VA improved from 3.1 logMAR (hand motion) at baseline to 1.02 (approximately 20/200) at 1 year, with 42% achieving final VA equal to or better than 0.477 logMAR (20/60) following early PPV. Positive prognostic factors were negative microbial cultures (P < 0.01) and etiology of post-cataract surgery (P < 0.01). In multivariable analyses adjusting for age and prognostic factors, patients with baseline VA of light perception and hand motion achieved greater visual gains than those with counting fingers, with gains of logMAR of -2.68, -2.09, and -0.85, respectively (P < 0.0001). Conclusions: Most patients who undergo early PPV experience substantial VA improvement. Negative microbial cultures and endophthalmitis after cataract surgery were associated with better final visual outcome. Patients with presenting VA of light perception or hand motion achieved higher visual gains than those with counting fingers, suggesting the possibility that early PPV may be beneficial in both groups

Projection of long-term visual acuity outcomes based on initial treatment response in neovascular age-related macular degeneration

PURPOSE To explore various methods for assessing the early response to vascular endothelial growth factor (VEGF) inhibitors for neovascular age-related macular degeneration and investigate their association with 3 year visual acuity (VA) outcomes. DESIGN Observational study from a prospectively collected registry. PARTICIPANTS Treatment-naïve eyes in the Fight Retinal Blindness! outcomes registry that commenced anti-VEGF therapy between 1st January 2007 and 1st March 2014 that received 3 anti-VEGF injections within the first 3 months. METHODS The early response was defined as occurring up until the 4th injection. Various early response metrics, which included both continuous and categorical variables, were explored: 1) achieving good VA (≥70 letters [20/40]), 2) absolute change in VA from baseline, 3) time to first grading of the choroidal neovascular lesion as inactive, 4) maximum rate of VA change between successive injections. MAIN OUTCOME MEASURES Proportion of eyes achieving ≥70 letters at 3 years. RESULTS This study included 2051 treatment-naïve eyes from 1828 patients. Achieving good vision at 3 years was significantly associated with 1) having good vision by the 4th injection (odds ratio [95% CI]: 9.8 [6.5, 14.7] for VA≥70 vs. VA5 letters) early VA gains (1.8 [1.2, 2.6], P = 0.002 and 1.8 [1.3, 2.5], P 3 injections), 4) gradual change (between -4 and 4 letters) or rapid (>5 letters) gains between successive injections (1.7 [1.1, 2.6], P = 0.015 and 1.6 [1.1, 2.3], P = 0.018 for gradual change and rapid gain vs. rapid loss). Eyes that achieved small or large early gains achieved similar vision at 3 years (65.0 and 64.7 letters respectively), and had better vision than eyes with early VA loss (57.2 letters). CONCLUSIONS Attainment of good vision by the 4th injection was strongly associated with 3 year visual outcomes, while other early response parameters had a moderate association. The early response during the initial 3 monthly loading doses can be a useful guide for subsequent treatment decisions

Outcomes and predictive factors after cataract surgery in patients with neovascular age-related macular degeneration. The Fight Retinal Blindness! Project

Purpose: To evaluate outcomes and predictive factors of visual acuity (VA) change after cataract surgery in patients being treated for neovascular age-related macular degeneration (nAMD). Design: Retrospective, matched case-control study. Methods: We studied eyes undergoing cataract surgery that had been tracked since they first started treatment for nAMD. These eyes were compared with a cohort of unoperated phakic eyes being treated for nAMD (three per case) matched for treatment duration before cataract surgery, baseline VA, age and length of follow-up. Results: We included 124 patients that had cataract surgery and 372 matched controls. The mean (95% CI) VA gained was 10.6 letters (7.8, 13.2; P < 0.001) 12 months following surgery; 26.0% had gained ≥ 3 lines and 1.6% had lost ≥ 3 lines of VA. Visual acuity (mean [SD]) 12 months after surgery was higher in eyes that had cataract extraction compared with controls (65.8 [17.1] vs. 61.3 [20.8] letters respectively, P = 0.018). The proportion of visits where the choroidal neovascular (CNV) lesion was graded active and the mean number of injections were similar before and after surgery (P = 0.506 and P = 0.316, respectively), while both decreased in the control group, suggesting that surgery modestly increased the level of activity of the CNV lesion. Mean [SD] VA prior to surgery was lower in eyes that gained ≥15 letters compared with eyes that gained 0-14 letters (40.2 [21.4] vs. 62.1 [15.1], P < 0.001). Patients undergoing cataract surgery within the first 6 months of anti-VEGF therapy were more likely to lose rather than gain vision (20.8% lost vision vs. 12.8% and 4.4% gaining ≥15 or 0-14 letters respectively, P = 0.023). Age, receiving an injection at least 2 weeks before surgery, and the CNV lesion type had no discernible association with VA outcomes. Conclusions: We found evidence of a modest effect of cataract surgery on CNV lesion activity in eyes being treated for nAMD. Despite this, visual outcomes were reassuringly good. Cataract surgery within 6 months of starting treatment for nAMD should be avoided if possible.The Fight Retinal Blindness Project was supported by a grant from the Royal Australian NZ College of Ophthalmologists Eye Foundation (2007-2009), a grant from the National Health and Medical Research Council, Australia (NHMRC 2010-2012) and a grant from the Macula Disease Foundation, Australia. Mark Gillies is a Sydney Medical Foundation Fellow and is supported by an NHMRC practitioner fellowship. Daniel Barthelmes was supported by the Walter and Gertud Siegenthaler Foundation Zurich, Switzerland and the Swiss National Foundation. Vincent Daien was supported by the research grant of the French Society of Ophthalmology and by Servier. Funding was also provided by Novartis and Bayer

Fundamental principles of an effective diabetic retinopathy screening program

Background: Diabetic retinopathy (DR) is the leading cause of blindness among working-age adults worldwide. Early detection and treatment are necessary to forestall vision loss from DR. Methods: A working group of ophthalmic and diabetes experts was established to develop a consensus on the key principles of an effective DR screening program. Recommendations are based on analysis of a structured literature review. Results: The recommendations for implementing an effective DR screening program are: (1) Examination methods must be suitable for the screening region, and DR classification/grading systems must be systematic and uniformly applied. Two-field retinal imaging is sufficient for DR screening and is preferable to seven-field imaging, and referable DR should be well defined and reliably identifiable by qualified screening staff; (2) in many countries/regions, screening can and should take place outside the ophthalmology clinic; (3) screening staff should be accredited and show evidence of ongoing training; (4) screening programs should adhere to relevant national quality assurance standards; (5) studies that use uniform definitions of risk to determine optimum risk-based screening intervals are required; (6) technology infrastructure should be in place to ensure that high-quality images can be stored securely to protect patient information; (7) although screening for diabetic macular edema (DME) in conjunction with DR evaluations may have merit, there is currently insufficient evidence to support implementation of programs solely for DME screening. Conclusion: Use of these recommendations may yield more effective DR screening programs that reduce the risk of vision loss worldwide

Editorial : To bleed or clot?

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Central retinal artery occlusion after phacoemulsification

Purpose: To report 2 cases of central retinal artery occlusion (CRAO) that occurred within 24 hours of routine phacoemulsification cataract surgery using peribulbar anesthesia. Methods: Case 1: An otherwise well 76-year-old woman with right pseudoexfoliation syndrome and bilateral open angle glaucoma presented with right visual acuity of counting fingers on the first postoperative day after cataract surgery. The CRAO was noted on fundoscopy. Emergency measures to reduce intraocular pressure (IOP) and hyperbaric oxygen treatment were performed. Case 2: A 59-year-old man with a history of non- Hodgkin's lymphoma, hypertension, hyperlipidemia, and ischemic stroke was similarly diagnosed with CRAO on the first postoperative day, with left visual acuity of counting fingers. Results: The final visual acuity remained at counting fingers in both cases. Conclusion: Central retinal artery occlusion after routine cataract surgery is unusual. We review the literature on CRAO after routine intraocular procedures and propose three hypotheses regarding the potential mechanisms involved. A vasoconstrictive effect of the anesthetic agent on the central retinal artery, a rise in lOPs after anesthesia administration resulting in closure of the central retinal artery, and a mechanical effect of the volume of anesthetic on the central retinal artery are considered as plausible mechanisms, with a mechanical effect being the favored hypothesis.3 page(s

Does unintentional macular translocation after retinal detachment repair influence visual outcome? Response

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Pars plana vitrectomy for the management of retained lens material after cataract surgery

Purpose: To evaluate the management and outcomes of patients undergoing pars plana vitrectomy (PPV) for retained lens material after cataract surgery; and to evaluate risk factors for poor visual outcome, retinal detachment, raised intraocular pressure (IOP), and cystoid macular edema (CME). Design: Retrospective interventional consecutive case series. Methods: Setting: Institutional and Clinical practice. study population: Patients with retained lens material after cataract surgery who underwent vitrectomy at Sydney Eye Hospital between July 1, 1998 and October 31, 2003. intervention: Standard three-port PPV/lensectomy. main outcome measures: Final best-corrected visual acuity (BCVA), retinal detachment, raised IOP, and CME. Results: A total of 223 eyes of 223 patients were included, with a mean follow-up of 20.5 months after vitrectomy. Final BCVA was 6/12 or better in 159 patients (71.3%). Retinal detachment occurred in 20 patients (9%), with 11 diagnosed before or during vitrectomy, and nine occurring after vitrectomy. Ten patients (5.0%) developed raised IOP and 42 (23.2%) developed CME. Poor final visual acuity was associated with retinal detachment (P = .0026), and with poor visual acuity at presentation (P = .030). There was a significant association between retinal detachment and a long interval (>30 days) between cataract surgery and vitrectomy (P = .00047) and between retinal detachment and younger age (P = .0070). Conclusions: Visual acuity results in this study compared favorably with previously published reports. Although the overall rate of retinal detachment was low, it was significantly higher in those with a delayed interval between cataract surgery and vitrectomy, and was significantly associated with a poorer visual outcome. Dislocation of lens fragments into the vitreous during cataract surgery is a potentially sight-threatening complication that has been reported to occur in 0.1% to 1.5% of cases. The sequelae commonly include corneal edema, elevated intraocular pressure (IOP), intraocular inflammation, cystoid macular edema (CME), retinal detachment, and reduced visual acuity. Removal by pars plana vitrectomy (PPV) is often required, unless fragments are small and elicit minimal inflammation. The aims of this study were to report the management and outcomes of 223 patients who underwent PPV for the removal of retained lens material after cataract surgery at a tertiary referral center in Sydney, Australia.7 page(s

Vitrectomy for diabetic macular edema : a systematic review and meta-analysis

Objective: To systematically review, and perform meta-analysis on, the available data regarding the efficacy of vitrectomy for diabetic macular edema. Design: Systematic review and meta-analysis of published randomized controlled trial data. Methods: We searched PubMed and the Cochrane database for randomized, controlled trials investigating vitrectomy for diabetic macular edema. Structural (foveal thickness) and functional (visual acuity) outcomes were used as the primary outcome measures. Results: Eleven studies met the criteria for inclusion in this review: these studies were heterogenous in their experimental and control interventions, follow-up period, and eligibility criteria. Seven studies compared vitrectomy with the natural history of diabetic maculopathy, with laser, or with intravitreal corticosteroid injection. Four studies compared vitrectomy with internal limiting membrane peeling to vitrectomy alone. One of the latter 4 studies was the only to investigate vitrectomy in patients with vitreomacular traction. Meta-analysis suggests a structural, and possibly functional, superiority of vitrectomy over observation at 6 months. Vitrectomy also appears superior to laser in terms of structural, but not functional, outcomes at 6 months. At 12 months, vitrectomy offers no structural benefit and a trend toward inferior functional outcomes when compared with laser. Conclusions: There is little evidence to support vitrectomy as an intervention for diabetic macular edema in the absence of epiretinal membrane or vitreomacular traction. Although vitrectomy appears to be superior to laser in its effects on retinal structure at 6 months, no such benefit has been proved at 12 months. Furthermore, there is no evidence to suggest a superiority of vitrectomy over laser in terms of functional outcomes.8 page(s