Treatment of cystoid macular edema with the new-generation NSAID nepafenac 0.1%

Seenu M Hariprasad1, Levent Akduman2, Joseph A Clever2, Michael Ober3,4, Franco M Recchia5, William F Mieler1,61Department of Ophthalmology and Visual Sciences, Vitreoretinal Service; 6Department of Ophthalmology and Visual Sciences, University of Chicago, Chicago, IL, USA; 2Vitreoretinal Service, Saint Louis University Eye Institute, Saint Louis, MO, USA; 3Vitreoretinal Service, Henry Ford Health Systems, West Bloomfield, MI, USA; 4Retinal Consultants of Michigan, Southfield, MI, USA; 5Vitreoretinal Service, Vanderbilt Eye Institute, Nashville, TN, USAPurpose: To describe the use of nepafenac 0.1% for cystoid macular edema (CME).Methods: This was a multicenter retrospective review of 22 CME cases (20 patients) treated with nepafenac 0.1% (six with concomitant prednisolone acetate 1%) from December 2005 to April 2008: three acute pseudophakic CME cases, 13 chronic/recalcitrant pseudophakic CME cases, and six cases of uveitic CME. Pre- and post-treatment retinal thickness and visual acuity were reported.Results: Following treatment for six weeks to six months, six eyes with uveitic CME showed a mean retinal thickness improvement of 227 ± 168.1 μm; mean best-corrected visual acuity (BCVA) improvement was 0.36 ± 0.20 logMAR. All three cases of acute pseudophakic CME improved after four to 10 weeks of nepafenac, with a mean improvement in retinal thickness of 134 ± 111.0 μm. BCVA improved in two patients (0.16 and 0.22 logMAR) but not in the third due to underlying retinal pigment epithelium changes. Thirteen eyes with chronic/recalcitrant pseudophakic CME demonstrated a mean improvement in retinal thickness of 178 ± 128.7 μm after nepafenac and mean BCVA improvement of 0.33 ± 0.19 logMAR.Conclusion: The positive outcomes of these 22 eyes strongly suggest that nepafenac 0.1% is a promising drug for the treatment of CME. Additional study under randomized controlled conditions is warranted.Keywords: macular edema, NSAID, nepafenac, cataract surgery, uveiti

Intravitreal Ampicillin Sodium for Antibiotic-Resistant Endophthalmitis: Streptococcus uberis First Human Intraocular Infection Report

Purpose. To describe the clinical characteristics, diagnosis, and treatment with intravitreal ampicillin sodium of a postoperative endophthalmitis case due to Streptococcus uberis; an environmental pathogen commonly seen in mastitis cases of lactating cows. Methods. Case Report. A 52-year-old, Hispanic diabetic patient who suddenly developed severe pain and severe loss of vision, following vitrectomy. Results. The patient was diagnosed with postoperative endophthalmitis secondary to a highly resistant strain of Streptococcus uberis that did not respond to intravitreal antibiotics. He was treated with an air-fluid interchange, anterior chamber washout, intravitreal ampicillin sodium (5 mg/0.1 mL), and silicon oil tamponade (5000 ck). The eye was anatomically stabilized, though there was no functional recovery. Conclusion. Streptococcus uberis is an uncommon pathogen to the human eye, which has unique features that help the strain in developing resistance to antibiotics. While treatment with intravitreal ampicillin is feasible, there are still concerns about its possible toxicity

Intravitreal Moxifloxacin: Retinal Safety Study with Electroretinography and Histopathology in Animal Models

PURPOSE. To determine whether moxifloxacin can be used safely as an intraocular antibiotic, retinal safety of intravitreal moxifloxacin was studied with electroretinography (ERG) and histopathology in animal models. METHODS. Moxifloxacin was injected into mouse eyes at intravitreal concentrations of 5 to 500 g/mL and into rabbit eyes at 150 g/mL. As the control, the vehicle was injected into the fellow eyes of each animal. Four weeks after injection, ERG recordings were performed, and animal eyes were processed for histologic examination. RESULTS. ERG studies showed no significant difference between control and moxifloxacin-injected eyes at any dose in either the mouse or rabbit model. Histologic examination revealed no retinal abnormality in mice at 5 to 100 g/mL or in rabbits at 150 g/mL intravitreal moxifloxacin. In mice at 500 g/mL, occasional focal retinal necroses were observed, suggesting isolated retinal toxicity at this concentration of moxifloxacin. CONCLUSIONS. Intravitreal moxifloxacin, up to 100 g/mL in mice or 150 g/mL in rabbits, caused no ERG or retinal histologic abnormality. These results indicate that moxifloxacin is a safe intravitreal antibiotic in mouse and rabbit animal models. If proven safe and efficacious by further study in humans, intravitreal injection of moxifloxacin could be considered as an alternative to currently used antibiotics in selected patients with resistance or allergy to the more traditional antibiotics

Evaluation of very high- and very low-dose intravitreal aflibercept in patients with neovascular age-related macular degeneration.

PURPOSE: To determine bioactivity and duration of effect of intravitreal aflibercept injection (also known as vascular endothelial growth factor Trap-Eye) for neovascular age-related macular degeneration (AMD). METHODS: In this double-masked, phase 1 study, 28 patients with lesions ≤12 disc areas, ≥50% active choroidal neovascularization (CNV), and best corrected visual acuity (BCVA) ≤20/40 were randomized 1:1 to a single intravitreal injection of aflibercept 0.15 or 4 mg. The primary end point was the change from baseline in central retinal/lesion thickness (CR/LT) at week-8. Secondary outcomes were the change from baseline BCVA, the change in CNV lesion size and area of leakage, and proportion of patients requiring repeat injection at 8 weeks. RESULTS: Mean percent decrease in CR/LT for the 4-mg and 0.15-mg groups was, respectively, 34.2 versus 13.3 at week 4 (P=0.0065), 23.8 versus 5.9 at week 6 (P=0.0380), and 25.2% versus 11.3% at week 8 (P=0.150). The 4-mg group gained a mean of 4.5 letters in BCVA (6/14 patients gaining ≥10 letters) versus 1.1 letters in 0.15-mg group (1/14 gaining ≥10 letters) at week 8. Fewer patients needed retreatment in the 4-mg group at week 8. No serious adverse event or ocular inflammation was reported in either group. CONCLUSIONS: Intravitreal aflibercept 4 mg had a safety profile similar to that of the very low dose 0.15 mg, and was well-tolerated. The 4-mg dose significantly reduced foveal thickening at weeks 4 and 6, significantly improved BCVA at weeks 6, and reduced the need for repeat injection after 8 weeks compared with intravitreal aflibercept 0.15 mg in neovascular AMD patients

Medications and retinal toxicity

Approximately three dozen medications have been associated with retinal toxicity, and it is important to be aware of such associations. Several medications, such as acetazolamide and latanoprost, are commonly prescribed by the ophthalmologist. Most of the other medications are commonly administered by the patient's primary physician. When assessing any patient for a retinal disturbance, it is imperative to question the patient regarding the use of systemic medications. This is especially important as more and more medications are brought to the market each year

Angiography in Pharmacologic Retinal Toxicity

Retinal angiography, specifically fluorescein angiography (FA), is important for the diagnosis and follow-up of pharmacologic retinal toxicity. At this time, there does not appear to be a significant role for indocyanine green (ICG) videoangiography, and even the role of optical coherence tomography (OCT) for these conditions is very limited. Fluorescein angiography appears to be particularly helpful in early cases of possible toxicity where the clinical findings may be mild. Early diagnosis is beneficial, as prompt discontinuation of the offending agent may on occasion reduce the risk of permanent vision loss