Delayed corneal epithelial healing after intravitreal bevacizumab: a clinical and experimental study

PURPOSE

To report corneal epithelial defects (CEDs) and delayed epithelial healing after intravitreal bevacizumab (IVB) injection and to describe delayed corneal epithelial healing with topical administration of bevacizumab in an experimental rabbit model.

METHODS

A retrospective chart review was performed on 850 eyes of 850 patients with neovascular eye disease and diabetic macular edema who had received 1.25 to 2.5 mg IVB. In the experimental arm of the study, photorefractive keratectomy was used to create a 3 mm CED in the right eyes of 18 New Zealand rabbits which were then randomized to three equal groups. All rabbits received topical antibiotics, additionally those in group A received topical bevacizumab and animals in group B were treated with topical corticosteroids. The rate of epithelial healing was assessed at different time points using slitlamp photography.

RESULTS

In the clinical study, seven eyes of seven subjects developed CEDs the day after IVB injection. All of these eyes had preexisting corneal edema. The healing period ranged from 3 to 38 days (average 11 days) despite appropriate medical management. In the experimental study, topical bevacizumab and corticosteroids both significantly hindered corneal epithelial healing at 12 and 24 hours.

CONCLUSION

Bevacizumab was demonstrated to cause CEDs in clinical settings. Moreover, corneal epithelial healing was delayed by topical application of bevacizumab, in the experimental model. These short-term results suggest that corneal edema may be considered as a risk factor for epithelial defects after IVB.

Immunohistochemical localization of low density lipoprotein receptor-related protein 1 and alpha(2)-Macroglobulin in retinal and choroidal tissue of proliferative retinopathies

The immunolocalization of the low density lipoprotein receptor-related protein 1 (LRP1) and its ligand alpha 2-Macroglobulin (alpha(2)M) was examined in tissues from human donor eyes of normal, diabetic and sickle cell disease subjects. Streptavidin alkaline phosphatase immunohistochemistry was performed with a mouse anti-human LRP1 and rabbit anti-human alpha(2)M antibodies. Retinal and choroidal blood vessels were labeled with mouse anti-human CD34 antibody in adjacent tissue sections. Mean scores for immunostaining from the pathological and control eyes were statistically compared. LRP1 immunoreactivity was very weak to negative in the neural retina of normal subjects except in scattered astrocytes. LRP1 expression in diabetic eyes was detected in the internal limiting membrane (ILM), astrocytes, inner photoreceptor matrix, choriocapillaris and choroidal stroma. The ligand alpha(2)M, however, was limited mainly to blood vessel walls, some areas of the inner nuclear layer (INL), photoreceptors, RPE-Bruch's membrane-choriocapillaris complex, intercapillary septa, and choroidal stroma. In sickle cell eyes, avascular and vascular retina as well as choroidal neovascularization (CNV) were analyzed. In avascular areas, LRP1 immunoreactivity was in innermost retina (presumably ILM, astrocytes, and Muller cells) and INL as well as RPE-Bruch's membrane-choriocapillaris complex and choroidal stroma. alpha(2)M was very weak in avascular peripheral retina compared to vascularized areas and limited to stroma in choroid. In contrast, in areas with CNV, LRP1 immunoreactivity was significantly decreased in overlying retina and in RPE-Bruch's membrane and choroidal stroma compared to the controls, while alpha(2)M was elevated in RPE-Bruch's membrane near CNV compared to normal areas in sickle cell choroid. The mean scores revealed that LRP1 and alpha(2)M in neural retina were significantly elevated in astrocytes and ILM in diabetic eyes (p < or = 0.05), whereas in sickle cell eyes scores were elevated in ILM and INL (p < or = 0.05). In addition, alpha(2)M immunoreactivity was in photoreceptors in both ischemic retinopathies. In choroid, the patterns of LRP1 and alpha(2)M expression were different and not coincident. This is the first demonstration of the presence of LRP1 and alpha(2)M in human proliferative retinopathies. Elevated LRP1 expression in sickle cell neural retina and diabetic inner retina and choroid suggests that LRP1 plays an important role in ischemic neovascular diseases.

Acute rhegmatogenous retinal detachment immediately following laser in situ keratomileusis

We report a case of acute rhegmatogenous retinal detachment (RRD) after laser in situ keratomileusis (LASIK) surgery in a highly myopic patient. Fourteen hours postoperatively, the uncorrected visual acuity was counting fingers in the left eye. Slitlamp examination revealed significant anterior chamber reaction with fibrin-like material. Fundus examination revealed 2 inferior retinal horseshoe tears associated with an RD. Preoperative fundus examination with scleral depression may detect predisposing retinal lesions in highly myopic patients. Further study is required to evaluate the relationship between LASIK, acute postoperative RRD, and predisposing factors.

Circulating anti-galectin-1 antibodies are associated with the severity of ocular disease in autoimmune and infectious uveitis

PURPOSE

Galectin (Gal)-1, an endogenous lectin found at sites of immune privilege, plays a critical role in the regulation of the immune response. Therapeutic administration of Gal-1 or its genetic delivery suppresses chronic inflammation in experimental models of autoimmunity. The purpose of this work was to investigate the occurrence of circulating anti-Gal-1 antibodies in patients with autoimmune and infectious uveitis as potential determinant factors of disease progression.

METHODS

IgG, IgE, and IgA anti-Gal-1 antibodies were assessed by ELISA and Western blot in sera from patients with autoimmune (n = 47) and infectious (n = 15) uveitis compared with healthy control subjects (n = 30). The frequency of anti-Gal-1 antibodies was examined in patients experiencing poor clinical outcome (n = 21) or good evolution (n = 9). Anti-Gal-1 antibodies were eluted by incubating patient sera with nitrocellulose filters adsorbed with rGal-1. The ability of these antibodies to recognize retinal tissue was assessed by ELISA, Western blot, and immunohistochemistry.

RESULTS

IgE, IgG, and IgA anti-Gal-1 antibodies were increased in sera from patients with autoimmune uveitis (P < 0.001 vs. controls) and toxoplasmic retinochoroiditis (P < 0.001). The level of anti-Gal-1 IgE and IgG antibodies was associated with progressive disease and poor outcome in autoimmune and infectious uveitis. Furthermore, these antibodies strongly immunoreacted with retinal lysates and recognized retinal structures mainly photoreceptors in retinal sections.

CONCLUSIONS

Anti-retinal Gal-1 antibodies are present in sera from patients with uveitis and can be associated with the progression of ocular disease, suggesting their potential use in follow-up observations of these patients.

Small choroidal melanoma with massive extraocular extension: invasion through posterior scleral emissary channels

Massive orbital extension arising from a small posterior pole uveal melanoma is rare. A 75-year-old male followed for an asymptomatic choroidal nevus developed a two and a half month history of mild decrease in visual acuity. Upon clinical examination minimal enlargement of the tumor with surrounding serous retinal detachment was observed. Pre-operative magnetic resonance imaging disclosed massive extrascleral extension. Histopathology revealed that the tumor was composed of spindle B malignant melanoma cells. Multiple serial sections of the entire tumor area failed to demonstrate permeation through scleral lamellae. Instead, peripapillary perivascular short posterior ciliary vessel invasion was observed. This route of dissemination may explain the rapid growth and clinically undocumented behavior of small malignant melanomas at this location.

Intravitreal triamcinolone acetonide injection in blind painful eyes. Intraocular steroids as a treatment for blind painful red eyes

PURPOSE

Phthisis bulbi results from different ocular conditions. We evaluated intravitreal triamcinolone acetonide as a treatment option in blind painful eyes.

METHODS

Thirty-one patients with unilateral phthisis were randomly divided into two groups. Group A received 0.3 ml (12.5 mg) triamcinolone acetonide intravitreally and Group B 0.3 ml balanced salt solution after retrobulbar anesthesia. Treatment success was assessed by subjective response to pain and clinically by biomicroscopic evaluation of conjunctival congestion. Tonometry was done before and after treatment. Follow-ups were at 24 hours, 3 weeks, 3 and 6 months, and 1 and 2 years.

RESULTS

Throughout the two-year follow-up, only two patients in Group A reported pain after the procedure and were retreated, one at week 4 and the other at week 7. Conjunctival congestion was significantly lower in Group A. Two patients with hypotony before treatment had normal tension after triamcinolone. All Group B patients were reinjected with triamcinolone because pain continued after balanced salt solution injection. No severe complications were found.

CONCLUSIONS

Intravitreal triamcinolone acetonide may be effective and safe for treating blind painful eyes.

[Submacular surgery in ocular toxocariasis: a clinic-pathologic correlation]

PURPOSE

To present a clinico-pathologic report on ocular toxocariasis in a nine-year-old boy with a submacular fibravascular membrane who underwent submacular surgery.

MATERIALS AND METHODS

A nine-year-old boy affected by chronic ocular toxocariasis in his right eye was treated. Fundus examination disclosed multiple vitreous strands attached to the retina in the inferonasal quadrant and a submacular membrane with a surrounding exudative macular detachment. Vitrectomy surgery with submacular membrane removal was performed.

RESULTS

Visual acuity improved from hand motion to 20/400 after two months of follow-up. The pathological findings revealed a fibrovascular scar without parasitic remnants in the serial section of the tissue.

CONCLUSION

In this case of ocular toxocariasis, submacular surgery turned out to be a good alternative treatment to improve the patient's visual acuity. Through this kind of surgery it could be possible not only to treat vitreoretinal complications of the disease but also to excise submacular membranes and reattach the retina in the macular area.

Rhodococcus globerulus keratitis after laser in situ keratomileusis

A healthy 20-year-old woman with myopia had uneventful bilateral laser in situ keratomileusis after which the uncorrected visual acuity was 20/20 in the right eye and 20/30 in the left eye. Fifteen days later, a stromal paraxial lesion was found in the right eye with a corresponding loss of visual acuity, pain, and photophobia. The flap was lifted and the infiltrate scraped for smears. Cultures showed that Rhodococcus globerulus was the infectious agent. Intensive topical antibiotic treatment was applied with good visual results.

Vitreoretinal alterations following laser in situ keratomileusis: clinical and experimental studies

BACKGROUND

The presence of vitreoretinal changes following laser in situ keratomileusis in myopia is evaluated.

METHODS

Clinically, 50 patients (100 eyes) with marked anisometropic myopia, 50 low-myopic eyes (<4.00 D) and 50 high-myopic eyes (>7.00 D) were prospectively evaluated pre- and postoperatively for the presence of newly recognized entoptic phenomena (vitreous floaters, light flashes, or both), and for vitreoretinal changes using indirect depressed fundus examination, a +90 D preset lens, Goldman three-mirror contact lens, and kinetic ultrasound (KU) before and after bilateral LASIK. Patients with previous partial or total posterior vitreous cortex detachment (PVD) were excluded. Experimentally, groups of adult pigs underwent KU, retinal fluorescein angiography (FA), and electroretinography (ERG) before and after applying the microkeratome suction ring for 30 s.

RESULTS

Clinically, 8% (4 eyes) had positive perception of postoperative vitreous floaters in the low myopia group, and 32% (16 eyes) in the high myopia group. Postoperative light flashes were noted only in the high myopia group, in 12% of cases. Partial or total posterior vitreous cortex detachment was detected by biomicroscopy in 2% (1 eye) of the low and in 10% (5 eyes) of the high myopia group and by KU in 4% (2 eyes) of the low and in 24% (12 eyes) of the high myopia group. Experimentally, 2 pig eyes out of 12 developed partial PVD by KU, immediately after microkeratome suction ring application. All pig eyes showed significantly diminished ERG amplitudes during and immediately after suction ring application. No FA changes or delays in retinal circulation time were noted during or immediately after removal of the suction ring.

CONCLUSIONS

Vitreoretinal alterations after LASIK were demonstrated clinically mainly by KU in high myopes. Experimentally, PVD were also demonstrated. Diminished ERG recordings with normal retinal circulation following suction ring application may suggest some transient choroidal circulation abnormalities.

Laser in Situ Keratomileusis for Myopia and Hyperopia Using the Lasersight 200 Laser in 300 Consecutive Eyes

PURPOSE

To evaluate effectiveness, safety, predictability, and short-term stability of laser in situ keratomileusis (LASIK) using the LaserSight Compac-200 Mini excimer laser with software version 9.0, for all refractive errors.

METHODS

One hundred fifty consecutive patients (300 eyes) that received bilateral LASIK for myopia, hyperopia, and astigmatism were studied prospectively. A new 9.0 software version applying a modified nomogram that takes advantage of bilateral surgery was used. Follow-up at 6 months was available for 267 eyes (89%).

RESULTS

Six months postoperatively, 131 eyes (96.32%) in the low to moderate myopia group (-1.00 to -5.99 D; n=136) had a spherical equivalent refraction within +/-1.00 D, and 123 eyes (90.44%) were within +/-0.50 D of emmetropia. In the high to extreme myopia group (-6.00 to -25.00 D; n=114), 97 eyes (87.08%) had a spherical equivalent refraction within +/-1.00 D and 78 eyes (68.42%) were within +/-0.50 D of emmetropia. In the hyperopia group (+1.00 to +6.00 D; n=50), 44 eyes (88%) had a postoperative spherical equivalent refraction within +/-1.00 D, and 31 eyes (62%) were within +/-0.50 D of emmetropia. Mean change in spherical equivalent refraction at 6 months was less than -0.50 D in the low to high myopia groups and -1.16 +/- 0.55 D in the extreme myopia group. At 6 months follow-up, uncorrected visual acuity was 20/20 or better in 73 eyes (54%) in the low to moderate myopia groups and 21 eyes (18%) in the high to extreme myopia groups. In the hyperopia group at 6 months follow-up, uncorrected visual acuity was 20/20 or better in 31 eyes (62%) and 20/40 or better in 41 eyes (82%). Only two eyes had a temporary loss of two or more lines of spectacle-corrected visual acuity due to corneal folds that were surgically treated. Six months after LASIK, no eye had lost any lines of best spectacle-corrected visual acuity in this series.

CONCLUSIONS

Our modified LASIK nomogram with the 9.0 software of the LaserSight 200 excimer laser (with a larger and smoother ablation pattern) resulted in safe and effective outcomes for the treatment of low to high myopia, astigmatism, and hyperopia.

Hypotony and experimental rubeosis iridis in primate eyes. A clinicopathologic study

Rubeosis iridis was produced in cynomolgus monkeys by subjecting their eyes to severe surgically induced hypotony. New vessels on the iris showed characteristic fenestrations of endothelial cell walls as well as mitotic activity.

Experimental retinal vascular occlusion. II. A clinico-pathologic correlative study of simultaneous occlusion of central retinal vein and artery

After experimentally occluding the central retinal vein and artery simultaneously at their point of entry into the optic nerve, acute retinal necrosis occurred, but not hemorrhagic retinopathy. In the retinal vasculature, stagnation of blood flow and thrombosis with subsequent recanalization was noted. The necrosis was extensive in the inner retinal layers but focal in the outer retinal layers. The internal limiting membrane was detached and disrupted in every case. Following the post-edematous stage, numerous micro and macroretinal cysts appeared. The peripheral retina showed much less ischemic changes. A clinico-pathologic correlation was made.

Experimental retinal vascular occlusion. III. An ultrastructural study of simultaneous occlusion of central retinal vein and artery

The retinal changes following the simultaneous occlusion of retinal vessels were examined at an ultrastructural level. The preservation of endothelial cells that prevented leakage of blood and horseradish peroxidase tracer material in the surrounding retinal tissues explained the lack of hemorrhages observed clinically. Mueller cell death resulted in severe structural disorganization of the retina, with disruption of the inner limiting membrane, involvement of the outer retinal layers, and fleurette formation. The retinal macrocysts were derived from ischemic infarction.

Ten years experience with eye wall resection for uveal malignant melanomas

Thirty-four patients underwent eye wall resection for choroidal malignant melanoma over a period of more than ten years. Of these, 11 eyes were later enucleated for complications. Average mean follow-up has been more than 5.3 years. Postoperative visual acuity ranged from light perception to 20/30. Two patients developed liver metastasis 4 years following eye wall resection and later died. However, no local metastasis has been observed. Two patients died from unrelated causes.

Resection of uveal melanocytoma: clinicopathological correlation

Four patients had pigmented lesions in the anterior uveal tract and choroid which presented clinically as malignant melanomas. All the lesions were successfully removed by local excision. Histopathological studies showed the tumours to be melanocytomas, indicating that enucleation or irradiation would have been contraindicated. The 3 patients with iris and ciliary body melanocytomas continue to maintain corrected visual acuities of 20/30 or better. In the patient with choroidal melanocytoma central visual acuity was compromised owing to cystoid macular oedema. All 3 melanocytomas involving the anterior segment were located inferiorly. Biomicroscopically, they were chocolate coloured (not black) and resembled malignant melanomas of the same location. The choroidal melanocytoma also resembled a malignant melanoma by ophthalmoscopic and angiographic criteria, and did not have the jet black or homogeneous pigmentation that characterises most melanocytomas of the disc.

Effects of argon and krypton laser on experimentally detached retinas

Krypton and argon laser photocoagulation on the foveas and blood vessels of experimentally detached monkey retinas were studied clinicopathologically. In this manner heat transmission from the retinal pigment epithelium (RPE) to the overlying sensory retina was avoided. Krypton lesions bypassed the sensory retina on every occasion to produce major photocoagulative effects at the level of the RPE and choroid. Argon laser wavelengths damaged the overlying retina in the foveal areas as well as in perivascular structures. Although the krypton laser appears preferable for treatment of macular diseases, proper parameters should be used to avoid serious complications.

Secondary pupillary membranes treated by the pars plana/pars plicata approach: long-term results of 108 cases

One hundred and eight pupillary membranes treated with the vitrophage through a pars plicata or pars plana approach were evaluated for long-term results. The average follow-up was 3.86 years, with a range of 1 to 7 years. No major operative complications were encountered. Anatomical success was achieved in all cases. Vision improved in 67.5% of eyes. In 4 cases (3.7%) postoperative visual acuity was worse, because of glaucoma secondary to previous blunt ocular trauma. Six cases showed delay rhegmatogenous retinal detachment postoperatively. These could not be attributed to the surgical procedure per se.

Full-thickness eye-wall biopsy: long-term results in 9 patients

Nine patients who had an eye-wall biopsy were evaluated for long-term results. The follow-up time ranged from 2 1/2 months to 7 years. Six patients were followed up for more than 2 years. Few operative and postoperative complications were observed. Except for 1 patient with reticulum cell sarcoma, all eyes retained preoperative visual acuity. Tractional retinal detachment occurred only in 1 patient, who had vitreous bands around the biopsy site and did not undergo a simultaneous vitrectomy during the biopsy operation.

An ultrastructural study of melanocytomas (magnocellular nevi) of the optic disk and uvea

We examined by light and electron microscopy five melanocytomas from four patients. Two types of cells were observed in each tumor. The predominant cell type in most of the tumors studied consisted of plump polyhedral nevus cells that contained numerous giant melanosomes. These cells showed advanced differentiation. They appeared to be metabolically inactive and to have been the cause of the heavy pigmentation and benign nature of these tumors. The second variant of melanocytoma cells were smaller spindle-shaped cells that were lightly pigmented. Other morphologic features of these cells such as high nucleus-cytoplasm ratio, prominent nucleolus, nuclear membrane infolding, numerous mitochondria, prominent rough endoplasmic reticulum, and free ribosomes, indicated a metabolically active cell, which may explain the infiltrating behavior of these tumors.