Intravitreal Bevacizumab as an Adjunct Treatment for Neovascular Glaucoma

Purpose

To assess the effect of adjunctive intravitreal bevacizumab treatment on neovascular glaucoma (NVG).

Methods

The medical records of all consecutive patients with NVG treated with intravitreal bevacizumab at our center from May 2006 to February 2008 were reviewed. The data collected included background features, findings on full ophthalmologic examination (including visual acuity, gonioscopy, and intraocular pressure), glaucoma medications prescribed, and additional procedures for glaucoma performed before and after bevacizumab injection. The interval between the diagnosis of NVG and intravitreal bevacizumab treatment was calculated.

Results

Eighteen patients (6 male, 12 female; mean age 63±13.2 years) met the study criteria. Causes of NVG were proliferative diabetic retinopathy (n=14), central retinal vein occlusion (n=2), occlusive vasculitis (n=1), and panuveitis (n=1). The mean duration of follow-up was 52 (±12) weeks. Mean intraocular pressure decreased from 32.3 (±4.99) to 18 (±6.1) mmHg (p<0.0001) and mean number of glaucoma medications decreased from 3.16 (±1.2) to 2.55 (±1.46) (p=0.1938). An interval of less than 6 months between the start of bevacizumab treatment and diagnosis was associated with better final visual acuity than delayed treatment (0.82±0.4 logMAR vs 1.88±1.1 logMAR, p=0.002) and a better regression of iris neovascularization (22% vs 89%; p=0.015).

Conclusions

Intravitreal bevacizumab is beneficial for the treatment of anterior segment neovascularization and NVG when used as an adjunct, making the administration of additional treatment for the underlying cause possible. Bevacizumab should be instituted promptly after diagnosis, before irreversible anatomic and functional damage occurs.

Scleral Cross-linking Using Riboflavin and Ultraviolet-A Radiation for Prevention of Axial Myopia in a Rabbit Model

Myopic individuals, especially those with severe myopia, are at higher-than-normal risk of cataract, glaucoma, retinal detachment and chorioretinal abnormalities. In addition, pathological myopia is a common irreversible cause of visual impairment and blindness. Our study demonstrates the effect of scleral crosslinking using riboflavin and ultraviolet-A radiation on the development of axial myopia in a rabbit model. The axial length of the eyeball was measured by A-scan ultrasound in New Zealand white rabbits aged 13 days (male and female). The eye then underwent 360° conjunctival peritomy with scleral crosslinking, followed by tarsorrhaphy. Axial elongation was induced in 13 day-old New Zealand rabbits by suturing their right eye eyelids (tarsorrhaphy). The eyes were divided into quadrants, and every quadrant had two scleral irradiation zones, each with an area of 0.2 cm² and a radius of 4 mm. Crosslinking was performed by dropping 0.1% dextran-free riboflavin-5-phosphate onto the irradiation zones 20 sec before ultraviolet-A irradiation and every 20 sec during the 200 sec irradiation time. UVA radiation (370 nm) was applied perpendicular to the sclera at 57 mW/cm² (total UVA light dose, 57 J/cm²). Tarsorrhaphies were removed on day 55, followed by repeated axial length measurements. This study demonstrates that scleral crosslinking with riboflavin and ultraviolet-A radiation effectively prevents occlusion-induced axial elongation in a rabbit model.

Scleral cross-linking using riboflavin and ultraviolet-a radiation for prevention of progressive myopia in a rabbit model

Our study demonstrates the effect of scleral cross-linking using riboflavin and ultraviolet-A radiation on the development of axial myopia in a rabbit model. Axial length of the eyeball was measured by A-scan ultrasound in 22 New Zealand white rabbits aged 13 days. The right eyes then underwent 360-degree conjunctival peritomy with (experimental group, n = 11) or without (control group, n = 11) scleral cross-linking, followed by tarsorrhaphy. The left eyes served as a control eye. In the experimental group, the right eyeballs were divided into quadrants, and every quadrant had either 2 (n = 8) or 6 (n = 3) scleral irradiation zones, each with an area of 0.2 cm² and radius of 4 mm. Cross-linking was performed by dropping 0.1% dextran-free riboflavin-5-phosphate onto the irradiation zones at 20 s before ultraviolet-A irradiation and every 20 s during the 200-s irradiation time. UVA radiation (370 nm) was applied perpendicular to the sclera at 57 mW/cm² (total UVA light dose, 57 J/cm²). Tarsorrhaphies were removed on day 55, followed by repeated axial-length measurement. In the control group, mean axial length in the right eyes increased from 10.50 ± 0.67 mm at baseline to 15.69 ± 0.39 mm 55 days later, for a mean change of 5.19 ± 0.85 mm. In the experimental group, corresponding values were 10.68 ± 0.74 mm and 14.29 ± 0.3 mm, for a mean change of 3.61 ± 0.76 mm. The between-group difference in the change in mean axial length was statistically significant (p < 0.001, Mann-Whitney nonparametric test). The present manuscript demonstrates that scleral cross-linking with riboflavin and ultraviolet-A radiation effectively prevents occlusion-induced axial elongation in a rabbit model.

Novel 'heavy' dyes for retinal membrane staining during macular surgery: multicenter clinical assessment

PURPOSE

  To evaluate the feasibility of two novel 'heavy' dye solutions for staining the internal limiting membrane (ILM) and epiretinal membranes (ERMs), without the need for a prior fluid-air exchange, during macular surgery.

METHODS

  In this prospective nonrandomized multicenter cohort study, the high molecular weight dyes ILM-Blue™ [0.025% brilliant blue G, 4% polyethylene glycol (PEG)] and MembraneBlue-Dual™ (0.15% trypan blue, 0.025% brilliant blue G, 4% PEG) were randomly used in vitrectomy surgeries for macular disease in 127 eyes of 127 patients. Dye enhanced membrane visualization of the ILM and ERMs, 'ease of membrane peeling', visually detectable perioperative retinal damage, postoperative best-corrected visual acuity (BCVA), dye remnants and other unexpected clinical events were documented by 21 surgeons.

RESULTS

  All surgeries were uneventful, and a clear bluish staining, facilitating the identification, delineation and removal of the ILM and ERMs, was reported in all but five cases. None of the surgeries required a fluid-air exchange to assist the dye application. BCVA at 1 month after surgery improved in 83% of the eyes in the MembraneBlue-Dual™ group and in 88% in the ILM-Blue™ group. No dye remnants were detected by ophthalmoscopy, and no retinal adverse effects related to the surgery or use of the dyes were observed.

CONCLUSION

  The 'heavy' dye solutions ILM-Blue™ and MembraneBlue-Dual™ can be injected into a fluid-filled vitreous cavity and may facilitate staining and removal of the ILM and/or ERMs in macular surgery without an additional fluid-air exchange.

Surgical and functional results of augmented superior oblique muscle z-tenotomy in patients with superior oblique overaction and Brown's syndrome

BACKGROUND AND OBJECTIVE

To compare the effectiveness of augmented superior oblique Z-tenotomy (SOZT) with fixed standard SOZT in canceling preoperative superior oblique overaction associated with A pattern anisotropia or V pattern in Brown's syndrome.

PATIENTS AND METHODS

Sixteen consecutive patients with superior oblique overaction or Brown's syndrome were treated by removal of a triangular piece of the superior oblique tendon near its insertion (augmented SOZT). Outcome was compared with 20 consecutive historical controls after standard SOZT.

RESULTS

The decrease in superior oblique overaction in the right and left eyes and fundus intorsion and the collapse of A pattern anisotropia were more significant for patients with superior oblique overaction (P = .003, P = .007, P = .05, P = .0015, respectively) and patients with Brown's syndrome (P = .025, P = .03, and P = .05, respectively). No study patient with superior oblique overaction and A pattern anisotropia required reoperation compared with 5 of 14 controls (37.5%); rates for patients with Brown's syndrome were 0 for the study group and 3 of 6 (50%) for the control group.

CONCLUSIONS

Augmented SOZT is superior to standard SOZT for correcting superior oblique overaction, intorsion, A or V pattern, and stereopsis. It is not associated with complications or reoperation. The size of the Z-tenotomy can be modified according to the intraoperative assessment to achieve symmetric results.

Familial exudative vitreoretinopathy and macular hole exhibited in same individual

This observational case report is designed to report the first known occurrence of Familial Exudative Vitreoretinopathy (FEVR) and macular hole in the same individual. Clinical exams and fluorescein angiography were used to evaluate patient. Indirect laser panretinal photocoagulation was used to treat the right eye. A nine-year old male was diagnosed with familial exudative vitreoretinopathy in both eyes, as well as a full-thickness macular hole in his right eye. Medical histories indicated that the macular hole was not caused by trauma. Indirect laser panretinal photocoagulation was performed to treat an exudative process caused by FEVR in the right eye, and the exudative retinal detachment regressed. A vitrectomy was later also performed to treat traction retinal detachment as well as macular hole in the right eye. Our conclusion is that macular hole can be associated with familial exudative vitreoretinopathy.

Effect of peripheral retinal ablation with cryotherapy versus diode laser photocoagulation on axial length in the growing rabbit eye

AIMS

To evaluate and compare the effects of peripheral retinal cryotherapy and diode laser photocoagulation on axial length, anterior chamber depth, and lens thickness in developing rabbit eyes.

METHODS

26 eyes of 6 week old Abbit rabbits were randomly assigned to undergo laser photocoagulation or cryotherapy of the peripheral retina. Eight eyes of four untreated rabbits served as controls. Biometric and intraocular pressure measurements were performed at 0, 5, and 10 weeks after treatment.

RESULTS

Five rabbits died, leaving 10 rabbits (20 eyes) in the study group and two (four eyes) in the control group. Average axial lengths for the control, laser treated, and cryo treated eyes were 15.72 mm, 16.08 mm, and 16.11 mm, respectively, at baseline and 17.48 mm, 18.09 mm, and 19.4 mm, respectively, at 10 weeks after treatment (p = 0.028, paired Wilcoxon test). Anterior chamber depth increased from 2.2 mm to 2.5 mm in both treatment groups, and from 2.14 mm to 2.28 mm in the control group. Lens thickness averaged 5.11 mm in the control group and 5.38 mm in the treatment groups before treatment, and 6.34 mm, 6.31 mm, and 6.38 mm, respectively, 10 weeks after treatment.

CONCLUSIONS

Peripheral retinal cryotherapy causes a significantly greater elongation of the eye compared to diode laser photocoagulation in a rabbit model.

Combined rectus muscle transposition with posterior fixation sutures for the treatment of double-elevator palsy

PURPOSE

To evaluate the surgical and functional results of full horizontal tendon rectus muscle transposition to the superior rectus (SR) insertion, augmented by posterior fixation sutures, in patients with double-elevator palsy (DEP).

DESIGN

Retrospective nonconcurrent interventional comparative case series.

PARTICIPANTS

Fourteen consecutive patients with DEP.

INTERVENTION

Six patients treated for DEP by vertical transposition of the horizontal muscles to the SR insertion (Knapp procedure) were compared with 8 patients treated by the Knapp procedure combined with fixation of the transposed muscles to the sclera, adjacent to the SR, with nonabsorbable sutures.

MAIN OUTCOME MEASURES

Postoperative ocular alignment, ductions, binocular functions, and rate of reoperation.

RESULTS

Ocular deviation: Mean distance and near deviations decreased by 84% and 83%, respectively (P = 0.012), in the augmented-surgery group versus 48% and 47%, respectively (P = 0.03), in the standard-surgery group. Duction: Mean elevation deficiency in abduction and adduction improved by 64% and 65%, respectively (P = 0.01), in the augmented surgery group versus 42% and 55% (P = 0.02) in the standard group. Binocular functions: 3 patients (37%), all in the study group, gained binocular function. Reoperation was required in 5 patients (83.3%) in the control group. The difference in postoperative improvement between the groups was statistically significant for all 4 parameters. No postoperative complications or duction anomalies were observed during the follow-up period of 15.4 months (standard deviation, 5.5).

CONCLUSIONS

The augmented Knapp procedure with superior posterior fixation suture is the preferred surgical treatment for patients with DEP. Its use in this series avoided the need for multiple surgeries on other extraocular muscles.

Ocular Growth in Premature Infants Conceived by In Vitro Fertilization versus Natural Conception

PURPOSE

To evaluate the possible effect of in vitro fertilization (IVF) on early development of the eye in premature infants.

METHODS

Biometric and keratometric values, intraocular pressure, and retinal vascular status were assessed in a cohort of 133 premature infants. These values were compared between premature infants conceived by IVF or naturally, and the relationship between these parameters and postconceptional age and weight at examination were evaluated.

RESULTS

The sample consisted of 133 premature infants, 62 (46.6%) born by IVF and 71 (53.4%) by natural conception. Postconceptional age at examination was 28 to 46 weeks. In both groups, axial length, anterior chamber depth, and corneal radius correlated with the postconceptional age and weight at examination and followed a linear growth pattern. Lens thickness changed very slightly. The rate of retinal vascularization correlated with the postconceptional age as well. No correlation was found between intraocular pressure and corrected age or weight at examination. There was no difference between the study and control groups in any of the biometric or keratometric parameters or in intraocular pressure, according to two-way analysis of variance.

CONCLUSIONS

IVF apparently does not affect early ocular growth, intraocular pressure, changes in corneal curvature, or retinal vascularization in premature infants. These findings may aid ophthalmologists in assessing ocular dimensions in this patient population.

Airbag-induced bilateral corneal graft dehiscence

PURPOSE

To report a case of bilateral corneal graft dehiscence caused by blunt trauma.

METHODS

Case report of bilateral simultaneous corneal graft dehiscence with expulsion of the lens and iris as a result of airbag-induced trauma.

RESULTS

Both corneal buttons were resutured, the prolapsed iris tissue was repositioned in the right eye, and anterior vitrectomy was performed bilaterally. Topical and systemic antibiotics, topical steroids, cycloplegic agents, and antiglaucoma drugs were initiated. Repeated B-scan ultrasound examinations demonstrated an attached retina in both eyes. Three weeks after admission, the right eye was reoperated for removal of remnant lens material and additional anterior vitrectomy. The patient was fitted with polycarbonate spectacles with an optical correction of +8 in both eyes. Visual acuity improved to 20/200 and 0.5/60 in the right and left eyes, respectively. The right corneal graft regained transparency, but the left one remained hazy.

CONCLUSION

Airbag deployment during motor vehicle collisions is a significant cause of ocular morbidity. The reported risk of airbag-related eye injury is 2.5% for any eye injury and 0.4% for severe eye injury. Patients undergoing corneal surgery should be counseled about the weakness of the donor-recipient interface and should consider wearing protective glasses.

Intraocular pressure variations after diode laser photocoagulation for threshold retinopathy of prematurity

PURPOSE

To investigate the intraocular pressure (IOP) variations occurring after indirect diode laser photocoagulation for threshold retinopathy of prematurity.

DESIGN

Prospective, nonrandomized, comparative study.

PARTICIPANTS

A study group-21 consecutive premature babies (42 eyes) undergoing diode laser photocoagulation for retinopathy of prematurity-and control groups-32 premature babies (64 eyes) undergoing retinal examination with or without scleral indentation.

INTERVENTION

Intraocular pressure was measured with a portable electronic tonometer before, immediately after, and 1, 2, and 3 days after diode laser photocoagulation in the study group; before retinal examination in control group 1; and before and after retinal examination with scleral indentation in control group 2.

MAIN OUTCOME MEASURE

Intraocular pressure after diode laser photocoagulation for threshold retinopathy of prematurity.

RESULTS

Mean IOP in the study group rose from 15 mmHg (standard deviation [SD] = 4.1) before coagulation to 33.2 mmHg (SD = 7.8; range, 20-50) immediately after, and then dropped to 22.2 (SD = 5.2), 16.5 (SD = 3), and 14.5 mmHg (SD = 2.1) 1, 2, and 3 days later, respectively. All the changes were statistically significant at P<0.0001, except for the difference between days 2 and 3 (P = 0.096). Mean baseline IOPs were 16.3 mmHg (SD = 3.7) in control group 1 and 15.7 mmHg (SD = 2.3) in control group 2 (P = 0.84 between control group 1 and study group, and P = 0.32 between control group 2 and the study group). At termination of the retinal examination with scleral indentation (control group 2), IOP measured 15.1 mmHg (SD = 2.2) (P = 0.49 compared with baseline).

CONCLUSIONS

Intraocular pressure may be significantly elevated after diode laser photocoagulation for retinopathy of prematurity. The mechanism and long-term clinical implications of this observation should be investigated.

Association of neovascular age-related macular degeneration and hyperhomocysteinemia

PURPOSE

To assess the relationship between plasma homocysteine levels and exudative neovascular age-related macular degeneration (AMD).

DESIGN

Cross-sectional study.

METHODS

A prospective comparative cross-sectional study was conducted in outpatient ophthalmology clinics in a university-affiliated medical institution. The cohort consisted of 59 patients (25 male, 34 female) with a mean age of 78 years (standard deviation [SD] = 8.4) with neovascular AMD who were candidates for photodynamic treatment. Patients were compared for plasma homocysteine levels with 58 patients who had dry AMD (24 male, 34 female) with a mean age of 76.3 years (SD = 8.4) and with a control group of 56 age-matched subjects (27 male, 29 female), with a mean age of 77.3 years (SD = 8.2). A 3-ml venous blood sample was obtained from each participant after an 8-hour fast. Levels of plasma homocysteine were measured by high performance liquid chromatography. The main outcome measure was hyperhomocysteinemia, defined as a plasma homocysteine level above 15 micromol/l.

RESULTS

Homocysteine levels were higher by 27.9% in the neovascular AMD than in the dry AMD group, and by 21.9% than in the control group (P <.02). Hyperhomocysteinemia was found in 44.1% of the study group, in 22.4% of the dry AMD group, and in 21.4% of the control group (P =.011).

CONCLUSIONS

This study suggests an association between an elevated plasma level of homocysteine and exudative neovascular AMD but not dry AMD.

Quantitative changes in botulinum toxin a treatment over time in patients with essential blepharospasm and idiopathic hemifacial spasm

PURPOSE

To evaluate the quantitative changes in botulinum toxin A (BTA) treatment required over time to achieve relief for 3 to 4 months in patients with essential blepharospasm (EBS) and idiopathic hemifacial spasm (IHFS).

DESIGN

Interventional case series.

METHODS

In this retrospective longitudinal study in an institutional ophthalmologic outpatient clinic, data were retrieved from patient files and a comparison between patients with EBS and IHFS was performed. The patient population consisted of 27 patients, 17 with EBS and 10 with IHFS, who were treated for the first time with BTA injections and were followed up for 4 to 6 consecutive years. All patients initially received 12 or more courses of treatment with a lower dose (<or=20 U) and were then switched to a higher dose (>20 U). The main outcome measures were the shift in the dose-response relationship between the lower and higher doses and were analyzed with respect to four variables: average number of treatments, dosage, duration of therapy, and interval of symptomatic relief.

RESULTS

In the EBS group the mean dose for each patient changed from 16.0 +/- 1.4 U (lower dose) to 24.2 +/- 1.4 U (higher dose). The shift occurred after a mean of 8.8 +/- 2.9 treatments per patient given for a mean of 33.5 +/- 13.3 months. The mean interval of relief was longer with the lower dose than with the higher dose (4.0 +/- 1.4 months vs 3.2 +/- 1.0 months, respectively). In the IHFS group, the mean dose / patient changed from 16.8 +/- 1.2 U to 25.0 +/- 1.8 U, and the switch occurred after a mean of 6.5 +/- 2.3 treatments given over a mean period of 23.8 +/- 6.6 months. The mean duration of treatment with the lower dose was shorter than with the higher dose. The interval of relief was similar for both dose ranges (3.8 +/- 10 months and 4.1 +/- 1.3 months, respectively). The IHFS group switched to the higher dose earlier, by both number and duration of treatments, than the EBS group. Only minor and transient side effects of treatment were observed in both groups.

CONCLUSIONS

Botulinum toxin A is an effective and safe treatment for EBS and IHFS. The dose in our study was increased over time by 50% to achieve 3 to 4 months of symptomatic relief with minimal complications.

Angiographic and flow patterns of retinal choroidal anastomoses in age-related macular degeneration with occult choroidal neovascularization

OBJECTIVE

To identify the angiographic features of retinal choroidal anastomoses (RCAs) in patients with newly diagnosed occult choroidal neovascularization (CNV) in the setting of age-related macular degeneration (AMD) and to determine the sequence of flow between the RCA and the CNV.

DESIGN

Retrospective cross-sectional study.

PARTICIPANTS

The angiograms of 205 eyes of 153 consecutive patients with occult CNV on fluorescein angiography (FA) and focal hot spots on indocyanine green angiography (ICGA) were evaluated retrospectively. METHODS OF TESTING: Red-free photographs and sequential digital fluorescein and indocyanine green angiograms obtained by confocal scanning laser ophthalmoscope (the Heidelberg Retina Angiograph; Heidelberg Engineering GmbH, Dossenheim, Germany).

MAIN OUTCOME MEASURES

The angiograms were evaluated for the presence of RCA. The following angiographic characteristics were recorded: number and type of anastomoses, location, distance from fovea, area of CNV, presence of pigment epithelium detachment (PED), cystoid macular edema on FA, and intraretinal leakage on ICGA. The direction of flow between the RCA and the CNV was identified by analyzing high-speed angiograms.

RESULTS

Retinal choroidal anastomoses were identified in 57 eyes (28%), in 49 of 154 eyes with PED (32%), and in 8 of 51 eyes without PED (16%). Of 109 anastomoses, 70% were venous and 30% were arterial. Ninety-six percent of the eyes had at least one venous anastomosis, 49% of the eyes had an arterial anastomosis, and 46% of the eyes had both. Cystoid macular edema was seen on FA in 37 eyes (65%), and intraretinal indocyanine green leakage was noted in 52 eyes (91%). Twenty-two eyes that underwent high-speed ICGA were analyzed for the direction of flow. All 15 eyes having arterial and venous anastomoses demonstrated a filling pattern from the retinal arteriole to the CNV, followed by the retinal venule. Seven eyes with venous RCA showed flow sequence from the CNV to the collecting retinal venule.

CONCLUSIONS

Our study supports the presence of RCA in the early stages of acute exudative AMD with occult CNV, mainly with serous PED. High-speed angiography helps to identify the filling sequence of the RCA and the CNV, and therefore may guide the clinician in planning treatment strategies.

Tactile corneal reflex development in full-term babies

OBJECTIVE

To evaluate the development of the tactile corneal reflex in healthy full-term babies.

DESIGN

Prospective longitudinal comparative case series.

PARTICIPANTS

One hundred and ninety-one babies aged 1 to 3 days examined in the nursery, and 200 babies aged 1 to 12 weeks examined in an orthopedic outpatient clinic.

METHODS

The tactile corneal reflex was evaluated by three ophthalmologists using the Cochet-Bonnet esthesiometer.

MAIN OUTCOME MEASURES

The probability of the presence of the tactile corneal reflex was calculated in relation to gestational age, postpartum age, postconceptional age, and birth weight.

RESULTS

The proportion of children with tactile corneal reflex was expressed in a linear logistic model. We found that 10% of the babies had tactile corneal reflex in at least one eye at 2 days of age, 25% at 1 week, 50% at 3.5 weeks, 75% at 6 weeks, and 100% at 12 weeks. The postpartum age had a greater impact on the development of the tactile corneal reflex than the gestational age. The birth weight also had a statistically significant influence (P = 0.005, Wald's test).

CONCLUSIONS

The tactile corneal reflex is present in only a minority of newborns and develops during the first 3 months of life. These results demonstrate that the tactile corneal reflex has a longitudinal neurologic development and is part of the normal neurologic maturation process.