A prospective multicentre randomized placebo-controlled superiority trial in patients with suspected bacterial endophthalmitis after cataract surgery on the adjuvant use of intravitreal dexamethasone to intravitreal antibiotics

PURPOSE

We aimed to determine whether intravitreal dexamethasone as an adjuvant to intravitreal antibiotics is beneficial in the treatment of suspected bacterial endophthalmitis after cataract surgery.

METHODS

Randomized, placebo-controlled superiority trial in three tertiary referral centres in the Netherlands. Patients with suspected bacterial endophthalmitis within 6 weeks after cataract surgery were eligible. A diagnostic vitreous biopsy was taken for culture, and patients received intravitreal injections of 400 μg dexamethasone (without preservatives) or placebo, in addition to 0.2 mg vancomycin and 0.05 mg gentamicin. The vancomycin and dexamethasone or placebo injections were repeated once at day 3 or 4. Primary outcome measure was best-corrected visual acuity (BCVA) at 1 year.

RESULTS

Between 1 November 2004 and 1 March 2014 (excluding two interruptions totalling 20 months), 324 eligible patients presented. A total of 167 patients (81 dexamethasone, 86 placebo) were available for the intention-to-treat analysis. Biopsies of 114 patients (68%) were culture-positive. Final BCVA did not differ between the dexamethasone and the placebo group (logMAR 0.31 ± 0.58 versus 0.27 ± 0.50; p = 0.90), nor did the number of patients with final vision of no light perception (LP, 7 versus 13). Pain, corneal oedema, the absence of a red fundus reflex on presentation, LP on presentation and culture of virulent pathogens from biopsy were statistically significantly associated with an unfavourable visual outcome.

CONCLUSION

Intravitreal dexamethasone without preservatives as an adjuvant to intravitreal antibiotics does not improve visual acuity (VA) in patients treated for suspected bacterial endophthalmitis after cataract surgery.

Vitreous base visualisation through trans-scleral illumination with a standard 25-gauge light probe

PURPOSE

To describe a technique of vitreous base visualisation through trans-scleral illumination using a standard 25-gauge light probe.

METHODS

All vitrectomies are performed using 25-gauge+ instruments and valved trocars. A non-contact viewing system is used to visualise the retina. After core vitrectomy and the necessary additional procedures, triamcinolone acetonide (Kenacort) is injected in the vitreous cavity. Then, the standard 25-gauge light pipe is covered with a sleeve obtained from a 20-gauge venflon cannula. The light brightness is increased to 100%, and the light probe used to indent the sclera and trans-illuminate the vitreous base. The vitreous cutter is activated between the crystals of triamcinolone acetonide and the retinal surface. Complete vitreous base shaving is carried out for 360°.

RESULTS

Iatrogenic peripheral retinal tears, as a result of vitreous shaving, occurred in 4.1% of cases with this technique.

CONCLUSIONS

This method represents a valid and low-cost option to achieve accurate vitreous base shaving.

Erosive Vitreoretinopathy and Wagner Disease Are Caused by Intronic Mutations inCSPG2/VersicanThat Result in an Imbalance of Splice Variants

PURPOSE

Linkage intervals for erosive vitreoretinopathy (ERVR) and Wagner disease previously were found to overlap at 5q14.3. In a Japanese family with Wagner disease, a CSPG2/Versican splice site mutation (c.4004-2A-->G) was recently reported that resulted in a 39-nucleotide exon 8 in-frame deletion. We investigated whether CSPG2/Versican was mutated in six Dutch families and one Chinese family with Wagner disease and in a family with ERVR.

METHODS

In all families, extensive ophthalmic examinations, haplotype analysis of the 5q14.3 region, and sequence analysis of CSPG2/Versican were performed. The effects of splice site mutations were assessed by reverse transcription-polymerase chain reaction (RT-PCR) and real-time quantitative RT-PCR (QPCR).

RESULTS

Three novel intron 7 sequence variants (c.4004-5T-->C, c.4004-5T-->A, c.4004-1G-->A) were identified in seven families. The c.4004-5T-->C variant was identified in four families with Wagner disease and a family with ERVR. The families were shown to carry the same 5q14.3 haplotype, strongly suggesting that this is a common Dutch founder variant. All three changes segregated with the disease in the respective families and were absent in 250 healthy individuals. In patients with the c.4004-5T-->A and c.4004-1G-->A variants, RT-PCR analysis of CSPG2/Versican showed activation of a cryptic splice site resulting in a 39-nt exon 8 in-frame deletion in splice variant V0. QPCR revealed a highly significant (P < 0.0001) and consistent increase of the V2 (>38-fold) and V3 (>12-fold) splice variants in all patients with intron 7 nucleotide changes and in a Chinese Wagner disease family, in which the genetic defect remains to be found.

CONCLUSIONS

Wagner disease and ERVR are allelic disorders. Seven of the eight families exhibit a variant in intron 7 of CSPG2/Versican. The conspicuous clustering of sequence variants in the splice acceptor site of intron 7 and the consistent upregulation of the V2 and V3 isoforms strongly suggest that Wagner disease and ERVR may belong to a largely overlooked group of diseases that are caused by mRNA isoform balance shifts, representing a novel disease mechanism.

A novel technique for self-sealing, wedge-shaped pars plana sclerotomies and its features in ultrasound biomicroscopy and clinical outcome

PURPOSE

To investigate a new type of self-sealing pars plana sclerotomy clinically and by means of ultrasound biomicroscopy and to compare the outcome with conventionally sutured sclerotomies.

DESIGN

Prospective, nonrandomized clinical trial.

METHODS

Twenty-one patients underwent pars plana vitrectomy either with (control group) or without suturing (study group) at the Institute of Ophthalmology, University Medical Centre Nijmegen, The Netherlands, between January 1 and March 31, 2002. One day and 6 to 8 weeks postoperatively, the sclerotomy sites were studied by clinical examination and ultrasound biomicroscopy. Results were graded according to verbal descriptor scales.

RESULTS

The study included 21 patients scheduled for pars plana vitrectomy of one eye. Mean follow-up time was 6.5 weeks (range, 6-8). Three patients were lost to follow-up. Of the remaining patients, 12 had self-sealing wedge-sclerotomies and six were conventionally operated. No intraoperative complications occurred in any participant and no visual loss or postoperative hypotony was observed. On the first day after surgery there was significantly more scleral dehiscence in the control group (P =.012). This divergence disappeared during the follow-up period. All other differences noticed were not statistically significant.

CONCLUSIONS

Our novel technique of sutureless wedge-shaped sclerotomy allows the creation of simple, reliable, and self-sealing pars plana openings. Clinical examination and assessment by ultrasound biomicroscopy showed results to be at least as safe as conventionally sutured sclerotomies. This new method allows stable intraoperative ocular pressure conditions and seems promising.

Rhegmatogenous retinal detachment and uveitis

PURPOSE

To evaluate the frequency, high-risk factors, and visual prognosis of rhegmatogenous retinal detachment (RRD) in patients with uveitis.

DESIGN

Retrospective case-control study.

PARTICIPANTS

We included 1387 consecutive patients with uveitis who consulted our uveitis clinic from January 1990 through December 1997 of whom 43 patients (46 eyes) with RRD were identified. The retinal detachment (RD) controls were 212 consecutive patients with RRD (221 eyes, first occurrence of RD, not associated with uveitis) who were admitted for surgery in the period from April 1999 to April 2000. The uveitis control group consisted of 150 age-matched patients (210 eyes) selected from the entire uveitis series.

INTERVENTION

Retrospective analysis of clinical data.

MAIN OUTCOME MEASURES

The presence of RRD and eventual risk factors for RRD, such as myopia, retinal lattice degeneration, prior intraocular surgery, anatomic location of uveitis, its specific diagnosis, and clinical manifestations. Furthermore, the surgical and nonsurgical outcomes of RRD, as well as the results of various treatment regimens, were analyzed.

RESULTS

RRD was identified in 3.1% of the patients with uveitis. RRD was most frequently associated with panuveitis (6.6%). RRD was associated more frequently with infectious (7.6%) than noninfectious uveitis (2.1%). At the onset of RRD, uveitis was active in most (46%) affected eyes. Proliferative vitreoretinopathy was present in 30% of the uveitic RRD eyes at presentation in contrast to 12% of the RRD control eyes. In uveitic RRD, the retina was reattached in 59% of eyes with a single operation; the final anatomic reattachment rate was 88%. Finally, a visual acuity of less than 20/200 was present in 71% of the uveitic RRD eyes, 10% of which had no light perception.

CONCLUSIONS

We discovered a high prevalence of RRD in patients with active panuveitis and infectious uveitis and document that uveitis in itself is a risk factor for the development of RRD. The visual prognosis of RRD in uveitis was poor because of the uveitis itself and the frequent development of proliferative vitreoretinopathy.