Systemic Adverse Events Among Patients With Diabetes Treated With Intravitreal Anti-Vascular Endothelial Growth Factor Injections

Importance

Anti-vascular endothelial growth factor (VEGF) agents are currently the mainstay of treatment for diabetic retinopathy (DR). Although effective, data on their systemic safety remains inconclusive, particularly in high-risk patient groups.

Objective

To explore the systemic safety of intravitreal anti-VEGF agents among patients with diabetes.

Design, Setting, and Participants

This was a retrospective, longitudinal population-based analysis of the Corporate Data Warehouse, a large-scale database of patients within the US Veteran Health Affairs. All patients 18 years and older with type 2 diabetes who were seen at any Veterans Affairs health care facility in the US between January 1, 2011, and December 31, 2012, were identified. Data were then extracted on incident systemic adverse events among this patient cohort from January 1, 2013, to December 31, 2017. All individuals with diabetes who did and did not receive anti-VEGF injections were included. Patients with a history of prior systemic adverse events and those who received an intravitreal injection between January 1, 2011, and December 31, 2012, were excluded. Data were analyzed from October 2019 to March 2023.

Exposure

Anti-VEGF injection.

Main Outcomes and Measures

Proportion of patients with any incident systemic adverse event, acute myocardial infarction, cardiovascular disease, or kidney disease at 1-, 3-, and 5-year follow-up.

Results

A total of 1 731 782 patients (mean [SD] age, 63.8 [12.3] years; 1 656 589 [95.7%] male) with type 2 diabetes were included. DR was present in 476 013 (27.5%), and 14 022 (0.8%) received anti-VEGF injections. Of the total number of patients with type 2 diabetes, 321 940 (18.6%) developed systemic adverse events between 2013 and 2017. The 5-year cumulative incidence of any systemic adverse event was 37.0% (5187/14 022) in the injection group vs 18.4% (316 753/1 717 760) in the noninjection group (P < .001). Anti-VEGF injections were independently associated with a higher likelihood of developing any systemic adverse event (odds ratio, 1.8; 95% CI, 1.7-1.9) when controlling for age, race, sex, ethnicity, tobacco use, severity of DR, Deyo-Charlson Comorbidity Index score, mean hemoglobin A1c, total number of injections, and statin use.

Conclusion and Relevance

In this study, intravitreal anti-VEGF injections were independently associated with a higher likelihood of systemic adverse events among patients with diabetes.

Locally Invasive Diffuse Iris Ring Melanoma Presenting as Unilateral Severe Glaucoma: Case Report and Review of Molecular Genetics

We report the clinical history and histopathological findings in a case of diffuse iris ring melanoma (DIM) and review the most recent literature and modern molecular genetics of this entity. An 85-year-old Hispanic man presented with severe unilateral glaucoma, managed at an outside institution for 2 years prior to presentation. Diffuse pigmentation was noted in the angle, on the intraocular lens implant, and in the vitreous without clear demonstration of a mass on ultrasound biomicroscopy. Workup for metastatic cutaneous melanoma was negative. Histopathological examination of the enucleated eye revealed a mixed cell type iris ring melanoma with diffuse intraocular involvement. Gene expression profiling (GEP) revealed a class 2 molecular signature indicating a very high risk for metastases. Unilateral glaucoma presenting with marked pigmentation in the anterior chamber angle should be managed as melanoma until proven otherwise. Iris ring melanomas are known to have an aggressive clinical course, and recent molecular analyses indicate that they are likely primarily GEP class 2 with a very poor prognosis, similar to the majority of ciliary body melanomas.

Validity of code based algorithms to identify primary open angle glaucoma (POAG) in Veterans Affairs (VA) administrative databases

PURPOSE

The validity of the International Classification of Diseases, 9th revision, Clinical Modification (ICD-9) code for primary open angle glaucoma (POAG) in the Department of Veterans Affairs (VA) electronic medical record has not been examined. We determined the accuracy of the ICD-9 code for POAG and developed diagnostic algorithms for the detection of POAG.

METHODS

We conducted a retrospective study of abstracted data from the Michael E. DeBakey VA Medical Center's medical records of 334 unique patients with at least one visit to the Eye Clinic between 1999 and 2013. Algorithms were developed to validly identify POAG using ICD-9 codes and pharmacy data. The positive predictive value (PPV), negative predictive value (NPV), sensitivity, specificity and percent agreement of the various algorithms were calculated.

RESULTS

For the ICD-9 code 365.1x, the PPV was 65.9%, NPV was 95.2%, sensitivity was 100%, specificity was 82.6%, and percent agreement was 87.8%. The algorithm with the highest PPV was 76.3%, using pharmacy data in conjunction with two or more ICD-9 codes for POAG, but this algorithm also had the lowest NPV at 88.2%.

CONCLUSIONS

Various algorithms for identifying POAG in the VA administrative databases have variable validity. Depending on the type of research being done, the ICD-9 code 365.1x can be used for epidemiologic or health services database research.

Outcomes of anterior chamber intraocular lenses placed by surgeons in training

PURPOSE

To evaluate risk factors and outcomes of unplanned, primary anterior chamber intraocular lenses (AC IOLs) placed by surgeons in training.

SETTING

Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.

DESIGN

Retrospective case series.

METHODS

Cataract surgeries performed primarily by a resident surgeon that resulted in an unplanned AC IOL were included. Cases that had concomitant retinal surgery were excluded. Preoperative data gathered included corrected distance visual acuity (CDVA), intraocular pressure (IOP), and ocular comorbid conditions. Operative times and complications requiring an AC IOL were assessed. Postoperative CDVA, IOP, corneal edema, persistent intraocular inflammation, macular edema, and need for additional surgery were analyzed for the first postoperative year.

RESULTS

Twenty-two eyes were included. The mean preoperative CDVA was 1.24 logMAR ± 0.92 SD and the mean preoperative IOP was 17.55 ± 3.88 mm Hg. The mean operative time was 103 ± 30 minutes. The most common operative complications necessitating an AC IOL were 7 (32%) capsule tears with vitreous prolapse requiring anterior vitrectomy and 7 (32%) capsule tears, zonular dehiscence, and vitreous prolapse requiring anterior vitrectomy. By the first postoperative year, the mean visual acuity was 0.40 ± 0.58 logMAR and the IOP was 15.05 ± 6.01 mm Hg. The most common complications 1 year postoperatively included persistent macular edema (23%) and need for additional surgery (18%).

CONCLUSION

This group of patients who received unplanned primary AC IOLs by surgeons in training had improved visual acuity and well-controlled IOP 1 year postoperatively.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

Topical silver nanoparticles result in improved bleb function by increasing filtration and reducing fibrosis in a rabbit model of filtration surgery

PURPOSE

To compare the effects of silver nanoparticles (AgNPs) and mitomycin C (MMC) on intraocular pressure (IOP) and external, histologic, and immunohistochemical bleb characteristics in a rabbit model of filtration surgery.

METHODS

Filtration surgery with concurrent topical application of either AgNPs or MMC was performed on 14 pigmented Dutch Belted rabbits. IOP and bleb characteristics were compared on postoperative day 1 and at weeks 1 through 6. Hematoxylin and eosin staining and smooth muscle actin (SMA) immunohistochemistry were performed at postoperative week 6.

RESULTS

Average IOP across all time points was reduced 5.8 and 3.8 mm Hg in AgNP- and MMC-treated eyes, respectively. At week 6, IOP was reduced 4.1 and 0.2 mm Hg in AgNP- and MMC-treated eyes, respectively. Blebs were smaller, thicker, and less ischemic in AgNP-treated eyes. AgNP-treated eyes showed less fibrosis and more stromal edema, suggesting increased filtration, and also had fewer SMA-positive myofibroblasts, suggesting reduced bleb contraction. AgNP-treated eyes showed more lymphocytes than MMC-treated eyes. There were few complications in both groups.

CONCLUSIONS

In a rabbit model of filtration surgery, AgNPs are a reasonable alternative to MMC as adjunctive therapy. Compared to MMC, AgNPs result in an improved and sustained reduction of IOP and promote blebs with decreased fibrosis and ischemia as well as increased filtration despite a smaller overall size. This combination may offer an opportunity to promote long-term surgical IOP reduction with an improved complication profile.

The PCP's role in chronic open-angle glaucoma

Chronic open-angle glaucoma is a leading cause of blindness and visual impairment in older adults. Optic nerve damage and the associated peripheral and subsequent central vision loss are irreversible, but early diagnosis and treatment will give patients the best chance to maintain functional vision and quality of life. Primary care physicians can assist with the diagnosis of glaucoma by making appropriate referrals for routine ophthalmic examinations, especially in patients with risk factors for glaucoma. Medication adherence and persistence may also be enhanced by discussing strategies to improve medication use and efficacy in the primary care setting. Recognition of adverse reactions from glaucoma medications and surgeries will allow proper management of these potentially serious conditions. Patients with advanced visual deficits can still benefit from treatment as well as low-vision and supportive care and should be referred for an ophthalmic evaluation. With an understanding of comprehensive glaucoma management, primary care physicians play an invaluable role in assisting their patients with effective and timely therapy that will result in improved outcomes.

The safety and efficacy of travoprost 0.004%/timolol 0.5% fixed combination ophthalmic solution

PURPOSE

To compare the safety and intraocular pressure (IOP)-lowering efficacy of travoprost 0.004%/timolol 0.5% fixed combination ophthalmic solution (Trav/Tim) to its components travoprost 0.004% ophthalmic solution, TRAVATAN, (Trav) and timolol 0.5% ophthalmic solution (Tim) in patients with open-angle glaucoma or ocular hypertension.

DESIGN

Randomized multicenter, double-masked, active-controlled, parallel group study.

METHODS

Two hundred sixty-three patients with open-angle glaucoma or ocular hypertension were randomized to receive Trav/Tim once daily AM (and vehicle PM), Trav once daily PM (and vehicle AM), or Tim twice daily (AM and PM). Efficacy and safety were compared across treatment groups over 3 months.

RESULTS

Trav/Tim produced a mean IOP decrease from baseline of 1.9 mm Hg to 3.3 mm Hg more than Tim, with a significant decrease in mean IOP at each of the nine study visits (P < or = .003). Trav/Tim decreased mean IOP by 0.9 mm Hg to 2.4 mm Hg more than Trav, with a significant decrease in mean IOP at seven of the nine study visits (P < or = .05). The adverse event profile for Trav/Tim was comparable to Trav or Tim alone.

CONCLUSIONS

Over the 3 months of treatment, Trav/Tim produced clinically relevant IOP reductions in patients with open-angle glaucoma or ocular hypertension that were greater than those produced by either Trav or Tim alone. The clinical results that Trav/Tim was safe and well tolerated with an incidence of adverse events was comparable to the results of Trav or Tim alone. Trav/Tim provides both more effective IOP reduction than its components and the benefits of once-daily dosing.

Corneal thickness in children

OBJECTIVE

To determine normal central and paracentral corneal thickness measurements in the pediatric population and to determine if these measurements are consistent across different pediatric age groups and different racial groups.

DESIGN

Prospective observational case series.

METHODS

Pachymetry measurements were performed on 198 eyes of 108 children. The measurements were taken centrally as well as at four paracentral sites 3 mm from the corneal center at the 3, 6, 9, and 12 o'clock positions. The two-tailed t test was used for comparison of the continuous means for values of corneal thickness. Analysis of variance (ANOVA) was performed to determine differences among age and ethnic groups

RESULTS

The mean central corneal thickness (CCT) was 549 +/- 46 microm. Paracentral corneal thickness mean values, as measured 3 mm from the corneal center, were as follows: superior, 575 +/- 52 microm; nasal, 568 +/- 50 microm; inferior, 568 +/- 51 microm; and temporal, 574 +/- 47 microm. The mean CCT values were significantly thinner than at each of the mean paracentral points (P < .05 for each comparison, paired t test). Paracentral corneal thickness measurements demonstrated no significant differences between locations (P > .05, variance analysis). The mean CCT +/- SD for each age group was as follows: 6 to 23 months, 538 +/- 40 microm; 2 to 4 years, 546 +/- 41 microm; 5 to 9 years, 566 +/- 48 microm; and 10 to 18 years, 554 +/- 35 microm (ANOVA P = .012). ANOVA performed on central pachymetry values demonstrated no significant differences among racial subgroups.

CONCLUSIONS

Pediatric central and paracentral corneal thicknesses increase slowly over time and reach adult thicknesses at 5 to 9 years of age.

Aspirin Use in Advanced Uncontrolled Glaucoma

PURPOSE

To evaluate if aspirin use affects progression of primary open angle glaucoma (POAG).

METHODS

A retrospective review of patients with uncontrolled glaucoma was performed. Incidence of aspirin use was noted by a one-time self-reporting survey. Controls were medically stable patients diagnosed with POAG. The primary outcome measure studied was a comparison of percentages of aspirin use in patients who have and have not undergone glaucoma filtering surgery (trabeculectomy).

RESULTS

Forty-one percent (26/64) of the patients in the trabeculectomy group and 23% (17/74) of controls were using aspirin. Patients undergoing trabeculectomy were twice as likely to take aspirin (O.R., 2.29; 95% C.I., 1.10-4.79). Subgroup analyses demonstrated increased aspirin use in those operative patients who are current or former smokers (O.R., 3.71; 95% C.I., 1.10-12.56), have systemic hypertension (O.R., 3.30; 95% C.I., 1.02-22.58), or have joint disease (O.R., 4.60; 95% C.I., 1.34-15.82).

CONCLUSION

A higher concurrence of aspirin use was observed in patients with POAG who required surgical management compared with patients having relatively medically stable glaucoma. This may be secondary to a higher rate of glaucoma surgery performed on patients with greater systemic illnesses, more of whom use aspirin.

Neurologic Impairment 10 Years After Optic Neuritis

BACKGROUND

Participants enrolled in the Optic Neuritis Treatment Trial have been observed for more than a decade to assess the relationship between optic neuritis and the development of clinically definite multiple sclerosis.

OBJECTIVE

To assess neurologic disability 10 to 12 years after an initial episode of optic neuritis.

DESIGN

Longitudinal follow-up of a clinical trial.

SETTING

Fourteen Optic Neuritis Treatment Trial clinical centers performed standardized neurologic examinations, including an assessment of neurologic disability.

PARTICIPANTS

One hundred twenty-seven patients who had developed clinically definite multiple sclerosis.

MAIN OUTCOME MEASURES

Functional Systems Scale and Expanded Disability Status Scale.

RESULTS

The disability of most patients was mild, with 65% of patients having an Expanded Disability Status Scale score lower than 3.0. The degree of disability appeared to be unrelated to whether the baseline magnetic resonance imaging scan was lesion-free or showed lesions (P =.51). Among patients with baseline lesions, the degree of disability was unrelated to the number of lesions that were present on the scan (P =.14). Two patients died owing to severe multiple sclerosis, one of whom had no lesions revealed on the baseline scan.

CONCLUSION

Most patients who develop clinically definite multiple sclerosis following an initial episode of optic neuritis will have a relatively benign course for at least 10 years.

Visual function more than 10 years after optic neuritis: experience of the optic neuritis treatment trial

PURPOSE

To assess visual function more than 10 years after an episode of optic neuritis in patients enrolled in the Optic Neuritis Treatment Trial.

DESIGN

Longitudinal follow-up of a randomized clinical trial.

METHODS

Vision testing included measures of visual acuity, contrast sensitivity, and visual field. Quality of life was assessed with the National Eye Institute Visual Function Questionnaire.

RESULTS

Examinations were completed on 319 patients. In most patients, visual function test results in the eyes that experienced optic neuritis at study entry ("affected eyes") were normal or only slightly abnormal after 9.9 to 13.7 years. Visual acuity in the affected eyes was >or=20/20 in 74%, 20/25 to 20/40 in 18%, <20/40 to 20/200 in 5%, and <20/200 in 3%. On average, visual function was worse in patients with multiple sclerosis (MS) than in those without MS. Recurrent optic neuritis in either eye occurred in 35% of patients. Such attacks were more frequent in patients with MS (P <.001). The National Eye Institute Visual Function Questionnaire scores were lower when visual acuity was abnormal and when MS was present.

CONCLUSIONS

Most patients retained good to excellent vision more than 10 years after an attack of optic neuritis. Recurrences were more frequent in patients with MS.

High- and low-risk profiles for the development of multiple sclerosis within 10 years after optic neuritis: experience of the optic neuritis treatment trial

OBJECTIVE

To identify factors associated with a high and low risk of developing multiple sclerosis after an initial episode of optic neuritis.

METHODS

Three hundred eighty-eight patients who experienced acute optic neuritis between July 1, 1988, and June 30, 1991, were followed up prospectively for the development of multiple sclerosis. Consenting patients were reassessed after 10 to 13 years.

RESULTS

The 10-year risk of multiple sclerosis was 38% (95% confidence interval, 33%-43%). Patients (160) who had 1 or more typical lesions on the baseline magnetic resonance imaging (MRI) scan of the brain had a 56% risk; those with no lesions (191) had a 22% risk (P<.001, log rank test). Among the patients who had no lesions on MRI, male gender and optic disc swelling were associated with a lower risk of multiple sclerosis, as was the presence of the following atypical features for optic neuritis: no light perception vision; absence of pain; and ophthalmoscopic findings of severe optic disc edema, peripapillary hemorrhages, or retinal exudates.

CONCLUSIONS

The 10-year risk of multiple sclerosis following an initial episode of acute optic neuritis is significantly higher if there is a single brain MRI lesion; higher numbers of lesions do not appreciably increase that risk. However, even when brain lesions are seen on MRI, more than 40% of the patients will not develop clinical multiple sclerosis after 10 years. In the absence of MRI lesions, certain demographic and clinical features seem to predict a very low likelihood of developing multiple sclerosis. This natural history information is a critical input for estimating a patient's 10-year multiple sclerosis risk and for weighing the benefit of initiating prophylactic treatment at the time of optic neuritis or other initial demyelinating events in the central nervous system.

Evaluation of travoprost as adjunctive therapy in patients with uncontrolled intraocular pressure while using timolol 0.5%

PURPOSE

To evaluate the intraocular pressure-lowering efficacy and safety of travoprost 0.0015% and 0.004%, dosed daily in the evening compared with vehicle, in patients with open-angle glaucoma or ocular hypertension, whose intraocular pressure was not adequately controlled on timolol 0.5% twice daily (twice daily).

METHODS

Subjects who qualified at screening began a run-in period dosing timolol twice daily for 3 weeks. If the subjects had an intraocular pressure of 24 to 36 mm Hg at 8 AM and 21 to 36 mm Hg at 10 AM and 4 pm in at least one eye on timolol, they were randomized to one of two concentrations of travoprost (0.0015% or 0.004%) or vehicle solution every day and were followed for 6 months. Four hundred twenty-six subjects were randomized. The mean intraocular pressure at 8 AM, 10 AM, and 4 PM in the patient's eye with the higher intraocular pressure was used for the analysis.

RESULTS

Mean baseline values (25 mm Hg) for subjects at eligibility (while maintained on timolol) were not significantly different (P <.0001) among the treatment groups. The intraocular pressure was lowered an additional -5.7 to -7.2 mm Hg and -5.1 to -6.7 mm Hg in the travoprost 0.004% and 0.0015% concentrations, respectively. These changes were significantly (P < or =.0001) different from the vehicle group (-1.3 to -2.8 mm Hg). The intraocular pressure range on treatment at all visit times over the 6-month treatment period ranged from 17.9 to 19.2 mm Hg for travoprost 0.004% and 18.3 to 20.1 mm Hg for travoprost 0.0015% compared with 22.4 to 24.1 mm Hg for vehicle. Average hyperemia scores ranged from trace to mild (mean 0.5 on a scale of 0 = none/trace; 1= mild; 2 = moderate; 3 = severe) for all treatment groups. No iris pigmentation changes were observed in any patient during this study. There were no clinically or statistically significant changes from baseline in visual acuity, ocular cells and flare, fundus parameter, cup-to-disk ratio and visual field between the treatment groups. There were no serious adverse events reported for any treatment group.

CONCLUSIONS

Travoprost produced clinically relevant and statistically significant additional intraocular pressure reductions from baseline when used adjunctively with timolol in subjects with open-angle glaucoma or ocular hypertension.

Central corneal thickness of Caucasians and African Americans in glaucomatous and nonglaucomatous populations

OBJECTIVE

To determine whether there is a difference in central corneal thickness between African American and Caucasian patients. If present, a difference might alter the measurement of intraocular pressure and potentially the assessment and management of glaucoma in these populations.

METHODS

Central corneal thickness was measured by means of ultrasound pachymetry in African American (n = 56) and Caucasian (n = 32) patients with suspected or confirmed glaucoma and control populations of African American (n = 26) and Caucasian (n = 51) subjects in whom there was no evidence of elevated intraocular pressure or glaucomatous optic nerve damage. Measurements of central corneal thickness were then compared between different subpopulations by means and population distribution analysis.

RESULTS

A statistically significant difference was noted between the mean (+/-SD) central corneal thickness of all African American (including those with and without glaucoma) (right eye, 531.0 +/- 36.3 microm; left eye, 530.0 +/- 34.6 microm) and all Caucasian (including those with and without glaucoma) (right eye, 558.0 +/- 34.5 microm; left eye, 557.6 +/- 34.5 microm) patients. Similar results were found when subpopulations were tested. Distribution analysis of central corneal thickness measurements noted the largest cluster of African American patients around 520 to 540 microm, whereas the largest cluster of Caucasian patients was between 580 and 600 microm.

CONCLUSIONS

African Americans were found to have thinner central cornea thickness measurements than Caucasians. This finding in African Americans may lead to lower applanation intraocular pressure readings compared with those of Caucasians, potentially resulting in an underestimation of the actual level of intraocular pressure.

Effects of atropine on anterior chamber depth and anterior chamber inflammation after primary trabeculectomy

PURPOSE

To investigate the effects of postoperative atropine on central and peripheral anterior chamber depth and anterior chamber inflammation in patients undergoing primary trabeculectomy.

METHODS

Two separate groups of patients who were phakic without previous intraocular surgery undergoing primary trabeculectomy were prospectively randomized to atropine or no atropine. In the first group of patients, 24 eyes of 21 patients undergoing primary trabeculectomy were prospectively randomized to atropine or no atropine, and their anterior chamber depth was measured. Central and peripheral chamber depths were measured using the EAS-1000 anterior segment analysis system (Nidek, Tokyo, Japan) before surgery and on postoperative days 1, 3, 7, 14, and 30. In the second group, 34 patients undergoing primary trabeculectomy were prospectively randomized to atropine or no atropine, and their anterior chamber reaction was documented. The amount of cells and flare was measured using the Kowa laser flare meter (FM-500) and cell counter (LC-500) (Kowa Electronics and Optics, Tokyo, Japan) preoperatively and on postoperative day 1, 7, and 30.

RESULTS

Compared with preoperative measurements, a small (approximately 0.1 mm) but statistically significant deepening of the central and peripheral anterior chamber depth on days 1, 7, 14, and 30 was found in patients who used atropine. In the nonatropine group, no statistically significant change was found in central or peripheral anterior chamber depths at any time as compared with preoperative values. There was no statistically significant difference in the cell or flare counts between the atropine and nonatropine groups at any time.

CONCLUSIONS

This study showed a small but statistically significant deepening of the anterior chamber with atropine. No statistically significant differences were observed in the cell or flare counts between atropine and nonatropine groups. Routine atropine use after trabeculectomy may not be necessary to reduce postoperative complications, such as shallowing of the anterior chamber or anterior chamber inflammation. In patients with a shallow anterior chamber, however, atropine would be expected to deepen the chamber.

Incidence of brimonidine allergy in patients previously allergic to apraclonidine

PURPOSE

This study was performed to determine the incidence of allergic reaction to brimonidine in patients who have previously demonstrated an allergic reaction to apraclonidine.

METHODS

A retrospective chart review was performed to identify patients who had demonstrated an allergic reaction to apraclonidine of sufficient severity to result in drug discontinuation. Within this group, those patients subsequently treated with brimonidine were isolated and analyzed, and the incidence of allergy to brimonidine was determined.

RESULTS

Forty-five patients were identified with a significant allergic reaction to apraclonidine that resulted in drug discontinuation. Of these patients, 22 subsequently received brimonidine. Follow-up on all patients was obtained for at least 15 months. All but two of the 22 patients were taking additional topical glaucoma medications, ranging from one to three additional agents with an average of 1.8+/-0.8 medications. Seventeen patients incurred no allergic reaction to brimonidine. Only five patients (22.7%) previously allergic to apraclonidine developed an allergic reaction to brimonidine. Three of these patients demonstrated only a follicular conjunctival reaction, one had conjunctival hyperemia, and one patient developed a periocular dermatitis. The allergic reactions developed at 8.2+/-1.2 months after initiation of brimonidine therapy.

CONCLUSIONS

In this study, the risk of developing an allergic reaction to brimonidine in patients known to be allergic to apraclonidine is 22.7%. This lack of a strong cross-reactive allergic response possibly suggests different allergic mechanisms for these two medications. Therefore, brimonidine therapy in patients previously identified as being allergic to apraclonidine is safe and does not result in a cross-reactive response in the great majority of patients (or in nearly four of five patients).

Early successful treatment of postoperative necrotizing pseudomonas scleritis after trabeculectomy

PURPOSE

The authors describe a patient who developed pseudomonas scleritis after a routine trabeculectomy.

METHOD

The patient underwent trabeculectomy for poorly controlled intraocular pressure and progressive visual field loss. On the second postoperative date he developed severe pain, significant anterior chamber reaction, and hypotony. Scleral cultures taken at the time of surgical choroidal drainage grew pseudomonas aeruginosa.

RESULT

Surgical reconstruction of the necrotic scleral area and intensive antibiotic treatment lead to a successful outcome.

CONCLUSION

Early recognition and aggressive treatment with antibiotics initially, followed by surgical debridement of necrotic tissue, resulted in an unexpected successful outcome in a patient with pseudomonas scleritis.

Clinical experience with apraclonidine 0.5%

PURPOSE

This study describes our long-term experience with apraclonidine 0.5% in the treatment of chronic glaucoma in clinical practice.

METHODS

A retrospective review was performed of all consecutive patients treated with apraclonidine 0.5%, specifically studying the magnitude of IOP reduction, incidence of allergic reaction, frequency of ineffectiveness, and its additivity to other anti-glaucoma medications. Patients previously treated with this agent or in whom multiple simultaneous medication changes were made were excluded.

RESULTS

A total of 174 patients were included in this study and followed up to 24 months. For 38 patients (21%), the drug was found to be ineffective at some point during the study. A similar number of patients developed an allergic reaction to the medication. Intraocular pressure lowering ranged from 19 to 26% overall, and 22.5 to 29% in those responding to apraclonidine 0.5%.

CONCLUSION

In this study, apraclonidine 0.5% was shown to be effective in reducing intraocular pressure, both for short-term situations and for longer periods of treatment, up to 24 months.

Acquired supranuclear ocular motor paresis following cardiovascular surgery

Acquired supranuclear ocular motor paresis is a rare disorder characterized by impaired saccadic and smooth pursuit eye movements in one or more directions of gaze. Vestibularly induced eye movements, however, are preserved. Six adult patients developed an acquired supranuclear ocular motor paresis following cardiopulmonary bypass surgery. Neuroimaging studies were normal in two patients and were consistent with small vessel ischemia in four patients. The mean cardiopulmonary bypass time was 132.3 min, and mean circulatory arrest time was 38.7 min; these were not outside established norms for this type of surgery. Patients undergoing cardiopulmonary bypass procedures with deep hypothermia are at risk for acquired supranuclear ocular motor paresis, but the development of this syndrome may not be predictable by duration of circulatory arrest or cardiopulmonary bypass times.

Picosecond neodymium:yttrium lithium fluoride (Nd:YLF) laser peripheral iridotomy

PURPOSE

We evaluated the picosecond neodymium:yttrium lithium fluoride (Nd:YLF) laser for performing peripheral iridotomies of predetermined size and shape in various types of irides.

METHODS

In the first part of the study, we determined operating parameters from performing 60 iridotomies in human cadaver eyes. Subsequently, using the parameters obtained in cadaver eyes, iridotomies were created in eyes of patients with primary angle-closure glaucoma.

RESULTS

In the cadaver eyes, the optimal parameters were a rectangular cutting pattern of 0.3 x 0.3 mm, 500-microns cutting depth, 50-microns spot separation, 200 to 400 microJ of energy per pulse, 200 to 400 pulses per second, and no focal offset distance. In 18 eyes of 11 patients, iridotomies with well-defined margins and size were created. Minimal hemorrhage occurred intraoperatively in ten of 18 eyes (55.6%), which did not affect the outcome of the procedure. Increases of postoperative intraocular pressure at one hour averaged 3.5 +/- 5.1 mm Hg, with an increase of more than 10 mm Hg in three eyes (16.7%), and a maximum of 12 mm Hg. We observed no corneal or retinal damage.

CONCLUSION

The picosecond Nd:YLF laser seems to be an effective instrument for reliably performing peripheral iridotomies of precise size and shape using low energy per pulse levels. This laser, unlike the argon laser, is successful independent of iris thickness or color and can easily make a larger iridotomy than is often possible with the Nd:YAG laser.

Gonioscopic ab interno Nd:YLF laser sclerostomy in human cadaver eyes

We explored the potential of the picosecond Nd:YLF laser to perform gonioscopic ab interno sclerostomy in human cadaver eyes. Full-thickness sclerostomies were created in 12 such eyes and confirmed by external scleral and histopathologic examination. Optimum parameters for successful completion of a sclerostomy were: a rectangular pattern of 0.3 mm by 0.3 mm, a repetition rate of 1000 pulses per second, an energy-per-pulse of 400 mJ, and a spot separation between 10 and 50 microns, with no focal offset. The Nd:YLF laser reliably created successful gonioscopic sclerostomies with minimal adjacent thermal damage in human cadaver eyes.

Low mature TGF-beta 2 levels in aqueous humor during uveitis

PURPOSE

To investigate whether transforming growth factor-beta 2 (TGF-beta 2), a strong immunosuppressive factor normally present in aqueous humor, is involved in the inflammatory process of clinical uveitis.

METHODS

Mature TGF-beta 2 levels were determined in aqueous humor samples of 9 patients with Fuchs' heterochromic cyclitis, aqueous humor samples of 21 patients with other uveitis entities, and vitreous fluid samples of 19 patients with uveitis by using a commercially available sandwich ELISA: Total TGF-beta 2 levels in ocular fluids were measured after heat activation. Aqueous humor samples from patients with cataract and glaucoma and vitreous fluid samples from eye bank eyes were tested as controls. Albumin levels, determined by radial immunodiffusion, were used as a measure of the disruption of the blood aqueous barrier.

RESULTS

Significantly lower mature TGF-beta 2 levels were detected in aqueous humor samples of patients with uveitis, compared to the two control groups without intraocular inflammation. Samples of patients with uveitis without detectable mature TGF-beta 2 did contain latent TGF-beta 2 levels (504 to 6024 pg/ml). In aqueous humor, there was a significant negative correlation between mature TGF-beta 2 and albumin levels. No mature TGF-beta could be detected in vitreous fluid. Total TGF-beta 2 levels in vitreous fluid were significantly lower in samples from patients with uveitis than in samples from eye bank eyes.

CONCLUSION

These results indicate that the mature TGF-beta 2 levels in aqueous humor and the total TGF-beta 2 levels in vitreous fluid are reduced during ocular inflammation. In aqueous humor, this might be caused by binding of mature TGF-beta to serum proteins, for instance, alpha 2-macroglobulin, or by a disturbance in the activation process of latent TGF-beta 2.

A human cadaver eye model for anterior and posterior segment laser applications

We have developed a cadaver eye model that allows anterior and posterior segment laser procedures to be performed under closely simulated in vivo conditions. The model consists of a reusable container with an artificial cornea with a refractive power and an anterior radius of curvature similar to those of the human cornea, and a fresh cadaver eye, prepared by removing the cornea and adjusting the biometric parameters to normal values. This cadaver eye model appears to be a valuable tool for teaching and practicing anterior and posterior segment laser procedures, as well as for research on new laser systems and applications.

Wound healing modulation in glaucoma filtration surgery

In some cases, modulation of wound healing, in association with glaucoma filtration surgery, results in lower postoperative intraocular pressures than would occur without such therapy. Treatments affecting wound healing increase the likelihood of achieving long-term filtration, especially in eyes with a poor surgical prognosis. After summarizing the wound-healing process following filtration procedures, we review the mechanism of action, the effectiveness, and the complications associated with some of the most commonly used wound healing inhibitors and then discuss new alternatives currently under investigation. Although much progress has been made, the challenge remains to develop new drugs or combinations of drugs that are less toxic and can yield more predictable results.