AIM:To examine associations between retinal thickness and rod-mediated dark adaptation in older adults with non-exudative age-related maculopathy (ARM) or normal macular health.METHODS:A cross-sectional study was conducted with 74 adults ≥ 50 years old from the comprehensive ophthalmology and retina services of an academic eye centre. ARM presence and disease severity in the enrolment eye was defined by the masked grading of stereofundus photos using the Clinical Age-Related Maculopathy grading system. High-definition, spectral-domain optical coherence tomography was used to estimate retinal thickness in a grid of regions in the macula. Rod-mediated dark adaptation, recovery of light sensitivity after a photo-bleach, was measured over a 20-min period for a 500 nm target presented at 5° on the inferior vertical meridian. Main outcomes of interest were retinal thickness in the macula (μm) and parameters of rod-mediated dark adaptation (second slope, third slope, average sensitivity, final sensitivity).RESULTS:In non-exudative disease retinal thickness was decreased in greater disease severity; thinner retina was associated with reductions in average and final rod-mediated sensitivity even after adjustment for age and visual acuity.CONCLUSIONS:Impairment in rod-mediated dark adaptation in non-exudative ARM is associated with macular thinning.

PURPOSE:To estimate the risk of hemorrhagic complications associated with 25-gauge pars plana vitrectomy (PPV) when warfarin (Coumadin; Bristol-Myers Squibb, New York, NY) or clopidogrel (Plavix; Bristol-Myers Squibb) are continued throughout the surgical period, as compared with a control group.DESIGN:A single-center, retrospective, cohort study of 289 consecutive patients receiving either warfarin therapy or clopidogrel therapy or neither of those therapies who underwent 25-gauge PPV.PARTICIPANTS:Included were 61 patients (64 eyes; 64 PPV procedures) in the warfarin group and 118 (125 eyes; 136 PPV procedures) in the clopidogrel group. Warfarin patients were subdivided into 4 groups by international normalized ratio (INR). A control group included 110 patients (110 eyes; 110 PPV procedures) who were not receiving warfarin or clopidogrel.METHODS:Retrospective chart review for which the criteria included: 25-gauge PPV, minimum age of 19 years, warfarin or clopidogrel use, and, if taking warfarin, an INR obtained within 5 days of surgery.MAIN OUTCOME MEASURES:Incidence of intraoperative and postoperative hemorrhagic complications.RESULTS:The most common indications for anticoagulation therapy included: atrial fibrillation (38%), valvular heart disease (17%), and thromboembolic disease (16%). The most common indications for antiplatelet therapy included: cardiac stent (49%), coronary artery bypass grafting (24%), and history of transient ischemic attack (16%). No patient experienced anesthesia-related hemorrhagic complications resulting from peribulbar or retrobulbar block. Transient vitreous hemorrhage occurred in 1 (1.6%) of 64 PPV procedures in the warfarin group (P = 0.6531), 5 (3.7%) of 136 PPV procedures in the clopidogrel group (P = 1.0), and 4 (3.6%) of 110 PPV procedures in the control group. No choroidal or retrobulbar hemorrhages occurred in any patient.CONCLUSIONS:The rate of 25-gauge PPV hemorrhagic complications in patients who underwent systemic anticoagulation or who were receiving platelet inhibitor therapy is extremely low. Given the risks associated with stopping these therapies, the authors recommend that patients continue their current therapeutic regimen without cessation.

PURPOSE:To assess the risk of hemorrhagic complications when performing intravitreal injections on systemically anticoagulated patients.METHODS:A single-center retrospective case series of 520 consecutive patients (675 eyes) receiving 3,106 antivascular endothelial growth factor injections. Patients on the systemic anticoagulants Coumadin (warfarin sodium) or Plavix (clopidogrel bisulfate) were identified, as well as patients on aspirin. Demographic parameters were recorded, as well as relevant anticoagulant medications, preoperative/postoperative best-corrected visual acuities and intraocular pressures, previous ocular surgery, relative ocular diagnoses, and injection complications.RESULTS:Of all patients, 104 were on Coumadin (134 eyes; 548 injections), 90 were on Plavix (123 eyes; 523 injections), 7 were on both Coumadin and Plavix (8 eyes; 33 injections), and 319 were not anticoagulated (400 eyes; 2002 injections). Also, 1,254 injections were on patients taking aspirin. There were no hemorrhagic complications (choroidal hemorrhage, vitreous hemorrhage, or increased submacular hemorrhage) noted in the Plavix (P = 1.0000; 95% confidence interval = 0.0000-0.0088), Coumadin (P = 1.0000; 95% confidence interval = 0.0000-0.0084), or aspirin (P = 1.0000; 95% confidence interval = 0.0000-0.0037) groups.CONCLUSION:The risk of hemorrhagic complications in systemically anticoagulated patients receiving intravitreal injections is extremely low. Because of the demonstrated thromboembolic risk of stopping anticoagulant therapy, we recommend that patients continue their current regiment without cessation.

PURPOSE:To report the incidence of acute endophthalmitis as a complication of intravitreal bevacizumab (Avastin) (IVB) injection in a tertiary vitreoretinal group practice. METHODS:A retrospective chart review of 5,233 consecutive eyes that underwent IVB injection at Retina Consultants of Alabama (RCA) from October 1, 2005, to August 31, 2007, was performed to identify cases of acute endophthalmitis. RESULTS:During the 23-month study interval, the overall incidence rate of postinjection endophthalmitis was 0.019% (1/5,233). In the single case of acute endophthalmitis, bacterial cultures revealed coagulase-negative Staphylococcus (CNS) species. Visual acuity after treatment for endophthalmitis was improved (baseline 4/400) to 20/400 at two months after the initial IVB injection. CONCLUSIONS:Acute endophthalmitis is a rare potential complication of IVB. Prophylaxis with topical povidone-iodine and adherence to aseptic technique minimizes the risk of postinjection infection. SUMMARY STATEMENT:A retrospective review of 5,233 consecutive intravitreal injections of bevacizumab (Avastin) revealed only a single case of acute endophthalmitis. Adherence to aseptic technique and the use of povidone-iodine prophylaxis minimizes the risk of postinjection intraocular infection.

Background and Objective: To determine risk factors for immediate severe vision loss in patients with age-related macular degeneration after transpupillary thermotherapy for occult subfoveal choroidal neovascularization. Patients and Methods: Retrospective review of 84 consecutive patients with age-related macular degeneration who received transpupillary thermotherapy for occult subfoveal choroidal neovascularization. Seven cases had severe vision loss and 77 were controls. All patients were treated with a diode infrared laser. Follow-up was completed on all patients 1, 3, and 6 months after treatment with transpupillary thermotherapy. Results: Pretreatment visual acuity ranged from 20/40 to 1/200. Seven of 84 consecutive eyes had an immediate visual acuity loss of 6 or more Snellen lines after transpupillary thermotherapy. Conclusion: Transpupillary thermotherapy has a small but significant risk of immediate severe vision loss in patients with age-related macular degeneration with occult subfoveal choroidal neovascularization. Statistically significant risk factors include a subretinal hemorrhage 5 disc areas or greater in size, 9 disc areas or greater of subretinal fluid, and a laser power greater than 550 mW.

MASON, JOHN O. III MD; YUNKER, JACOB J. MD; VAIL, RACHEL S. COT; WHITE, MILTON F. Jr MD; FEIST, RICHARD M. MD; THOMLEY, MARTIN L. MD; ALBERT, MICHAEL A. Jr MD; PERSAUD, TAREK O. MDEditor(s): Williams, George A. Author Information

PURPOSE: To report the use of intravitreal bevacizumab (Avastin) as an adjunctive treatment for proliferative diabetic retinopathy (PDR).DESIGN: Retrospective case review.METHODS: Institutional review board approval to review patient data was obtained for this retrospective study. Three patients underwent intravitreal injection of bevacizumab as part of their treatment for PDR after informed consent was signed. Each patient also under, went fundus photographs before the bevacizumab injection and then one to three weeks after.RESULTS: All three patients showed complete regression of their neovascularization elsewhere (NVE) and neovascularization of the disk (NVD) between one and three weeks after injection.CONCLUSIONS: The speed and degree of neovascular regression after the injection of intravitreal bevacizumab may make this procedure an important adjunctive treatment in the management of selected cases with severe PDR.

We appreciate Liu et al’s comments regarding our report on the beneficial effects of surgery on our patients undergoing vitrectomy with sheathotomy for branch retinal vein occlusion. We believe in the validity of our observations, as we did have a control group consisting of not only observed patients, but also laser-treated patients.Liu et al mention one particular case series demonstrating that posterior hyaloid detachment was more important than sheathotomy itself. 1Charbonnel J. Glacet-Bernard A. Korobelnik J.F. et al.Management of branch retinal vein occlusion with vitrectomy and arteriovenous adventitial sheathotomy, the possible role of surgical posterior vitreous detachment.Graefes Arch Clin Exp Ophthalmol. 2004; 242: 223-228Crossref PubMed Scopus (64) Google Scholar However, this particular small case series had only 3 eyes with a preoperative posterior vitreous detachment (PVD), which is too small a number to make meaningful conclusions. Liu et al also state that other authors, Saika et al, revealed that surgical PVD leads to resolution of macular edema and better postoperative visual acuity (VA). 2Saika S. Tanaka T. Miyamoto T. et al.Surgical posterior vitreous detachment combined with gas/air tamponade for treating macular edema associated with branch retinal vein occlusion retinal tomography and visual outcome.Graefes Arch Clin Exp Ophthalmol. 2001; 239: 729-732Crossref PubMed Scopus (100) Google Scholar We referenced that article in our “Discussion,” and of interest, this was a case series with no control group. We agree that Figueroa et al have shown improvement in VA in patients with or without arteriovenous sheathotomy. 3Figueroa M.S. Torres R. Alvarez M.T. Comparative study of vitrectomy with and without vein decompression for branch retinal vein occlusion a pilot study.Eur J Ophthalmol. 2004; 14: 40-47PubMed Google Scholar We believe that future studies will clarify the role of vitrectomy with or without sheathotomy surgery.Liu et al request, in the interest of readers, that we provide further angiographic evidence to support our claim that patients have increased perfusion after surgery. We are happy to present the fluorescein angiography of one of our patients included in our study. This patient had a dramatic improvement in VA after surgery. His initial presurgical VA was 20/400, and the fluorescein angiogram demonstrated a branch retinal vein occlusion with decreased perfusion to the foveal avascular zone (Fig 1). Ten days postoperatively, VA had improved to 20/100, and the fluorescein angiogram demonstrated an increase in perfusion to the fovea, as a draining vein could be seen at the superior-nasal edge of the fovea (Fig 2). Vision 6 weeks postoperatively improved to 20/40.Figure 2View Large Image Figure ViewerDownload (PPT)We thank Liu et al for their interest in our study, and we look forward to future studies on the treatment of branch retinal vein occlusions. We appreciate Liu et al’s comments regarding our report on the beneficial effects of surgery on our patients undergoing vitrectomy with sheathotomy for branch retinal vein occlusion. We believe in the validity of our observations, as we did have a control group consisting of not only observed patients, but also laser-treated patients. Liu et al mention one particular case series demonstrating that posterior hyaloid detachment was more important than sheathotomy itself. 1Charbonnel J. Glacet-Bernard A. Korobelnik J.F. et al.Management of branch retinal vein occlusion with vitrectomy and arteriovenous adventitial sheathotomy, the possible role of surgical posterior vitreous detachment.Graefes Arch Clin Exp Ophthalmol. 2004; 242: 223-228Crossref PubMed Scopus (64) Google Scholar However, this particular small case series had only 3 eyes with a preoperative posterior vitreous detachment (PVD), which is too small a number to make meaningful conclusions. Liu et al also state that other authors, Saika et al, revealed that surgical PVD leads to resolution of macular edema and better postoperative visual acuity (VA). 2Saika S. Tanaka T. Miyamoto T. et al.Surgical posterior vitreous detachment combined with gas/air tamponade for treating macular edema associated with branch retinal vein occlusion retinal tomography and visual outcome.Graefes Arch Clin Exp Ophthalmol. 2001; 239: 729-732Crossref PubMed Scopus (100) Google Scholar We referenced that article in our “Discussion,” and of interest, this was a case series with no control group. We agree that Figueroa et al have shown improvement in VA in patients with or without arteriovenous sheathotomy. 3Figueroa M.S. Torres R. Alvarez M.T. Comparative study of vitrectomy with and without vein decompression for branch retinal vein occlusion a pilot study.Eur J Ophthalmol. 2004; 14: 40-47PubMed Google Scholar We believe that future studies will clarify the role of vitrectomy with or without sheathotomy surgery. Liu et al request, in the interest of readers, that we provide further angiographic evidence to support our claim that patients have increased perfusion after surgery. We are happy to present the fluorescein angiography of one of our patients included in our study. This patient had a dramatic improvement in VA after surgery. His initial presurgical VA was 20/400, and the fluorescein angiogram demonstrated a branch retinal vein occlusion with decreased perfusion to the foveal avascular zone (Fig 1). Ten days postoperatively, VA had improved to 20/100, and the fluorescein angiogram demonstrated an increase in perfusion to the fovea, as a draining vein could be seen at the superior-nasal edge of the fovea (Fig 2). Vision 6 weeks postoperatively improved to 20/40. We thank Liu et al for their interest in our study, and we look forward to future studies on the treatment of branch retinal vein occlusions. Sheathotomy for Vein OcclusionOphthalmologyVol. 112Issue 7PreviewMason et al’s study on the effect of arteriovenous adventitial sheathotomy in decompressing branch retinal vein occlusion (BRVO) rests on the demonstration of the improvement of visual acuity (VA) in the surgery group relative to the control group, in which patients underwent either observation or grid laser photocoagulation. 1 Visual acuity, however, has been shown to be under pitfall influence from a confounding bias such as vitrectomy, 2–4 which was not properly addressed in this study. The validity of the authors’ observations may thus be weakened. Full-Text PDF

Background and Objective:Evaluation of surgical treatment of full-thickness macular holes secondary to diabetic tractional retinal detachments was conducted.Patients and Methods:A retrospective review of medical records, fluorescein angiograms, fundus photographs, optical coherence tomography images, and operative findings of six consecutive patients with full-thickness macular holes and diabetic tractional retinal detachments was completed. Each eye was treated with pars plana vitrectomy, tractional retinal detachment repair, membranectomy, indocyanine green-assisted internal limiting membrane peeling, and intraocular gas tamponade.Results:Surgical intervention resulted in the closure of all full-thickness macular holes. Mean best-corrected visual acuity was 20/250 preoperatively and 20/100 postoperatively, with all patients having improvement after a mean follow-up of 10 months.Conclusion:Closure of tractional retinal detachments related to full-thickness macular holes can be achieved via pars plana vitrectomy, complete membranectomy, and intraocular gas. Vitrectomy with dissection of proliferative membranes helps to relieve the tractional forces responsible for full-thickness macular hole formation, enabling successful closure of the diabetic full-thickness macular holes and resulting in visual acuity improvement.