Macular Degeneration: Singh RP

Singh RP, Kaiser PK. · Cole Eye Institute, Cleveland Clinic Foundation, USA. · Indian J Ophthalmol. · Pubmed #17951897 links to  free full text

Abstract: Age-related macular degeneration (AMD) is one of the most common causes of severe vision loss in the western world. Both animal and human studies have established that vascular endothelial growth factor (VEGF) plays an important role in the pathogenesis of this process. Ranibizumab (Lucentis(TM) Genentech, South San Francisco, CA) is a monoclonal antibody fragment (Fab) directed toward all isoforms of VEGF-A that was specifically designed to target wet AMD. The human antibody fragment is produced by an E. coli expression system and has a molecular weight of 48kD allowing for excellent retinal penetration. The most common ocular complaints of patients receiving ranibizumab injections in randomized clinical trials were transient conjunctival hemorrhage, vitreous floaters, intraocular inflammation, increased intraocular pressure and eye pain. The rates of serious adverse events such as retinal detachment, cataract and endophthalmitis were similar to those that have been reported with other intravitreal injections and patients should always be treated under strict aseptic conditions to reduce this risk. There were no significant non-ocular events found during any study so far and the risk of thromboembolic events was less than 4% and not different than sham. The MARINA, ANCHOR and PIER studies validated the safety and efficacy of ranibizumab amongst a large population with different choroidal neovascular membrane lesion types against sham or standard of care treatment. These studies recommended monthly intravitreal ranibizumab for patients. However, the PIER study reported that an alternative dosing of every three months is acceptable but less effective than monthly injections.

Singh RP, Lewis H. · Cole Eye Center, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA. · Clin Geriatr Med. · Pubmed #16860252 No free full text.

Abstract: The field of ophthalmology has undergone revolutionary changes during the past few decades. Advancements in understanding the pathophysiology of eye diseases, superior surgical instrumentation and surgeon skills, and cotreatment with medical therapies have enhanced outcomes. The geriatric population, preferentially affected by these illnesses, has seen a meaningful visual benefit from these surgical innovations. Most importantly, these improvements have led to increases in quality-of-life measures and mental and physical well-being of aging patients.

Kumar A, Tiwari HK, Singh RP, Verma L, Prasad N. · Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi. · Acta Ophthalmol Scand. · Pubmed #10726795 No free full text.

Abstract: METHODS: 40 cases of vitreous haemorrhage secondary to Eales' disease were taken up for vitrectomy. Depending upon duration of vitreous haemorrhage patients were divided into two groups: Group I (20 eyes) - early vitrectomy group with duration between 3-6 months; Group II (20 eyes) - deferred vitrectomy group with duration of more than 6 months. All patients were followed up for a minimum period of 3 months following vitrectomy. RESULTS: Eyes in Group I showing a preoperative ultrasonic picture of complete posterior vitreous detachment, less mobility of organised vitreous haemorrhage and mid vitreous organisation on kinetic echography achieved a final visual acuity of 6/9 or better in 13 (65%) eyes as compared to 4 (20%) eyes in Group II (p<0.01). Poor visual outcome in the deferred group was secondary to cystoid macular oedema, macular scar, macular pucker formation and macular degeneration. CONCLUSION: Improved visual outcome in the early vitrectomy group was probably because the haemorrhagic blood and its toxic products had less time to damage the macula, a lesser incidence of macular traction and cystoid macular oedema.

Margolis R, Singh RP, Bhatnagar P, Kaiser PK. · Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA. · Acta Ophthalmol. · Pubmed #17608830 No free full text.

Abstract: PURPOSE: To evaluate the effect of intravitreal injections of triamcinolone acetonide (IVTA) combined with panretinal photocoagulation (PRP) on visual acuity (VA) and foveal thickness in patients with concomitant high-risk proliferative diabetic retinopathy (PDR) and clinically significant macular oedema (CSMO). METHODS: This retrospective interventional case series included seven eyes diagnosed with both high-risk PDR and CSMO that underwent PRP and a single injection of 4 mg of IVTA. The main outcome measures were VA and foveal thickness, measured by optical coherence tomography (OCT) before treatment and throughout the follow-up period. RESULTS: Median follow-up was 301 days (range 180-715 days). Foveal thickness data were available for four of seven eyes. Before the combined treatment, median LogMAR (logarithm of the minimum angle of resolution) VA and median foveal thickness were 1 (Snellen 20/200, range 20/40-20/800) and 559 microm (range 333-689 microm), respectively. After treatment, median vision improved to LogMAR 0.544 (Snellen 20/70, range 20/40-20/1000) (P = 0.13). Vision improved or remained stable in six of seven eyes. Median foveal thickness at final follow-up was 436 microm (range 259-623 microm) (P = 0.15). Foveal thickness decreased or remained stable in all eyes. CONCLUSION: The addition of IVTA to PRP in the treatment of eyes with high-risk PDR and CSMO may prevent PRP-induced foveal thickening and loss of vision.

Taban M, Singh RP, Chung JY, Lowder CY, Perez VL, Kaiser PK. · Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA. · Am J Ophthalmol. · Pubmed #17601427 No free full text.

Abstract: PURPOSE: To report an association between uveitis and sterile endophthalmitis after intravitreal triamcinolone acetonide injection. DESIGN: Retrospective case series. METHODS: A retrospective analysis of all patients receiving intravitreal triamcinolone injection at the Cole Eye Institute from January 2006 through September 2006 was carried out to evaluate for the occurrence of bacterial or sterile endophthalmitis. Indication for treatment, ocular history, best-corrected Snellen visual acuity, and clinical examination findings were recorded from the clinical charts before injection and at last follow-up. RESULTS: A total of 310 eyes received intravitreal triamcinolone injection for various causes, including age-related macular degeneration (AMD), diabetic retinopathy, vascular occlusion, and cystoid macular edema (CME) resulting from uveitis. There were no cases of culture-positive infectious endophthalmitis. There were six cases (1.9%) of sterile endophthalmitis. Of these six cases, four had prior history of uveitis, whereas only 20 of the 310 cases had a prior history of uveitis. All six patients sought treatment within three days of injection, and all recovered rapidly. Presenting visual acuity was either counting fingers or hand movements. Median best-corrected visual acuity before injection was 20/100(+), whereas median final visual acuity was 20/80(-). CONCLUSIONS: Patients with a history of uveitis may be at increased risk of experiencing sterile endophthalmitis resulting from intravitreal triamcinolone injection.

Ufret-Vincenty RL, Singh RP, Lowder CY, Kaiser PK. · Cleveland Clinic Cole Eye Institute, Cleveland, Ohio 44195, USA. · Am J Ophthalmol. · Pubmed #17258523 No free full text.

Abstract: PURPOSE: To report a case of cytomegalovirus (CMV) retinitis after placement of a fluocinolone acetonide (Retisert) implant. DESIGN: Interventional case report. METHODS: Retrospective chart review. RESULTS: A 65-year-old man with a history of Adamantiades-Behcet disease and bilateral recurrent uveitis that was unresponsive to systemic corticosteroid-sparing immunosuppressive therapy developed clinical evidence of CMV retinitis after receiving his second intravitreal Retisert implant in the left eye, while on no systemic immunosuppression. He did not develop CMV retinitis in the right eye despite multiple intraocular and periocular steroid injections. The patient responded well to intravitreal foscarnet followed by placement of an intravitreal ganciclovir implant. CONCLUSIONS: Ophthalmologists should be aware of the potential risk for development of CMV retinitis after local ocular immunosuppressive therapy.

Singh RP, Margolis R, Kaiser PK. · Digital Optical Coherence, Tomography Reading Center (DOCTR), 9500 Euclid Avenue, Cleveland, OH 44195, USA. · Br J Ophthalmol. · Pubmed #17229807 No free full text.

Abstract: OBJECTIVE: To evaluate the new surgical technique of cystoid macular oedema puncture (CMOP) in patients with longstanding cystoid macular oedema refractory to standard treatments. DESIGN: Interventional, retrospective case series METHODS: Retrospective review of patients with chronic cystoid macular oedema from vascular retinopathy for whom maximal medical or surgical treatment failed and who underwent pars plana vitrectomy and CMOP. Clinical findings, best-corrected Snellen visual acuity, stereo colour fundus photography, intravenous fluorescein angiograms, and optical coherence tomography were obtained before and after treatment to evaluate the efficacy and safety of the treatment. RESULTS: Seven patients were included in the study. Cystoid macular oedema was due to diabetic retinopathy in five patients, central retinal vein occlusion in one patient and branch retinal vein occlusion in one patient. Preoperative intravitreal steroids failed for all patients, and three patients also had focal grid photocoagulation. Previous pars plana vitrectomy, with elevation of the posterior hyaloid, internal limiting membrane peeling, and intravitreal steroid injection, had failed in three patients. The median time to CMOP was 488 days. Resolution or improvement of cystoid oedema occurred in all patients as determined by fluorescein angiography or optical coherence tomography, or both. However, visual acuity was unchanged in five patients, declined in one patient and stable in one patient. CONCLUSIONS: Although cystoid macular oedema does improve quantitatively after CMOP, the technique fails to improve visual acuity in patients.

Elgohary MA, McCluskey PJ, Towler HM, Okhravi N, Singh RP, Obikpo R, Lightman SS. · Moorfields Eye Hospital, London EC1V 2PD, UK. · Br J Ophthalmol. · Pubmed #17229800 No free full text.

Abstract: AIMS: To examine the visual outcome and identify risk factors for postoperative uveitis, macular oedema and neodymium-doped yttrium aluminium garnet (Nd:YAG) capsulotomy after phacoemulsification and intraocular lens (IOL) implantation in patients with uveitis. METHOD: This is a retrospective review of the medical records of 101 eyes of 101 patients. One eye was randomly selected for inclusion in patients who had bilateral surgery. Patients with juvenile arthritis, keratouveitis and lymphoma-associated uveitis were excluded. RESULTS: At the first postoperative and final visits, visual acuity was significantly better (p<0.001), and 64.4% and 71.3% of patients, respectively, had achieved >or=2 Snellen's lines of visual improvement. The cumulative probability of doubling of the visual angle was 52% over 6 years of follow-up, and this occurred at a higher rate in the presence of preoperative retinal or optic nerve lesions (HR (95% CI) 4.49 (1.41 to 14.29)). Within 3 months after operation, uveitis was more likely to develop in female patients (OR (95% CI) 6.21 (1.41 to 27.43)) and in the presence of significant intraoperative posterior synechiae (OR (95% CI) 8.43 (1.09 to 65.41)); macular oedema was more likely to develop in patients who developed postoperative uveitis (OR (95% CI) 7.45 (1.63 to 34.16)). Nd:YAG capsulotomy occurred at a higher rate in patients aged <or=55 years (HR (95% CI) 2.28 (1.06, 4.93)) and in those with hydrogel IOLs (HR (95% CI) 3.71 (1.04 to 13.20)), and occurred at a lower rate in patients who had prophylactic systemic corticosteroids (HR (95% CI) 0.25 (0.11 to 0.59)), with plate-haptic silicone IOLs (HR (95% CI) 0.23 (0.08 to 0.64)) and three-piece silicone IOLs (HR (95% CI) 0.19 (0.05 to 0.74)) in comparison to those with polymethylmethacrylate IOLs. CONCLUSION: Most patients with uveitis achieve improved visual acuity after phacoemulsification, but an increasing rate of visual loss is observed in those with pre-existent macular or optic nerve lesions. Identifying patients who are at risk of postoperative complications should help in patient counselling and to pre-empt these complications by using preoperative prophylactic corticosteroids, careful IOL selection and postoperative intensive corticosteroids.

Singh RP, Sears JE. · Retina Service, Cole Eye Center, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA. · Am J Ophthalmol. · Pubmed #16815269 No free full text.

Abstract: PURPOSE: To report two cases of retinal pigment epithelium (RPE) tears following intravitreal pegaptanib injections for occult choroidal neovascularization. DESIGN: Noncomparative case series. METHODS: The charts of two patients with pigment epithelial tears after receiving intravitreal pegaptanib were reviewed. Approval from the institutional review board and informed consent were obtained before chart review. Fundus photos, intravenous fluorescein angiograms, and optical coherence tomography (OCT) were obtained before and after therapy confirmed the diagnosis. RESULTS: Two patients had turbid pigment epithelial detachments (PEDs) and occult choroidal neovascular membranes (CNVMs) treated with intravitreal pegaptanib. Both patients developed RPE tears weeks following one intravitreal pegaptanib injection. CONCLUSIONS: This report describes the development of RPE tears after intravitreal pegaptanib injection. Caution should be taken in cases of turbid pigment epithelial detachments in the monocular patient when treatment with intravitreal pegaptanib is entertained. Future studies should be performed to evaluate which subtypes of lesions are most susceptible to this devastating visual complication.

Singh RP, Patel C, Sears JE. · Vitreo-retinal Service, Cole Eye Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA. · Br J Ophthalmol. · Pubmed #16547320 links to  free full text

Abstract: BACKGROUND/AIMS: Recent studies on the treatment of acute subretinal macular haemorrhage have shown that the volume of the clot and the time to evacuation have strong prognostic factors for visual outcome. A novel technique for surgical evacuation of these lesions involves direct injection of tissue plasminogen activator (t-PA) into the haematoma using pars plana vitrectomy. The aim of this study was to evaluate the clinical outcomes of this recently described procedure. METHODS: 17 consecutive patients with subretinal macular haemorrhages caused by age related macular degeneration were enrolled. Patient demographics, acuities, and fluorescein angiograms were obtained for all evaluations. All patients underwent complete three port pars plana vitrectomy to enable direct cannulation of the subretinal space and injection of 48 mug of t-PA, partial fluid-air exchange, 1 hour face up supine positioning postoperatively, followed by upright positioning overnight. RESULTS: 88% of patients within the study had stabilisation or improvement of visual acuity. Nine patients had total clearing of the macular haemorrhage and eight patients had subtotal clearing. Two patients had recurrence of the haemorrhage after the procedure and one patient underwent repair for retinal detachment. Occult lesions demonstrated similar outcomes to classic or predominately classic lesions. Nine patients required no therapy after the study to treat subfoveal neovascularisation. CONCLUSIONS: This study represents one of the largest case series to date showing that direct injection of subretinal t-PA with air-fluid exchange only and no intraoperative clot lysis period can have favourable results.