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This chapter comprehensively covers all aspects of endogenous endophthalmitis from systemic infectious agents, with an emphasis on reported and newer etiologies to broaden the diagnostic and investigative acumen of treating ophthalmic providers. The discussion includes the etiology of metastatic endophthalmitis and diagnostic investigations, including polymerase chain reaction (PCR), for identification of bacterial and viral infections involving the eye in both immunosuppressed in non-immunosuppressed patients. Additionally, we present clinical and diagnostic findings of fungal infections, protozoal infections, and helminthic infections. Pediatric cases are also reported and etiologies described. We discuss both etiology and diagnostic challenges. Current therapeutic modalities and outcomes are reviewed. While no two cases of metastatic endophthalmitis are the same, some similarities may exist that allow us to generalize how to approach and treat this potentially sight- and life-threatening spectrum of diseases and find the underlying systemic cause.

A real-time and non-invasive thermometry method is crucial for thermal therapies to monitor and control the treatment. Ultrasound can be used as an attractive thermometry modality for its relatively high sensitivity to change in temperature and fast data collection and processing abilities. In this work, an ultrasound thermometry method based on the change in backscattered energy (CBE) is used to control the tissue temperature using a closed-loop controller in real-time. A clinical high-frequency ultrasound scanner was used to acquire RF echo data from ex vivo porcine tissue samples while the tissue was being exposed to an interstitial laser heating source. The control system was used to rapidly increase the temperature from 37°C (baseline temperature) to 43 °C (target temperature) and maintain the target temperature for about 6 minutes. The results show that the ultrasound thermometry based on CBE generated by a high-frequency ultrasound scanner can be used to generate 2D temperature maps of a localized heating region in the hyperthermia temperature range (∼43°C). The estimated temperature varied by an average of ±0.8 °C compared to a calibrated fiber-optic measurement. Thus, a non-invasive ultrasound thermometry method based on the CBE technique can be used for real-time monitoring and control of hyperthermia treatments, using the interstitial laser heating source with acceptable accuracy.

Tunable spherical fluidic lenses are among the most essential components in adaptive optics. However, fabricating cylindrical tunable lenses has proven more challenging, mainly due to the difficulty in eliminating the defocus component. We demonstrate a parametric approach to minimize the defocus in cylindrical tunable fluidic lenses. We theoretically model and experimentally verify that a dog-bone-shaped tunable cylindrical fluidic lens exhibits almost pure cylindrical performance within the range of ± 5 D of astigmatism. We anticipate these results will facilitate the use of tunable cylindrical fluidic lenses in adaptive optics applications and particularly ophthalmic devices, where rapid and reliable wavefront correction is required.

Purpose A real-time and non-invasive thermometry technique is essential in thermal therapies to monitor and control the treatment. Ultrasound is an attractive thermometry modality due to its relatively high sensitivity to change in temperature and fast data acquisition and processing capabilities. A temperature-sensitive acoustic parameter is required for ultrasound thermometry in order to track the changes in that parameter during the treatment. Currently, the main ultrasound thermometry methods are based on variation in the attenuation coefficient, the change in backscattered energy of the signal (CBE), the backscattered radio-frequency (RF) echo-shift due to change in the speed of sound and thermal expansion of the medium, and change in the amplitudes of the acoustic harmonics. In this work, an ultrasound thermometry method based on second harmonic CBE (CBEh2) and combined fundamental and second harmonic CBE (CBEcomb) is used to produce 2D temperature maps, detect localized heated region generated by low intensity focused ultrasound (LIFU), and control temperature in the heated region. Materials and methods Ex vivo pork muscle tissue samples were exposed to localized LIFU heating source and 2D temperature maps were produced from the RF data acquired by a 4.2 MHz linear array probe using a Verasonics Vantage™ ultrasound scanner (Verasonics Inc., Redmond, WA) after the exposure. Calibrated needle thermocouples were also placed in the ex vivo tissue sample close to the LIFU focal zone for temperature calibration purposes. The estimated temperature maps were the established echo-shift technique. A tissue motion compensation algorithm was also used to reduce the susceptibility to motion artifacts. Results 2D temperature maps were generated using CBE of acoustic harmonic and echo-shift techniques. The results show a direct correlation between the CBE of acoustic harmonics and focal tissue temperature for a range of temperatures from 37 °C (baseline) to 47 °C. Conclusions The findings of this study show that the CBE of acoustic harmonics technique can be used to noninvasively estimate temperature change in tissue in the hyperthermia temperature range.

Cataract surgery is one of the most commonly performed surgeries worldwide, with nearly 20 million cases annually. Appropriate prophylaxis after cataract surgery can contribute to a safe and quick visual recovery with high patient satisfaction. Despite being the current standard of care, the use of multiple postoperative eye drops can create a significant burden on these patients, contributing to documented and significant non-adherence to the postoperative regimen. Over the past 25 years, there have been a few studies analyzing the use of intracameral dexamethasone (DXM) in controlling inflammation following cataract surgery. This review explores various drug delivery approaches for managing intraocular inflammation after cataract surgery, documenting the strengths and weaknesses of these options and examining the role of intracameral DXM (among these other strategies) in controlling postoperative intraocular inflammation. Intracameral DXM has a particular advantage over topical steroids in possibly decreasing postoperative inflammatory symptoms and objective anterior cell and flare scores. Compared to topical steroids, there may be a slightly less theoretical risk of significant intraocular pressure spikes and systemic absorption. In addition, surveys indicate patients prefer an intraoperative intracameral injection over a self-administered postoperative eye drop regimen. However, there are several adverse effects associated with intracameral DXM delivery that are not seen with the noninvasive topical approach. Although it is unlikely that intracameral DXM will replace topical medications as the standard management for postoperative inflammation, it is seemingly another safe and effective strategy for controlling postoperative inflammation after routine cataract surgery.

To compare the efficacy of 2 doses of intravitreal ziv-aflibercept (IVZ) with intravitreal bevacizumab (IVB) in the treatment of center-involved diabetic macular edema (DME) at 12 weeks.Three-armed, double-blind, randomized clinical trial.Eyes with center-involved DME.In this trial, 123 eyes with DME were randomly assigned to 3 injections of 1.25 mg IVZ, 2.5 mg IVZ, and 1.25 mg IVB every 4 weeks. Complete ophthalmologic examination and central macular thickness (CMT) measurement by optical coherence tomography were performed every 4 weeks up to 12 weeks.Change in best-corrected visual acuity (BCVA) at 12 weeks.Although no significant difference was evident between the 2 ziv-aflibercept groups at 12 weeks, the BCVA change was significantly better in the ziv-aflibercept 1.25 mg group than in the IVB group at the 12-week visit (P = 0.021). In regard to CMT changes, there was no significant difference between the 2 ziv-aflibercept groups; however, a significantly greater reduction in CMT was observed in the ziv-aflibercept 2.5 mg group compared with the IVB group at 12 weeks (P = 0.037). Subgroup analysis disclosed no difference in BCVA outcomes at 12 weeks among the groups in the eyes with baseline BCVA ≥20/50. In the eyes with baseline BCVA20/50, the improvement was significantly better at 12 weeks in the ziv-aflibercept 1.25 mg group compared with the IVB group (P = 0.011).The 12-week results of this trial disclosed that both 1.25 mg and 2.5 mg doses of IVZ and IVB demonstrated BCVA improvement over baseline in the treatment of center-involved DME. However, a stronger effect of IVZ compared with IVB in terms of both visual acuity improvement and macular thickness reduction was detected in the eyes with initial BCVA20/50. Longer-term efficacy and safety data will be needed to understand the role for this drug in practice.

A 65-year-old woman with left hemiparesis and sudden loss of visual acuity in her right eye presented a few hours after cosmetic injection of autologous fat to her forehead. Right eye visual acuity was no light perception. Funduscopy revealed widespread retinal whitening and multibranch retinal vessel occlusion. Fluorescein angiography showed markedly delayed choroidal and retinal filling together with occlusion of multiple branches of retinal arteries and veins. On magnetic resonance imaging of the brain, multiple lesions compatible with recent infarction were detected. The authors diagnosed multibranch retinal artery and vein occlusion in the right ophthalmic and middle cerebral arteries due to fat emboli. This case emphasizes the need to reevaluate the safety of such aesthetic procedures, particularly in the facial zone to prevent devastating complications. [ Ophthalmic Surg Lasers Imaging Retina . 2015;46:593–596.]

This review is timely because the outcomes of surgical invention in uveitic eyes with cataract can be optimized with adherence to strict anti-inflammatory principles.All eyes should be free of any cell/ flare for a minimum of 3 months preoperatively. Another helpful maneuver is to place dexamethasone in the infusion fluid or triamcinolone intracamerally at the end of surgery. Recent reports about the choice of intraocular lens material or lens design are germane to the best surgical outcome. Integrating these findings will promote better visual outcomes and allow advancement in research to further refine these surgical interventions in high-risk uveitic eyes.Control of inflammation has been shown to greatly improve postoperative outcomes in patients with uveitis. Despite better outcomes, more scientific research needs to be done regarding lens placement and materials and further research needs to adhere to the standardized reporting of uveitis nomenclature. Future studies should improve postoperative outcomes in eyes with uveitis so that they approach those of eyes undergoing routine cataract procedures.

Using a phoropter to measure the refractive error is one of the most commonly used methods by ophthalmologists and optometrists. Here, we demonstrate design and fabrication of a portable automatic phoropter with no need for patient’s feedback. The system is based on three tunable-focus fluidic lenses and thin-film holographic optical elements to perform automatic refractive error measurement and provide a diagnostic prescription without supervision. Three separate lenses are deployed to correct the defocus and astigmatism. The refractive error is measured using a Shack-Hartmann wavefront sensor that calculates the Zernike values of an infrared wavefront emerging from the eye. Holographic optical elements steer the emerging wavefront into the wavefront sensor, while simultaneously providing an unobstructed view for the subject. The power of each lens is controlled by pumping a liquid in and out of the lens chamber using servo motor actuated diaphragm pumps. Spherical and cylindrical correction range of −10 to +10 diopters with 0.1 diopter increments is achieved in less than 15 seconds using wavefront sensor feedback to the pumps. This system can be used in rapid screening of large patient populations especially in the developing countries that lack sufficient facilities and specialist doctors.

Phoropters are the most common instrument used to detect refractive errors. During a refractive exam, lenses are flipped in front of the patient who looks at the eye chart and tries to read the symbols. The procedure is fully dependent on the cooperation of the patient to read the eye chart, provides only a subjective measurement of visual acuity, and can at best provide a rough estimate of the patient’s vision. Phoropters are difficult to use for mass screenings requiring a skilled examiner, and it is hard to screen young children and the elderly etc. We have developed a simplified, lightweight automatic phoropter that can measure the optical error of the eye objectively without requiring the patient’s input. The automatic holographic adaptive phoropter is based on a Shack-Hartmann wave front sensor and three computercontrolled fluidic lenses. The fluidic lens system is designed to be able to provide power and astigmatic corrections over a large range of corrections without the need for verbal feedback from the patient in less than 20 seconds.

Retinal diseases such as Age-Related Macular Degeneration (ARMD) affect nearly one in three elderly patients. ARMD damages the central vision photoreceptors in the fovea. The Photostress Test is a simple technique for testing for the early effects of ARMD. Here, the illumination sources in a novel self-administered Photostress Testing device were modeled for safety and distribution in illumination software. After satisfying the design constraints in the model, a prototype of the illumination system was fabricated and tested to confirm the modeling results. The resultant prototype can be used to aid in the diagnosis of retinal disease and is well within retinal safety levels.

The purpose of the study is to compare single injection of intravitreal diclofenac (IVD) with intravitreal bevacizumab (IVB) in the treatment of eyes with naïve diabetic macular edema (DME). In this randomized clinical trial, 57 eyes of 57 patients were randomly assigned to IVD group (30 eyes), cases who received a single intravitreal injection of diclofenac (500 μg/0.1 ml), and IVB group (27 eyes), cases who received a single intravitreal injection of bevacizumab (1.25 mg). Change in best-corrected visual acuity in logMAR at week 12 was the primary outcome measure. Secondary outcomes included changes in central macular thickness, macular leakage, and potential injection-related complications. Best-corrected visual acuity improved significantly more in the IVD group than in the IVB group (P = 0.033), from 0.57 ± 0.25 to 0.49 ± 0.31 versus 0.55 ± 0.24-0.59 ± 0.27 logMAR at 12 weeks, respectively. However, the difference of macular thickness changes was in favor of IVB, but not to a significant level. The amount of change in leakage was not significantly different between the groups either. None of the eyes, in either group, developed ocular hypertension (≥23 mmHg) or cataract progression. No important injection-related complication was observed during the study period. This study demonstrated the superiority of IVD over IVB in the treatment of naïve DME regarding functional, but not anatomical outcomes. Therefore, using IVD as an adjunct or even alternative to other treatments might enhance the functional outcomes in such cases. Further studies are warranted to confirm potential benefit of IVD observed in this study.

Purpose: To compare the efficacy of intravitreal bevacizumab (IVB) injection alone or with intravitreal triamcinolone acetonide (IVB/IVT) versus macular photocoagulation (MPC) in bilateral diabetic macular edema (DME). Methods: In this study we revisited data from a subset of subjects previously enrolled in a randomized clinical trial. The original study included 150 eyes randomized to three treatment arms: 1.25 mg IVB alone, combined injection of 1.25 mg IVB and 2 mg IVT, and focal or modified grid MPC. To eliminate the possible effects of systemic confounders, we selected fellow eyes of bilaterally treated subjects who had undergone different treatments; eventually 30 eyes of 15 patients were re-evaluated at baseline, 6, 12, 18, and 24 months. Using mixed model analysis, we compared the treatment protocols regarding visual acuity (VA) and central macular thickness (CMT). Results: Improvement in VA in the IVB group was significantly greater compared to MPC at months 6 and 12 (P = 0.037 and P = 0.035, respectively) but this difference did not persist thereafter up to 24 months. Other levels of VA were comparable at different follow-up intervals (all P > 0.05). The only significant difference in CMT was observed in favor of the IVB group as compared to IVB/IVT group at 24 months (P = 0.048). Conclusion: Overall VA was superior in IVB group as compared to MPC up to 12 months. Although the IVB group showed superiority regarding CMT reduction over 24 months as compared to IVB/IVT group, it was comparable to the MPC group through the same period of follow up.

The authors describe indocyanine green angiography (ICGA) and enhanced depth imaging optical coherence tomography (EDI-OCT) in a 46-year-old male patient with acute macular neuroretinopathy (AMN). The chief complaint was decreasing visual acuity and metamorphopsia in both eyes of 1-month duration. Visual field assessment, fluorescein angiography, OCT, ICGA, and EDI-OCT were performed initially and at 3 months. ICGA showed choroidal vascular hyperpermeability and punctuate choroidal hyperfluorescent spots, especially in the left eye. EDI-OCT showed increased choroidal macular thickness, with inner and outer retinal layers affected. EDI-OCT and ICGA reveal that both the choroid and retina can be affected in AMN; however, the primary pathology and localization of depth of involvement in AMN remains unclear.

This article describes a feasibility study of a novel trans-scleral tonometer based on the use of an instrumented form of digital palpation tonometry. Similar to manual digital palpation tonometery, trans-scleral tonometer utilizes two force probes offset by a fixed distance. Force indentation data from these probes have been shown to correlate with the intraocular pressure (IOP) of the eye. Enucleated porcine eyes were used to experimentally validate the approach. The observed hysteresis in the force data was analyzed using an analytical model that accounts for the outflow of the aqueous humor. The predictions of the model indicate that the primary reason behind the observed hysteresis is stress relaxation (accommodation) in the visco-elastic corneo-scleral shell. Experimental data from eye distention and indentation tests were then used to infer the conditions under which the novel tonometer would be expected to have an accuracy of ±1 mmHg. Analysis of the data shows that indentation rates should be kept below 0.5 mm/s for a pressure range of 10-35 mmHg. Two commonly used pressure control protocols were tested in an effort to ensure accurate IOP values during the palpation tests. Due to the large increase of IOP during digital palpation, the trans-scleral (intra-vitreous) pressurization was found to be inadequate, leading to clogging of the line by the displaced vitreous. No such problems were identified when the eye was pressurized through the cornea and into the anterior chamber. Force data from multiple palpation experiments are used to generate calibration curves for a two-probe conceptual tonometer. The calibration showed that a 10 mN of force variation corresponds to 1 mmHg of IOP change. A possible implementation using a contoured facial mask is also presented.

Alzheimer's disease (AD) is an increasingly common disease with massive personal and economic costs. While it has long been known that AD impacts the visual system, there has recently been an increased focus on understanding both pathophysiological mechanisms that may be shared between the eye and brain and how related biomarkers could be useful for AD diagnosis. Here, were review pertinent cellular and molecular mechanisms of AD pathophysiology, the presence of AD pathology in the visual system, associated functional changes, and potential development of diagnostic tools based on the visual system. Additionally, we discuss links between AD and visual disorders, including possible pathophysiological mechanisms and their relevance for improving our understanding of AD.

Central serous chorioretinopathy (CSR) is a serous detachment of the neurosensory retina commonly associated with male sex, Type-A personality and corticosteroid use. Exogenous administration of androgens and development of CSR in men has been reported. Only one case of CSR in a postmenopausal woman receiving exogenous androgen therapy has been reported. The authors describe three cases of chronic CSR in postmenopausal women receiving exogenous testosterone therapy.Diagnosis was based on characteristic clinical, fluorescein angiographic, and optical coherence tomography findings. The three women were being treated with exogenous testosterone and progesterone therapy for symptoms of menopause and libido loss.Average age at presentation was 54.7 years (53-56 years), average duration of exogenous androgen use was 61 months (36-87 months), with average 19.7-month follow-up. Resolution of symptoms seemed correlated with cessation of androgen use despite treatment with oscillatory photodynamic therapy and intravitreal pharmacotherapy with antivascular endothelial growth factor agents.Exogenous testosterone is increasingly prescribed for menopausal symptoms and libido loss. Treatment with oscillatory photodynamic therapy, supplemental bevacizumab intravitreal pharmacotherapy, and cessation of exogenous androgen therapy was successful in three cases of chronic, therapy-resistant CSR. Ophthalmologists should inquire about androgen usage in patients who present with CSR, especially in the setting of therapy resistance.

The purpose of this study was to report the 24-month findings of a randomized clinical trial comparing intravitreal bevacizumab (IVB) injection alone or in combination with intravitreal triamcinolone acetonide (IVT) versus macular laser photocoagulation (MPC) as a primary treatment for diabetic macular edema.The eyes were randomly assigned to 1 of the 3 study arms: the IVB group, patients who received 1.25 mg IVB; the IVB/IVT group, patients who received 1.25 mg of IVB and 2 mg of IVT; and the MPC group, patients who underwent focal or modified grid laser. Of 150 eyes (50 in each group) in the primary trial, 123, 119, and 113 eyes completed follow-ups at 12, 18, and 24 months, respectively. A total of 39 (78%), 36 (72%), and 38 (76%) eyes in the IVB, IVB/IVT, and MPC groups remained in the study within 24 months, respectively. Retreatment was performed at 3-month intervals whenever indicated. Data from a 24-month follow-up are presented. Changes in best-corrected visual acuity and central macular thickness up to 24 months were the main outcome measures in this study.Retreatment was required in 37 (94.9%), 27 (75.0%), and 31 (81.6%) eyes, respectively, in the IVB, IVB/IVT, and MPC groups up to 24 months. The significant superiority of visual acuity improvement in the IVB group, which had been noted at Month 6, did not sustain thereafter up to 24 months, and the difference among the groups was not significant at all visits. However, the mean visual acuity improvement was greater in the IVB group than the other groups and in the IVB/IVT group compared with the MPC group. The reduction of central macular thickness was more in the IVB group in relation to the other two treatment groups; however, the difference among the groups was not statistically significant at any of the follow-up visits.In terms of vision improvement, the significant superiority of the IVB over the combined IVB/IVT and MPC treatment that had been observed at Month 6 did not sustain up to 24 months. This means that although IVB treatment may be a better choice than two other options in short term, the magnitude of this beneficial effect diminishes over time.

We demonstrate a variable focal length achromatic lens that consists of a flat liquid crystal diffractive lens and a pressure-controlled fluidic refractive lens. The diffractive lens is composed of a flat binary Fresnel zone structure and a thin liquid crystal layer, producing high efficiency and millisecond switching times while applying a low ac voltage input. The focusing power of the diffractive lens is adjusted by electrically modifying the sub-zones and re-establishing phase wrapping points. The refractive lens includes a fluid chamber with a flat glass surface and an opposing elastic polydimethylsiloxane (PDMS) membrane surface. Inserting fluid volume through a pump system into the clear aperture region alters the membrane curvature and adjusts the refractive lens’ focal position. Primary chromatic aberration is remarkably reduced through the coupling of the fluidic and diffractive lenses at selected focal lengths. Potential applications include miniature color imaging systems, medical and ophthalmic devices, or any design that utilizes variable focal length achromats.

Purpose We prospectively evaluated a new treatment for recalcitrant choroidal neovascularization (CNV) in 4 patients. We used an infrared laser (810 nm) in oscillatory thermotherapy (OTT) mode combined with indocyanine green (ICG) dye, utilizing the beneficial effect of both thermotherapy and photodynamic therapy. We describe preliminary experiences with ICG-assisted OTT (I-OTT) combined with intravitreal bevacizumab/dexamethasone for refractory peripapillary CNV resistant to standard therapy. Methods Clinical examination, funduscopy, fluorescein angiography, and optical coherence tomography were performed at baseline and postoperatively. Infrared laser spot size was approximately one-half the lesion size (oscillation 2-3 Hz). Intravitreal injections of bevacizumab (1.25 mg) and dexamethasone (1000 µg) were done during the same visit. Results Mean follow-up was 12.5 months (range 5-17). Mean energy level was 325 mW (range 200-500) in oscillatory mode (2-3 Hz/sec) pre- and post-ICG infusion. Indocyanine green dose was approximately 1 mg/kg (75 mg/patient). All patients had a single treatment. Mean visual acuity improved in 1 patient from 20/60 to 20/30 and remained the same in the other 3 (20/20, 20/40, and 20/400). At final examination, there was no evidence of clinical or angiographic activity of CNV. Conclusions Indocyanine green-assisted OTT has the potential to treat CNV in wet age-related macular degeneration. It may reduce thermal side effects and eliminate or reduce the need for frequent intravitreal treatment. We postulate that I-OTT has a synergistic effect of thermal energy combined with a weak photosensitizer (ICG) applied in an individualized manner, which minimizes thermal damage to retinal and choroidal tissue. Additional anti-vascular endothelial growth factor pharmacotherapy enhances the effect of I-OTT on abnormal new vessels.

Purpose To evaluate the safety and effect of combined intravitreal methotrexate and bevacizumab on choroidal neovascularization in age-related macular degeneration (AMD). Methods Seven eyes of 7 patients (4 female; mean age 65.43±5.96 years) with choroidal neovascularization secondary to AMD were studied. Patients received intravitreal injection of methotrexate and bevacizumab and were examined every 1.5 months. Reinjections were performed with bevacizumab only. Results Three patients had 3 months, 3 had 4.5 months, and 1 had 8 months of follow-up. Mean number of reinjections was 2.0. In all patients, best-corrected visual acuity (BCVA) improved compared to baseline. Central macular thickness (CMT) decreased in all but one patient who had no reduced visual acuity. Mean BCVA (logMAR) was 1.27±0.43 D at baseline, 1.1 ±0.38 D at week 6, and 0.93±0.31 D at month 3. Mean BCVA in 3 patients at 4.5 months was 1.1±0.15 D. There were statistically significant differences between BCVA before injection and at week 6 (p=0.017), 3 months (p=0.005), and 4.5 months (p=0.04). Mean baseline CMT was 389±177 μm, 371±154 μm at 6 weeks, and 317±108 μm at 3 months. Mean CMT in 3 patients at 4.5 months was 266±66 μm. There were no statistically significant differences between baseline CMT and after treatment. No scar formation, increase of scar, or adverse reaction to methotrexate injection were seen. Conclusions Addition of intravitreal methotrexate to bevacizumab was safe in 7 eyes of 7 patients. It may enhance the therapeutic effect in regression of neovascularization in AMD and may reduce development of a fibrous component and disciform scar formation.

Purpose: To describe an unusual case of idiopathic retinal vasculitis, aneurysms, and neuroretinitis syndrome associated with a positive perinuclear antineutrophil cytoplasmic antibody test. Methods: This is an interventional case report. A 22-year-old man with decreased vision underwent ophthalmoscopic, angiographic, and laboratory evaluation. The left eye underwent laser therapy due to circinate retinopathy and more severe involvement. Results: Extensive systemic workup was negative. The only positive laboratory test was a positive perinuclear antineutrophil cytoplasmic antibody (1/40 dilution) detected by indirect immunofluorescence and enzyme-linked immunosorbent assay (positive for antimyeloperoxidase antibody). The patient was observed for 2 years. The disorder remained limited to the eyes, and further systemic workup was unrevealing; perinuclear antineutrophil cytoplasmic antibody titer remained positive. Vision remained stable in the treated eye and was slightly reduced in the untreated eye. Conclusion: Idiopathic retinal vasculitis, aneurysms, and neuroretinitis syndrome may be suggestive of a retinal form of perinuclear antineutrophil cytoplasmic antibody–associated vasculitis.

After evaluating experimentally the diffusion processes in the retina using peroxidase as a tracer material (previously published work), we found that junctional complexes of the retinal pigment epithelium and retinal capillaries were the major impediment to free diffusion between the retina and choroidal-retinal blood vessels. These experiments indicated that to achieve high therapeutic concentrations of medications inside the eye, it was necessary to administer them by intravitreal injection. Soon after initial experimental work the necessity of combining antibiotics or antibiotics with steroids became obvious. As the use of intravitreal injection grew over the last 2 decades, so did the concept of combination therapy.This review describes potential causes of drug-drug interaction and the rationale for combination therapy when injected into the vitreous cavity, encompassing publications between 1971 and 2008.We describe the conditions that can cause physical-chemical interactions between the medications and the need for combination therapy for treatment of various intraocular disease processes.The intravitreal injection of medication and their combinations has become a part of standard care for many diseases of the retina and choroid. This article reviews the potential interaction of nontoxic doses of medications when injected simultaneously in the vitreous cavity, and disease processes that are now treated with these combination therapies.

Background Intravitreal injection (IVI) with administration of various pharmacological agents is a mainstay of treatment in ophthalmology for endopthalmitis, viral retinitis, age-related macular degeneration, cystoid macular edema, diabetic retinopathy, uveitis, vascular occlusions, and retinal detachment. The indications and therapeutic agents are reviewed in this study. Methods A search of the English, German, and Spanish language MEDLINE database was conducted. A total of 654 references spanning the period through early 2008 were individually evaluated. Results The advantage of the IVI technique is the ability to maximize intraocular levels of medications and to avoid the toxicities associated with systemic treatment. Intravitreal injection has been used to deliver several types of pharmacological agents into the vitreous cavity: antiinfective and antiinflammatory medications, immunomodulators, anticancer agents, gas, antivascular endothelial growth factor, and several others. The goal of this review is to provide a detailed description of the properties of numerous therapeutic agents that can be delivered through IVI, potential complications of the technique, and recommendations to avoid side effects. Conclusion The IVI technique is a valuable tool that can be tailored to the disease process of interest based on the pharmacological agent selected. This review provides the reader with a comprehensive summary of the IVI technique and its multitude of uses.

Fifteen patients underwent a pars plana approach vitrectomy and membranectomy after acute and chronic injury. In all cases the lens fragments, hemorrhage, and secondary membranes were removed restoring clarity to the ocular media. In two cases the final visual acuity was limited by pre-existing retinal injury. The advantages of pars plana approach are the small incision and minimal ocular manipulation during surgery. In the presence of retinal injury, diathermy during the procedure or photocoagulation within 24 hours is also indicated.

We evaluated the effects of argon-green (514.5 nm) and CW neodymium YAG (1060 nm) wavelengths on experimentally detached retinas of primates. Neither laser produced damage to the sensory retina of the fovea. The argon green wavelength, which was absorbed by haemoglobin in the vessel or by extravasated red blood cells, created vasospasm and nerve fiber layer damage. The beam of the CW YAG was not absorbed by haemoglobin; therefore, no vasospasm could be produced on experimentally detached retinas.

To evaluate the clinical features and functional and anatomical outcomes after surgical intervention in pediatric rhegmatogenous retinal detachment.In this retrospective case series, pediatric patients with rhegmatogenous retinal detachment who had surgical intervention were included. Cases were categorized into five main etiology groups: congenital or developmental (48 eyes); trauma (54 eyes); myopia alone (12 eyes); previous intraocular surgery (10 eyes); and miscellaneous (3 eyes). Patients' demographic, clinical, and surgical outcomes, as well as fellow eye findings were evaluated.One hundred twenty-seven eyes of 108 patients (mean age: 12.1 +/- 4.1 year, 80.6% male) were included. Scleral buckling was the initial procedure in 31% of eyes and vitrectomy in 63%. Mean follow-up was 34 +/- 21 months (median 33 months). Retinal reattachment at last follow-up was achieved in 74.9% of eyes. Visual acuity was/=20/200 in 14% of eyes preoperatively and in 47.9% of eyes at final follow-up (P = 0.001). Retinal pathologies (mostly lattice degeneration) were noted in 82.2% of fellow eyes.Trauma and congenital-developmental anomalies were the leading etiologies in pediatric rhegmatogenous retinal detachment in this review. Despite the complexity of rhegmatogenous retinal detachment and presence of vision-threatening anomalies, anatomic and functional outcomes were acceptable. Regular ophthalmoscopy of the sound eye is recommended for children at risk.

PURPOSE To report visual outcomes and complication rates associated with one-stage surgery for the management of uveitic cataract associated with posterior segment disease. METHODS In this interventional case series, 19 eyes (19 patients) with posterior segment involvement due to chronic uveitis underwent sutureless scleral tunnel incision phacoemulsification combined with total vitrectomy using 25-gauge instruments and posterior chamber intraocular lens (PC-IOL) implantation. Membrane peeling and endolaser photocoagulation were performed when indicated. Outcome measures were visual acuity, inflammatory activity, macular edema, and complications of surgery. RESULTS After a minimum 12-month follow-up, visual acuity was >or=20/100 in 12 eyes (63.2%); 6 eyes (31.6%) had visual acuity of >or=20/40. A decrease in postoperative inflammatory activity of 1 grade was observed in 8 eyes (42.1%). Sixteen eyes had cystoid macular edema before surgery; and 12 eyes had cystoid macular edema after surgery. Early postoperative complications included the following: transient corneal edema, 10 eyes (50.3%); fibrin reaction, 3 eyes (15.8%), and posterior synechiae, 9 eyes (47.3%). Glaucoma was the most common late postoperative complication (3 eyes [18.8%]). Nine eyes (47.4%) needed YAG laser capsulotomy during the first year. CONCLUSION Sutureless combined 25-gauge total vitrectomy, phacoemulsification, and PC-IOL implantation may be well tolerated with an acceptable complication rate for selected uveitic eyes with significant cataract and coexisting posterior segment disease for restoring useful vision.

To evaluate the effect of topically administered doxycycline in various doses; the combination of triamcinolone acetonide and low-molecular-weight heparin (LMWH); and the combination of triamcinolone acetonide and doxycycline on experimental corneal neovascularization in rats.This project is the combination of 2 separate studies. First, the chemical cauterization of corneas in 36 eyes of 36 Long Evans male rats was performed by using silver nitrate/potassium nitrate sticks. Topical instillation of doxycycline at 0.05% (pH = 3.3), 0.1% (pH = 3.1), 1% (pH = 2.3), 2% (pH = 2.1), 2% (pH neutralized to 7.4), and normal saline continued for 7 days. Second, the chemical cauterization of the corneas in 24 eyes of 24 rats was achieved by application of silver nitrate/potassium nitrate sticks. Topical instillation of triamcinolone acetonide (10 microg/mL) and either LMWH (10 mg/mL) or doxycycline (10 mg/mL) was compared with normal saline treatment of 7 days. For both studies, the percent area of the cornea covered by neovascularization and scar in each group was calculated separately by using computer software on digital photographs. All corneas were evaluated histopathologically in study and control groups.The mean percent area of corneal neovascularization determined in the eyes given doxycycline 0.05%, 0.1%, 1%, 2%, and 2% (pH neutralized) study groups and control groups was 69.8% +/- 18.0%, 64.5% +/- 14.0%, 56.4% +/- 20.8%, 54.8% +/- 6.0%, 36.2% +/- 4.3%, and 69.4% +/- 5.7%, respectively. The mean of percent area of neovascularization in the 2% doxycycline (pH neutralized) doxycycline group was significantly less than that of the control group and the1% doxycycline concentrations (P0.05). The percent corneal neovascularization in the 2% (pH neutralized) doxycycline group was not significantly different from that of the 1% and 2% doxycycline groups (P0.05). There was no significant difference in percent area of corneal scar between control and study groups (P0.05). The mean percent area of corneal neovascularization in triamcinolone acetonide and LMWH, triamcinolone acetonide and doxycycline, and control groups was 2.35% +/- 4.42%, 9.42% +/- 6.8%, and 64.7% +/- 10.0%, respectively. The mean percent area of neovascularization in the triamcinolone acetonide plus LMWH or triamcinolone acetonide plus doxycycline groups was significantly different from that of the control group (P = 0.001 for both). There was no significant difference between study groups with regard to percent area of neovascularization or percent area of corneal scar between the control and study groups.Topically administered combinations of triamcinolone acetonide plus LMWH or triamcinolone acetonide plus doxycycline had effects that contributed to efficient suppression of corneal neovascularization; these drugs were ineffective at similar concentrations used alone. Topically administered 2% (pH neutralized) doxycycline has antiangiogenic effects, which contributed to significant suppression on corneal neovascularization. This drug may be therapeutically beneficial in treatment of corneal neovascularization in clinical trials.

Oxygen saturation (OS) levels in the juxta-papillary retina particularly inferotemporal retina were investigated in open-angle glaucoma (OAG) patients as well as normal subjects. Fifty-six eyes of 56 OAG Japanese patients and 20 eyes of 20 age-matched normal subjects were recruited for the study. OAG eyes (56) were subdivided into two groups: 15 eyes of low-tension (LT) subgroup and 41 eyes of high-tension (HT) subgroup. The average of age of the LT, HT subgroup and normal group were 60.5, 55.9 and 52.6 years, respectively. OS levels in the retina were measured using a Fourier transform-based spectral retinal imaging (SRI) system (Retinal Cube; ASI Co. Migdal Hemak, Israel), with which OS levels in the fundus could be computed at every pixel point of a 35 degrees fundus image. We calculated OS levels at five points in the retina near the optic disc and retinal arteries and veins in all eyes. The OS levels were also compared with the results analyzed using Humphrey visual field Analyzer with the program 30-2 SITA. At the superior and nasal juxta-papillary retinal points, OS level of the LT subgroup showed significant decrease as compared with the HT subgroup and the normal group ( p = 0.048–0.009). The LT and the HT subgroups were significantly lower than the normal group at the inferotemporal and the average of the retinal points ( p = 0.047–0.001). There were no statistically significant differences among the three groups in regards to the OS in the retinal artery. There was a statistical significant correlation between the mean of total deviation of the 17 points in the upper arcuate area and OS of the inferotemporal point ( p = 0.018), and between mean deviation and the average of OS of the inferotemporal and the superotemporal point ( p = 0.037) in the HT subgroup. However, there was no significant correlation in the LT subgroup. OS levels in the retina were especially decreased in the low-tension glaucoma subtype. There was a correlation between the visual field defect and OS in the HT eyes in the inferotemporal region. OS measurement may be a novel adjunct to study glaucoma patients.

Background and Objective:To evaluate histopathologic features of optic neurotomy with microvitreoretinal (MVR) blade or excimer laser.Materials and Methods:Optic neurotomy was performed in 11 cadaver eyes using a 20-gauge MVR blade and 3 cadaver eyes with pulsed xenon chloride excimer laser. Hematoxylin–eosin stained slides were used to evaluate the posterior segments of the globes, including the optic nerve head.Results:No eyes in the MVR group had scleral macroscopic or microscopic perforation and there was no injury to the central retinal vein or artery. The distance between the neurotomy site and the central retinal vessels ranged from 50 to 500 μm at all histologic levels in 10 eyes and was approximately 10 μm in two histologic sections and 200 μm in a third section in 1 eye. Intraneural hemorrhage was found in 11% of eyes. Neurotomy was successful in 2 of 3 eyes with the excimer laser and no neurotomy was evident on sectioning in the third eye due to cloudy media.Conclusions:Optic neurotomy with an MVR blade was an effective procedure for scleral outlet relaxation in cadaver eyes, with no significant surgical complications. This preliminary study also demonstrates that the excimer laser can make non-mechanical cuts with relative ease and reliability.

To measure the buffering capacity of bovine vitreous to HCl, NaOH, and triamcinolone acetonide.Vitreous was dissected from 10 bovine globes, homogenized, and divided into 5.0-mL aliquots. The carbonate/bicarbonate buffer of the vitreous was maintained by performing all subsequent titrations under an atmosphere of 5% CO2/95% air. The pH was monitored during the addition of 0.1 N HCl, 0.1 N NaOH, or 40 mg/mL triamcinolone acetonide to the vitreous sample; 0.9% NaCl was used as control.The buffering capacity of bovine vitreous to HCl was 10 times greater than that of 0.9% NaCl. The buffering capacity of vitreous to NaOH was four times greater than that of 0.9% NaCl. Bovine vitreous was able to resist pH changes from addition of triamcinolone acetonide at levels 20 times greater than commonly injected intravitreally.Vitreous had a greater buffering capacity than 0.9% NaCl, indicating a greater capacity to remain stable when acidic or alkaline pharmaceuticals are injected in microliter amounts.

The aim of this study was to evaluate the retinal toxicity of high-dose intravitreal etanercept, a U.S. Food and Drug Administration-approved anti-inflammatory drug, in the rabbit model.Twenty (20) New Zealand albino rabbits were divided into 5 groups (n=4); eyes in each group were intravitreally injected with one of the following doses of etanercept: 125 microg, 250 microg, 500 microg, 1 mg, or 2.5 mg. One (1) eye in each animal was used for the study dose; the fellow eye was injected with buffered sterile saline as a control. All animals were examined using indirect ophthalmoscopy and slit-lamp biomicroscopy before and after intravitreal injection and at days 1, 7, and 14. Electroretinography (ERG) was performed on all animals before intravitreal injection and 14 days after injection. The animals were euthanized on day 14. Histological preparations of the enucleated eyes were examined with light microscopy for retinal toxicity.Clinical examination, histological evaluation, and ERG results of all 5 groups demonstrated no signs of retinal toxicity.Intravitreal doses as high as 2.5 mg of etanercept did not cause retinal toxicity. Intravitreal doses of up to 2.5 mg of etanercept may provide a more potent, prolonged effect than the lower doses previously recommended.

This study was undertaken to evaluate the effect of topical administration of Rubus suavissimus. S. Lee (Rosaceae) (RUS), an extract of Chinese sweet leaf tea, in the prevention of experimentally induced corneal neovascularization. Corneal neovascularization was induced in 40 rat eyes (1 per animal) by a silver nitrate cauterization technique. Three concentrations (0.1%, 1%, and 10% w/v) of RUS in saline were administered topically twice a day for 7 days. The coverage of the corneal surface by neovascular vessels was measured, using photographs, as a percentage of total cornea area. A histopathologic score was assigned to each cornea. The difference in mean burn stimulus scores of treatment and placebo groups was not statistically significant (p = 0.714). The 10% RUS solution caused a significant decrease in the percentage of neovascularization in response to cauterization (p < 0.01); the 0.1% and 1% concentrations were not significantly different from controls (p = 0.173). The 10% concentration g...

BACKGROUND AND OBJECTIVE To describe the biodistribution of a hydrophilic sensitizer, mono-L-aspartyl chlorin e6 (NPe6), in a primate model of choroidal neovascularization (CNV). MATERIALS AND METHODS NPe6 (25 mg/kg) and indocyanine green (ICG, 15 mg/kg) were intravenously administered simultaneously in monkeys with laser-induced CNVs. Eyes were enucleated and examined by fluorescence microscopy immediately, 20 minutes, and 1, 4, and 24 hours after dye injection. RESULTS Fluorescence peaked in retinal vessels immediately after dye administration; rapid washout began 1 hour postinjection. In contrast, experimental CNV demonstrated little fluorescence immediately after injection, with increased intensity at later time points. Peak dye fluorescence in CNV occurred 1 hour following dye injection. NPe6 fluorescence diminished rapidly and washed out completely by 24 hours. The dye accumulation and retention pattern of ICG dye resembled that of NPe6. CONCLUSIONS This study demonstrated the selective accumulation of NPe6 photosensitizer and ICG dye within experimental CNV and rapid clearance from the circulation and retinochoroidal tissue. [Ophthalmic Surg Lasers Imaging 2007;38:142-147.] AUTHORS From the Department of Ophthalmology (KM, KK, SY), Saitama Medical University, Iruma, Saitama, Japan; and the Department of Ophthalmology (GAP), University of Arizona College of Medicine, Tucson, Arizona. Accepted for publication November 30, 2006. Drs. Mori and Yoneya have a proprietary interest in Meiji Seika Kaisha, Ltd. Supported in part by a grant-in-aid for scientific research (11771070) from the Ministry of Education, Culture and Science in Japan. Supported in part by a grant-in-aid for scientific research (11771070) from the Ministry of Education, Culture and Science in Japan. Address correspondence to Keisuke Mori, MD, PhD, Department of Ophthalmology, Saitama Medical University, 38 Morohongo, Moroyama, Iruma, Saitama, 350-0495 Japan.

BACKGROUND AND OBJECTIVE To report the efficacy of intravitreal triamcinolone acetonide as an adjuvant in the surgical management of cases with advanced proliferative vitreoretinopathy (PVR). PATIENTS AND METHODS Patients with complicated rhegmatogenous retinal detachment and PVR grade C2 or greater were recruited for this interventional, noncomparative, prospective study. All patients underwent three-port pars plana vitrectomy, membrane peeling, laser photocoagulation, and silicone oil injection to reattach the retina followed by 0.1 mL (4 mg) of triamcinolone acetonide injected through the pars plana into the silicone oil. All patients had supplemental laser therapy around retinal breaks and retinectomy edges at 1 to 2 weeks postoperatively. RESULTS Patients included 15 males and 9 females, with an average age of 53.6 years (range: 15 to 84 years) and PVR grade C2 to PVR C9. The mean follow-up period was 11.0 months (range: 3 to 26 months). Twenty-one (87.5%) patients had attached retinas at the final followup visit. Visual acuity improved in all patients following surgery (P < .05). CONCLUSION Triamcinolone acetonide may have potential as an adjuvant in the treatment of retinal detachment with PVR. Further research is required to evaluate the efficacy of this adjuvant treatment. [Ophthalmic Surg Lasers Imaging 2007;38:365- 370.] AUTHORS From the Cardiff Eye Unit (RAC, AJ, ADL, KL), University Hospital of Wales, Cardiff, United Kingdom; the Department of Ophthalmology and Vision Science (GAP), University of Arizona College of Medicine, Tucson, Arizona; and South Texas Eye Consultants (TF), Corpus Christi, Texas. Accepted for publication November 20, 2006. Address correspondence to Gholam A. Peyman, MD, Department of Ophthalmology and Vision Science, University of Arizona College of Medicine, 655 North Alvernon Way, Suite 108, Tucson, AZ 85711.

This article presents the early results from a 10-person human subject study evaluating the accuracy of a novel method of indirect estimation of intraocular pressure using tactile sensors. Manual digital palpation tonometery is an old method used to estimate the eye pressure through palpation with ones fingers. Based on this concept, we present an instrumented measurement method, where multiple tactile stiffness sensors are used to infer the intraocular pressure of the eye. The method is validated using experimental data gathered from human subjects with eye pressures from 15 to 22 mmHg and determined by Goldman applanation tonometry (GAT). Bland-Altman plots comparing the GAT measurements and the proposed through-the-eye-lid tonometry indicate a statistical error of 5.16 mmHg, within the 95% confidence interval, which compares favorably with the FDA-mandated error bound of 5 mmHg. Details on the unit operation and data filtering are also presented. Due to its indirect and non-invasive nature, the proposed new tactile tonometry method can be applied at home as a self-administered home tonometer for management of glaucoma.Copyright © 2015 by ASME

To determine the efficacy of various combinations of flurbiprofen, low molecular weight heparin (LMWH), and doxycycline on the inhibition of corneal neovascularization in rats.Chemical cauterization of the cornea in 32 eyes of 32 rats was performed using silver nitrate/potassium nitrate sticks. The animals were divided into 4 groups. Topical instillation of 0.015% flurbiprofen with 5 mg/mL LMWH (group 1); flurbiprofen with 10 mg/mL doxycycline (group 2); doxycycline with LMWH (group 3), and saline (group 4; control) was performed twice a day for 7 days. Slit-lamp photography was used to determine the percent areas of cornea covered by neovascularization and also by scar in each group. The means were compared to find any significant (P0.05) difference between groups. The animals were euthanized and the eyes enucleated for histological evaluation.The mean of percent area of corneal neovascularization 5 in group 1 was 48.5 +/- 13.1; group 2, 6.6 +/- 5.5; group 3, 22.0 +/- 27.6 and group 4, 64.6 +/- 9. The means of percent area of neovascularization in groups 2 and 3 were significantly lower compared with control and group 1. There was no significant difference in the percent corneal neovascularization between groups 2 and 3 or between group 1 and the control group. Histological findings were consistent with slit-lamp evaluations.Topical instillation of combinations of doxycycline with either flurbiprofen or LMWH can effectively inhibit corneal neovascularization made by chemical cauterization of the cornea in rats.

PURPOSE To assess the retinal toxicity of varying concentrations of intravitreally injected garenoxacin. METHODS Twenty eyes of 20 New Zealand albino rabbits were used for this study. The animals were anesthetized with ketamine (35-50 mg/kg) and xylazine (3-5 mg/kg). Garenoxacin was titrated using distilled water to the following concentrations: 4,000, 2,000, 1,000, 400, 200, and 100 microg/0.1 mL. Each concentration was injected intravitreally (0.1 mL) into three rabbit eyes. Three control eyes were injected with 0.1 mL of balanced saline solution. All animals were examined before and after injection by indirect ophthalmoscopy and slit-lamp biomicroscopy. Electroretinography was performed on all animals before intravitreal injection and 14 days after injection. The animals were examined by indirect ophthalmoscopy and slit-lamp biomicroscopy before they were killed; the eyes were enucleated and examined with light microscopy. RESULTS No electroretinographic changes or signs of retinal toxicity by slit-lamp examination, indirect ophthalmoscopy, or light microscopy were seen in any eyes 14 days after intravitreal injection of garenoxacin (< or =4,000 microg/0.1 mL). CONCLUSIONS Garenoxacin injected intravitreally appeared safe at concentrations of < or =4,000 microg/0.1 mL.

BACKGROUND AND OBJECTIVE To assess the retinal toxicity of varying concentrations of intravitreally injected gatifloxacin and levofloxacin. MATERIALS AND METHODS In this experimental, controlled study, levofloxacin (initial concentration = 25 mg/mL) and gatifloxacin (initial concentration = 2 mg/mL) were titrated using 5% dextrose solution to concentrations of 2,500 to 156 µg/0.1 mL and 400 to 50 µg/0.1 mL, respectively. Each concentration was injected intravitreally into two rabbit eyes (one eye per animal); two control eyes were injected with 0.1 mL of 5% dextrose solution. All animals were examined and electroretinography was performed before and 14 days after injection. The animals were killed at 14 days; the eyes were enucleated and prepared for light microscopy. RESULTS The levofloxacin group exhibited significant decreases in electroretinography in the eyes injected with 1,250 and 2,500 µg. No signs of retinal toxicity were observed on slit-lamp examination, indirect ophthalmoscopy, or light microscopy in all eyes injected intravitreally with 625 µg or less of levofloxacin or in any eyes given gatifloxacin. CONCLUSION Intravitreally injected concentrations of 625 µg or less of levofloxacin and 400 µg or less of gatifloxacin appeared nontoxic. [Ophthalmic Surg Lasers Imaging 2006;37:224-229.] AUTHORS From the Department of Ophthalmology (AAK, CMJ, GAP, EA, MR-E), Tulane University Health Sciences Center, New Orleans, Louisiana; and the Department of Ophthalmology (AAK), Liaquat University of Medical and Health Sciences, Hyderabad, Pakistan. Accepted for publication March 16, 2006. Address reprint requests to Gholam A. Peyman, MD, Department of Ophthalmology, Tulane University Health Sciences Center, 1430 Tulane Avenue, SL-69, New Orleans, LA 70112-2699.

Background and Objectives To evaluate the in vitro energy attenuation by transpupillary thermotherapy (TTT) using an 810-nm diode laser after the treatment of exudative age-related macular degeneration. Study Design/Materials and Methods In this experiment, an 810-nm diode laser was coupled to a slit lamp to deliver laser energy to a laser-power sensor adjusted in the track of the laser light. The spotlight was 0.5 mm in diameter; duration of exposure, 3 seconds. Citrated Pasteur pipettes were filled with blood diluted in saline in several concentrations and placed in the path of the laser light. The absorption of the light measured by the power sensor was tested for various delivered irradiances between 50.92 and 509.29 W/cm2. The differences were analyzed statistically. Results There were significant differences in laser blockage comparing various conditions for all power levels (P

Objectives Pharmacotherapeutics has begun to play an increasingly important role in the management of patients with neovascular age-related macular degeneration (AMD). Because micro- and nano-particulates are currently being evaluated as a potential drug-delivery option for AMD patients, the purpose of this analysis was to describe how micro- and nano-particulates have been used experimentally and what their potential clinical applications may be. Findings Micro- and nano-particulates have been used primarily on a pre-clinical basis as new drug-delivery devices in experimental models of neovascular AMD. Conclusions It is likely that micro- and nano-particulates will become an important component of targeted clinical pharmacotherapeutics in patients with neovascular AMD.

Objective To compare the efficacy of the classic treatment of ocular toxoplasmosis (pyrimethamine, sulfadiazine, and prednisolone) with a regimen consisting of trimethoprim/sulfamethoxazole (co-trimoxazole) plus prednisolone. Design Prospective randomized single-blind clinical trial. Participants Fifty-nine patients with active ocular toxoplasmosis were randomly assigned to 2 treatment groups: 29 were treated with pyrimethamine/sulfadiazine, and 30 patients received trimethoprim/sulfamethoxazole. Intervention Treatment consisted of 6 weeks' treatment with antibiotics plus steroids. Antitoxoplasmosis antibodies (immunoglobulin M [IgM] and IgG) were measured using an enzyme-linked immunosorbent assay. Main Outcome Measures Changes in retinochoroidal lesion size after 6 weeks' treatment, visual acuity (VA) before and after intervention, adverse drug reactions during follow-up, and rate of recurrence. Results Active toxoplasmosis retinochoroiditis resolved in all patients over 6 weeks' treatment, with no significant difference in mean reduction of retinochoroidal lesion size between the 2 treatment groups (61% reduction in the classic treatment group and 59% in the trimethoprim/sulfamethoxazole group, P = 0.75). Similarly, no significant difference was found in VA after treatment between the 2 groups (mean VAs after treatment were 0.12 logarithm of the minimum angle of resolution [logMAR] [20/25] in the classic treatment group and 0.09 logMAR [20/25] in the trimethoprim/sulfamethoxazole group, P = 0.56). Adverse effects were similar in both groups, with one patient in each suffering from any significant drug side effects. The overall recurrence rate after 24 months' follow-up was 10.16%, with no significant difference between the treatment groups ( P = 0.64). Conclusions Drug efficacies in terms of reduction in retinal lesion size and improvement in VA were similar in a regimen of trimethoprim/sulfamethoxazole and the classic treatment of ocular toxoplasmosis with pyrimethamine and sulfadiazine. Therapy with trimethoprim/sulfamethoxazole seems to be an acceptable alternative for the treatment of ocular toxoplasmosis.

This review outlines the applications of liposomal formulations in ophthalmology. In ophthalmology, liposomes have been used to treat disorders of both the anterior and posterior segments. These include dry eyes, keratitis, corneal transplant rejection, uveitis, endophthalmitis, and proliferative vitreoretinopathy. Liposomes also have shown promise as vectors for genetic transfection and monoclonal antibody-directed vehicles. Furthermore, heat-activated liposomes have spurred research in focal laser and heat-induced release of liposomal drugs and dyes for selective drug delivery. These techniques have been useful in selective tumor and neovascular vessel occlusion, angiography, and retinal and choroidal blood-flow studies. Although verteporfin is the only liposomal drug currently approved for use in the eye, the benefits of liposomes will likely be applied widely in all treatment, diagnostic, and research aspects of ophthalmology in the future.

* BACKGROUND AND OBJECTIVE: To evaluate the management of a series of eyes with magnetic intravitreal foreign bodies. * PATIENTS AND METHODS: This retrospective review examined consecutive cases of ocular injury associated with intraocular foreign bodies; 71 eyes included had a single metallic intraocular foreign body (< 5 mm) located in the vitreous cavity removed by external magnet or intraocular forceps. Variables included preoperative and postoperative visual acuity, retinal break formation, retinal detachment, presence of an afferent pupillary defect, intraocular pressure, entrance site, foreign body size, method of extraction, and time between occurrence and surgical extraction. * RESULTS: Factors predictive of good visual outcome (visual acuity > 20/200) were: shortest interval between trauma and foreign body extraction, preoperative visual acuity of 20/200 or better, and absence of afferent pupillary defect. * CONCLUSIONS: In this nonrandomized study, good visual results could be obtained in eyes undergoing prompt foreign body removal, especially those with good preoperative visual acuity and no afferent pupillary defect. [Ophthalmic Surg Lasers Imaging 2004;35:372378.]

Two consecutive patients with idiopathic central serous chorioretinopathy and decreased vision subsequent to subfoveal choroidal neovascular membranes were treated with photodynamic therapy applied using the protocol of the Treatment of AgeRelated Macular Degeneration with Photodynamic Therapy Study Group. Main outcome measures included best-corrected visual acuity, biomicroscopic appearance, and leakage on fluorescein and indocyanine green angiography. Photodynamic therapy offered anatomical, angiographic, and functional improvement. After an initial complete response, the patients required re-treatment at 3 and 4 months, respectively. Cessation of leakage with improvement in visual acuity occurred, but subretinal fibrosis posed a possible limitation for full functional recovery. Although choroidal neovascular membranes complicating idiopathic central serous chorioretinopathy portend a poor visual prognosis, the overall response to photodynamic therapy was favorable. [Ophthalmic Surg Lasers Imaging 2004;35:168-171.]