Faculty Bibliography

A 79-year-old man presented with a symptomatic, full-thickness macular hole with concurrent vitreomacular traction (VMT), stage 2. The patient was treated with a single injection of ocriplasmin. Within 1 week, the macular hole had closed, but there was persistence of vitreomacular traction. Two months after injection, the VMT released with sustained closure of the macular hole. The temporal course of macular hole closure antecedent to VMA release runs contrary to our current understanding of macular hole closure and warrants further research to decipher the mechanism by which ocriplasmin achieves its intended effect.

BACKGROUND AND OBJECTIVE: To compare subfoveal choroidal thickness (CT) measurements in eyes with nonexudative age-related macular degeneration (AMD) in the presence or absence of reticular pseudodrusen (RPD). PATIENTS AND METHODS: Subfoveal CT measurements obtained from patients with AMD enrolled in the COMPLETE study (30 drusen-only eyes and 30 eyes with geographic atrophy [GA]) were compared with an age-distributed normal control group. Multimodal images were evaluated to detect the presence of RPD. RESULTS: After controlling for age and axial length, the mean CT was significantly thinner in the GA group with RPD (213.7 +/- 53.1 microm) than in the GA group without RPD (335.3 +/- 123.2 microm; P = .001). The mean CT in the GA group without RPD was not statistically different from the mean CT in the normal control group (P = .076) or the drusen group without RPD (P = .45). In eyes without RPD, there was a correlation between the increasing size of GA and a decrease in CT measurements. CONCLUSION: Subfoveal choroidal thinning in eyes with nonexudative AMD was associated with the presence of RPD. In the absence of RPD, CT only decreased as the size of GA increased.

Neovascular age-related macular degeneration (NVAMD) is one of the leading causes of blindness. Over the last decade, the treatment of NVAMD has been revolutionized by the development of intravitreal anti-vascular endothelial growth factor (VEGF) therapies. Several anti-VEGF medications are used for the treatment of NVAMD. The safety and tolerability of these medications deserve review given the high prevalence of NVAMD and the significant utilization of these medications. Numerous large randomized clinical trials have not shown any definitive differential safety relative to ocular or systemic safety of these medications. Intravitreal anti-VEGF therapy does appear to impact systemic VEGF levels, but the implications of these changes remain unclear. One unique safety concern relates drug compounding and the potential risks of contamination, specifically for bevacizumab. Continued surveillance for systemic safety concerns, particularly for rare events, is merited. Overall, these medications are well tolerated and effective in the treatment of NVAMD.

PURPOSE: To evaluate the changes of vascular endothelial growth factor (VEGF) plasma levels after intravitreal injections of aflibercept or ranibizumab in patients with exudative age-related macular degeneration (AMD). METHODS: Thirty-eight patients with exudative AMD were included in this randomised, prospective study. Nineteen patients were randomised to treatment with intravitreal aflibercept (2.0 mg) and 19 to intravitreal ranibizumab (0.5 mg). The concentration of VEGF was measured by ELISA just before the injection, after 7 days and 1 month. Twenty-two age- and sex-matched healthy patients without chorioretinal diseases served as control. RESULTS: The median baseline plasma VEGF concentration was 61.0 pg/ml in the control group, 43.0 pg/ml in the aflibercept group and 59.0 pg/ml in the ranibizumab group (p=0.127). Seven days after intravitreal injection of aflibercept plasma levels were significantly reduced to values below the minimum detectable dose (MDD) in 17 of 19 patients (89.5%) resulting in a median VEGF concentration of <9 pg/ml (p<0.001). The reduction persisted throughout 1 month with values below the MDD in 5 of 19 patients (26.3%) and a median measurement of 17.0 pg/ml (p<0.001). In patients treated with ranibizumab no significant effects could be observed with a baseline VEGF of 59.0 pg/ml, 54.0 pg/ml at 7 days (p=0.776) and 58.5 pg/ml at 4 weeks of follow-up (p=0.670). CONCLUSION: After intravitreal aflibercept injection, the systemic VEGF levels were significantly reduced throughout the observational period of 4 weeks. No significant systemic effects of intravitreal ranibizumab on plasma VEGF were observed.

BACKGROUND AND OBJECTIVE: To evaluate subfoveal choroidal thickness (CT) and the extent of outer retinal disruption in patients with macular telangiectasia type 2 (MacTel2) compared with healthy eyes. PATIENTS AND METHODS: In this prospective, observational, cohort study, 62 patients (62 eyes) with Mac-Tel2 and 130 healthy controls (130 eyes) underwent a complete ophthalmological examination, spectral-domain optical coherence tomography (SD-OCT) imaging, and axial length measurements. Patients in the study group also underwent color fundus photography, fundus autofluorescence, and fluorescein angiography. En face SD-OCT imaging was used to assess abnormalities involving the photoreceptor inner segment/outer segment/ellipsoid zone (IS/OS/EZ). RESULTS: After adjusting for age and axial length, the authors found that eyes with MacTel2 had a mean CT measurement that was greater than control eyes (P = .007). There was a negative correlation between the visual acuity and the area of IS/OS/EZ damage (P = .009), but no statistically significant correlation was seen between CT and the area of IS/OS/EZ damage. CONCLUSION: Eyes with MacTel2 were found to have thicker CT measurements than control eyes. While the extent of IS/OS/EZ disruption correlated with the loss of visual acuity, this damage did not correlate with CT measurements.

PURPOSE: To report a brimonidone-induced allergic reaction that mimicked a limbal form of vernal keratoconjunctivitis in the setting of background ocular surface toxicity. PATIENTS AND METHODS: A 78-year-old male with a history of primary open angle glaucoma presented with symptoms of unilateral blurry vision, irritation, and redness shortly after starting brimonidine exclusively in the right eye. Examination revealed injected palpebral and bulbar conjunctiva, diffuse punctate epithelial erosion and discrete, non-staining corneal limbal infiltrates superiorly. RESULTS: Given the unilateral presentation, the patient was diagnosed with an allergic limbal keratoconjunctivitis secondary to bromonidine. Shortly after discontinuing the brimonidine, there was full resolution of the corneal limbal infiltrates. The punctate epithelial erosions and tear film abnormalities remained. CONCLUSION: Direct medication allergy and ocular surface disease are two distinct entities that often co-exist. Distinguishing between the two entities, sometimes by trial and error, is critical in the management of these patients.

BACKGROUND AND OBJECTIVE: To evaluate subfoveal choroidal thickness (CT) in healthy eyes using spectral-domain optical coherence tomography (SD-OCT) and provide correlations between age and axial length. PATIENTS AND METHODS: Enhanced depth SD-OCT imaging was performed with Cirrus (Carl Zeiss Meditec, Dublin, CA) and Spectralis (Heidelberg Engineering, Heidelberg, Germany) instruments. CT was measured from the outer limit of the retinal pigment epithelium to the inner surface of the sclera. RESULTS: The study enrolled 155 patients, with at least 20 in each decade between 22 and 89 years old. Mean axial length was 23.6 mm. Mean Heidelberg subfoveal CT was 286 microm. The correlation between Heidelberg and Zeiss subfoveal CT measurements was strong (r = .978) and significant (P < .001). Mean subfoveal CT was 7.7 microm thinner by Heidelberg versus Cirrus (P < .001). Multiple linear regression analysis revealed that age (P < .001), axial length (P = .001), and sex (P = .025) were significantly related to Heidelberg subfoveal CT. CONCLUSION: There is a strong negative correlation between CT and age (P <.001), with a 25 microm decrease in CT for each decade of life. Increasing axial length demonstrated a negative correlation with CT, decreasing 24.9 microm for each mm of axial length. Future studies of CT measurements can be performed on either instrument and must account for axial length, age, and sex to make appropriate conclusions.

BACKGROUND AND OBJECTIVE: To report outcomes of pneumatic retinopexy (PR) for retinal detachment (RD) occurring after prior scleral buckling surgery (SB) or pars plana vitrectomy (PPV). PATIENTS AND METHODS: Single-center study evaluating all patients treated between January 2000 and March 2013. RESULTS: Ten eyes underwent PR after prior SB. Nine of these 10 eyes had persistent subretinal fluid posterior to the buckle in the setting of an open break on the scleral buckle. The mean time to PR in these cases was 8.5 days after SB. PR achieved anatomic reattachment in eight of 10 eyes, but two of 10 eyes required additional PPV to achieve retinal reattachment. Seven eyes underwent PR after prior PPV. The average time to RD after PPV was 67 days (range: 15-232 days). The location of the break was superior in four eyes, horizontal in two, and inferior in one. Anatomic reattachment with PR alone occurred in four of seven eyes (57%). CONCLUSION: In the setting of recurrent RD after initial SB, pneumatic retinopexy was usually successful in the early postoperative course. In the setting of a new-onset RD after PPV, pneumatic retinopexy was a useful option, but recurrent RD was more common.