Faculty Bibliography

PURPOSE: To identify the spectrum and susceptibility pattern of pathogens responsible for culture-positive endophthalmitis referred to a single institution and investigate possible trends in both pathogens and antibiotic sensitivities over the past 25 years. DESIGN: A retrospective, laboratory-based study of consecutive microbiological isolates. PARTICIPANTS: A total of 988 consecutive culture-positive endophthalmitis isolates from 911 eyes. METHODS: All culture-positive endophthalmitis isolates collected from 1987 to 2011 were identified. Susceptibility rates to a variety of antibiotics were calculated. Chi-square test for trend was used to detect changes in spectrum or susceptibility over time. MAIN OUTCOME MEASURES: Microbial spectrum and susceptibility pattern over time. RESULTS: A total of 988 isolates were identified from 911 eyes. The average patient age was 67+/-18 years, and 55% of the patients were female. The most prevalent pathogens were coagulase-negative staphylococcus (39.4%), followed by Streptococcus viridans species (12.1%) and Staphylococcus aureus (11.1%). Gram-negative organisms and fungi accounted for 10.3% and 4.6% of all isolates, respectively. With the exception of 2 isolates, Enterococcus faecium and Nocardia exalbida, all the other 725 (99.7%) gram-positive bacteria tested were susceptible to vancomycin. Of the 94 gram-negative organisms tested against ceftazidime, 2 were of intermediate sensitivity and 6 were resistant. For 8 antibiotics, increasing microbial resistance over time was observed: cefazolin (P = 0.02), cefotetan (P = 0.006), cephalothin (P<0.0001), clindamycin (P = 0.04), erythromycin (P<0.0001), methicillin/oxacillin (P<0.0001), ampicillin (P = 0.01), and ceftriaxone (P = 0.006). For 3 antibiotics, increasing microbial susceptibility was observed: gentamicin (P<0.0001), tobramycin (P = 0.005), and imipenem (P<0.0001). CONCLUSIONS: Coagulase-negative staphylococcus remains the most frequently identified cause of endophthalmitis. Vancomycin and ceftazidime seem to be excellent empiric antibiotics for treating endophthalmitis. Although a statistically significant trend toward increasing microbial resistance against a variety of antibiotics, including cephalosporins and methicillin, was observed, a significant trend toward decreasing microbial resistance against aminoglycosides and imipenem also was detected.

OBJECTIVE: To resolve the controversy surrounding the shape and relationship of posterior vitreous spaces by characterizing the connections between the premacular bursa, the area of Martegiani, and Cloquet's canal. DESIGN: Comprehensive posterior vitreous maps were created using swept-source optical coherence tomography (SS OCT) in a cross-sectional study. PARTICIPANTS: The posterior vitreous of 102 eyes of 51 volunteers 21 to 54 years of age without ocular pathologic features was imaged using SS OCT. METHODS: The DRI OCT-1 Atlantis 3D SS OCT (Topcon Medical Systems, Oakland, NJ) was used to acquire scans of the posterior vitreous over an 18x18-mm area. MAIN OUTCOME MEASURE: Posterior vitreous spaces and their relationships were identified. RESULTS: The premacular bursa was identified in all 102 eyes and was found to extend superiorly beyond our scanning ability at a variable angle. No discernible superior borders could be identified. Instead, a connection of the bursa with the preoptic area of Martegiani or its extension, Cloquet's canal, was found in 101 of 102 eyes. This connection occurred at a variable distance from the optic nerve, where it formed a flat and broad superior channel. The skyward direction of this channel was found to be gravity dependent in all 14 eyes of the 7 subjects examined in various head positions. Although SS OCT was able to identify vitreous degeneration, the above changes were present in 28 eyes even without any discernible vitreous degeneration. CONCLUSIONS: The premacular bursa, also called the posterior precortical vitreous pocket, was found to continue superiorly beyond the posterior pole without a detectable border. The bursa fused broadly with the extension of the preoptic area of Martegiani, namely Cloquet's canal, or the hyaloidal tract of Eisner. These findings suggest that there is a direct anteroposterior connection between the retrolental and premacular and preoptic spaces already existent in the eyes of young adults before the occurrence of vitreous degeneration. This observation may have important implications with respect to the movement of intrinsic and extrinsic mediators between the anterior and posterior segments.

BACKGROUND/AIMS: To report the outcomes of patients undergoing pars plana vitrectomy (PPV) for myopic macular retinoschisis. METHODS: Retrospective, non-randomised case series of patients who underwent PPV for myopic macular retinoschisis. Macular holes and foveal retinal detachments that occurred with myopic macular retinoschisis were also included in the series. Myopic macular retinoschisis was confirmed with optical coherence tomography. Visual acuity (VA) and central foveal thickness (CFT) were measured at baseline and 6 months following surgery. RESULTS: A total of 41 eyes were identified that met the inclusion criteria. The mean follow-up time was 192 days (range 132-272). The mean preoperative VA was 20/130, and the mean VA at 6 months was 20/70 (p=0.02). Following surgery, 14 (34.1%) eyes had VA of 20/40 or better. In 15 (36.6%) eyes, VA was 20/50-20/100 and in 12 (29.2%) eyes, VA was 20/200 or worse. CFT improved from a mean of 558 microns at baseline to 265 microns at 6 months (p<0.001). CONCLUSIONS: PPV generally resulted in stable or improved VA for eyes with myopic macular retinoschisis. Eyes with concurrent macular hole or foveal retinal detachment often had improved VA, but to a lesser extent than eyes with myopic macular retinoschisis alone.

PURPOSE: To describe the nature and evolution of acquired macular detachments in patients with immunogammopathies and to propose a mechanism for their development. DESIGN: Retrospective observational case series. METHODS: Three patients with multiple myeloma and 1 with light chain deposition disease were diagnosed with vitelliform macular detachments based on clinical examination, fundus autofluorescence, fluorescein angiography, and optical coherence tomography. These patients were followed over time and their clinical examinations and imaging studies were compared and contrasted. RESULTS: Three patients (5 eyes) with multiple myeloma and 1 patient (2 eyes) with light chain deposition disease presented with acquired macular yellowish subretinal deposits on funduscopic examination that corresponded to hyperautofluorescent lesions on fundus autofluorescence imaging and subretinal hyperreflective material on spectral-domain optical coherence tomography. One patient (2 eyes) had diffuse serous retinal detachments involving not only the macular region but also the midperiphery of the retina. These acquired macular vitelliform detachments were not associated with signs of hyperviscosity retinopathy in 5 eyes and resolved after successful treatment of the multiple myeloma in 6 eyes. CONCLUSION: Patients with an immunogammopathy such as multiple myeloma or light chain deposition disease may develop serous elevations of the macula that we classify as acquired vitelliform detachments using multimodal imaging. Appropriate evaluation including serum protein electrophoresis and hematology consultation should be considered in the management of patients with acquired vitelliform detachments of uncertain etiology.

PURPOSE: To report a case of subretinal deposits, paramacular atrophy, and pigmentary retinopathy associated with mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes. METHODS: Retrospective review of medical records. RESULTS: A 45-year-old white woman presented with progressive deterioration of vision and dark adaptation over several years. She had a background of an undiagnosed neurodegenerative disorder, including sensorineural hearing loss, cognitive disturbance, and peripheral neuropathy. On examination, subretinal deposits were visible along the superotemporal arcades. A diagnosis of mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes was confirmed by genetic testing (A3243G gene mutation). Four years later, she had developed paramacular atrophy and pigmentary retinopathy. CONCLUSION: Mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes may be associated with paramacular atrophy and pigmentary retinopathy. Autofluorescent changes may precede these signs and can help distinguish this condition from Stargardt disease-fundus flavimaculatus. As far as we are aware, this is the first report of fundus autofluorescence imaging and optical coherence tomography in mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes-associated retinopathy. Subretinal deposit may be an early sign.

Purpose. To describe the complete sequence of the progressive vasculopathy in macular telangiectasia type 2.Methods. This is a report of a case demonstrating the complete vasogenic sequence in macular telangiectasia type 2 over the course of 15 years, and representative images from a collective of 150 patients with macular telangiectasia type 2 employing fundus photography, fluorescein angiography, and optical coherence tomography.Results. Macular telangiectasia may progress along a predictable vasogenic sequence which consists of nonproliferative stages, characterized by temporal loss of macular luteopigment and inner retinal volume loss in the absence of vascular changes, followed by a progressive proliferative vasculopathy, first involving the deep capillary plexus with eventual extension of the vascular changes circumferentially in the inner retinal capillary plexus. Late proliferative stages may become indistinguishable from advanced neovascular age-related macular degeneration.Conclusions. While it is rare to observe the complete vasogenic sequence of macular telangiectasia type 2, a classification into nonproliferative and proliferative stages can be established, and may prove helpful as the mechanisms driving the pathogenic process through those stages are identified.

PURPOSE: : To describe simultaneous scanning laser ophthalmoscope indocyanine green angiographic and eye-tracked spectral-domain optical coherence tomography findings in eyes with polypoidal choroidal vasculopathy (PCV). METHODS: : Eighteen eyes of 18 patients with PCV because of a variety of different diagnoses were imaged with simultaneous scanning laser ophthalmoscope indocyanine green angiography and eye-tracked spectral-domain optical coherence tomography to localize the polyps and their associated vascular structures with respect to the retinal layers. RESULTS: : Regardless of the underlying diagnosis, simultaneous scanning laser ophthalmoscope indocyanine green angiography and eye-tracked spectral-domain optical coherence tomography imaging localized the polypoidal structures of PCV to within larger Type 1 neovascular complexes occurring within or above Bruch membrane. In 8 eyes, PCV appeared to adhere to the undersurface of an elevated retinal pigment epithelial detachment. In 1 eye, a PCV lesion was detected within the neurosensory retina having apparently eroded through the overlying retinal pigment epithelium. CONCLUSION: : Simultaneous scanning laser ophthalmoscope indocyanine green angiography and eye-tracked spectral-domain optical coherence tomography demonstrate that a majority of PCV represents a variant of the Type 1 neovascular growth pattern, which can occur in a variety of different neovascularized maculopathies. Polypoidal choroidal vasculopathy lesions appear to originate from long-standing choroidal neovascularization, rather than from the choroidal vasculature itself. Given these observations, PCV would be more accurately described as a neovasculopathy rather than as a choroidal vasculopathy.

BACKGROUND: Best disease is an autosomal dominant retinal dystrophy with a variable phenotypic expression. Clinically, it is characterized by a vitelliform lesion in the macula because of the deposition of yellow material in a dome-shaped configuration, believed to be lipofuscin that accumulates within and beneath the retinal pigment epithelium. Best disease is occasionally complicated by the development of choroidal neovascularization (CNV), which typically occurs in the macula. We report a case of peripapillary CNV in Best disease. METHODS: Interventional case report. RESULTS: A 12-year-old boy who was previously diagnosed with Best disease was treated with reduced fluence photodynamic therapy for subfoveal CNV in the right eye. After 2 months, he presented with peripapillary CNV in the left eye, which was treated with repeated sessions of reduced fluence photodynamic therapy. CONCLUSION: Ophthalmologists must be aware that peripapillary CNV may occasionally complicate Best disease and can be successfully treated with photodynamic therapy.