DOCSLIB.ORG

Incidence and Management of Acute Endophthalmitis After Intravitreal

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Incidence and Management of Acute Endophthalmitis After Intravitreal Eye (2009) 23, 2187–2193 & 2009 Macmillan Publishers Limited All rights reserved 0950-222X/09 $32.00 www.nature.com/eye Incidence and O Artunay, E Yuzbasioglu, R Rasier, A Sengu¨l CLINICAL STUDY and H Bahcecioglu management of acute endophthalmitis after intravitreal bevacizumab (Avastin) injection Abstract recognition and treatment are key in maximizing outcomes in patients who Introduction The aim of this study was to developed endophthalmitis after intravitreal report the incidence and management of acute injection of bevacizumab. endophthalmitis after intravitreal injection of Eye (2009) 23, 2187–2193; doi:10.1038/eye.2009.7; Avastin (bevacizumab), and visual acuity published online 13 February 2009 outcomes of three eyes of three patients who developed acute endophthalmitis following Keywords: intravitreal injection; bevacizumab; intravitreal injection of Avastin. endophthalmitis Methods This clinical retrospective, non-comparative study included 3022 Introduction intravitreal injections of 1.25 mg bevacizumab consecutively performed for 1822 eyes with Intravitreal injection of medications is becoming exudative age-related macular degeneration increasingly accepted for treatment of various and other retinal diseases. Of 3022 injections, retinal disorders, with effective intravitreal 1200 were reinjections. After clinical therapies being commonly administered in the appearance of post-injection endophthalmitis, vitreoretinal clinical or surgical environment. Department of immediate intervention was performed, With the increase in use of these agents, the risk Ophthalmology, Istanbul including injection of intravitreal antibiotics of endophthalmitis is becoming an important Bilim University, Istanbul, Turkey and early pars plana vitrectomy. concern. Off-label intravitreal injections of Results Three eyes of three patients with bevacizumab (Avastin; Genentech Inc., South Correspondence: O Artunay, acute postoperative endophthalmitis were San Francisco, CA, USA) have been given for Sisli Florence Nightingale identified in the first week following the treatment of neovascular and exudative Hastanesi, intravitreal injections of 1.25 mg bevacizumab. ocular diseases since May 2005.1,2 Since then, Abide-i Hurriyet Sok. No: 1 Among of these patients, two cases were the use of intravitreal bevacizumab (IVB) has Sisli, Istanbul, Turkey Tel: þ 90 212 224 49 66; culture-positive and one case was spread worldwide, but the drug-related adverse Fax: þ 90 212 224 49 culture-negative. Compared with presenting events associated with its use have been 50-5633. visual acuities, all of three patients improved reported in a few retrospective reviews. IVB is E-mail: artunay@ at the end of follow-up time. The overall increasingly being used for the treatment of gmail.com incidence rate of post-injection culture-proven ocular diseases. However, the treatment is not endophthalmitis was 0.066%. without risks. None of the adverse event rates Received: 19 November 2008 Discussion Acute culture-proven 3 exceeded 0.21%. Endophthalmitis is a serious Accepted in revised form: endophthalmitis is still a potential intraocular inflammatory disorder resulting 5 January 2009 complication of intravitreal bevacizumab from infection of the vitreous cavity. Exogenous Published online: injection (approximately 0.066%) despite using endophthalmitis occurs when infecting 13 February 2009 maximal sterile techniques. Acute organisms gain entry into the eye by direct All the authors have no post-injection endophthalmitis following inoculation through intraocular surgery, proprietary interest in any 4 intravitreal bevacizumab occurs rapidly and penetrating trauma, or intravitreal injection. products or concepts can result in severe loss of vision. Prompt The risk of endophthalmitis after intravitreal mentioned in this article. Incidence and management of acute endophthalmitis O Artunay et al 2188 injection may vary among agents that are employed.5 The understanding on the potential benefits and risks of IVB reported incidence of endophthalmitis per patient in treatment and other alternative treatment modalities. The multi-centre clinical trials with anti-vascular endothelial study protocol was complied with the provisions of the growth factor (VEGF) therapy ranged from 0.019 to Declaration of Helsinki Principles and was reviewed and 1.6%.6–8 Although cases of acute endophthalmitis approved by the ethics committee. Patients were following IVB have occurred, the exact incidence excluded from the study if the bevacizumab was used as rate remains unknown. Concerns have been raised part of another surgical procedure (ie cataract surgery, regarding injection technique and also about the use pars plana vitrectomy (PPV), air–fluid exchange). Eyes of bevacizumab because of compounding issues. were also excluded from the study if another intraocular Generalized categories that lump adverse events are less procedure was performed at least 4 weeks before useful than a clear statement of the rate of individual, injection. clinically relevant endophthalmitis. Treating physician IVB injection was performed as an outpatient wants to know the specific rates of endophthalmitis and procedure under strict aseptic technique. Local its management. The purpose of our study was to report anaesthesia was achieved using 0.5% proparacaine the incidence rates of culture-positive and culture- (Alcaine; Alcon Laboratories Inc., Fort Worth, TX, USA) negative endophthalmitis for patients receiving IVB. and 10% povidone-iodine solution was applied to the The current study also includes the clinical findings, eyelids and in the conjunctival sac for 5 min, followed by causative organisms, management, and visual acuity draping and insertion of a lid speculum. Intravitreal outcomes of three eyes of three patients who developed injection of 1.25 mg bevacizumab in 0.05 ml was then acute postoperative endophthalmitis after IVB injection. carried out using a separate, sterile 30-gauge needle at 4-mm post-limbus in the inferior or inferotemporal quadrant. The needle was removed simultaneously with Materials and methods the application of a cotton tip over the entry site. This is a retrospective, interventional case series of 3022 Immediately after injection, 10% povidone-iodine consecutive eyes that were administered IVB injection at solution was applied on the ocular surface. Bevacizumab our reference clinic for miscellaneous retinal disease, (100 mg/4 ml; Roche; Genentech Inc.) was kept which was presented after March 2005. The indications refrigerated at 41C in its 4 ml original vial, and the for injection included predominately exudative studied volume of 0.05 ml was directly withdrawn from age-related macular degeneration (AMD; n ¼ 1453), the vial just before each injection. Ten patients were choroidal neovascular membranes secondary to myopic grouped together for treatment to provide multiple doses degeneration (n ¼ 21), idiopathic, and other secondary from a single vial. The top of the container was cleaned causes (n ¼ 18); cystoid or diffuse macular oedema from with alcohol wipe before injection. Any unused drug was central and branch vein occlusions, diabetes, uveitis and discarded after the vial had been opened for 4 h to retinitis pigmentosa (n ¼ 310); and proliferative prevent drug contamination. The optic nerve head was retinopathies (n ¼ 20). All patients included in the then examined for arterial pulsation to look for study were identified using comprehensive billing complications, and indirect ophthalmoscopy was records. A search of the office database was conducted performed to ensure correct placement of the injection for endophthalmitis diagnosis codes and intravitreal and to evaluate the retina. Tonometry was carried out injection procedure codes to identify all patients having after the procedure. Patients were given topical ofloxacin IVB and those who developed endophthalmitis. Patients (Exocin; Allergan Pharmaceuticals Ltd, Westport, were included in the study if they had clinical evidence Ireland) 3 mg/ml q.i.d. (four times a day) for 1 week after of acute postoperative endophthalmitis after receiving an each injection. Following the injection, the patients were IVB injection. Acute postoperative endophthalmitis was educated about symptoms of endophthalmitis. defined as the presence of progressive inflammation in At baseline and during the follow-up period, patients the vitreous cavity (vitritis) and/or anterior chamber received a comprehensive ophthalmic examination. Post- (iritis) within 4 weeks following intravitreal injections injection examinations were scheduled between 1 and 7 of bevacizumab. Culture-positive endophthalmitis was days, 4 weeks, and 8 weeks. considered to be present if the patient had either a positive gram stain or a positive culture. If the fungal, Results aerobic, and anaerobic culture were all negative, then this case was accepted as culture-negative endophthalmitis. A total of 3022 intravitreal injections of bevacizumab Common clinical findings were hypopyon, pain, red eye, were performed for 1822 eyes with exudative AMD and and decreased vision. Informed consents were obtained other exudative, proliferative retinal diseases during this from all participants after thorough discussion and full time period. Of 3022 injections, 1200 were reinjections. Eye Incidence and management of acute endophthalmitis O Artunay et al 2189 Follow-up after each injection was at least 6 weeks. Three loss. Orbital ultrasonograms before PPV showed dense patients were identified with signs
Load more

Recommended publications
  • Endophthalmitis After Intravitreal Injections in Patients with Self-Reported Iodine Allergy
    Endophthalmitis After Intravitreal Injections in Patients With Self-reported Iodine Allergy BOBECK S. MODJTAHEDI, TAVE´ VAN ZYL, HEMANG K. PANDYA, ROBERT E. LEONARD, II, AND DEAN ELIOTT PURPOSE: To present cases of endophthalmitis IMITING THE RISK OF POSTINJECTION ENDOPHTHAL- following intravitreal injections where povidone-iodine mitis is an area of considerable practical and aca- (PI) was not used as part of the surgical preparation. demic interest, especially in the era of regular L DESIGN: Retrospective case series. intravitreal injections. Although the incidence of postin- METHODS: All cases of presumed injection-related jection endophthalmitis is low (0.056% per injection in a endophthalmitis presenting to the Massachusetts Eye recent meta-analysis),1 the risk to an individual patient is and Ear Infirmary between June 2008 and November magnified by the recurrent nature of the procedure. Using 2014 and Dean McGee Eye Institute between January povidone-iodine (PI) for surgical antisepsis is well estab- 2010 and January 2015 were identified. Patients who lished and is the only preoperative measure shown to did not receive PI preparation owing to documented reduce the risk of endophthalmitis in patients undergoing self-reported allergy to iodine, iodine-containing contrast intraocular surgery.2 The importance of PI application material, or shellfish were identified and their injection prior to intravitreal injection has been observed by histories and clinical courses reviewed. Nentwich and associates,3 Bhavsar and Sandler,4 and Bryn- 5 RESULTS: The combined rate of postinjection endoph- skov and associates, the latter of whom described no cases thalmitis at these 2 centers was 0.019%. Among 42 of endophthalmitis after 20 293 injections.
    [Show full text]
  • Intravitreal Angiogenesis Inhibitors for Retinal Vascular Conditions
    MEDICAL COVERAGE GUIDELINES ORIGINAL EFFECTIVE DATE: 06/01/19 SECTION: DRUGS LAST REVIEW DATE: 04/16/19 LAST CRITERIA REVISION DATE: ARCHIVE DATE: LUCENTIS® (ranibizumab) for intravitreal injection Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific benefit plan. This Medical Coverage Guideline must be read in its entirety to determine coverage eligibility, if any. This Medical Coverage Guideline provides information related to coverage determinations only and does not imply that a service or treatment is clinically appropriate or inappropriate. The provider and the member are responsible for all decisions regarding the appropriateness of care. Providers should provide BCBSAZ complete medical rationale when requesting any exceptions to these guidelines. The section identified as “Description” defines or describes a service, procedure, medical device or drug and is in no way intended as a statement of medical necessity and/or coverage. The section identified as “Criteria” defines criteria to determine whether a service, procedure, medical device or drug is considered medically necessary or experimental or investigational. State or federal mandates, e.g., FEP program, may dictate that any drug, device or biological product approved by the U.S. Food and Drug Administration (FDA) may not be considered experimental or investigational and thus the drug, device or biological product may be assessed only on the basis of medical necessity. Medical Coverage Guidelines are subject to change as new information becomes available. For purposes of this Medical Coverage Guideline, the terms "experimental" and "investigational" are considered to be interchangeable.
    [Show full text]
  • Intravitreal Injection Procedure Instructional Outline
    Intravitreal Injection Procedure Instructional Outline Anh-Danh T. Phan, M.D. Indiana University School of Medicine Department of Ophthalmology Intravitreal Injection Procedure Instructional Outline Anh-Danh T. Phan, M.D. Assistant Professor of Ophthalmology Retina and Vitreous Service Indiana University School of Medicine Department of Ophthalmology / Glick Eye Institute Indianapolis, IN Email: [email protected] Background Statement: Intravitreal injection is the most common procedure in ophthalmology, yet carries associated risks. Mastery of the procedure particularly during residency training is critical to address the staggering patient treatment needs. Objectives: To transfer, along with accompanying instructional video, useful knowledge and skills for performing the intravitreal injection during ophthalmology training, enabling residents to understand: (1) the precautions before, during, and after the procedure, including risk of endophthalmitis; (2) the technique performed at a major university medical center; and (3) a method to standardize the procedure across multiple clinical settings. Residents are encouraged to gather instructional input from their supervising retinal specialists during training to develop their own procedural approach most comfortable, while observing the underlying principles and concepts outlined herein. Conflict of Interest The author has no propriety interest in either the outline or its subject matter. Legal Disclaimer The author provides this material for educational purposes only. It is not intended
    [Show full text]
  • Informed Consent for Lucentis Tm (Ranibizumab) Intravitreal Injection
    PATIENT _________________________________________DATE __________________ OD OS INFORMED CONSENT FOR LUCENTIS TM (RANIBIZUMAB) INTRAVITREAL INJECTION INDICATIONS Age-related macular degeneration (AMD) is the leading cause of blindness in people over 50 years of age. There are two types of macular degeneration: dry and wet. In the “wet” form of AMD, abnormal blood vessels grow in the back of the eye. Sometimes these vessels leak blood or fluid that causes blurred or distorted vision. Without treatment, vision loss may be quick and severe. POSSIBLE BENEFITS, LIMITATIONS, AND ADMINISTRATION Lucentis TM works by inhibiting the growth of the abnormal blood vessels that cause AMD. It is also used to treat swelling of the macula due to MAD. The goal of treatment is to prevent further loss of vision. Although some patients have regained vision, the medication may not restore vision that has already been lost, and may not ultimately prevent further loss of vision caused by the disease. After the pupil is dilated and the eye is numbed with anesthesia, the medication is injected into the vitreous or jelly-like substance in the back chamber of the eye. Lucentis TM is administered by an injection into your eye as needed at regular intervals (about every four weeks); your ophthalmologist will tell you how often you will receive the injection, and for how long. ALTERNATIVES You do not have to receive treatment for your condition, although without treatment, AMD can lead to further vision loss and blindness, sometimes very quickly. Other forms of treatment are available. At present, there are two other FDA-approved treatments for neovascular AMD: Photodynamic therapy with a drug called Visudyne TM and injection into the eye of a drug called Macugen TM .
    [Show full text]
  • Intravitreal Injections
    Intravitreal Injections This material will help you understand your intravitreal injection treatment and what you can expect. What are intravitreal injections? An intravitreal injection (IVI) is a shot of medicine into your eye using a thin needle. The inside of your eye is filled with a gel-like fluid called the vitreous (vit-ree-us). The doctor or nurse will inject the medicine through the front of the eye into the vitreous, near the retina at the back of the eye (see picture on right). Image courtesy of the Collaborative Ocular Melanoma Study Group The medicine used will depend on your condition being treated. IVIs are used to treat many eye problems, including macular degeneration, diabetic retinopathy, and some cases of eye cancer. What can I expect before my treatment? There are no special preparations for IVI. You should eat normally and take all your regular medicines before you come in. Let your doctor know any medications you are currently taking, as well as any allergies you have. Kellogg Eye Center Intravitreal Injections 1 This treatment is performed in your doctor’s office, so you will be able to go home the same day. If you do not feel comfortable driving after your treatment, you may want to bring a friend or family member with you to drive you home. What can I expect on the day of my treatment? On the day of your IVI, you will come to the Kellogg Eye Center Oncology Clinic. First, you will be given eye drops to dilate (widen) your pupils. Your doctor will then have you lie down in a comfortable face-up position.
    [Show full text]
  • Ocular Anti-VEGF Therapy for Diabetic Retinopathy
    900 Diabetes Care Volume 37, April 2014 Ning Cheung,1,2,3 Ian Y. Wong,1 and Ocular Anti-VEGF Therapy for Tien Y. Wong2,3 BENCH TO CLINIC SYMPOSIA Diabetic Retinopathy: Overview of Clinical Efficacy and Evolving Applications Diabetes Care 2014;37:900–905 | DOI: 10.2337/dc13-1990 Ocular anti-vascular endothelial growth factor (VEGF) therapy represents one of the most significant advances in modern medicine. The introduction and widespread use of ocular anti-VEGF therapy for age-related macular degenera- tion heralded a new era in the treatment of vascular and exudative diseases of the retina. Its expanding indications now include diabetic macular edema and proliferative diabetic retinopathy, two vision-threatening forms of diabetic retinopathy. It is widely anticipated that ocular anti-VEGF therapy could spark a dramatic shift in the treatment paradigm for diabetic retinopathy. However, despite its clear efficacy shown in clinical trials, the dynamic landscape of evolving medical, ethical, and economic issues related to this new treatment suggests significant challenges ahead. In this article, we provide a discussion of this topic as part of this two-part Bench to Clinic narrative. Here, our Clinic contribution provides an overview of the current evidence from clinical trials on anti-VEGF therapy for diabetic retinopathy, and highlights the hopes and fears of this new treatment from clinical and public health standpoints. In the Bench narrative that precedes this contribution, Simo´ et al. provide an overview of the role of VEGF in the pathogenesis of diabetic retinopathy. Ocular anti-vascular endothelial growth factor (VEGF) therapy represents one of the most significant advances in modern medicine.
    [Show full text]
  • The Role of Topical Antibiotic Prophylaxis to Prevent Endophthalmitis After Intravitreal Injection
    The Role of Topical Antibiotic Prophylaxis to Prevent Endophthalmitis after Intravitreal Injection Philip Storey, MD, MPH,1 Michael Dollin, MD,1 John Pitcher, MD,1 Sahitya Reddy, BA,2 Joseph Vojtko, BA,2 James Vander, MD,1 Jason Hsu, MD,1 Sunir J. Garg, MD,1for the Post-Injection Endophthalmitis Study Team* Objective: To compare the incidence of endophthalmitis after intravitreal injection with and without topical postinjection antibiotic prophylaxis. Design: Retrospective case-control study. Participants: All patients treated with intravitreal injection of ranibizumab, bevacizumab, or aflibercept for a variety of retinal vascular diseases at a single, large retina practice between January 1, 2009, and October 1, 2012, were included. Methods: The total numbers of patients and injections were determined from a review of billing code and practice management records. Endophthalmitis cases were determined from billing records and from an infection log. All cases of endophthalmitis were confirmed with chart review. A 28-month period when topical antibiotics were prescribed after intravitreal injection was compared with a 9-month period when topical antibiotics were not prescribed. Patients treated during an 8-month transition period were excluded to allow for the conversion of antibiotic prescription practices. Main Outcome Measures: Incidence of endophthalmitis, visual acuity outcomes, and microbial spectrum. Results: During the study period, a total of 117 171 intravitreal injections were performed (57 654 injections during the topical antibiotic period, 24 617 during the transition period, and 34 900 during the no-antibiotic period), with a total of 44 cases of suspected endophthalmitis (0.038%; 1 in 2663 injections), 17 of which showed culture-positive results (0.015%; 1 in 6892 injections).
    [Show full text]
  • Intravitreal Injections Policy Background Anti-VEGF Agents
    Intravitreal Injections Policy Patients undergoing intravitreal injections require the care and judgment of an ophthalmologist experienced in diagnosing and treating retinal diseases as well as potential complications that may necessitate surgical intervention. The Academy strongly supports the position that all intravitreal injections should be performed only by ophthalmologists, which are licensed doctors of medicine or osteopathy. Background Intravitreal injections of air were first used in 1911 for the purpose of repairing retinal detachments.1 Since that time, intravitreal injections have been used to treat a variety of conditions, including endophthalmitis, intraocular lymphoma, cytomegalovirus (CMV) retinitis, submacular hemorrhage, vitreous hemorrhage, retinal vascular occlusive disease, diabetic retinopathy, and neovascular age-related macular degeneration (AMD). The primary benefit of intravitreal injection is the targeting of the therapeutic agent in the eye while minimizing systemic absorption. In 1998, the United States Food and Drug Administration (FDA) approved the use of the first agent for intravitreal injections, fomivirsen sodium (Vitravene®, Isis Pharmaceuticals, Carlsbad, CA), an antiviral used in the treatment of CMV retinitis. Anti-VEGF Agents The frequency of intravitreal injections significantly increased with the introduction of anti-vascular endothelial growth factor (anti-VEGF) medications. In the early 2000s, the use of intravitreal injections accelerated fueled by clinical trials and technology assessments
    [Show full text]
  • Intravitreal Injections/Implants
    Intravitreal Injections/Implants Last Review Date: September 2, 2021 Number: MG.MM.PH.18 Medical Guideline Disclaimer Property of EmblemHealth. All rights reserved. The treating physician or primary care provider must submit to EmblemHealth the clinical evidence that the patient meets the criteria for the treatment or surgical procedure. Without this documentation and information, EmblemHealth will not be able to properly review the request for prior authorization. The clinical review criteria expressed below reflects how EmblemHealth determines whether certain services or supplies are medically necessary. EmblemHealth established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). EmblemHealth expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by EmblemHealth, as some programs exclude coverage for services or supplies that EmblemHealth considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members.
    [Show full text]
  • (ASRS) Statement Compounding Listening Session, June 3, 2016 Food and Drug Administration
    American Society of Retina Specialists (ASRS) Statement Compounding Listening Session, June 3, 2016 Food and Drug Administration Thank you for the opportunity to present during the 2016 listening sessions on drug compounding. On behalf of the American Society of Retina Specialists (ASRS), its members and their patients, we submit the following comments on FDA draft guidance documents. The ASRS is the largest retinal organization in the world, representing over 2700 fellowship-trained members. Retina specialists are board-certified ophthalmologists who have completed fellowship training in the medical and surgical treatment of retinal diseases. Retina patients are treated with a myriad of compounded therapies including injectable antibiotics, anesthetics, dyes used during surgery, and bevacizumab (Avastin). In general, retina doctors have access to these therapies either through 503B outsourcing facilities, or through 503A facilities pursuant to an individual prescription. However, in certain emergencies we have difficulty accessing medications needed for our patients. Limited access to compounded antibiotics for intravitreal injection We would like to thank the FDA for acknowledging the need for retina specialists to have compounded antibiotics on hand to treat emergency infections such as endopthalmitis. This scenario is described in the current draft guidance on the prescription requirement under Section 503A (line 103 – 110): “Sometimes, it is necessary for health care practitioners in hospitals, clinics, offices, or other settings to have certain compounded drug products on hand that they can administer to a patient who presents with an immediate need for the compounded drug product. For example, if a patient presents at an ophthalmologist’s office with a fungal eye infection, timely administration of a compounded antifungal medication may be critical to preventing vision loss.
    [Show full text]
  • Emerging Concepts in the Management of Acute Retinal Necrosis
    Downloaded from http://bjo.bmj.com/ on January 3, 2016 - Published by group.bmj.com Review Emerging concepts in the management of acute retinal necrosis Robert William Wong,1,2 J Michael Jumper,2 H Richard McDonald,2 Robert N Johnson,2 Arthur Fu,2 Brandon J Lujan,2,3 Emmett T Cunningham, Jr2,4 ▸ Additional files are ABSTRACT now exists on the characteristics, causes and treat- published online only. To view Acute retinal necrosis (ARN), also known as Kirisawa- ment of this condition. these files please visit the journal online (http://dx.doi. type uveitis, is an uncommon condition caused by org/10.1136/bjophthalmol- infection of the retina by one of the herpes family of CLINICAL SIGNS AND SYMPTOMS 2012-301983). viruses, most typically varicella zoster virus or herpes Acutely, ARN may present with eye redness, periorbi- 1Austin Retina Associates, simplex virus and less commonly cytomegalovirus. tal pain, photophobia and/or vision loss. On anterior Austin, Texas, USA Clinical diagnosis can be challenging and is often aided segment examination, patients may show episcleritis, 2The Department of by PCR-based analysis of ocular fluids. Treatment scleritis, keratitis and/or anterior chamber inflamma- Ophthalmology, California typically involves extended use of one or more antiviral tion, which may be either non-granulomatous or Pacific Medical Center, fi San Francisco, California, USA agents. Long term retinal detachment risk is high. We granulomatous ( gure 2). Examination of the poster- 3Department of Vision Science, review the literature on ARN and present an approach to ior segment may reveal vitreous inflammation, arter- School of Optometry, University the diagnosis and management of this serious condition.
    [Show full text]
  • Treatment of Acute Retinal Necrosis
    Treatment of Acute Retinal Necrosis Michael D. Tibbetts, MD,1 Chirag P. Shah, MD, MPH,2 Lucy H. Young, MD, PhD,3 Jay S. Duker, MD,4 Joseph I. Maguire, MD,2 Michael G. Morley, MD5 Objectives: To compare outcomes from patients with acute retinal necrosis (ARN) treated in the acyclovir- only era with those treated in the era of newer antiviral therapies, identify variables affecting outcomes in ARN, and evaluate strategies for fellow eye prophylaxis. Design: Multicenter, nonrandomized, retrospective, interventional series. Participants: A cohort of 58 patients diagnosed with ARN by a retina specialist at 1 of 4 referral centers between 1981 and 2008. The cohort was divided into 2 subgroups: patients treated during the acyclovir-only era (n ϭ 36) and patients treated during the current era of newer antiviral medications (n ϭ 22). Intervention: Intravenous, oral, or intravitreal antiviral medications, including acyclovir, valacyclovir, famci- clovir, valganciclovir, ganciclovir, and foscarnet; prophylactic laser retinopexy; aspirin; oral steroids. Main Outcome Measures: Visual acuity, retinal detachment, and fellow eye involvement. Results: A wide range and combination of antiviral agents are currently used for initial and long-term treatment of ARN. Outcomes from the newer antivirals era were similar to those achieved during the acyclovir- only era. In both groups, the incidence of 20/200 or worse visual acuity was 24% per person-year (P ϭ 0.91). The prevalence of retinal detachment was approximately 50% in each group (P ϭ 0.59). No variables, including prophylactic laser retinopexy, were associated with risk of retinal detachment. Two patients (3.4%) developed ARN in the initially unaffected eye.
    [Show full text]