Topical nonsteroidal anti-inflammatory drugs can improve the results of intravitreal corticosteroid and anti-vascular endothelial growth factor injections in treating chronic cystoid macular edema, says a study at the University of Kansas. The single-center, randomized, investigator-masked study included 39 patients with chronic pseudophakic CME. All patients were treated with an intravitreal triamcinolone and bevacizumab injection at study entry; the bevacizumab injection was repeated at one month. To evaluate the effect of adding an NSAID, patients were randomized to treatment with one of four topical NSAIDs (diclofenac 0.1%, ketorolac 0.4%, nepafenac 0.1% and bromfenac 0.09%) or placebo for 16 weeks.

At weeks 12 and 16, both the nepafenac and bromfenac groups showed a significant reduction in retinal thickness compared with that in placebo (nepafenac, p=0.0048, bromfenac, p=0.0113). A difference, however, between these two NSAID groups was observed in that only the nepafenac group was able to maintain the demonstrated retinal thickness decrease at weeks 12 and 16. The nepafenac group also experienced a significant improvement in visual acuity at weeks 12 (p=0.0084) and 16 (p=0.0233). The addition of NSAIDs did not produce an increase in mean intraocular pressure over the course of therapy.

Retina 2010;30:260-6

Warren KA, Bahrani H, Fox JE.


Fixed-Combination Therapy Shown to be Equal to Monotherapy

Fixed-combination latanoprost-timolol therapy has proven to be as safe and as effective in lowering intraocular pressure in patients with either ocular hypertension or glaucoma as monotherapy with latanoprost or timolol. These results came from a 12-week, randomized, double-masked, parallel-group study that included patients with open-angle glaucoma or ocular hypertension treated with a beta-blocker and with a baseline IOP of 26 through 36 mmHg. Following washout, eligible patients were randomized to once-daily FCLT in the evening, latanoprost in the evening or timolol in the morning. Outcome was measured by post-baseline IOP assessments at 8 a.m., 10 a.m. and 4 p.m. at weeks two, six and 12; and statistical superiority of FCLT for the 18 pairwise comparisons between FCLT and the two monotherapies, using analysis of variance.

All therapies resulted in significant IOP reductions from baseline. Pairwise comparisons favored FCLT at all time points. When the 18 comparisons were tested simultaneously, FCLT was statistically superior to latanoprost at seven of nine time points and at all nine time points when compared with timolol. In addition, FCLT was associated with greater percentage reductions in diurnal IOP levels and a greater likelihood of achieving lower mean diurnal IOP levels. Diurnal IOP reductions of 30 percent or more from baseline to week 12 were achieved by 73.5 percent, 57.5 percent and 32.8 percent of those treated with FCLT, latanoprost and timolol, respectively (p=0.007 for FCLT vs timolol; p<0.001 for FCLT vs. latanoprost). All therapies were well tolerated.

Arch Ophthalmol 2010;128:165-72

Higginbotham EJ, Olander KW, Kim EE, et al.


Post-LASIK Epithelial Ingrowth 
Proves 'Manageable'

Post-LASIK epithelial ingrowth can be quite manageable, according to a Wills Eye Institute study. The author reviewed data from all patients between 1996 and 2007 who were referred to the Wills Cornea Service in Philadelphia after having undergone LASIK. Charts of all patients with the diagnosis of epithelial ingrowth were analyzed. Data included patient demographics, previous ocular history, visual acuity, size and location of the ingrowth and management. Additional data on eyes that underwent removal of the ingrowth at Wills were obtained.

Three hundred and five patients (153 female and 152 male, mean age: 44.7 years) were referred for eye problems after LASIK during the study period. Epithelial ingrowth was confirmed in 46 patients (15 percent; 19 female and 27 male; mean age: 47.4 years) involving 55 eyes (27 right and 28 left). Patients with epithelial ingrowth were seen at a mean of 26 months after LASIK (range: 0.5 to 108 months). Twenty-four eyes had undergone previous enhancements, two of them twice. Fourteen eyes had undergone previous removal of epithelial ingrowth, eight more than once (range: two to eight). In 35 eyes, observation was recommended. In seven eyes, epithelial removal was recommended to the referring physician. Thirteen eyes underwent flap lift and epithelial removal; nine included flap suturing. One eye required repeat treatment with flap suturing and fibrin glue, after which no recurrence was found. In the other 12 eyes, there was no recurrence in nine, small recurrences in two, and a large recurrence in one (mean follow-up: 16 months).

In the experience of the author, epithelial ingrowth after LASIK was not rare. He determined that mild ingrowth can be observed, whereas significant ingrowth can respond well to removal with a low chance of significant recurrence.

Cornea 2010;29:307-13

Rapuano CJ.

Vitrectomy Could Lead to CME
Rupture of the posterior capsule and anterior vitrectomy during cataract surgery is a risk factor for developing clinical cystoid macular edema after cataract surgery, says a new study.

The study's authors reviewed the records of patients who had cataract surgery between 1998 and 2006 without prior history of CME, known risk factors for developing CME, or previous non-glaucoma ocular laser procedures or intraocular surgeries. Clinical CME was diagnosed by fundus examination within three months postoperatively and confirmed with fluorescein angiography or optical coherence tomography. Outcome measures included prevalence of clinical CME by comparing patients with and without glaucoma; and risk factor analysis for clinical CME by comparing patients who did and did not develop it after cataract surgery.

Seven hundred patients (eyes) with glaucoma and 553 patients (eyes) without were included. The prevalences of clinical CME in glaucoma and non-glaucoma patients were 5.14 percent and 5.79 percent, respectively (p=0.618). Patients who developed clinical CME (68 patients) had statistically higher rates of posterior capsule rupture or required anterior vitrectomy during surgery (p=0.010, odds ratio=3.35, 95 percent CI 1.33 to 8.45) compared to patients who did not develop clinical CME (1,185 patients). No glaucoma medications used either pre- or postoperatively were associated with clinical CME (p>0.05). The study demonstrated that there is no statistically significant difference in the prevalence of clinical CME after small corneal incision phacoemulsification cataract surgery between glaucoma and non-glaucoma patients.

J Glaucoma 2010;19:100-4

Law SK, Kim E, Yu F, et al.

Cost Effectiveness of Exudative AMD Treatments

Both pegaptanib sodium and ranibizumab injections were proven inferior to photodynamic therapy with verteporfin in terms of cost and/or effectiveness in treating choroidal neovascularization secondary to age-related macular degeneration in a recent study. Investigators analyzed outcomes data from the pivotal trials and the Medicare reimbursable costs for each treatment and associated medical procedures. A multi-state transition model with three-month cycles was created to compare incremental medical costs associated with pegaptanib or ranibizumab versus PDT for patients with starting vision of 20/40, 20/80 and 20/200 Snellen equivalent.

The analyses showed that two-year medical treatment costs ranged from $3,100 to $54,100 depending on treatment and lesion type. Photodynamic therapy was less costly and more effective than pegaptanib for predominantly classic and minimally classic lesions. Ranibizumab was more effective than PDT for all lesion types but also more costly.

Retina 2010;30:212-21

Gower EW, Cassard SD, Bass EB, et al


Rituximab Reduces Benign Lymphoid Hyperplasia

A new study has shown that rituximab is an effective treatment for benign lymphoid hyperplasia. The authors of the study evaluated two patients—a 41-year-old female (Case 1) and a 23-year-old female (Case 2)—affected by the disorder, which is characterized by polyclonal lymphocytic infiltration of orbital tissues, predominantly with B-cells. Both patients presented with recurrent orbital masses involving the lacrimal glands, the diagnosis of which was confirmed through surgical biopsy.

For this study, both patients were treated with intravenous rituximab. Case 1 was evaluated by the authors' orbital oncology service and presented with periorbital swelling, ptosis, diplopia and decreased vision. Due to an intolerance for steroids and a refusal of radiation therapy, she was administered one dose of rituximab (375 mg/m2) intravenously with no adverse reactions. After examination and MRI three months later, the patient showed 50-percent reduction in eyelid edema, proptosis and the size of lacrimal gland mass as well as resolution of symptoms. At last follow-up, nine months after treatment, the patient continued to show no evidence of orbital disease.

Case 2 presented a similar situation, also after undergoing steroid treatment. Unlike the first case, this patient had her left orbit treated with radiation therapy six months prior to presenting for orbital oncology service. Lymphadenopathy and moderate symmetrical proptosis was found, as well as large, mobile, firm masses bilaterally causing ptosis of both eyelids. MRI revealed symetical enlargment of the lacrimal glands. Intravenous rituximab (375 mg/m2) was administered weekly over four weeks with no adverse effects.
At last follow-up three months after treatment, the patient showed significant decrease in orbital swelling bilaterally and MRI showed a 50-percent decrease in the size of lacrimal gland masses with no adverse effects.

Ophthal Plast Reconstr Surg 2010; 26:11-13

Ho HH, Savar A, Samaniego F, et al.


IOL Power: First Eye Improves Second Eye Results

Using the one-month post-operative error of predicted refraction of the first eye to alter intraocular lens power selection for the second eye has the potential to improve results for patients undergoing bilateral, sequential phacoemulsification with IOL implantation, according to a recent study. The retrospective, consecutive case series evaluated 300 consecutive patients who underwent uncomplicated bilateral, sequential phaco/IOL between January 2006 and December 2007 by a single surgeon using a single IOL platform. The observed second eye one-month postoperative spherical equivalent refractive error was compared with calculations of the hypothetical one-month postoperative spherical equivalent refractive error if the first-eye error had been fully or partially incorporated into the choice of IOL power for the second eye. The optimal amount of partial adjustment was determined. Outcome was measured by the error of predicted refraction—the difference between the actual or hypothetical spherical equivalent refractive errors and those predicted by preoperative calculations.

A total of 206 patients met inclusion criteria. The average of the absolute value of the unadjusted second eye error (UNADJ) was +0.44 D compared with +0.42 D for the fully adjusted second eye error (FULL). The optimal amount of adjustment for the second eye IOL power was 50 percent; the average of the absolute value of this partially adjusted second eye error was +0.36 D; this was statistically different from UNADJ (p<0.0001) and FULL (p=0.001). The statistically significant benefit was observed for patients with myopic or hyperopic errors in the first eye. The percentages of patients achieving postoperative refractions within 0.5 D and 1 D of the predicted refraction were 66.5 percent and 90.3 percent for the unadjusted second eye, 67 percent and 90.8 percent for the hypothetical fully adjusted second eye, and 74.3 percent and 93.7 percent for the hypothetical partially adjusted (50 percent) second eye.

Am J Ophthalmol 2009;149:95-101

Anand A, Tello C, Sidoti PA, et al.


Brimonidine/Timolol Added to Therapy Could Lower IOP

Using a fixed combination of brimonidine/timolol could potentally lower intraocular pressure in patients on multiple-drug therapy including prostaglandin analog therapy, according to a new study. The prospective, nonrandomized, open-label study involved patients on dorzolamide 2%/timolol 0.5% with a PA who needed lower IOP and patients on brimonidine with dorzolamide 2%/timolol 0.5% with a PA who wanted to simplify their treatment regimens. After the baseline evaluation, patients were continued on the PA but their other IOP-lowering medications were replaced with brimonidine 0.2%/timolol 0.5%. IOP was measured at baseline and months one and three.

Results showed that replacement of dorzolamide/timolol with brimonidine/timolol might help achieve a lower IOP, while replacement of brimonidine plus dorzolamide/timolol may help achieve as low an IOP with fewer medications. For patients who replaced dorzolamide/timolol with brimonidine/timolol (n=45), the mean IOP at baseline was 15.9 mmHg (standard deviation, 1.4), 13.3 mmHg  (0.9) after one month (p<0.001 vs. baseline) and 13.3 mmHg (1.0) after three months (p<0.001 vs. baseline). In patients who replaced both brimonidine and dorzolamide/timolol with brimonidine/timolol (n=15), the mean IOP was 15.9 mmHg (5.2) at baseline, 13.8 mmHg (1.8) after one month (p=0.053 vs. baseline), and 13.8 mmHg (1.4) after three months (p=0.079 vs. baseline). Allergy was reported in five patients previously treated with dorzolamide/timolol and one patient previously treated with brimonidine plus dorzolamide/timolol.

J Ocul Pharmacol Ther 2009;25:541-4

Nguyen QH, Earl M.