A prospective study designed to quantify the effect of scattered UV-A radiation reaching the patient, surgeon and surrounding areas during a collagen cross-linking procedure suggests that CXL appears to be a safe operation with respect to the UV-A radiation exposure surgeons receive.

Three patients with keratoconus underwent a CXL procedure with UV-A light and riboflavin. Irradiance was measured using a spectrometer for various distances from the source, at various angles and for different durations of radiation. The spectrometer was also used to measure the dampening effect produced by gown, latex gloves and UV-protective glasses.

The maximum UV-A radiation (1.4 x 10-9 mW/cm2) was measured at two centimeters from the limbus, when the probe was held at a 45-degree angle to the floor. UV-A radiation reaching the surgeon’s eye and abdomen was 3.403 x 10-11 and 2.36 x 10-11 mW/cm2. Gown (99.58 percent), latex gloves (95.01 percent) and UV-protective glasses (99.73 percent) were all effective at limiting UV-A radiation exposure.

Shetty R, Rohit S, Mahendradas P, Shetty BK.

Cataract Surgery a Risk Factor For Developing OAG After PPV 
A group of researchers has determined, through a retrospective chart review and a matched case-control analysis, that cataract extraction is a strong risk factor for the development of late-onset open-angle glaucoma after uncomplicated pars plana vitrectomy.

Of 285 vitrectomized eyes that met the enrollment criteria of PPV without preexisting glaucoma or reason for secondary development of glaucoma, including at least six months of follow-up, 11.6 percent (n=33) developed glaucoma after vitrectomy. In the analysis, the only variable that had a statistically significant association with the development of OAG was cataract surgery, as compared with phakic status at the last follow-up (odds ratio = 16.4 percent; p=0.007). 

The difference in incidence between phakic and nonphakic eyes was statistically significant (p=0.001), and there was no difference in OAG development between eyes that had cataract surgery before or at the time of PPV and those that had it after PPV. The overall incidence of OAG development after PPV was 11.6 percent (all eyes), 1.4 percent (phakic eyes) and 15 percent (nonphakic eyes).

The overall incidence of OAG development after PPV is substantial, and preoperative counseling should include the risk for developing glaucoma in addition to cataract development and the connection between the two. Patients who have undergone PPV, especially those who had cataract surgery in the same eye, should be carefully monitored for glaucoma.

Koreen L, Yoshida N, Escarlo P, Niziol L, et al.

Endophthalmitis Outbreak After Bevacizumab Injection 
An outbreak of Streptococcus mitis/oralis was likely caused by contamination during syringe preparation by the compounding pharmacy, according to doctors from the Bascom Palmer Eye Institute in Miami.

In a retrospective review of medical charts, seven women (58 percent) and five men (42 percent) were identified with endophthalmitis presenting one to six days after receiving intravitreal bevacizumab injections in July 2011. While the injections occurred in four different Florida locations, the bevacizumab was prepared at a single compounding pharmacy. None of the infections originated at the Bascom Palmer Eye Institute, although nine patients presented to its tertiary-care ophthalmic emergency room for treatment, and an additional three cases were seen in consultation.

All patients were initially treated with a vitreous tap and injection of antibiotics; eight patients subsequently required a vitrectomy. Preinjection visual acuities ranged from 20/25 to count fingers; after four months of follow-up, all but one patient had count fingers or worse visual acuity, and three required evisceration or enucleation. 

Seven unused syringes of bevacizumab prepared by the compounding pharmacy at the same time as those prepared for the patients were positive for S. mitis/oralis, and microbiology cultures for 10 patients were also positive for S. mitis/oralis. Local, state and federal health department officials continue to investigate the original source of contamination. 

Goldberg RA, Flynn HW Jr, Isom RF, Miller D, Gonzalez S. 

Treatment of Giant Fornix Syndrome Increases Patient QoL
Giant fornix syndrome can lead to chronic relapses of purulent conjunctivitis and toxic keratitis. A retrospective chart review of five elderly female patients, (median age 75 years, mean 80, range 70 to 95) with a median duration of eye symptoms before presentation of two years (mean 2.4, r: one to four), at the Wills Eye Institute suggests that removing infected debris from the afflicted fornix and reconstructing the upper eyelid may prevent these recurrent infections.

Conjunctival culture grew methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa and S. aureus in singular cases. Before referral, the chronic conjunctivitis was treated with topical antibiotics in all cases, and with additional dacryocystorhinostomy in one patient. The median duration of follow-up was four months (mean 21.6, r: 1 to 84).

Case 1 was treated with topical moxifloxacin, Case 2 was treated with topical vancomycin and repair of the upper eyelid, Case 3 was treated with topical besifloxacin, and Case 4 was treated with dacryocystorhinostomy and topical vancomycin. Case 5 was treated with reconstruction of the upper eyelid.

Age-related dehiscence of the levator palpebrae aponeurosis appears to create deep fornices that harbor pathogenic bacteria, leading to infection. Adequate treatment of giant fornix syndrome should prevent chronic ocular surface abnormalities and improve quality of life in elderly patients.

Turaka K, Penne R, Rapuano C, Ayres B, et al. 

Bevacizumab Adjunctive to Trabeculectomy Controls IOP
Researchers from Tehran University report that while adjunctive subconjunctival bevacizumab with trabeculectomy is effective in controlling intraocular pressure, its effect is less prominent than mitomycin C.

Thirty-six eyes from 34 patients were enrolled in a prospective, randomized, comparative study. Eighteen eyes underwent trabeculectomy with subconjunctival bevacizumab injection (2.5 mb/0.1 mL) and 18 eyes underwent trabeculectomy with MMC (0.02% for three minutes). The mean follow-up times for the bevacizumab and MMC groups were 7.4 ±24 months and 7.8 ±2.2 months (p=0.62).

There was a statistically significant difference in the IOP between the two groups at the last visit (p<0.001). The mean preoperative IOP in the bevacizumab group improved from 21.9 ±7.9 mmHg with 2.7 ±0.8 antiglaucoma medications to 13.6 ±3.2 mmHg with 0.2 ±0.5 antiglaucoma medications at the last visit (p<0.001 and p<0.001). The mean preoperative IOP in the MMC group improved from 23.3 ±4.9 mmHg with 2.6 ±0.7 antiglaucoma medications to 9.6 ±2.7 mmHg with no antiglaucoma medications at the final visit (p<0.001). The cumulative probabilities of total success at the last follow-up, according to Kaplan-Meier analysis, were 100 percent in the bevacizumab group and 94.4 percent in the MMC group (p=0.32). A larger cohort of patients and a longer follow-up period are warranted to determine the possible long-term complications of subconjunctival bevacizumab and its effect on the outcome of trabeculectomy.

Nilforushan N, Yadgari M, Kish SK, Nassiri N 

BAK-free Travoprost Comparable With BAK-preserved Eye Drops
Benzalkonium chloride-free travoprost may have beneficial effects on the ocular surface while showing IOP-lowering efficacy comparable with BAK-preserved eye drops. 

One hundred and fourteen patients with open-angle glaucoma or ocular hypertension who had been treated with latanoprost monotherapy for at least three months participated in a prospective, open-label, multicenter study. The main outcome measures were hyperemia, superficial punctate keratopathy and IOP; all were consecutively assessed at baseline, one, three and 12 months.  

After 12 months of treatment there were fewer total ocular surface complications. Though transition to BAK-free travoprost showed no significant effect on hyperemia at one month, there were significant decreases at three and 12 months compared with baseline (p<0.05). The prevalence of SPK at all points was significantly reduced compared with baseline (p<0.05). The IOP at baseline and at 12 months after transition was 14.9 ±3.4 and 14.3 ±3.3 mmHg, indicating a significant reduction after the change in regimen compared with the baseline (p<0.05).

Aihara M, Otani S, Kozaki J, Unoki K, et al.