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1.  Comparison of 4 mg versus 20 mg intravitreal triamcinolone acetonide injections 
Aims
To compare the non-decanted (standard) 4 mg versus the decanted 20 mg intravitreal triamcinolone acetonide (IVTA) injections and to assess their effect on intraocular pressure (IOP).
Methods
We retrospectively reviewed the records of 92 consecutive eyes, which received an intravitreal injection of either dose of triamcinolone acetonide, at a single retina centre. The change in IOP (elevation of at least 5 mm Hg from baseline or above 21 mm Hg) was analysed with a multivariate logistic analysis. The mean follow-up period in both groups was 27 weeks. A subgroup analysis comparing vitrectomised to non-vitrectomised eyes in both groups was also performed.
Results
Of the 92 eyes, 46% (23 of 51) in the 4 mg group versus 30% (12 of 41) in the 20 mg group had an IOP >21 mm of Hg (p = 0.14) after a mean follow-up period of 27 weeks. The vitrectomised eyes (3 of 24) in the 20 mg group had a significantly lower rate of IVTA induced IOP elevation than the non-vitrectomised eyes (9 of 17) (p = 0.013). The IOP elevation occurred significantly earlier in the 4 mg group (vitrectomised eyes 27 (SD 43) days and non-vitrectomised eyes 61 (52) days) than in the 20 mg group (vitrectomised eyes 104 (56) days and non-vitrectomised eyes 119 (82) days), independent of the vitreous status (vitrectomised p = 0.05 and non-vitrectomised p = 0.04). The mean value of initial high IOP in the non-vitrectomised eyes was higher in the 4 mg group than in the corresponding 20 mg group (p = 0.048).
Conclusion
Decanted 20 mg IVTA may not pose a significantly greater risk of IOP elevation than the 4 mg non-decanted IVTA.
doi:10.1136/bjo.2007.126227
PMCID: PMC2776725  PMID: 18420748
2.  Phase I clinical trial results of verteporfin enhanced feeder vessel therapy in subfoveal choroidal neovascularisation in age related macular degeneration 
The British Journal of Ophthalmology  2006;90(9):1152-1156.
Aims
To investigate the safety and effectiveness of extrafoveal photodynamic therapy (PDT) occlusion of feeder vessels (FVs) in patients with subfoveal choroidal neovascularisation (CNV) as a result of age related macular degeneration.
Methods
FVs were identified using dynamic fluorescein and indocyanine green angiography with scanning laser ophthalmoscope. The standard doses of verteporfin and laser wavelength were used. The light dose was escalated by increasing the duration of the light dose so the light regimen was 50 J/cm2 for patients 1 and 2; 100 J/cm2 for patients 3, 4, 5; 125 J/cm2 for patients 6 and 7; and 150 J/cm2 for patients 8 and 9. Patients were examined at weeks 1, 4, and 12.
Results
The mean improvement on EDTRS chart 3 months after treatment was an increase of 2.1 lines (p = 0.07). Closure of the FV was achieved angiographically in three eyes at various light doses, in three eyes the FV was hypoperfused, and in three eyes the vessels were were neither closed nor hypoperfused. At the last follow up all FVs were reperfused. There was no evidence of retinal damage.
Conclusion
Verteporfin enhanced FV therapy does not cause subfoveal retinal damage and may have potential to improve central vision in subfoveal CNV caused by exudative macular degeneration. It is not recommended as a monotherapy for CNV.
doi:10.1136/bjo.2006.095141
PMCID: PMC1857394  PMID: 16774958
macular degeneration; photodynamic therapy; choroidal neovascular membrane; feeder vessel
3.  Photographic estimation of the duration of high dose intravitreal triamcinolone in the vitrectomised eye 
Aim
To determine the duration of residence of triamcinolone in the vitrectomised eye.
Methods
23 eyes of 23 patients underwent intravitreal injection of high dose (20 mg) decanted triamcinolone acetonide (Kenalog) at the conclusion of vitrectomy surgery or in previously vitrectomised eyes with macular oedema from diabetes, uveitis, cataract surgery, or other surgery.
Results
The median time to disappearance of triamcinolone in the vitrectomised eye was 113 days (95% confidence interval (CI) 85 to 191). In the phakic eyes the median time to disappearance was 191 days (95% CI 148 to 191). In the pseudophakic eyes the median time to disappearance was 102 days (95% CI 85 to 113). This difference was not significant (p = 0.12). There were no cases of endophthalmitis or severe inflammatory reaction. Five eyes (22%) experienced intraocular pressure rise ⩾10 mm Hg.
Conclusions
High dose decanted intravitreal triamcinolone has a median residence time of 113 days in the vitrectomised eye. Although this appears to be shorter than in the non‐vitrectomised eye, this study suggests that a sufficient duration of action will be present to be clinically useful.
doi:10.1136/bjo.2005.088278
PMCID: PMC1860213  PMID: 16531422
diabetes; macular degeneration; macular oedema; triamcilone; vitreous injection
4.  Intravitreal properties of porous silicon photonic crystals 
Aim
To determine the suitability of porous silicon photonic crystals for intraocular drug-delivery.
Methods
A rugate structure was electrochemically etched into a highly doped p-type silicon substrate to create a porous silicon film that was subsequently removed and ultrasonically fractured into particles. To stabilise the particles in aqueous media, the silicon particles were modified by surface alkylation (using thermal hydrosilylation) or by thermal oxidation. Unmodified particles, hydrosilylated particles and oxidised particles were injected into rabbit vitreous. The stability and toxicity of each type of particle were studied by indirect ophthalmoscopy, biomicroscopy, tonometry, electroretinography (ERG) and histology.
Results
No toxicity was observed with any type of the particles during a period of >4 months. Surface alkylation led to dramatically increased intravitreal stability and slow degradation. The estimated vitreous half-life increased from 1 week (fresh particles) to 5 weeks (oxidised particles) and to 16 weeks (hydrosilylated particles).
Conclusion
The porous silicon photonic crystals showed good biocompatibility and may be used as an intraocular drug-delivery system. The intravitreal injectable porous silicon photonic crystals may be engineered to host a variety of therapeutics and achieve controlled drug release over long periods of time to treat chronic vitreoretinal diseases.
doi:10.1136/bjo.2007.133587
PMCID: PMC2666262  PMID: 18441177
6.  Scanning laser entoptic perimetry for the detection of visual defects associated with diabetic retinopathy 
Aim
To determine the sensitivity and specificity of entoptic perimetry for diagnosing diabetic retinopathy at all levels of severity.
Methods
A prospective clinical study at the Shiley Eye Center, University of California, and San Diego. 30 patients with photographically documented diabetic retinopathy and 24 controls with a similar age distribution. Sensitivity and specificity of entoptic perimetry were computed for detecting clinically significant macular oedema within the central 120 degree radius of the fovea compared to fundus photographs.
Results
Entoptic perimetry can detect clinically significant diabetic retinopathy with a sensitivity of 0.88 and specificity of 1.00. Entoptic perimetry can detect the earliest stages of diabetic retinopathy with a sensitivity of 0.86.
Conclusion
Scanning laser entoptic perimetry is an effective tool for detecting visual function loss caused by diabetic retinopathy.
doi:10.1136/bjo.2005.075887
PMCID: PMC1856910  PMID: 16361659
diabetic retinopathy; visual field; vision; retina; perimetry
7.  Improved visualisation of choroidal neovascularisation by scanning laser ophthalmoscope using image averaging 
The British Journal of Ophthalmology  2005;89(8):1026-1030.
Aims: To improve visualisation of angiographic features in patients with age related macular degeneration associated with choroidal neovascularisation (CNV) and related complications. To evaluate if image averaging can achieve this goal.
Methods: 27 eyes of 20 sequential patients with age related macular degeneration over a 3 month period were studied. Indocyanine green angiograms (ICGA), fluorescein angiograms (FA), and oral fluorescein angiograms were recorded with a confocal scanning laser ophthalmoscope. Software was used to average multiple images from a 10–20 image series (over 0.5–1.0 seconds). Image quality was assessed by two masked observers and graded on a scale of 0–3. A more quantifiable grading method was devised by adding a variable amount of Gaussian noise to the improved image until the original and image averaged image appeared equal.
Results: Masked review showed mild to strong improvement of visualisation of structures including borders of CNV. Improvement varied depending on the type and phase of the angiogram. Improvement was highest in late phase FA, mid and late phase ICGA, and all phases of oral FA.
Conclusion: Image averaging using software based algorithms improves the quality of angiographic images, particularly late ICGA images and oral FAs. This method may assist in the visualisation of choroidal neovascularisation in age related macular degeneration.
doi:10.1136/bjo.2004.057364
PMCID: PMC1772758  PMID: 16024859
scanning laser ophthalmoscope; image averaging; image processing; age related macular degeneration; choroidal neovascularisation
8.  Long term visual outcome of patients with cytomegalovirus retinitis treated with highly active antiretroviral therapy 
Background: Healed cytomegalovirus (CMV) retinitis in the setting of highly active antiretroviral therapy (HAART) is complicated by inflammatory sequelae and vision loss.
Aim: To determine the long term visual outcome of AIDS patients with CMV retinitis who received HAART.
Methods: 90 eyes of 63 consecutive AIDS patients with extramacular CMV retinitis were studied prospectively.
Results: Immune recovery status was related to time to onset of epiretinal membrane (p=0.05) and cystoid macular oedema (p=0.06) as well as to the incidence of cataract (p=0.001) and moderate vision loss (p<0.0001). Severe vision loss was associated with retinal detachment (p<0.001).
Conclusion: AIDS patients with extramacular CMV retinitis lose vision while on HAART. HAART related immune recovery is associated with increased frequencies of epiretinal membrane, cystoid macular oedema, cataract, and retinal detachment with resultant vision loss in AIDS patients with healed CMV retinitis.
PMCID: PMC1771778  PMID: 12812884
cytomegalovirus retinitis; highly active antiretroviral therapy
9.  Interobserver and intraobserver variability of measurements of uveal melanomas using standardised echography 
The British Journal of Ophthalmology  2002;86(12):1390-1394.
Aim: To report on the intraindividual and interindividual variability of tumour size (height and base diameter) measurements using standardised echography in a masked prospective study.
Methods: 20 consecutive eyes of 20 patients were examined on four different visits by three experienced examiners using standardised echography. As common in standardised echography, tumour height was evaluated with A-scan technique, while transverse and longitudinal base diameter were calculated with B-scan.
Results: Tumour height measurements using A-scan were more accurate than base diameter measurements using B-scan. The standard deviation for tumour height over all visits/measurements was 0.18 mm (A-scan), 0.79 mm for transverse, and 0.69 mm for longitudinal base diameters (B-scan). The interclass correlation coefficient (ICC) was much higher for tumour height measurements with A-scan (0.7735 for three examiners on one visit) than for transverse (0.6563) or longitudinal (0.4522) base diameter measurements with B-scan techniques.
Conclusions: A-scan techniques for tumour height measurements provide very reproducible results with little intraindividual and interobserver variability. As B-scan techniques for tumour base evaluation are less accurate they should be used for topographic and morphological examinations.
PMCID: PMC1771401  PMID: 12446372
uveal melanomas; echography; observer variability
10.  Evaluation of outpatient experience with vitreoretinal surgery. 
The experience of 55 consecutive individuals undergoing outpatient vitreoretinal surgery was evaluated. Objective variables, including preoperative and intraoperative information, subjective postoperative pain, and discomfort were measured with a previously validated 100 mm visual analogue scale. Patients also ranked the overall experience. Average pain and discomfort scores in the recovery room were 21.8 and 22.6 and overnight were 26.7 and 30.4 (scale 0 to 100), respectively. Eighty eight per cent of subjects were satisfied with the experience. Elevated pain and discomfort scores were statistically correlated with scleral buckling, prolonged surgical or recovery room time, requirement for parenteral pain medications, and high intraocular pressure on the first postoperative visit. None of the patients needed further hospital treatment. This study suggests that vitreoretinal surgery in an appropriately selected population does not require routine inpatient care.
PMCID: PMC504163  PMID: 1739718
11.  Cytomegalovirus retinitis: a manifestation of the acquired immune deficiency syndrome (AIDS). 
Two homosexual males with the "gay bowel syndrome' experienced an acute unilateral loss of vision. Both patients had white intraretinal lesions, which became confluent. One of the cases had a depressed cell-mediated immunity; both patients ultimately died after a prolonged illness. In one patient cytomegalovirus was cultured from a vitreous biopsy. Autopsy revealed disseminated cytomegalovirus in both patients. Widespread retinal necrosis was evident, with typical nuclear and cytoplasmic inclusions of cytomegalovirus. Electron microscopy showed herpes virus, while immunoperoxidase techniques showed cytomegalovirus. The altered cell-mediated response present in homosexual patients may be responsible for the clinical syndromes of Kaposi's sarcoma and opportunistic infection by Pneumocystis carinii, herpes simplex, or cytomegalovirus.
Images
PMCID: PMC1040068  PMID: 6303386

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