Treatment of acute pseudophakic cystoid macular edema: Diclofenac versus ketorolac

PURPOSE: To investigate whether topical diclofenac sodium 0.1% solution (Voltaren Ophthalmic) is as efficacious as topical ketorolac tromethamine 0.5% solution (Acular) in the treatment of established, chronic cystoid macular edema (CME) after uneventful phacoemulsification cataract extraction with posterior chamber intraocular lens (IOL) implantation. SETTING: Referral-based vitreoretinal private practice. METHODS: This randomized prospective study comprised 34 consecutive patients with clinical CME after uneventful phacoemulsification cataract extraction with posterior chamber IOL implantation who were referred to a private vitreoretinal practice for evaluation and management. Exclusion criteria included a history of previous intraocular surgery, vitreous loss during cataract surgery, CME, uveitis, and vitreoretinal pathology. The eye with CME was treated with 1 drop 4 times daily of diclofenac sodium 0.1% solution or ketorolac tromethamine 0.5% solution. Outcomes were measured by observing for improvement in CME and visual acuity. RESULTS: Both treatment methods resulted in a significant reduction in CME and a significant improvement in visual acuity. Within 26 weeks, diclofenac reduced CME in 16 patients (89%) and ketorolac, in 14 patients (88%) (P =.92, confidence interval [CI] 95%). Within 26 weeks, diclofenac eliminated CME in 14 patients (78%) and ketorolac, in 12 patients (75%) (P =.86, CI 95%). The mean time to initial CME reduction was 7.5 weeks with diclofenac and 8.0 weeks with ketorolac (P =.41, CI 95%). The mean time to CME resolution was 13.6 weeks with diclofenac and 12.8 weeks with ketorolac (P =.49, CI 95%). CONCLUSIONS: Diclofenac sodium 0.1% solution and ketorolac tromethamine 0.5% topical ophthalmic solution eyedrops were equally effective in reducing the severity and duration of CME after uneventful phacoemulsification with posterior chamber IOL implantation. Either solution may be considered for CME after cataract surgery, especially in patients who may not tolerate corticosteroid treatment.     

Pseudophakic cystoid macular edema: ketorolac alone vs. ketorolac plus prednisolone

BACKGROUND: Pseudophakic cystoid macular edema (CME) following phacoemulsification is the most common complication after cataract surgery. Treatment focuses on the reduction of inflammation with topical use of both steroids and NSAIDS. The latter have been shown to be of benefit in chronic CME, but topical NSAID and steroid treatment has only recently been shown to be of benefit in acute CME. We evaluated the use of topically administered NSAIDS and steroids in the management of both acute and chronic pseudophakic CME. METHODS: This was a prospective double-masked randomized controlled trial. Patients with clinical CME occurring at least 6 weeks following cataract extraction were referred for consideration of enrolment. Patients were excluded if they had Snellen vision better than 20/40, no CME on clinical examination, no CME on angiography, recent use of steroids, preexisting macular disease or diabetic maculopathy on angiography. Ten patients were randomly assigned to receive either 0.5% ketorolac tromethamine plus placebo (four patients) or 0.5% ketorolac tromethamine plus 1% prednisolone acetate (six patients); all 10 completed the study. Patients were assessed at baseline and at 30, 60 and 90 days. Fluorescein angiography was performed at baseline and at 90 days. The primary outcome measures were improvement in Early Treatment Diabetic Retinopathy Study Snellen equivalent vision and resolution of cysts on clinical examination. RESULTS: No statistically significant differences were found between the two groups in either of the outcome measures at any visit. Subgroup analysis of the patients with chronic CME also showed no significant difference between the two groups. INTERPRETATION: We found no statistically significant difference in outcome between patients who received ketorolac and those who received ketorolac plus prednisolone for acute or chronic CME. The value of topical steroid therapy for chronic CME remains unproven.     

Prognostic factors for visual acuity improvement after intravitreal triamcinolone injection

PURPOSE: In some patients with macular oedema, intravitreal triamcinolone acetonide injection (IVTA) fails to improve visual acuity, although oedema shows clinical and angiographic improvement. Side effects can include increased intraocular pressure, cataract development, and (rarely) endophthalmitis. Our purpose was to identify prognostic factors for visual acuity improvement after IVTA. METHODS: Data on patients treated by IVTA for macular oedema were retrospectively reviewed. Three months postinjection, visual acuity was rated as 'improved' (two or more Snellen lines gained) or 'nonimproved' (unchanged or worsened). Comparative demographic data and pre- and post-IVTA clinical and fluorescein angiographic findings were analysed with SPSS software. RESULTS: Of 57 eyes (57 patients), 27 (47%) improved after IVTA. Initial visual acuity ('good', 'moderate', or 'poor') and aetiology of macular oedema (diabetic, venous occlusion, or pseudophakic) did not differ between the two groups. Improvement occurred in significantly more eyes with clinical or angiographic evidence of cystoid macular oedema (CME) than in those with diffuse retinal thickening (P=0.04) or diffuse leakage on fluorescein angiography (P=0.02), respectively, and in significantly more pseudophakic than phakic eyes (P=0.046). Conclusions: Pseudophakia and clinical or angiographic CME, but not aetiology or initial visual acuity, were prognostic of visual acuity improvement after IVTA for macular oedema.     

Effectiveness of ketorolac tromethamine 0.5% ophthalmic solution for chronic aphakic and pseudophakic cystoid macular edema

The effect of ketorolac tromethamine 0.5% ophthalmic solution (a new nonsteroidal anti-inflammatory agent) treatment was compared to placebo treatment in patients with chronic, angiographically proven aphakic or pseudophakic cystoid macular edema (visual acuity less than or equal to 20/40 for six months) during a three- to four-month double-masked, randomized study. Twenty-six patients completed this study without significant ocular or systemic toxicity. The improved distance visual acuity observed in the ketorolac treatment group (8/13 patients) was statistically different from the improved vision observed in the placebo treated group (1/13 patients) (P = .005). No patient on a regimen of ketorolac therapy had a significant decrease in Snellen distance visual acuity while on treatment, but two patients in the placebo group demonstrated a decrease in visual acuity of two lines or more. Fluorescein angiography was consistent with changes in visual acuity.     

Comparison of the results of first and second cataract eye surgery

OBJECTIVE: To compare the outcomes of second eye cataract surgery with those of first eye surgery. In particular, to evaluate changes in visual acuity (VA), visual function, and health status after the first and second eye surgeries. DESIGN: A cohort (case series) analysis of patients recruited in a clinical trial. PARTICIPANTS: A total of 403 consecutive patients with indication of noncombined first eye or second eye cataract surgery were recruited in 3 public hospitals in Barcelona, Spain. First eye surgery patients are compared to second eye surgery patients. INTERVENTION: Patients were evaluated both before surgery and 4 months after surgery by a standardized telephone interview and clinical examination. MAIN OUTCOME MEASURES: Visual acuity, visual function index (VF-14), a 14-item instrument designed to measure visual function, and the Sickness Impact Profile (SIP), a generic measure of health status. RESULTS: Full data were obtained from 315 (78%) patients: 249 who underwent first eye surgery only and 66 different patients who underwent second eye surgery. Significant improvement was found in both groups of patients for best-corrected VA in the operated eye (4.4 Snellen lines, P < 0.001; 4.2 Snellen lines, P < 0.001, respectively), VA in the better eye (2.8 Snellen lines, P < 0.001; 1.4 Snellen lines, P < 0.001), and visual function (26.3 Snellen lines, P < 0.001; 17.0 Snellen lines; P < 0.001). Four months after the operation, the VF-14 of the second eye group was slightly better (93.4 vs. 88.5; P = 0.09; score range: 0, worst, to 100, best). Psycho-social SIP scores improved in both groups (4.8, P < 0.001; 3.1, P = 0.016). Physical SIP score improved only in the first eye surgery group (1.8, P = 0.003) but not in the second eye surgery group (-1.0, P = 0.338; score range: 0, best, to 100, worst). CONCLUSIONS: The results of our study suggest that patients undergoing second eye cataract surgery show significant improvements in VA, visual function, and psycho-social health status. However, global and physical health status does not change after second eye cataract surgery.     

Extracapsular cataract extraction and posterior chamber intraocular lens implantation in uveitis patients.

PURPOSE: Intraocular lens implantation in uveitis patients has been a controversial issue. The purpose of this study is to evaluate the visual and surgical outcomes of extracapsular cataract extraction (ECCE) and posterior chamber intraocular lens (PC IOL) implantation in a diverse group of uveitis patients. PATIENTS AND METHODS: The results of 39 cases of ECCE and PC IOL implantation in 30 patients with uveitis were retrospectively analyzed. Five patients (six eyes) had pars plana vitrectomies combined with ECCE and PC IOL implantation. Patient age ranged from 26 to 71 years (average, 53.0 years). Specific uveitic syndromes were determined for 22 patients (73.3%). The postoperative follow-up period ranged from 6 to 43 months (average, 20.3 months). RESULTS: Visual acuity improved postoperatively in 38 eyes (97.4%), and this improvement ranged from 1 to 11 Snellen lines (average, 7.5 Snellen lines). Visual acuity improved postoperatively to 20/40 or better in 32 eyes (82%). Seven eyes had visual acuity worse than 20/40, which was attributed to posterior segment abnormalities after ECCE and PC IOL implantation. Uveitis recurred in 20 eyes (51.3%), and postoperative cystoid macular edema (CME) was observed in 18 eyes (46.2%). In all cases, the recurrent uveitis and CME improved or resolved with corticosteroid therapy. CONCLUSION: These results suggest selected uveitis patients can have improved vision without unacceptable risk for 1 to 3 years after ECCE and PC IOL implantation.     

Photodynamic therapy for juxtafoveal choroidal neovascularization due to ocular histoplasmosis syndrome

PURPOSE: To report the use of photodynamic therapy with verteporfin in patients with juxtafoveal choroidal neovascularization (CNV) for ocular histoplasmosis syndrome (OHS). METHODS: Retrospective review. Data regarding the following variables were extracted from patient charts: demographic characteristics, previous surgeries, angiographic features, number and time of treatments, follow-up time, and change in visual acuity. RESULTS: This study sample consisted of 23 eyes of 23 consecutive patients who were treated with photodynamic therapy for the management of juxtafoveal CNV. When post-treatment visual acuity (mean logMAR acuity=0.321) was compared to baseline acuity (mean logMAR visual acuity=3.89) vision improved by more than three Snellen lines in 30% of eyes, remained the same (+/-2 Snellen lines) in 52% of eyes, and worsened (greater than a two-line loss in visual acuity) in 18% of eyes. Although this series was uncontrolled, the patients had a trend toward a therapeutic benefit when compared to published natural history of similar cases (OR=0.292, P value=0.071 when compared to data from the Macular Photocoagulation Study for treatment of juxtafoveal lesions). CONCLUSION: Photodynamic therapy with verteporfin may be beneficial in patients with juxtafoveal CNV secondary to OHS in terms of both visual stabilization and improvement.     

Evaluation of the potential acuity meter in predicting visual acuity after photodynamic therapy for choroidal neovascularization.

BACKGROUND AND OBJECTIVE: To evaluate the potential acuity meter in predicting visual acuity after photodynamic therapy of choroidal neovascular membranes caused by age-related macular degeneration. PATIENTS AND METHODS: Retrospective study of 55 eyes in 51 patients with subfoveal predominantly classic choroidal neovascularization due to age-related macular degeneration. Pre-photodynamic therapy Snellen visual acuity minus the visual acuity with the potential acuity meter was compared with the actual improvement in visual acuity. Significant improvement in visual acuity after photodynamic therapy was defined as a gain of more than 2 lines in Snellen visual acuity (0.2 logarithm of the minimal angle of resolution units). RESULTS: Eighteen (51.4%) of 35 eyes with a potential for improvement experienced an actual improvement in their Snellen visual acuity after photodynamic therapy (P < .001). All eyes lacking a potential for improvement failed to experience an actual improvement in visual acuity after photodynamic therapy. CONCLUSION: The eyes that demonstrated better visual acuity with the potential acuity meter in this study seemed more likely to experience an improvement in visual acuity after photodynamic therapy.     

Pars plana vitrectomy for epiretinal membrane associated with sarcoidosis

PURPOSE: To examine retrospectively the visual outcomes in patients undergoing vitrectomy for epiretinal membranes secondary to sarcoid uveitis. METHODS: Eleven consecutive patients (11 eyes) with epiretinal membrane and uveitis associated with sarcoidosis underwent pars plana vitrectomy. RESULTS: Nine eyes (82%) gained two or more lines of Snellen visual acuity at 1-12 months after surgery. However, 4 of these 9 eyes lost two or more lines of Snellen visual acuity by the final visit. Overall, 5 eyes (45%) had attained at least two Snellen lines of visual acuity improvement, 5 eyes (45%) were unchanged, and 1 eye (10%) had worsened by two lines at the final visit. Nine eyes (81%) achieved visual acuity of 20/40 or better by the final visit. Slit-lamp biomicroscopy and fluorescein angiography showed that cystoid macular edema had resolved in 4 of 7 eyes postoperatively; vitritis improved in all cases. Postoperative complications included cataract formation, glaucoma, and membrane recurrence. Subsequent surgeries consisted of cataract extraction in 2 eyes and membrane peeling in 1 eye. CONCLUSIONS: Pars plana vitrectomy appears to have a beneficial effect on restoring vision in eyes with epiretinal membrane and uveitis associated with sarcoidosis, but final visual acuity was limited by the development of cataract and membrane recurrence.     

Impact of topical nonsteroidal anti-inflammatory drugs in prevention of macular edema following cataract surgery in diabetic patients

AIM: To evaluate the efficacy of prophylactic administration of topical non-steroidal anti-inflammatory drugs (NSAIDs) on macular edema following cataract surgery in diabetic patients, and to compare between types of NSAIDs (ketorolac tromethamine 0.4% and nepafenac 0.1%). METHODS: Group 1 (control) received artificial tears substitute as a placebo group, group 2 (nepafenac) received topical nepafenac 0.1%, and group 3 (ketorolac) received topical ketorolac tromethamine 0.4%. Patients were examined postoperatively after completing one week, one month, two months and three months'' intervals for evaluating cystoid macular edema (CME) development. The main study outcomes were achieving the best corrected visual acuity (BCVA) and change in the central macular thickness (CMT) measured with optical coherence topography (OCT). RESULTS: Eighty eyes of 76 patients were included in this study. BCVA showed a statistically significant difference at the third month postoperative follow up between the control group and the NSAIDs groups (P=0.04). There was an increase in the CMT in all cases starting from postoperative first week until third month. CMT showed a statistically significant difference between control group and NSAIDs groups from postoperative first month until third month (P=0.008, 0.027, 0.004). There was no statistically significant difference between nepafenac and ketorolac groups in BCVA and OCT CMT. CONCLUSION: Prophylactic preoperative and postoperative NSAIDs may have a role in reducing the frequency and severity of CME in diabetic eyes following cataract surgery.     

Cataract Surgery in Retinitis Pigmentosa Patients

From the UCLA Retinitis Pigmentosa Registry, 30 patients with 54 aphakic eyes were studied in a retrospective analysis to evaluate the results of cataract surgery. Patients consisted of 19 men and 11 women, with an age range at the time of cataract surgery from 24 to 75 years (mean 47 years). After surgery all aphakic eyes showed some improvement in visual acuity; 83% of eyes demonstrated improvement in visual acuity of at least two lines on the Snellen chart, and 52% of eyes achieved a visual acuity of 20/50 or better. In all eyes, the postoperative visual field was unchanged when compared with the preoperative visual field. Subjectively, 83% of patients reported benefit from cataract surgery. Guidelines for the preoperative evaluation of retinitis pigmentosa (RP) patients with cataracts are presented.     

Cystoid and diabetic macular edema treated with nepafenac 0.1%.

Cystoid macular edema (CME), a common complication following cataract surgery, is routinely medically treated with topical nonsteroidal anti-inflammatory drugs (NSAIDs), alone or in combination with steroids. In this paper, we describe 6 patients with CME and 1 patient with diabetic macular edema (DME), all of whom were treated with nepafenac 0.1%, a novel prodrug NSAID. Three (3) patients with acute CME following cataract surgery were treated for 3-4 weeks with nepafenac 0.1%, with or without concomitant steroids. Both retinal thickness and visual acuity improved in all 3 cases. The 3 patients with chronic CME, each of whom had been previously treated with steroids with or without concomitant NSAID therapy, were started on nepafenac 0.1% three times daily. Retinal thickness and visual acuity improved in each case, except for 1 patient with 20/25 pretreatment visual acuity. The mean improvement in visual acuity of all 6 CME patients was 2.5 lines and the mean decrease in retinal thickness was 282.8 microm. The patient with DME also showed improvement in retinal thickness and visual acuity after 6 months of treatment with nepafenac. These clinical data strongly suggest that nepafenac 0.1% is a promising drug for the treatment of posterior segment inflammation, including CME, and warrants further investigation.     

Differential treatment of postoperative and uveitis-induced inflammatory cystoid macular edema]

Twenty-five eyes (23 patients) with inflammatory cystoid macular edema (CME) (11 after cataract surgery and 14 eyes (12 patients) with uveitis) were followed in a prospective open study. The aim was to determine the efficiency of a combined treatment of Diamox (acetazolamide), Voltaren Ophtha (diclofenac, a NSAID) and Ultracortenol (prednisolone acetate) and in the case of treatment failure, the usefulness of posterior subtenon's injections of corticosteroids (Kenacort 40 mg (triamcinolone)). Seven eyes (all pseudophakic CMEs) responded successfully to the initial therapy. Their mean visual acuity improved from 0.31 +/- 0.13 to 0.93 +/- 0.08 after 18 +/- 5 days (p less than or equal to 0.001). Of the sixteen of 18 evaluable eyes that were additionally treated with a mean of 3.28 +/- 1.07 three-weekly posterior subtenon's injections, 15 eyes including all uveitis CME responded to treatment. Their mean visual acuity improved from 0.49 +/- 0.20 to 0.96 +/- 0.31 (p less than or equal to 0.001). Two patients were excluded; in 22/23 eyes the sequential treatment was successful with an overall success rate of 95% of cases (improvement of five lines on the Snellen chart or final visual acuity of 0.8 or better). Initial angiographic cystoid macular edema was comparable and significantly improved after therapy in the two treatment groups. No mean intraocular pressure rise was noted after steroid injections. Measurement of anterior chamber inflammation with the laser flare-cell meter (Kowa FC-1000) showed elevated flare in all cases which significantly decreased in both treatment groups and represented a good follow-up parameter for the effect of antiinflammatory treatment and restoration of blood-ocular barrier.(ABSTRACT TRUNCATED AT 250 WORDS)     

Topical ketorolac tromethamine 0.5% ophthalmic solution in ocular inflammation after cataract surgery

PURPOSE: To compare the efficacy and safety of ketorolac 0.5% ophthalmic solution with its vehicle in the treatment of ocular inflammation after cataract surgery and intraocular lens implantation. DESIGN: Multicenter clinical study. PARTICIPANTS: One hundred four patients were prospectively randomized, 52 patients in treatment group, 52 patients in control group. METHODS: Patients received either ketorolac or vehicle four times daily in the operated eye for 14 days starting the day after surgery in a prospective, double-masked, randomized, parallel group study. Only patients with moderate or greater postoperative inflammation the day after surgery were enrolled. MAIN OUTCOME MEASURES: The main outcome measures include inflammation (cell, flare, ciliary flush), intraocular pressure and visual acuity. RESULTS: Ketorolac was significantly more effective than vehicle in reducing the manifestations of postoperative ocular inflammation, including: anterior chamber cells (P: = 0.002) and flare (P: = 0.009), conjunctival erythema (P: = 0.010), ciliary flush (P: = 0.022), photophobia (P: = 0.027), and pain (P: = 0.043). Five times as many patients were dropped from the study for lack of efficacy from the vehicle group (22/52) than from the ketorolac group (4/52; P: = 0.001). Ketorolac was found to be equally as safe as vehicle in terms of adverse events, changes in visual acuity, intraocular pressure, and biomicroscopic and ophthalmoscopic variables. CONCLUSIONS: Ketorolac tromethamine 0.5% ophthalmic solution was significantly more effective than vehicle in the treatment of moderate or greater ocular inflammation following routine cataract surgery, while being as safe as vehicle.     

Comparison of the efficacy and safety of ketorolac tromethamine 0.5% and prednisolone acetate 1% after cataract surgery.

PURPOSE: To compare the anti-inflammatory and analgesic efficacy and safety of ketorolac tromethamine 0.5% ophthalmic solution with those of prednisolone acetate 1% in patients having cataract surgery. SETTING: Shawnee Mission Eye Care, Shawnee Mission, Kansas, USA. METHODS: This double-blind, randomized, single-site study comprised 59 healthy men and women with a clinical diagnosis of routine ocular cataract requiring surgical removal. All patients had extracapsular cataract extraction and posterior chamber intraocular lens implantation. After surgery, patients were randomized to receive ketorolac tromethamine 0.5% or prednisolone acetate 1%, self-instilled in the treated eye, according to the following schedule: 1 to 2 drops 4 times daily (week 1); 3 times daily (week 2); 2 times daily (week 3); once daily (week 4). Patients were examined postoperatively on days 1, 7, and 28. Intraocular anti-inflammatory efficacy was assessed by lid edema, lid injection, conjunctival injection, corneal edema, ciliary flush, and anterior chamber cells. Analgesic efficacy was assessed by patient self-rated pain severity, pain frequency, total symptom sum, and overall global improvement. RESULTS: Both treatments produced comparable reductions in intraocular inflammation and pain after cataract surgery and were well tolerated by patients. No adverse events were reported, and there were no significant changes in intraocular pressure in either group. Improvements in visual acuity were also similar in both groups. CONCLUSION: Ketorolac tromethamine 0.5% ophthalmic solution was as effective and well-tolerated as prednisolone acetate 1% solution in controlling postoperative inflammation and pain after cataract surgery.     

The Pyhäjärvi Cataract Study II. Criteria for cataract surgery

Purpose: It is necessary to develop tools for patient selection to target cataract surgery to patients with the best expected outcomes. We used visual acuity, visual functioning 14 (VF‐14) test, the 15‐dimension health‐related quality‐of‐life questionnaire (15D) and the New Zealand priority criteria to evaluate the criteria for cataract surgery in a post hoc setting. Material and methods: Ninety‐three consecutive patients living in a defined rural area in Finland had cataract surgery as a part of the Pyhäjärvi Cataract Study in 2003. Success of cataract surgery was defined as improvement of visual acuity by at least 2 lines and/or improvement of visual function measured by questionnaires. Results: The patients with a visual acuity of 0.30 logMAR (0.5 Snellen decimal) or worse in the better eye and/or 0.52 logMAR (0.3 Snellen decimal) in the worse eye had successful surgery in 59–83% of cases depending on the definition of success. When subjective judgement was added, the success rates varied between 63% and 91%. Conclusion: Setting indication criteria, it seems sufficient to use two global questions in addition to visual acuity: one on the subjective view on disability, and one on a more neutral view on visual function, such as the 15D item on vision. The VF‐14 did not perform any better than the single item counterparts.     

Exudative age-related macular degeneration treated by intravitreal triamcinolone acetonide. A prospective comparative nonrandomized study

PURPOSE: To report on visual outcome of patients receiving an intravitreal injection of triamcinolone acetonide as treatment of progressive exudative age-related macular degeneration. METHODS: The prospective comparative nonrandomized clinical interventional study included 187 consecutive patients with progressive exudative age-related macular degeneration, divided into a study group of 115 patients receiving an intravitreal injection of 25 mg triamcinolone acetonide, and a control group of 72 patients without treatment. The mean follow-up was 6.0+/-4.2 months. RESULTS: Visual acuity increased significantly (P=0.03) in the study group, and decreased significantly (P=0.01) in the control group, at 1 month and 3 months after start of the study. Between the study group and control group, the differences in change of visual acuity were significant (P=0.001). In the study group, the number of patients with an increase in visual acuity of 2 or more Snellen lines was significantly (P=0.001) larger than in the control group. Correspondingly, the number of patients with a decrease of 2 or more Snellen lines was significantly (P=0.007) smaller in the study group. In all, 43 (37.4%) patients of the study group experienced an increase in best visual acuity by 2 or more Snellen lines. CONCLUSIONS: Visual acuity increased in patients with exudative age-related macular degeneration at 1 month and 3 months after an intravitreal injection of 25 mg triamcinolone acetonide.     

Ketorolac tromethamine LS 0.4% versus nepafenac 0.1% in patients having cataract surgery. Prospective randomized double-masked clinical trial

PURPOSE: To compare the clinical, subjective, and objective outcomes of the use of 2 topical nonsteroidal antiinflammatory drugs--ketorolac tromethamine LS 0.4% (Acular) and nepafenac 0.1% (Nevanac)--in patients having cataract surgery. SETTING: Single-center private practice, Las Vegas, Nevada, USA. METHODS: One hundred eighty-three patients (193 eyes) with visually significant cataract were recruited for the study. Consenting patients were randomized to a standard regimen of Acular, gatifloxacin 0.3% (Zymar), and prednisolone acetate 1% (Pred Forte) (ketorolac group) or Nevanac, moxifloxacin hydrochloride 0.5% (Vigamox), and prednisolone acetate (Econopred) (nepafenac group). Analysis included subjective complaints (burning, itching, foreign-body sensation, pain level after surgery) and objective findings (visual function, degree of inflammation in the anterior segment, complications). RESULTS: The ketorolac group consisted of 94 patients (100 eyes) and the nepafenac group, 89 patients (93 eyes). The between-group differences in visual outcomes and anterior chamber inflammation were not statistically significant (mean P = .33). There was a higher incidence of posterior capsule opacification in the nepafenac group (P = 0.019). Patient satisfaction, patient compliance, and postoperative pain control were statistically significantly better in the ketorolac group (P = .022, P = .023, and P = .025, respectively). CONCLUSION: Ketorolac tromethamine was statistically significantly better than nepafenac in terms of patient satisfaction, compliance, and postoperative pain control.     

Anisometropic amblyopia: is the patient ever too old to treat?

Amblyopia is an example of abnormal visual development that is clinically defined as a reduction of best corrected Snellen acuity to less than 6/9 (20/30) in one eye or a two-line difference between the two eyes, with no visible signs of eye disease. We describe a sequential management program for anisometropic amblyopia that consists of four steps: (1) the full refractive correction, (2) added lenses or prism when needed to improve alignment of the visual axes, (3) 2 to 5 h/day of direct occlusion, and (4) active vision therapy to develop monocular acuity and improve binocular visual function. We examined records of 19 patients over 6 years of age who had been treated using this sequential management philosophy. After 15.2 (+/- 7.7) weeks of treatment the Amblyopia Success Index (ASI) documented an average improvement in visual acuity of 92.1% +/- 8.1 with a range from a low of 75% by a 49-year-old patient to a maximum of 100% achieved by 42.1% of the patients (8 of 19). Patients who had completed therapy 1 or more years ago (N = 4) maintained their acuity improvement. From these results we conclude that following a sequential management plan for treatment of anisometropic amblyopia can yield substantial long-lasting improvement in visual acuity and binocular function for patients of any age.     

Radial optic neurotomy with adjunctive intraocular triamcinolone for central retinal vein occlusion: 63 consecutive cases

PURPOSE: Central retinal vein occlusion (CRVO) is a leading cause of permanent retinal vascular blindness. In a previous communication the authors reported the results of radial optic neurotomy (RON) in 117 consecutive patients with severe CRVO. Persistent cystoid macular edema (CME) and macular pigmentation (MP) were observed and correlated with worse macular function. Intraocular triamcinolone (IOK) has been used to treat patients with CME and CRVO. The authors performed RON with simultaneous, adjunctive IOK (RON/IOK) in patients with CRVO to ascertain any anatomic or visual benefit of this combined approach. METHODS: Pars plana vitrectomy and RON were performed on a case-by-case basis on 63 consecutive patients with CRVO and visual acuity of 20/200 or worse. At the end of the case, 4 mg of triamcinolone was injected into the vitreous cavity (RON/IOK). Patients were observed with serial fundus photographs, fluorescein angiography (FA), Snellen visual acuity (VA), intraocular pressures (IOP), and biomicroscopy for anterior segment neovascularization (ANV). Anatomic and visual outcomes were compared to a previous series of 117 patients with severe CRVO undergoing RON alone. RESULTS: Clinical improvement as determined by fundus examination, photography, and FA was noted in 93% of patients following RON/IOK. Snellen VA improved by an average of three lines (range one to seven) in 68% of all patients. Two or more lines were gained in 44% of patients and four or more lines were gained in 20% of patients. ANV developed in 7% of patients following RON/IOK. Persistent CME and MP were noted in 17% and 28% of patients, respectively. These outcomes were similar to patients undergoing RON alone without IOK. Elevated IOP was noted in 25% of patients and one patient developed endophthalmitis following RON/IOK. CONCLUSIONS: Surgical decompression of CRVO via RON/IOK is a technically feasible procedure. Clinical resolution of the CRVO and improved visual function noted in RON/IOK paralleled outcomes following RON alone. RON/IOK was associated with a higher incidence of elevated IOP and endophthalmitis.