Purpose To determine longitudinal rates of ocular complications after anti-vascular endothelial growth factor (VEGF) treatment for neovascular age-related macular degeneration (AMD) in a nationally representative longitudinal sample. Design retrospective, longitudinal case-control study. Methods Using the Medicare 5% claims database, diagnoses of neovascular AMD and anti-VEGF injections of ranibizumab, bevacizumab, or pegaptanib were identified from International Classification of Diseases (ICD-9-CM) and Current Procedural Terminology (CPT) procedure codes. 6,154 individuals undergoing anti-VEGF treatment for neovascular AMD (total of 40,903 injections) were compared with 6,154 matched controls with neovascular AMD who did not undergo anti-VEGF treatment. Propensity score matching was used to match individuals receiving anti-VEGF injections with controls. Rates of post-injection adverse outcomes (endophthalmitis, rhegmatogenous retinal detachment, retinal tear, uveitis, and vitreous hemorrhage) were analyzed by cumulative incidence and Cox proportional hazards model to control for demographic factors and ocular comorbidities. Results At 2-year follow-up, the rates of endophthalmitis per injection (0.09%; p<0.01), uveitis (0.11%; p<0.01), and vitreous hemorrhage per injection (0.23%; p<0.01) were significantly higher in the anti-VEGF treatment group. With Cox proportional hazards modeling, the anti-VEGF treatment group had an 102% higher risk of severe ocular complications overall, and a 4% increased risk per injection, both of which were statistically significant (p<0.01) Conclusions Rates of endophthalmitis, uveitis, and vitreous hemorrhage were higher in the group treated with anti-VEGF injection than in the control group, though nevertheless rare in both groups. The overall risk of severe ocular complications was significantly higher in the anti-VEGF treatment group.

Purpose We have recently developed a high-resolution microscope-integrated spectral domain optical coherence tomography (MIOCT) device designed to enable OCT acquisition simultaneous with surgical maneuvers. The purpose of this report is to describe translation of this device from preclinical testing into human intraoperative imaging. Methods Prior to human imaging, surgical conditions were fully simulated for extensive preclinical MIOCT evaluation in a custom model eye system. MIOCT images were then acquired in normal human volunteers and during vitreoretinal surgery in patients who consented to participate in a prospective Institutional Review Board-approved study. MIOCT images were obtained before and at pauses in surgical maneuvers and were compared based on pre-determined diagnostic criteria to images obtained with a high-resolution research handheld spectral domain OCT system (HHOCT, Bioptigen Inc., Research Triangle Park, NC) at the same time point. Cohorts of five consecutive patients were imaged. Successful endpoints were pre-defined, including ≥80% correlation in identification of pathology between MIOCT and HHOCT in ≥80% of patients. Results MIOCT was favorably evaluated by study surgeons and scrub nurses, all of whom responded that they would consider participating in human intraoperative imaging trials. The preclinical evaluation identified significant improvements that were made prior to MIOCT use during human surgery. The MIOCT transition into clinical human research was smooth. MIOCT imaging in normal human volunteers demonstrated high-resolution comparable to tabletop scanners. In the operating room, after an initial learning curve, surgeons successfully acquired human macular MIOCT images before and after surgical maneuvers. MIOCT imaging confirmed preoperative diagnoses, such as full-thickness macular hole and vitreomacular traction, and demonstrated post-surgical changes in retinal morphology. Two cohorts of five patients were imaged. In the second cohort, the predefined endpoints were exceeded with ≥80% correlation between MMOCT and HHOCT imaging in 100% of patients. Conclusion This report describes high-resolution MIOCT imaging using our prototype device in human eyes during vitreoretinal surgery, with successful achievement of pre-defined endpoints for imaging. Further refinements and investigations will be directed towards fully integrating MIOCT with vitreoretinal and other ocular surgery to image surgical maneuvers in real time.

Purpose To assess changes in Medicare payments for neovascular age-related macular degeneration (AMD) since introduction of anti-vascular endothelial growth factor (VEGF) therapies. Design Retrospective, longitudinal cohort study Methods Using the Medicare 5% sample, beneficiaries with new diagnoses of neovascular AMD in 1994 (N=2,497), 2000 (N=3,927), and 2006 (N=6,041) were identified using International Classification of Diseases (ICD-9-CM). The total first year health and eye care costs were calculated for each beneficiary. Propensity score matching was used to match individuals in the 2000 and 2006 cohorts with the 1994 cohort on age, gender, race, Charlson Comorbidity Index, and low vision/blindness. Results The number of beneficiaries newly diagnosed with neovascular AMD more than doubled between the 1994 and 2006 cohorts. Overall yearly Part B payments per beneficiary increased significantly from $3,567 for the 1994 to $5,991 for the 2006 cohort (p<0.01) in constant 2008 dollars. Payments for eye care alone doubled from $1,504 for the 1994 cohort to $3,263 for the 2006 cohort (p<0.01). Most of the increase in payments for eye care in 2006 reflected payments for anti-VEGF injections, which were $1,609 over 1 year. Mean annual numbers of visits and imaging studies also increased significantly between the 1994 and 2006 cohort. Results were similar in the matched sample. Conclusions The introduction of anti-VEGF intravitreal injections has offered remarkable clinical benefits for patients with neovascular AMD, but these benefits have come at the cost of an increased financial burden of providing care for these patients.

Intravitreal injection of expansile sulfur hexafluoride gas is a low-cost and minimally invasive alternative for the treatment of symptomatic VMT syndrome. Further study is warranted.

Background/Aims To study the susceptibility of Fusarium and Aspergillus isolated from keratitis to amoxicillin, cefazolin, chloramphenicol, moxifloxacin, tobramycin, and benzalkonium chloride (BAK). Methods 10 isolates of Fusarium and 10 isolates of Aspergillus from cases of fungal keratitis at Aravind Eye Hospital in South India were tested using microbroth dilution for susceptibility to amoxicillin, cefazolin, chloramphenicol, moxifloxacin, tobramycin, and BAK. The minimum inhibitory concentration (MIC) median and 90th percentile were determined. Results BAK had the lowest MIC for both Fusarium and Aspergillus. Chloramphenicol had activity against both Fusarium and Aspergillus, while moxifloxacin and tobramycin had activity against Fusarium but not Aspergillus. Conclusions The susceptibility of Fusarium to tobramycin, moxifloxacin, chloramphenicol, and BAK and of Aspergillus to chloramphenicol and BAK may explain anecdotal reports of fungal ulcers that improved with antibiotic treatment alone. While some of the MICs of antibiotics and BAK are lower than the typically prescribed concentrations, they are not in the range of antifungal agents such as voriconazole, natamycin, and amphotericin B. Antibiotics may, however, have a modest effect on Fusarium and Aspergillus when used as initial treatment prior to identification of the pathologic organism.