Publications by authors named "Harry W Flynn"

430 Publications

Postoperative Endophthalmitis Caused by (Formerly ) Acnes: Case Series and Review.

Case Rep Ophthalmol 2021 Jan-Apr;12(1):1-10. Epub 2021 Jan 7.

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA.

We report the clinical features, treatment strategies and outcomes in a series of patients with infectious endophthalmitis after cataract surgery caused by , formerly known as . This retrospective case series includes six eyes of six patients with chronic postoperative endophthalmitis caused by culture-proven from December 2010 to July 2019 at a University referral center. All patients underwent prior cataract extraction with intraocular lens (CE/IOL) implantation. The mean time between cataract surgery and the microbiologic diagnosis of endophthalmitis was 7.4 ± 5.2 months (range 1.5-17 months). The average time from obtaining the specimen to culture positivity was 7.7 ± 4.4 days (range 3-15 days). Three eyes (50%) presented with hypopyon and three eyes (50%) presented with prominent keratic precipitates without hypopyon. Presenting visual acuity ranged from 20/25 to 2/200. Initial treatments included intravitreal antibiotics alone ( = 2), pars plana vitrectomy (PPV) with partial capsulectomy and intravitreal antibiotics ( = 3), and pars plana vitrectomy with IOL removal and intravitreal antibiotics ( = 1). Follow-up treatments included IOL removal ( = 2), intravitreal antibiotics ( = 1), and topical antibiotics ( = 1). The best-corrected visual acuity at last follow-up was 20/70 or better in all patients. In a literature review, the clinical features and treatment outcomes for all case series of delayed-onset postoperative endophthalmitis caused by ( = 120) are listed. A definitive cure (the absence of recurrent inflammation) was achieved in 100% of patients that underwent IOL removal, in 77% of those that underwent PPV/partial capsulectomy and intravitreal antibiotics, and in 18% of cases treated with intravitreal antibiotics alone. Endophthalmitis after CE/IOL caused by is characterized by slowly progressive intraocular inflammation and has a protracted course from surgery to microbiologic diagnosis. Visual outcomes are generally favorable, but IOL explantation may be necessary for definitive cure.
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http://dx.doi.org/10.1159/000510208DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7879283PMC
January 2021

Nutritionally variant streptococci causing endophthalmitis associated with intravitreal anti-vascular endothelial growth factor injection.

Am J Ophthalmol Case Rep 2021 Mar 27;21:101019. Epub 2021 Jan 27.

Department of Ophthalmology, Bascom Palmer Eye Institute, 900 NW 17th St., Miami, FL, USA.

Purpose: To describe the clinical course and microbial properties of the first two reported cases of nutritionally variant Streptococci ( and ) endophthalmitis following intravitreal anti-vascular endothelial growth factor injection (IVI).

Observations: A 74 year-old female developed endophthalmitis following IVI. The patient underwent a pars plana vitrectomy and visual acuity recovered to 20/30 in six weeks. Similarly, an 88 year-old male developed endophthalmitis after IVI. After a pars plana vitrectomy, the visual acuity recovered to 20/60 at five weeks.

Conclusions And Importance: Endophthalmitis due to species has traditionally resulted in uniformly poor visual outcomes. However, nutritionally variant Streptococci, now reclassified as and species, appear to have a less aggressive clinical course and better visual acuity outcomes. To the authors' knowledge, these are the first reports of nutritionally variant Streptococci following IVI related endophthalmitis.
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http://dx.doi.org/10.1016/j.ajoc.2021.101019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7851176PMC
March 2021

Multimodal Imaging in the Diagnosis of Exophytic Juxtapapillary Retinal Capillary Hemangioblastoma.

Am J Ophthalmol 2021 Jan 12. Epub 2021 Jan 12.

Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida. Electronic address:

Purpose: Exophytic juxtapapillary retinal capillary hemangioblastoma (JRCH) can be difficult to diagnose. We explore the value of multimodal imaging to aid in the diagnosis.

Design: Retrospective case series.

Methods: Medical records and multimodal imaging studies were reviewed on all patients diagnosed with retinal capillary hemangioblastoma at Bascom Palmer Eye Institute between January 2013 and December 2019. Patients with exophytic lesions within 2 mm of the disc were included. One patient from Baylor College of Medicine was included. Patient demographics, referring diagnosis, history of von Hippel-Lindau (VHL) syndrome, initial and last visual acuity, and treatments were recorded. Fundus photography, autofluorescence (FAF), fluorescein angiography (FA), indocyanine green angiography (ICGA), OCT, OCT angiography (OCTA), and B-scan images were reviewed.

Results: 12 patients were identified with exophytic JRCH. Mean age was 54 years (range 38-73 years). 5 had VHL syndrome. The most common referral diagnoses were choroidal neovascularization and neuroretinitis. Imaging features included nodular outer retinal thickening with shadowing and intra-/subretinal fluid on OCT, hypoautofluorescence on FAF, middle to outer retinal hypervascularity on OCTA, early hyperfluorescence with late leakage on FA, and lack of choroidal vascular lesion on ICGA. Treatments included photodynamic therapy (PDT) (6 patients), intravitreal anti-VEGF therapy (6 patients), argon laser photocoagulation (2 patients), intravitreal or sub-Tenon triamcinolone (3 patients), and observation (4 patients).

Conclusions: A key to accurate diagnosis of exophytic JRCH is its intraretinal location, typically involving the outer retinal layers, which results in a clinical appearance that is distinct from the more common and easily recognizable endophytic RCH. Multimodal imaging can aid in ruling out choroidal neovascularization and disc edema by demonstrating an absence of involvement of those structures.
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http://dx.doi.org/10.1016/j.ajo.2021.01.002DOI Listing
January 2021

Refractive Outcomes of Four-Point Scleral Fixation of Akreos AO60 Intraocular Lens Using Gore-Tex Suture.

Clin Ophthalmol 2020 21;14:4431-4437. Epub 2020 Dec 21.

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA.

Background/objective: To determine the refractive outcomes after 4-point scleral fixation of the Akreos AO60 intraocular lens with Gore-Tex suture.

Methods: This was a single referral center, multi-surgeon, retrospective consecutive case series. A total of 63 eyes met the inclusion criteria for having received surgical implantation of the Akreos AO60 intraocular lens with Gore-Tex suture from August 2014 to December 2018. Exclusion criteria included all ocular pathology that precluded an accurate refraction, concurrent ocular surgery, poor corrected pre-operative visual potential, among other factors. Main outcome measures included post-operative uncorrected visual acuity (VA), best-corrected VA, and spherical equivalent deviation from target.

Results: Mean pre-operative BCVA was 0.67 ± 0.64 LogMAR (20/93 Snellen). Mean final post-operative BCVA was 0.17 ± 0.18 (20/28 Snellen) and mean final post-operative UCVA was 0.31 ± 0.22 (20/41 Snellen). Mean post-operative spherical equivalent was -0.57 D. Mean post-operative astigmatism was 0.85 D.

Conclusion: Refractive outcomes after secondary implantation with Akreos AO60 are favorable in eyes with good visual potential.
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http://dx.doi.org/10.2147/OPTH.S282094DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7762441PMC
December 2020

Postoperative Endophthalmitis and Toxic Anterior Segment Syndrome Prophylaxis: 2020 Update.

Ann Transl Med 2020 Nov;8(22):1548

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA.

Improved surgical techniques have led to an increase in the number of outpatient ophthalmic procedures. In spite of decreased surgical times and overall improved outcomes, endophthalmitis remains one of the most severe complications of ophthalmic surgery. Although there are well known risk factors for postoperative endophthalmitis, some prophylaxis strategies remain controversial. A category of noninfectious postoperative inflammation, known as toxic anterior segment syndrome (TASS), is a rare but important complication of cataract surgery. While several worldwide outbreaks of TASS have occurred, it is challenging to identify an etiology in order to reduce the risk of further cases. Endophthalmitis and TASS cannot be prevented completely, but their rates may be decreased through risk reduction strategies supported by peer-reviewed evidence. This review highlights the current evidence in the prevention strategies for postoperative endophthalmitis and TASS.
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http://dx.doi.org/10.21037/atm-2019-rcs-02DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7729369PMC
November 2020

The retina as a window to the basal ganglia: Systematic review of the potential link between retinopathy and hyperkinetic disorders in diabetes.

Parkinsonism Relat Disord 2020 11 13;80:194-198. Epub 2020 Oct 13.

The Edmond J. Safra Program in Parkinson Disease and the Morton and Gloria Shulman Movement Disorders Clinic, Division of Neurology, Department of Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.

There is evidence that glycemic fluctuations trigger vascular-mediated dysfunction in both the retina and the striatopallidal regions in patients with diabetes. The latter is associated with a variety of hyperkinetic disorders that are rare but disabling and potentially preventable. We conducted a systematic review of the potential association between diabetic retinopathy and the risk and prognosis of hyperkinetic disorders in patients with diabetes. We identified a total of 461 articles and 147 were eligible for review. Nine out of 147 articles (6.12%) reported 13 patients with information on diabetic retinopathy. Glycemic fluctuations were present at onset in 10 patients (77%) and retinopathy was present in nine of them (69.23%). The degree of retinopathy was reported in four patients. Two had severe, bilateral proliferative retinopathy, one had moderate-to-severe non-proliferative retinopathy and one had non-proliferative retinopathy. In the nine patients with retinopathy, hyperkinesia persisted, required higher doses of dopamine receptor antagonists or deep brain stimulation. Retinopathy was absent in four cases (30.77%). In these patients, hyperkinesia resolved spontaneously or with lower doses of dopamine receptor antagonists. Diabetic retinopathy could be an indirect marker of striatopallidal microangiopathy in patients with diabetes. The severity of retinopathy may be associated with increased risk or worse prognosis for patients who develop hyperkinetic disorders of the diabetic striatopathy spectrum. Early detection of retinopathy could identify patients in which avoiding glycemic fluctuations may prevent the development of striatopathy and hyperkinetic disorders.
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http://dx.doi.org/10.1016/j.parkreldis.2020.10.025DOI Listing
November 2020

Characterization of Pseudomonas aeruginosa isolates from patients with endophthalmitis using conventional microbiologic techniques and whole genome sequencing.

J Ophthalmic Inflamm Infect 2020 Sep 28;10(1):25. Epub 2020 Sep 28.

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, 900 NW 17th Street, Miami, FL, 33136, USA.

Purpose: To demonstrate antibiotic susceptibility and genomic virulence factor profiles of Pseudomonas aeruginosa isolates from patients with culture-confirmed endophthalmitis.

Methods: Clinical isolates from patients diagnosed with pseudomonas endophthalmitis were included. Laboratory antibiotic susceptibility testing and whole genome sequencing was performed on all isolates.

Results: In the current study, 8 patients had vitreous culture-confirmed endophthalmitis due to P. aeruginosa. All isolates were multi-drug resistant but sensitive to ceftazidime and each fluoroquinolone tested. Whole genome sequencing revealed a total of 179 unique genes. The most common type of virulence genes included those involved in adherence and the secretion system. Seven of 8 (88%) isolates were of the cytoinvasive phenotype (exoST) and no isolates contained exoU.

Conclusions: P. aeruginosa associated endophthalmitis is often multi-drug resistant and demonstrates a variety of virulence factors with those involved in adherence and the secretion system being the most common.
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http://dx.doi.org/10.1186/s12348-020-00216-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7520479PMC
September 2020

Severe Neovascular Glaucoma Exacerbation as a Complication of Carotid Artery Stenting: A Case Report.

Neurohospitalist 2020 Oct 22;10(4):301-304. Epub 2020 May 22.

Vascular Neurology Division, Department of Neurology, University of Miami Miller School of Medicine, FL, USA.

Introduction: Neovascular glaucoma (NVG) has been rarely reported as an acute complication of carotid endarterectomy, but there is scant literature available regarding this potential condition following carotid artery stenting (CAS). We present a case of severe worsening of NVG occurring after bilateral CAS with progressive deterioration of vision ultimately leading to blindness.

Case Description: A 66-year-old male with multiple stroke risk factors, bilateral cataract extraction, proliferative diabetic retinopathy of left eye, and nonproliferative diabetic retinopathy of right eye, and prior left eye pars plana vitrectomy presented with episodes of transient right eye vision loss in context of bilateral high-grade internal carotid artery stenoses. He underwent right CAS with subsequent elevation of bilateral intraocular pressures (IOPs) concerning for acute NVG. Over time, the patient had some interval improvement in IOPs and underwent planned left CAS. After the procedure, he again developed elevated IOPs, concerning for acute NVG which eventually led to right eye pars plana vitrectomy for vitreous hemorrhage and refractory IOP elevation. At 6-month follow-up from initial stenting, the patient was blind in both eyes.

Discussion: We present a case of recurrent IOP elevations following CAS eventually resulting in bilateral eye blindness. This case is important not only as an illustration of an underrecognized postprocedural CAS complication but also as a demonstration of likely elevated risk of NVG following CAS for patients with other predisposing risk factors for ocular hypertension such as glaucoma, proliferative diabetic retinopathy, prior cataract extraction, and prior pars plana vitrectomy.
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http://dx.doi.org/10.1177/1941874420923914DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7495707PMC
October 2020

The Central Subfoveal Bouquet in Idiopathic Epiretinal Membranes.

Clin Ophthalmol 2020 17;14:2353-2359. Epub 2020 Aug 17.

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA.

Purpose: To report both the unoperated clinical course and the surgical outcomes of eyes with a central foveal bouquet (CB) secondary to idiopathic epiretinal membranes (iERMs).

Design: Retrospective, consecutive, and observational case series.

Methods: All patients examined between January 1, 2014, and December 31, 2019, for evaluation of epiretinal membrane with a CB lesion identified on spectral domain optical coherence tomography (SD-OCT) were included. Exclusion criteria included vitreoretinal comorbidities associated with secondary ERMs and an absence of CB lesions on SD-OCT. Patients were divided into two groups: those who were followed with observation (Group I) and those who received surgery (Group II). Each group had 3 different types of mechanical abnormalities of the CB previously described as cotton ball sign, subfoveal detachment, or acquired vitelliform lesion, without a subanalysis discrimination.

Main Outcome Measures: Best-corrected visual acuity (BCVA) at baseline and last follow-up, subjective metamorphopsia, central retinal thickness (CMT), mechanical stress lesions of the CB, and resolution or evolution of the CB lesions during the follow-up interval.

Results: Two hundred seventy-six eyes with iERM were reviewed, and 46 eyes met the inclusion criteria. Among these, 21 of 46 (46%) were observed, and 25 of 46 (54%) underwent surgery. Metamorphopsia was identified in 61.9% of patients in Group I and 81.2% of patients in Group II, at baseline. The mean BCVA was 0.19 ± 0.17 (20/30) in Group I and 0.31 ± 0.33 (20/40) in Group II at presentation. At the final exam, patients in Group I achieved a mean BCVA of 0.24 ± 0.18 (20/30), while patients in Group II obtained a mean BCVA of 0.15 ± 0.21 (20/30). Spontaneous resolution of the CB sign occurred in 5 of 21 eyes (23.8%) that were observed, whereas, after surgery, the CB sign resolved in 16 of 25 eyes (61.5%). Mean CMT was 422 ± 84.2μm in Group I and 531 ± 143.9μm in Group II, at baseline, while at the latest follow-up, the mean CMT was 400 ± 40.8μm in the cases followed with observation and 454 ± 148.7μm in the surgical cases.

Conclusion: The clinical course and surgical outcomes of CB findings in iERM are favorable in terms of visual acuity. However, those receiving surgery had an increase in visual acuity and resolution of the CB abnormality.
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http://dx.doi.org/10.2147/OPTH.S254544DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7493214PMC
August 2020

Outcomes of Pars Plana Vitrectomy Alone versus Combined Scleral Buckling plus Pars Plana Vitrectomy for Primary Retinal Detachment.

Ophthalmol Retina 2021 Feb 25;5(2):169-175. Epub 2020 Sep 25.

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida. Electronic address:

Purpose: We compared the outcomes of primary uncomplicated rhegmatogenous retinal detachment (RRD) repair using pars plana vitrectomy (PPV) alone versus combined scleral buckling plus PPV (SB+PPV).

Design: Retrospective, observational study.

Participants: Patients with primary RRD who underwent PPV or SB+PPV from June 1, 2014, through December 31, 2017.

Methods: We performed a single-institution, retrospective, observational study of 488 consecutive patients with primary RRD repaired via PPV alone or SB+PPV and gas tamponade. We excluded patients younger than 18 years and those with advanced proliferative vitreoretinopathy, giant retinal tear, trauma, or secondary forms of RRD. We performed logistic regression and Cox proportional hazard regression analyses to identify potential risk factors associated with a retinal redetachment.

Main Outcome Measures: Single-operation anatomic success (SOAS), defined as adequate retinal reattachment achieved with only 1 procedure.

Results: The mean follow-up interval was 14.3 months. Single-operation anatomic success and final anatomic success were achieved in 425 eyes (87.1%) and 487 eyes (99.8%), respectively. Single-operation anatomic success was achieved in 90 of 111 eyes (81.1%) with PPV alone compared with 345 of 374 eyes (92.2%) with SB+PPV (P = 0.0010). Scleral buckling plus PPV showed greater SOAS than PPV alone in phakic eyes (P < 0.0001), but not in eyes with a posterior chamber intraocular lens (PCIOL). Retinal redetachments occurred on average at 1.5 and 9 months after the initial surgery. Significant best-corrected visual acuity improvement was associated with SOAS (P < 0.0001).

Conclusions: Scleral buckling plus PPV resulted in greater SOAS outcomes than PPV alone for primary RRD repair. Phakic eyes achieved greater surgical success with SB+PPV, whereas eyes with a PCIOL achieved similar results with both methods. Most retinal redetachments occurred within the initial postoperative 3-month period. Single-operation anatomic success was associated with statistically significant visual improvement.
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http://dx.doi.org/10.1016/j.oret.2020.09.013DOI Listing
February 2021

Central Serous Chorioretinopathy: Multimodal Imaging and Management Options.

Case Rep Ophthalmol Med 2020 14;2020:8890404. Epub 2020 Aug 14.

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA.

Central serous chorioretinopathy (CSCR) is an idiopathic maculopathy characterized by thickened choroid, retinal pigment epithelial detachment, and variable subretinal fluid. CSCR predominantly affects young men, with risk factors including corticosteroid use, the type A behavior pattern, and psychological stress. While usually self-limited with a good visual prognosis, recurrent and persistent CSCR can lead to outer retinal and/or retinal pigment epithelial atrophy, choroidal neovascularization, and visual loss. This article reviews current multimodal imaging and treatment options, which include observation, mineralocorticoid receptor antagonists, thermal laser photocoagulation, and off-label photodynamic therapy with verteporfin.
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http://dx.doi.org/10.1155/2020/8890404DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7443246PMC
August 2020

Chronic, Recurrent Bacterial Endophthalmitis Caused by : Clinical Features and Management.

Int Med Case Rep J 2020 9;13:265-269. Epub 2020 Jul 9.

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami, Miller School of Medicine, Miami, FL, 33136, USA.

A 79-year-old man presented to a tertiary referral center from the Dominican Republic with an opaque corneal graft and a diagnosis of chronic, recurrent culture-positive endophthalmitis of the left eye. The patient had a history of penetrating keratoplasty for Fuchs' dystrophy and had undergone multiple intraocular surgeries including pars plana vitrectomy and anterior chamber wash out for the diagnosis and management of chronic endophthalmitis. After being referred, the patient underwent a third PKP, removal of his intraocular lens (IOL), capsulectomy, and injection of intravitreal antibiotics. All surgical specimens demonstrated the growth of . Five months after surgery, the graft remained clear without evidence of infection and best-corrected visual acuity was 20/350.
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http://dx.doi.org/10.2147/IMCRJ.S259899DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7358084PMC
July 2020

Widefield Fluorescein Angiography in the Fellow Eyes of Patients with Presumed Unilateral Persistent Fetal Vasculature.

Ophthalmol Retina 2021 Mar 26;5(3):301-307. Epub 2020 Jul 26.

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami, Florida. Electronic address:

Purpose: To examine the retinal vascular findings on widefield fluorescein angiography (FA) in the fellow eyes of patients with unilateral persistent fetal vasculature (PFV).

Design: Retrospective case series.

Participants: Consecutive patients with unilateral PFV evaluated by a single physician at an academic medical center from February 1, 2011, to November 30, 2018.

Methods: Clinical and demographic information, including age, gender, race, ethnicity, affected eye, subtype, stalk origin, complications on presentation, length of follow-up, and examination findings, was reviewed using the electronic medical record. Fluorescein angiograms of the affected and fellow eyes were reviewed by 2 authors for characteristic retinal vascular abnormalities. Agreement between the authors' scores was analyzed using Cohen's Kappa.

Main Outcome Measures: Fluorescein angiography abnormalities, including peripheral vessel avascularity, aberrant circumferential vessels, terminal supernumerary branching, regional capillary dropout, terminal bulbing, abnormal choroidal flush, abnormal vessel straightening, and peripheral vessel leakage or dilation.

Results: Inclusion criteria were met by 41 patients. The average age at initial visit was 10.0 months. The average length of follow-up was 36.4 months. Abnormalities on FA were seen in 31 (75.6%) fellow eyes: peripheral vessel avascularity in 27.5 (67.1%), aberrant circumferential vessels in 20 (48.8%), terminal supernumerary branching in 17 (41.5%), regional capillary dropout in 9 (22.0%), terminal bulbing in 6 (14.6%), abnormal choroidal flush in 3.5 (8.5%), and abnormal vessel straightening and peripheral vessel leakage in 2.5 (6.1%). Statistical analysis disclosed an overall observed agreement of 93.4% among the raters (κ = 0.84, P < 0.0001).

Conclusions: Retinal vascular abnormalities seen in patients with unilateral PFV were present in the majority of fellow eyes. This suggests that unilateral PFV may in fact be a bilateral, asymmetric process, but the clinical significance of these subtle findings is not known.
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http://dx.doi.org/10.1016/j.oret.2020.07.020DOI Listing
March 2021

Rhegmatogenous Retinal Detachment after Intravitreal Injection.

Ophthalmol Retina 2021 Feb 14;5(2):178-183. Epub 2020 Jul 14.

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida. Electronic address:

Purpose: To describe the clinical features and outcomes in patients with rhegmatogenous retinal detachment (RRD) after intravitreal injection of pharmacologic agents.

Design: Retrospecitve case series.

Participants: Patients diagnosed with rhegmatogenous retinal detachment within 3 months of receiving an intravitreal injection of a pharmacologic agent for treatment of macular disease.

Methods: Retrospective case series of reported cases of RRD in patients with prior intravitreal injection who underwent subsequent surgical repair at a university referral center.

Main Outcome Measures: Visual acuity (VA), single surgery anatomic success rate (SSAS) and retinal reattachment at last follow-up.

Results: Thirteen patients were identified to have RRD within 3 months of intravitreal injection. Injection was performed in the inferotemporal quadrant in 12 of 13 eyes (92%) with a 31- or 32-gauge needle. Additional risk factors for RRD other than intravitreal injection were present in 5 of 13 eyes (38%), including prior pars plana vitrectomy (3 eyes), history of retinal tear (1 eye), and history of RRD in the fellow eye (1 eye). Average duration from time of injection to diagnosis of RRD was 27 days (range, 5-43 days). Retinal reattachment was achieved in 12 of 13 eyes (92%). Visual acuity returned to baseline in only 3 of 13 eyes (23%) at the last follow-up visit.

Conclusions: Although RRD after intravitreal injection is rare, prior retinal surgery and alternate risk factors for RRD may predispose to RRD after intravitreal injection. Surgical outcomes were generally favorable, but VA outcomes were limited by the high rate of macula-off RRD and the underlying macular disease.
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http://dx.doi.org/10.1016/j.oret.2020.07.007DOI Listing
February 2021

The Role of Systemic Antimicrobials in the Treatment of Endophthalmitis: A Review and an International Perspective.

Ophthalmol Ther 2020 Sep 1;9(3):485-498. Epub 2020 Jul 1.

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA.

Background: The optimal management of patients with endophthalmitis is challenging and includes both intravitreal and, in some cases, systemic antimicrobials. Systemic antimicrobials may be administered either intravenously or orally. In this article we review systemic antimicrobial options currently available for the treatment of types of endophthalmitis and the role of systemic antimicrobials (antibiotics and antifungals) in these treatments.

Review: While systemic antimicrobials are not universally utilized in the management of endophthalmitis, they may be helpful in some circumstances. The blood-retinal barrier affects the penetration of systemic medications into the posterior segment of the eye differently; for example, moxifloxacin and imipenem cross the blood-retinal barrier relatively easily while vancomycin and amikacin do not. However, inflammation, including endophthalmitis, may disrupt the blood-retinal barrier, enhancing the penetration of systemic agents into the eye.

Conclusion: Systemic antimicrobials may be particularly beneficial in patients with certain types of endophthalmitis; as such, they are standard treatment in the management of endogenous endophthalmitis (fungal and bacterial) and also widely used for prophylaxis and treatment of open-globe injuries. Although systemic antimicrobials are used in some patients with acute-onset postoperative endophthalmitis following cataract surgery, the literature generally does not support this practice. It is noted that there are currently no randomized clinical trials demonstrating a benefit of systemic antibiotics for any category of endophthalmitis.
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http://dx.doi.org/10.1007/s40123-020-00270-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7406615PMC
September 2020

Pars Plana Vitrectomy Reoperations for Complications of Proliferative Diabetic Retinopathy.

Clin Ophthalmol 2020 10;14:1559-1563. Epub 2020 Jun 10.

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA.

Objective: To report visual acuity in patients undergoing pars plana vitrectomy (PPV) reoperations for complications of proliferative diabetic retinopathy (PDR).

Design: Retrospective case series.

Subjects: Diabetic patients undergoing reoperation with PPV between 2015 and 2018 at a university referral center.

Methods: Patient charts were reviewed for indication for initial and repeat PPV, baseline clinical characteristics including gender, age, and lens status, and pre- and post-operative best-corrected visual acuity.

Main Outcome Measures: Best-corrected visual acuity at last follow-up.

Results: Of 538 eyes (409 patients) undergoing a PPV for diabetic retinopathy, 153 (28.4%) eyes had reoperation. Among the 130 eyes (119 patients) that met the inclusion criteria, 55 eyes (50 patients) underwent reoperation for complications of PDR, defined as non-clearing vitreous hemorrhage (NCVH) and/or tractional retinal detachment (TRD). Within this subgroup of 55 eyes, 19 (34.5%) eyes had an indication for the first surgery of NCVH. Fourteen (73.7%) of these NCVH eyes achieved a visual acuity of 20/80 or better. When the indication for the first surgery was TRD (33 eyes, 60%), 8 (24.2%) eyes achieved this same outcome (p=0.0011).

Conclusion: Approximately one of every four eyes treated with PPV for PDR will undergo repeat PPV during follow-up. VA outcomes after the repeat PPV were variable, with NCVH cases achieving better outcomes compared to TRD.
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http://dx.doi.org/10.2147/OPTH.S252285DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7293964PMC
June 2020

Follow-up Non-Compliance: A Significant Risk Factor for Reduced Visual Outcomes in Patients With Diabetic Retinopathy.

Am J Ophthalmol 2020 08 11;216:A12-A13. Epub 2020 Jun 11.

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, 900 NW 17th Street, Miami, Florida 33126, USA. Electronic address:

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http://dx.doi.org/10.1016/j.ajo.2020.04.004DOI Listing
August 2020

Genotypic and Phenotypic Antibiotic Resistance in Staphylococcus Epidermidis Endophthalmitis.

Ophthalmic Surg Lasers Imaging Retina 2020 05;51(5):S13-S16

Background And Objective: To evaluate antibiotic resistance patterns in Staphylococcus epidermis endophthalmitis isolates, identify antibiotic resistance genes, and compare this to their phenotypic resistance.

Materials And Methods: Retrospective case series of S. epidermidis isolates from January 2012 to December 2017. Phenotypic resistance was determined from minimum inhibitory concentration values. Genotypic resistance was determined from DNA microarray. The relationship between these was analyzed using Cohen's kappa and predictive value.

Results: Seventy-five isolates were included. More than 60% were resistant to methicillin and erythromycin. Approximately 60% possessed the resistance genes for methicillin and erythromycin, and 25% for clindamycin. There was near perfect agreement between genotype and phenotype for erythromycin and methicillin (kappa = 0.88 and 0.89, respectively). Approximately 98% (P < 0.0001) of isolates with erythromycin and methicillin resistance genes and 90% (P = 0.0006) with clindamycin resistance genes were phenotypically resistant to those antibiotics. None were resistant to vancomycin.

Conclusion: The relationship between genotypic and phenotypic antibiotic resistance highlights that resistance may be polygenic, and genes may be silent. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:S13-S16.].
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http://dx.doi.org/10.3928/23258160-20200108-02DOI Listing
May 2020

and endogenous panophthalmitis: clinical and histopathological features.

Am J Ophthalmol Case Rep 2020 Sep 11;19:100738. Epub 2020 May 11.

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, USA.

Purpose: To report an unusual case of endogenous panophthalmitis involving and describe its clinical and histopathological features.

Findings: A 30 year-old man with history of human immunodeficiency virus, polysubstance abuse, syphilis, and recently treated pneumonia presented with polymicrobial endogenous panophthalmitis. Two separate ocular specimens confirmed simultaneous and involvement. Histopathological analysis demonstrated fulminant polymorphonuclear infiltration of all ocular tissue layers. Despite aggressive management including two intravitreal injections and enucleation, the patient died, ultimately after receiving care at four neighboring urban medical centers.

Conclusions And Importance: has been a recently and increasingly described pathogen leading to mortality in metropolitan hospitals worldwide. To the authors' knowledge, has not previously been reported with endophthalmitis or panophthalmitis. Future cases may be expected with the reported rise in . A high suspicion of its contribution to panophthalmitis could be warranted early in the evaluation and management of profoundly immunocompromised patients, particularly those who have had sequential care at multiple neighboring metropolitan hospitals.
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http://dx.doi.org/10.1016/j.ajoc.2020.100738DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7240712PMC
September 2020

Tamponade in surgery for retinal detachment associated with proliferative vitreoretinopathy.

Cochrane Database Syst Rev 2020 05 13;5:CD006126. Epub 2020 May 13.

Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA.

Background: Retinal detachment (RD) with proliferative vitreoretinopathy (PVR) often requires surgery to restore normal anatomy and to stabilize or improve vision. PVR usually occurs in association with recurrent RD (that is, after initial retinal re-attachment surgery), but occasionally may be associated with primary RD. Either way, for both circumstances a tamponade agent (gas or silicone oil) is needed during surgery to reduce the rate of postoperative recurrent RD.

Objectives: The objective of this review was to assess the relative safety and effectiveness of various tamponade agents used with surgery for RD complicated by PVR.

Search Methods: We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (the Cochrane Library 2019, Issue 1), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to January 2019), Embase (January 1980 to January 2019), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to January 2019), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 2 January 2019.

Selection Criteria: We included randomized controlled trials (RCTs) on participants undergoing surgery for RD associated with PVR that compared various tamponade agents.

Data Collection And Analysis: Two review authors screened the search results independently. We used the standard methodological procedures expected by Cochrane.

Main Results: We identified four RCTs (601 participants) that provided data for the primary and secondary outcomes. Three RCTs provided data on visual acuity, two reported on macular attachment, one on retinal reattachment and another two on adverse events such as RD, worsening visual acuity and intraocular pressure. Study Characteristics Participants' characteristics varied across studies and across intervention groups, with an age range between 21 to 89 years, and were predominantly men. The Silicone Study was conducted in the USA and consisted of two RCTs: (silicone oil versus sulfur hexafluoride (SF) gas tamponades; 151 participants) and (silicone oil versus perfluropropane (CF) gas tamponades; 271 participants). The third RCT compared heavy silicone oil (a mixture of perfluorohexyloctane (FH) and silicone oil) with standard silicone oil (either 1000 centistokes or 5000 centistokes; 94 participants). The fourth RCT compared 1000 centistokes with 5000 centistokes silicone oil in 85 participants. We assessed most RCTs at low or unclear risk of bias for most 'Risk of bias' domains. Findings Although SF gas was reported to be associated with worse anatomic and visual outcomes than was silicone oil at one year (quantitative data not reported), at two years, silicone oil compared to SF gas showed no evidence of a difference in visual acuity (33% versus 51%; risk ratio (RR) 1.57; 95% confidence interval (CI) 0.93 to 2.66; 1 RCT, 87 participants; low-certainty evidence). At one year, another RCT comparing silicone oil and CF gas found no evidence of a difference in visual acuity between the two groups (41% versus 39%; RR 0.97; 95% CI 0.73 to 1.31; 1 RCT, 264 participants; low-certainty evidence). In a third RCT, participants treated with standard silicone oil compared to those receiving heavy silicone oil also showed no evidence of a difference in the change in visual acuity at one year, measured on logMAR scale ( mean difference -0.03 logMAR; 95% CI -0.35 to 0.29; 1 RCT; 93 participants; low-certainty evidence). The fourth RCT with 5000-centistoke and 1000-centistoke comparisons did not report data on visual acuity. For macular attachment, participants treated with silicone oil may probably experience more favorable outcomes than did participants who received SF at both one year (quantitative data not reported) and two years (58% versus 79%; RR 1.37; 95% CI 1.01 to 1.86; 1 RCT; 87 participants; low-certainty evidence). In another RCT, silicone oil compared to CF at one year found no evidence of difference in macular attachment (RR 1.00; 95% CI 0.86 to 1.15; 1 RCT, 264 participants; low-certainty evidence). One RCT that compared 5000 centistokes to 1000 centistoke reported that retinal reattachment was successful in 67 participants (78.8%) with first surgery and 79 participants (92.9%) with the second surgery, and no evidence of between-group difference (1 RCT; 85 participants; low-certainty evidence). The fourth RCT that compared standard silicone oil with heavy silicone oil did not report on macular attachment. Adverse events In one RCT (86 participants), those receiving standard 1000 centistoke silicone oil compared with those of the 5000 centistoke silicone oil showed no evidence of a difference in intraocular pressure elevation at 18 months (24% versus 22%; RR 0.90; 95% CI 0.41 to 1.94; low-certainty evidence), visually significant cataract (49% versus 64%; RR 1.30; 95% CI 0.89 to 1.89; low-certainty evidence), and incidence of retina detachment after the removal of silicone oil (RR 0.36 95% CI 0.08 to 1.67; low-certainty evidence). Another RCT that compared standard silicone oil with heavy silicone oil suggests no difference in retinal detachment at one year (25% versus 22%; RR 0.89; 95% CI 0.54 to 1.48; 1 RCT; 186 participants; low-certainty evidence). Retinal detachment was not reported in the RCTs that compared silicone oil versus SF and silicone oil versus to CF.

Authors' Conclusions: There do not appear to be any major differences in outcomes between CF and silicone oil. Silicone oil may be better than SF for macular attachment and other short-term outcomes. The choice of a tamponade agent should be individualized for each patient. The use of either CF or standard silicone oil appears reasonable for most patients with RD associated with PVR. Heavy silicone oil, which is not available for routine clinical use in the USA, may not demonstrate evidence of superiority over standard silicone oil.
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http://dx.doi.org/10.1002/14651858.CD006126.pub4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7388158PMC
May 2020

Facedown Postoperative Positioning for Large Macular Holes.

JAMA Ophthalmol 2020 07;138(7):730-731

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida.

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http://dx.doi.org/10.1001/jamaophthalmol.2020.0986DOI Listing
July 2020

Wide field swept source OCT angiography of multifocal retinal and choroidal occlusions from embolic triamcinolone acetonide.

Am J Ophthalmol Case Rep 2020 Jun 14;18:100704. Epub 2020 Apr 14.

Bascom Palmer Eye Institute, Miami, FL, USA.

Purpose: Multifocal retinal arterial occlusions and choroidal infarctions due to embolic triamcinolone acetonide (TA) administered during a septoplasty were imaged using swept source OCT angiography (SS-OCTA) to demonstrate the utility of this imaging modality for the diagnosis and longitudinal follow-up of retinal and choroidal vascular diseases.

Observations: A 37-year-old man presented with vision loss in his left eye upon awakening from a left-sided septoplasty during which TA was injected. Examination of the left eye demonstrated retinal whitening in the macula, white material in the distal lumen of retinal arterioles, and multifocal hypopigmented choroidal lesions. SS-OCTA imaging showed the absence of detectable flow in areas of retinal and choroidal whitening. Corresponding B-scans demonstrated hyperreflective material, thought to be embolic TA, within the retinal vessels and inner choroid.

Conclusions: Wide field SS-OCTA was sufficient for the diagnosis and longitudinal evaluation of retinal and choroidal occlusions without the need for dye-based angiography.
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http://dx.doi.org/10.1016/j.ajoc.2020.100704DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7170946PMC
June 2020

Long-term chorioretinal changes following strabismus surgery-possible occult needle penetration.

Int J Ophthalmol 2020 18;13(3):518-519. Epub 2020 Mar 18.

Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida 33136, United States.

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http://dx.doi.org/10.18240/ijo.2020.03.23DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7154210PMC
March 2020

Long-Term Outcomes After Idiopathic Epiretinal Membrane Surgery.

Clin Ophthalmol 2020 31;14:995-1002. Epub 2020 Mar 31.

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA.

Purpose: To report anatomic and logMAR best-corrected visual acuity (BCVA) outcomes with long-term follow-up after pars-plana vitrectomy and epiretinal membrane peeling (PPV-MP).

Design: A retrospective case-series.

Participants: Patients with epiretinal membrane (ERM) who underwent PPV-MP performed by one surgeon.

Methods: Best-corrected visual acuity (BCVA) was recorded as a logMAR preoperatively and, when available, at 1, 2, 3, 5, 8, 10 years after surgery. The integrity of outer retinal layers was evaluated using spectral domain optical coherence tomography (SD-OCT).

Main Outcome Measures: Postoperative BCVA at different follow-up visits and its correlation with different OCT parameters.

Results: Fifty-five eyes of 49 patients were followed postoperatively with a mean of 8.6± 2.6 years (median: 9 years, range 5-16 years). The mean BCVA improved from 0.56±0.29 (20/72) preoperatively to 0.33±0.25 (20/42) at 1 year, 0.29±0.27 (20/38) at 2 years, 0.25±0.28 (20/35) at 3 years, 0.29±0.32 (20/38) at 5 years, 0.28±0.31 (20/38) at 8 years, and 0.28±0.25 (20/38) at 10 years (p<0.001). The BCVA improved at each of the first 3 years postoperatively and remained stable at 5, 8, and 10 years. Postoperative improvement in the integrity of ELM, and EZ, on SD-OCT correlated with improved BCVA.

Conclusion: BCVA continues to improve after PPV-MP during the first 3 years postoperatively and remains stable. Improved anatomic integrity of outer retinal layers correlated with improved BCVA.
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http://dx.doi.org/10.2147/OPTH.S242681DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7127775PMC
March 2020

Endophthalmitis Caused by following Intravitreal Aflibercept for Diabetic Retinopathy.

Case Rep Ophthalmol 2020 Jan-Apr;11(1):22-27. Epub 2020 Jan 9.

Department of Ophthalmology, Bascom Palmer Eye Institute, Miami, Florida, USA.

is a gram-negative bacillus rarely implicated in ocular disease. A 79-year-old male who performed extensive yardwork following intravitreal injection with aflibercept for diabetic macular edema developed endophthalmitis caused by on post-injection day 7. The patient was treated with vitreous tap and intravitreal injection of vancomycin and ceftazidime with clearance of the infection and restoration of his baseline visual acuity at 20/80.
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http://dx.doi.org/10.1159/000505227DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7098332PMC
January 2020

The Evolving Treatment of Diabetic Retinopathy.

Clin Ophthalmol 2020 4;14:653-678. Epub 2020 Mar 4.

Retina Center of Minnesota, Minneapolis, MN 55404, USA.

Purpose: To review the current therapeutic options for the management of diabetic retinopathy (DR) and diabetic macular edema (DME) and examine the evidence for integration of laser and pharmacotherapy.

Methods: A review of the PubMed database was performed using the search terms diabetic retinopathy, diabetic macular edema, neovascularization, laser photocoagulation, intravitreal injection, vascular endothelial growth factor (VEGF), vitrectomy, pars plana vitreous surgery, antiangiogenic therapy. With additional cross-referencing, this yielded 835 publications of which 301 were selected based on content and relevance.

Results: Many recent studies have evaluated the pharmacological, laser and surgical therapeutic strategies for the treatment and prevention of DR and DME. Several newer diagnostic systems such as optical coherence tomography (OCT), microperimetry, and multifocal electroretinography (mfERG) are also assisting in further refinements in the staging and classification of DR and DME. Pharmacological therapies for both DR and DME include both systemic and ocular agents. Systemic agents that promote intensive glycemic control, control of dyslipidemia and antagonists of the renin-angiotensin system demonstrate beneficial effects for both DR and DME. Ocular therapies include anti-VEGF agents, corticosteroids and nonsteroidal anti-inflammatory drugs. Laser therapy, both as panretinal and focal or grid applications continue to be employed in management of DR and DME. Refinements in laser devices have yielded more tissue-sparing (subthreshold) modes in which many of the benefits of conventional continuous wave (CW) lasers can be obtained without the adverse side effects. Recent attempts to lessen the burden of anti-VEGF injections by integrating laser therapy have met with mixed results. Increasingly, vitreoretinal surgical techniques are employed for less advanced stages of DR and DME. The development and use of smaller gauge instrumentation and advanced anesthesia agents have been associated with a trend toward earlier surgical intervention for diabetic retinopathy. Several novel drug delivery strategies are currently being examined with the goal of decreasing the therapeutic burden of monthly intravitreal injections. These fall into one of the five categories: non-biodegradable polymeric drug delivery systems, biodegradable polymeric drug delivery systems, nanoparticle-based drug delivery systems, ocular injection devices and with sustained release refillable devices. At present, there remains no one single strategy for the management of the particular stages of DR and DME as there are many options that have not been rigorously tested through large, randomized, controlled clinical trials.

Conclusion: Pharmacotherapy, both ocular and systemic, will be the primary mode of intervention in the management of DR and DME in many cases when cost and treatment burden are less constrained. Conventional laser therapy has become a secondary intervention in these instances, but remains a first-line option when cost and treatment burden are more constrained. Results with subthreshold laser appear promising but will require more rigorous study to establish its role as adjunctive therapy. Evidence to support an optimal integration of the various treatment options is lacking. Central to the widespread adoption of any therapeutic regimen for DR and DME is substantiation of safety, efficacy, and cost-effectiveness by a body of sound clinical trials.
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http://dx.doi.org/10.2147/OPTH.S236637DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7061411PMC
March 2020

In vitro Susceptibilities of Methicillin-Susceptible and Resistant Staphylococci to Traditional Antibiotics Compared to a Novel Fluoroquinolone.

J Ophthalmic Inflamm Infect 2020 Feb 27;10(1). Epub 2020 Feb 27.

Department of Ophthalmology, Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, Miami, FL, USA.

Background: To assess the in-vitro efficacy of delafloxacin, a new fourth generation fluoroquinolone, against Staphylococcus vitreous isolates from patients with clinically diagnosed endophthalmitis. This is the first investigation of delafloxacin in ocular tissues.

Methods: Intravitreal isolates of culture-proven S. aureus and S. epidermidis were identified between 2014 and 2018. Minimum inhibitor concentrations (MIC) were determined using ETEST strips. The antibiotic susceptibilities were tested against a panel of drugs including glycopeptides such as vancomycin, as well as traditional and newer fluoroquinolones (levofloxacin, moxifloxacin, and delafloxacin).

Results: Of 45 total isolates identified between 2014 and 2018, 13% (6) were methicillin-resistant S. aureus (MRSA), 9% (4) were methicillin-sensitive S. aureus (MSSA), 53% (24) were methicillin-resistant S. epidermidis (MRSE), and 24% (11) were methicillin-sensitive S. epidermidis (MSSE). Among the fluoroquinolones, resistance rates were 61% for levofloxacin, 50% for moxifloxacin, and 12% for delafloxacin. Inter-class comparisons between delafloxacin and the two other fluoroquinolones demonstrated higher Gram-positive susceptibility to delafloxacin (p < 0.01). MIC90 values were lowest for delafloxacin (1.0 μg/mL) compared to levofloxacin (8.0 μg/mL) and moxifloxacin (8.0 μg/mL). Vancomycin was 100% effective against all isolates with MIC90 value of 0.75 μg/mL.

Conclusion: Compared to levofloxacin and moxifloxacin, the newer fluoroquinolone delafloxacin demonstrated the lowest MICs values and lowest rates of resistance for Gram-positive in-vitro S. epidermidis and S. aureus vitreous isolates.
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http://dx.doi.org/10.1186/s12348-020-0200-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7044395PMC
February 2020

Anti-Vascular Endothelial Growth Factor Therapy for Choroidal Rupture-Associated Choroidal Neovascularization.

Ophthalmol Retina 2020 02 21;4(2):226-228. Epub 2019 Sep 21.

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami, Miller School of Medicine, Miami, Florida. Electronic address:

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http://dx.doi.org/10.1016/j.oret.2019.09.008DOI Listing
February 2020