Acta Ophthalmologica 2015
and thinning of the cornea. In one patient, the anterior chamber was absent with the iris agglutinated to the corneal endothelium and the lens capsule agglutinated to the posterior iris (Fig. 1B). Ciliary body inflammation was noted in most cases whereas the retina was preserved with normal histological features. All cases took place over a time period of 23 months and they all had a relationship to the drug environment in Copenhagen. Ammonium hydroxide can be used by drug addicts in the preparation of cocaine for smoking or intravenous drug abuse and at the time of the assaults it was readily available for purchase in kiosks in the geographical area of Copenhagen associated with drug abuse. This case series of serious eye injuries lead to a concerted action by ophthalmologists, social workers and police authorities. Ammonium hydroxide can be substituted by baking powder containing sodium bicarbonate (NaHCO3) and an acid salt. For a long period, baking powder was distributed free of charge among drug abusers. Furthermore, court conviction and imprisonment of the assailants has probably led to increased awareness that the consequences of using ammoniumhydroxide as an assault weapon are severe. No further assaults with ammonium hydroxide eye injuries were seen for the next 18 months showing that severe eye injuries can be prevented by simple measures.
References Brodovsky SC, McCarty CA, Snibson G, Loughnan M, Sullivan L, Daniell M & Taylor HR (2000): Management of alkali burns: an 11-year retrospective review. Ophthalmology 107: 1829–1835. Paterson CA, Pfister RR & Levinson RA (1975): Aqueous humor pH changes after experimental alkali burns. Am J Ophthalmol 79: 414–419. Roper-Hall MJ (1965): Thermal and chemical burns. Trans Ophthalmol Soc U K 85: 631– 653. Saini JS & Sharma A (1993): Ocular chemical burns–clinical and demographic profile. Burns 19: 67–69.
Correspondence: Line Kessel Department of Ophthalmology Copenhagen University Hospital Glostrup Nordre Ringvej 57 DK-2600 Glostrup
Denmark Tel: +45 3863 4700 Fax: +45 3863 4669 Email: [email protected] Line Kessel received a grant from the Danish Medical Research Agency.
Assessment of ocular pain following ranibizumab intravitreal injection Nathalie Massamba, Maud Elluard, Wassila Agoune, Vincent Guyader, April Ingram, Bernard Pasquier and Juliette Knoeri Department of Ophthalmology, Centre Hospitalier de Cergy Pontoise, Cergy, France doi: 10.1111/aos.12531
Editor, he current standard of care for neovascular age related macular degeneration (AMD) is anti-VEGF therapy delivered by intravitreal (IVT) injection, which is generally safe and well tolerated. IVT injection proce-
T
dures have been studied and standardized to minimize the risk of complications. Within the literature, there appears to be no agreement on the best anaesthetic and post-injection protocol to minimize ocular pain, although the trend seems to be towards topical anaesthesia because it is safe and cost-effective (Sanabria et al. 2013). Recently, Moisseiev et al. (2012) reported on ocular pain after IVT of bevacizumab. Their findings suggest a trend that indicated that less pain was associated with injections performed in the lower left quadrant (Moisseiev et al. 2012). Our prospective, interventional case series evaluated pain related to IVT injection of 0.5 mg/0.05 ml ranibizumab, in a cohort of patients with exudative AMD (n = 54) or cystoid macular edema (CME) secondary to diabetic retinopathy (n = 49) or retinal vein occlusion (RVO) (n = 9), and correlated their pain score with age, gender, frequency of IVT, previous cataract surgery, the location and timing of IVT (Table 1). After receiving ethics review board approval, 112 of 112 patients were enrolled between May and September 2013 at Cergy Hospital. Patients were
Table 1. Patient characteristics and relationship between pain score (VAS) and studied variables. Variable Gender Male, n = 63 (56%) Female, n = 59 (44%) Age Mean 72.3 (range 51–91) No. IVT injections 1–3 Mean 4.19 (range 1–13) 4–6 >6 Phakic Yes, n = 57 (50.9%) No Eye Right Left, n = 56 (50%) Location IVT injection Superior temporal quadrant (n = 64) Inferior temporal quadrant (n = 48) Time to IVT injection Grp 1: 45 min (n = 37) Ophthalmologist NM JK
Pain score (mean, SD)
p-value
1.82 2.29 1.74 2.27
0.98
1.78 2.26
0.76
2.06 2.46
0.24
1.67 2.14 1.30 1.92 1.74 2.22 1.81 2.33
0.89
1.41 2.06 2.14 2.41
0.05*
1.35 1.82 2.33 2.06
0.04*
1.54 1.96 1.74 2.06 2.06 2.74
0.74
1.81 2.29 1.65 2.18
0.39
IVT, intravitreal. *Statistically significant values ≤ 0.05.
e231
Acta Ophthalmologica 2015 excluded if they had refractive error >6 dioptres; choroidal neovascularization (CNV) attributable to active intraocular inflammation or any other retinopathy; ocular pain prior to procedure or IVT injection contraindication. Ranibizumab IVT injection was performed according to a standardized technique. One ophthalmologist (NM) injected 80 patients during 11 sessions, and a second ophthalmologist (JK) injected 32 eyes during three sessions. All injections were evaluated by the same observer (ME) to reduce bias. Both injectors were right-handed and were positioned temporally. Prior to IVT injection, patients received two sets of 0.5% tetracaine topical anaesthetic drops, 10 min apart, as per Haute autorite de la Sante guidelines. Ranibizumab was injected into the vitreous cavity via a 29-gauge needle inserted through the pars plana 3.5 mm from the limbus in aphakic/ pseudophakic patients and 4.0 mm in phakic patients. Patient reported pain was evaluated immediately after the injection and scored according to a modified Visual Analog Scale Score (VAS) (0 = no pain; 10 = worst imaginable pain). To compare wait times, patients were divided into groups according to the time elapsed between their arrival and time of injection; 45 min. All patient demographic and baseline information, as well as, outcome measurement data were entered into Excel (Microsoft Corp., Redmond, WA, USA) tables from which descriptive statistics were generated. Statistical analyses were performed using R Core Team (R Foundation for Statistical Computing, Vienna, Austria). Chisquare tests were used to compare groups relative to nominal variables such as gender and eye. Because the pain scores are ordinal, the Kruskal– Wallis test was used to compare the responses across groups. Significance level was set at 0.05 for these tests. Greater pain scores were associated with injections in the left eye (p = 0.04), as well as, in the temporal superior quadrant (p = 0.01). Variables not significantly correlated to pain included: Age (p = 0.76), gender (p = 0.98), number of previous injections (p = 0.24), waiting time (p = 0.74) and history of cataract surgery (p = 0.89). Pain following IVT injection has been assessed as an outcome in previous
e232
studies, including Knip & V€ alim€ aki (2012), who found no significant difference in pain scores for patients given prophylactic anterior chamber paracentesis prior to IVT pegaptanib injections. An eyelid speculum was used in all our patients, which Mendez et al. (2013) found increased the likelihood of patient reporting higher levels of discomfort, but did not demonstrate statistical significance in that regard. All of our injections were performed using a 29-gauge needle, as has been previously noted to cause patients less pain than 26- or 27-gauge needles (Rodrigues 2011). Contrary to our hypothesized impressions, there was no difference in the perceived pain in men compared with women, young and older patients feel and perceive pain equally and those patients that had undergone previous cataract surgery did not perceive and less intense pain due to their previous surgical experiences. Patients that had received the greater number of IVT treatments tended to report less pain than those patients who had fewer injections, equivalent to a declining rate for each additional IVT injection of 0.18 on the 10-point scale of pain; however, this result was not significant (p = 0.24). We hypothesized that patients who have undergone repeated injections may become accustomed to the treatment and therefore report less pain, corroborating with the previous work published by Moisseiev et al. (2012). We found that our patients experienced significantly less pain in their right eye, 1.24 points less out 10, and can only hypothesize that, because the injector was right-handed, this result may be related to injection dexterity. We recognize that our study had several limitations, particularly due to the complexity of each patient’s individualized definition and quantification of pain. We feel that future additional studies with a large patient sample, multiple injectors, consideration of co-medications and intra-ocular pressure variations, longer follow-up, and analysis according to advanced forms of AMD would be helpful.
References Knip MM & Va¨lima¨ki J (2012): Effects of pegaptanib injections on intraocular pres-
sure with and without anterior chamber paracentesis: a prospective study. Acta Ophthalmol 90: 254–258. Mendez PC, Va´zquez CM, Villar JO & Pazos JA (2013): Assessment of the use of the speculum for intravitreal injections of antiVEGF. Acta Ophthalmol 91: e244–e246. Moisseiev E, Regenbogen M, Bartfeld Y & Barak A (2012): Evaluation of pain in intravitreal bevacizumab injections. Curr Eye Res 37: 813–817. Rodrigues EB, Grumann A Jr, Penha FM et al. (2011): Effect of needle type and injection technique on pain level and vitreal reflux in intravitreal injection. J Ocul Pharmacol Ther 27: 197–203. Sanabria MR, Montero JA, Losada MV, Ferna´ndez-Mu~ noz M, Galindo A, Ferna´ndez I, Coco RM & Sampedro A (2013): Ocular pain after intravitreal injection. Curr Eye Res 38: 278–282.
Correspondence: Nathalie Massamba, MD Department of Ophthalmology Centre Hospitalier de Cergy Pontoise 6 Avenue de Charles de Gaulles 95303 Cergy, France Tel: +33 1 30 75 71 82 Fax: +33 1 30 75 59 47 Email: [email protected]
Anterior segment optical coherence tomography in autosomal recessive cornea plana Elina Rantala and Anna Majander Helsinki University Eye Hospital, Helsinki, Finland doi: 10.1111/aos.12533
Editor, utosomal recessive cornea plana (ARCP) (CNA2, MIM 217300) is a rare hereditary developmental anomaly characterized by a central corneal opacity, slight microcornea, a widened limbal zone, a shallow anterior chamber, low corneal refractive power and hyperopia (Forsius et al. 1998). ARCP has been linked to missense mutations in KERA gene (Pellegata et al. 2000) encoding a cornea-specific proteoglycan, keratocan (Liu et al. 2003). ARCP is a rare
A
Copyright of Acta Ophthalmologica (1755375X) is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
and thinning of the cornea. In one patient, the anterior chamber was absent with the iris agglutinated to the corneal endothelium and the lens capsule agglutinated to the posterior iris (Fig. 1B). Ciliary body inflammation was noted in most cases whereas the retina was preserved with normal histological features. All cases took place over a time period of 23 months and they all had a relationship to the drug environment in Copenhagen. Ammonium hydroxide can be used by drug addicts in the preparation of cocaine for smoking or intravenous drug abuse and at the time of the assaults it was readily available for purchase in kiosks in the geographical area of Copenhagen associated with drug abuse. This case series of serious eye injuries lead to a concerted action by ophthalmologists, social workers and police authorities. Ammonium hydroxide can be substituted by baking powder containing sodium bicarbonate (NaHCO3) and an acid salt. For a long period, baking powder was distributed free of charge among drug abusers. Furthermore, court conviction and imprisonment of the assailants has probably led to increased awareness that the consequences of using ammoniumhydroxide as an assault weapon are severe. No further assaults with ammonium hydroxide eye injuries were seen for the next 18 months showing that severe eye injuries can be prevented by simple measures.
References Brodovsky SC, McCarty CA, Snibson G, Loughnan M, Sullivan L, Daniell M & Taylor HR (2000): Management of alkali burns: an 11-year retrospective review. Ophthalmology 107: 1829–1835. Paterson CA, Pfister RR & Levinson RA (1975): Aqueous humor pH changes after experimental alkali burns. Am J Ophthalmol 79: 414–419. Roper-Hall MJ (1965): Thermal and chemical burns. Trans Ophthalmol Soc U K 85: 631– 653. Saini JS & Sharma A (1993): Ocular chemical burns–clinical and demographic profile. Burns 19: 67–69.
Correspondence: Line Kessel Department of Ophthalmology Copenhagen University Hospital Glostrup Nordre Ringvej 57 DK-2600 Glostrup
Denmark Tel: +45 3863 4700 Fax: +45 3863 4669 Email: [email protected] Line Kessel received a grant from the Danish Medical Research Agency.
Assessment of ocular pain following ranibizumab intravitreal injection Nathalie Massamba, Maud Elluard, Wassila Agoune, Vincent Guyader, April Ingram, Bernard Pasquier and Juliette Knoeri Department of Ophthalmology, Centre Hospitalier de Cergy Pontoise, Cergy, France doi: 10.1111/aos.12531
Editor, he current standard of care for neovascular age related macular degeneration (AMD) is anti-VEGF therapy delivered by intravitreal (IVT) injection, which is generally safe and well tolerated. IVT injection proce-
T
dures have been studied and standardized to minimize the risk of complications. Within the literature, there appears to be no agreement on the best anaesthetic and post-injection protocol to minimize ocular pain, although the trend seems to be towards topical anaesthesia because it is safe and cost-effective (Sanabria et al. 2013). Recently, Moisseiev et al. (2012) reported on ocular pain after IVT of bevacizumab. Their findings suggest a trend that indicated that less pain was associated with injections performed in the lower left quadrant (Moisseiev et al. 2012). Our prospective, interventional case series evaluated pain related to IVT injection of 0.5 mg/0.05 ml ranibizumab, in a cohort of patients with exudative AMD (n = 54) or cystoid macular edema (CME) secondary to diabetic retinopathy (n = 49) or retinal vein occlusion (RVO) (n = 9), and correlated their pain score with age, gender, frequency of IVT, previous cataract surgery, the location and timing of IVT (Table 1). After receiving ethics review board approval, 112 of 112 patients were enrolled between May and September 2013 at Cergy Hospital. Patients were
Table 1. Patient characteristics and relationship between pain score (VAS) and studied variables. Variable Gender Male, n = 63 (56%) Female, n = 59 (44%) Age Mean 72.3 (range 51–91) No. IVT injections 1–3 Mean 4.19 (range 1–13) 4–6 >6 Phakic Yes, n = 57 (50.9%) No Eye Right Left, n = 56 (50%) Location IVT injection Superior temporal quadrant (n = 64) Inferior temporal quadrant (n = 48) Time to IVT injection Grp 1: 45 min (n = 37) Ophthalmologist NM JK
Pain score (mean, SD)
p-value
1.82 2.29 1.74 2.27
0.98
1.78 2.26
0.76
2.06 2.46
0.24
1.67 2.14 1.30 1.92 1.74 2.22 1.81 2.33
0.89
1.41 2.06 2.14 2.41
0.05*
1.35 1.82 2.33 2.06
0.04*
1.54 1.96 1.74 2.06 2.06 2.74
0.74
1.81 2.29 1.65 2.18
0.39
IVT, intravitreal. *Statistically significant values ≤ 0.05.
e231
Acta Ophthalmologica 2015 excluded if they had refractive error >6 dioptres; choroidal neovascularization (CNV) attributable to active intraocular inflammation or any other retinopathy; ocular pain prior to procedure or IVT injection contraindication. Ranibizumab IVT injection was performed according to a standardized technique. One ophthalmologist (NM) injected 80 patients during 11 sessions, and a second ophthalmologist (JK) injected 32 eyes during three sessions. All injections were evaluated by the same observer (ME) to reduce bias. Both injectors were right-handed and were positioned temporally. Prior to IVT injection, patients received two sets of 0.5% tetracaine topical anaesthetic drops, 10 min apart, as per Haute autorite de la Sante guidelines. Ranibizumab was injected into the vitreous cavity via a 29-gauge needle inserted through the pars plana 3.5 mm from the limbus in aphakic/ pseudophakic patients and 4.0 mm in phakic patients. Patient reported pain was evaluated immediately after the injection and scored according to a modified Visual Analog Scale Score (VAS) (0 = no pain; 10 = worst imaginable pain). To compare wait times, patients were divided into groups according to the time elapsed between their arrival and time of injection; 45 min. All patient demographic and baseline information, as well as, outcome measurement data were entered into Excel (Microsoft Corp., Redmond, WA, USA) tables from which descriptive statistics were generated. Statistical analyses were performed using R Core Team (R Foundation for Statistical Computing, Vienna, Austria). Chisquare tests were used to compare groups relative to nominal variables such as gender and eye. Because the pain scores are ordinal, the Kruskal– Wallis test was used to compare the responses across groups. Significance level was set at 0.05 for these tests. Greater pain scores were associated with injections in the left eye (p = 0.04), as well as, in the temporal superior quadrant (p = 0.01). Variables not significantly correlated to pain included: Age (p = 0.76), gender (p = 0.98), number of previous injections (p = 0.24), waiting time (p = 0.74) and history of cataract surgery (p = 0.89). Pain following IVT injection has been assessed as an outcome in previous
e232
studies, including Knip & V€ alim€ aki (2012), who found no significant difference in pain scores for patients given prophylactic anterior chamber paracentesis prior to IVT pegaptanib injections. An eyelid speculum was used in all our patients, which Mendez et al. (2013) found increased the likelihood of patient reporting higher levels of discomfort, but did not demonstrate statistical significance in that regard. All of our injections were performed using a 29-gauge needle, as has been previously noted to cause patients less pain than 26- or 27-gauge needles (Rodrigues 2011). Contrary to our hypothesized impressions, there was no difference in the perceived pain in men compared with women, young and older patients feel and perceive pain equally and those patients that had undergone previous cataract surgery did not perceive and less intense pain due to their previous surgical experiences. Patients that had received the greater number of IVT treatments tended to report less pain than those patients who had fewer injections, equivalent to a declining rate for each additional IVT injection of 0.18 on the 10-point scale of pain; however, this result was not significant (p = 0.24). We hypothesized that patients who have undergone repeated injections may become accustomed to the treatment and therefore report less pain, corroborating with the previous work published by Moisseiev et al. (2012). We found that our patients experienced significantly less pain in their right eye, 1.24 points less out 10, and can only hypothesize that, because the injector was right-handed, this result may be related to injection dexterity. We recognize that our study had several limitations, particularly due to the complexity of each patient’s individualized definition and quantification of pain. We feel that future additional studies with a large patient sample, multiple injectors, consideration of co-medications and intra-ocular pressure variations, longer follow-up, and analysis according to advanced forms of AMD would be helpful.
References Knip MM & Va¨lima¨ki J (2012): Effects of pegaptanib injections on intraocular pres-
sure with and without anterior chamber paracentesis: a prospective study. Acta Ophthalmol 90: 254–258. Mendez PC, Va´zquez CM, Villar JO & Pazos JA (2013): Assessment of the use of the speculum for intravitreal injections of antiVEGF. Acta Ophthalmol 91: e244–e246. Moisseiev E, Regenbogen M, Bartfeld Y & Barak A (2012): Evaluation of pain in intravitreal bevacizumab injections. Curr Eye Res 37: 813–817. Rodrigues EB, Grumann A Jr, Penha FM et al. (2011): Effect of needle type and injection technique on pain level and vitreal reflux in intravitreal injection. J Ocul Pharmacol Ther 27: 197–203. Sanabria MR, Montero JA, Losada MV, Ferna´ndez-Mu~ noz M, Galindo A, Ferna´ndez I, Coco RM & Sampedro A (2013): Ocular pain after intravitreal injection. Curr Eye Res 38: 278–282.
Correspondence: Nathalie Massamba, MD Department of Ophthalmology Centre Hospitalier de Cergy Pontoise 6 Avenue de Charles de Gaulles 95303 Cergy, France Tel: +33 1 30 75 71 82 Fax: +33 1 30 75 59 47 Email: [email protected]
Anterior segment optical coherence tomography in autosomal recessive cornea plana Elina Rantala and Anna Majander Helsinki University Eye Hospital, Helsinki, Finland doi: 10.1111/aos.12533
Editor, utosomal recessive cornea plana (ARCP) (CNA2, MIM 217300) is a rare hereditary developmental anomaly characterized by a central corneal opacity, slight microcornea, a widened limbal zone, a shallow anterior chamber, low corneal refractive power and hyperopia (Forsius et al. 1998). ARCP has been linked to missense mutations in KERA gene (Pellegata et al. 2000) encoding a cornea-specific proteoglycan, keratocan (Liu et al. 2003). ARCP is a rare
A
Copyright of Acta Ophthalmologica (1755375X) is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
