Areas Of Retinal Capillary Nonperfusion Research Articles

Study of Nonperfusion Area Changes after Ranibizumab Intravitreal Injection for Diabetic Macular Edema by Means of Widefield OCT Angiography

Introduction: The aim of this study was to evaluate changes in retinal capillary nonperfusion areas (RCNPA) and the retinal capillary vessel density (RCVD) of the superficial capillary plexus (SCP) and deep capillary plexus (DCP) using widefield optical coherence tomography angiography (WFOCTA) in patients with diabetic retinopathy (DR) and diabetic macular edema (DME) treated with intravitreal ranibizumab injection (IRI). Materials and Methods: Twenty-four eyes of 24 patients with DR and DME candidates to a loading dose of IRI were enrolled. All patients underwent WFOCTA with the PLEX Elite 9000 device with 15 × 9 mm scans centered on the foveal center at baseline (T0) and 1 month after each intravitreal injection at 30 days (T1), 60 days (T2), and 90 days (T3). In all patients, the variation of RCNPA and the RCVD of the SCP and DCP were calculated using automatic software written in MATLAB (MathWorks, Natick, MA, USA). Results: The SCP showed a significant longitudinal variation of RCNPA (p = 0.04). Post hoc analysis revealed a statistically significant reduction of RCNPA at T1 (p = 0.04) and a nonsignificant reduction at T2 (p = 0.18) and T3 (p = 0.96). The DCP showed longitudinal changes in the RCNPA that tended to statistical significance (p = 0.09). Post hoc analysis revealed a trend toward a statistically significant reduction of RCNPA at T3 (p = 0.09) not statistically significant at T1 (p = 0.17) and T2 (p = 0.75). The RCVD of SCP and DCP showed no significant changes at any of the time points. Conclusions: WFOCTA showed a decrease in RCNPA after IRI, probably related to the reperfusion of retinal capillaries.

Возможности и перспективы лечения хронической ишемической ретинопатии, ассоциированной с гемодинамически значимым стенозом внутренней сонной артерии

Purpose . In prospective research to assess clinical efficacy of different surgical treatments for patients with chronic ocular ischemic syndrome (COIS) associated with hemodynamically significant internal carotid artery stenosis (ICAS). Material and methods . The research included 20 patients with 3rd degree severity COIS. Patients were divided into 3 groups due to type of their treatment. 1st group – 7 patients; only carotid endarterectomy (CE) of ICAS was performed; 2nd group – 6 patients; panretinal photocoagulation (PRP) of retina was performed; 3rd group – 7 patients; combined treatment: PRP of retinal capillary non-perfusion areas was performed by the 1st stage, then after 2 weeks by the 2nd stage CE was performed. All patients underwent standard and specialized ophthalmologic examination methods. Assessment of blood flow in brachiocephalic vessels, vessels of eye was performed by ultrasound scan, spiral computed tomography, fundus fluorescein angiography. Results . Monitoring of groups of patients for 1 year depending on type of treatment of COIS, allowed us to determine tactics of patients management and features of the postoperative period. CE at hemodynamically significant ICAS caused positive dynamic in intraocular blood flow, which contributed to improvement and preservation of best corrected visual acuity in 71% of patients; preventive PRP of retina, before performing reconstructive surgery of ICAS, optimized and reduced the time of visual recovery. PRP of retina as independent method of treatment of COIS, complicated by neovascular glaucoma, caused full or partial regression of neovascularization in iris, which increased possibilities of its effective treatment. Conclusion . Combined staged treatment of COIS associated with hemodynamically significant stenosis, which including PRP of retina and CE of ICAS, allows to stop the progression of ischemia in retina and to avoid complications, leading to loss of vision, and can be recommended for use in clinical practice for the treatment of COIS. PRP of retina can be use to stabilize process at impossible to perfomed CE. Surgical reconstruction of the ICAS, despite restoration of blood flow in ophthalmic artery, can aggravate processes of ischemic damage to the neurosensory layer of the retina with decreased vision.

A Custom-Made Semiautomatic Analysis of Retinal Nonperfusion Areas After Dexamethasone for Diabetic Macular Edema.

PurposeTo evaluate the changes of retinal capillary nonperfusion areas and retinal capillary vessel density of the superficial capillary plexus (SCP) and deep capillary plexus in patients with diabetes with diabetic macular edema treated with an intravitreal dexamethasone implant (IDI).MethodsWe enrolled 28 patients with diabetic retinopathy and diabetic macular edema candidates to IDI. All patients underwent widefield optical coherence tomography angiography with PLEX Elite 9000 device with 15 × 9 mm scans centered on the foveal center at baseline, 1 month, 2 months, and 4 months after IDI. In all the patients, the variation of the retinal capillary nonperfusion areas and of the retinal vessel density of the SCP and deep capillary plexus were calculated using an automatic software written in Matlab (MathWorks, Natick, MA).ResultsDuring follow-up, SCP showed a statistically significant reduction of ischemic areas at 1 month after IDI (P = 0.04) and slightly increased not significantly thereafter (P = 0.15). The percentage of nonperfusion areas changed from 11.4% at baseline, to 6.3% at 1 month, 8.1%, at 2 months, and 10.2% at 4 months. The whole vessel density of SCP slightly increased (not significantly) from 35.30% at baseline to 38.00% at 1 month, and then decreased to 37.85% at 2 months and 36.04% at 4 months (P = 0.29). Retinal capillary nonperfusion areas and retinal vessel density at the deep capillary plexus did not change significantly (P = 0.31 and P = 0.73, respectively).ConclusionsWidefield optical coherence tomography angiography showed a decrease in retinal capillary nonperfusion areas after dexamethasone implant suggesting a possible drug-related reperfusion of retinal capillaries particularly evident in the early period.Translational RelevanceA custom-made automatic analysis of retinal nonperfusion areas may allow a better and precise evaluation of ischemic changes after intravitreal therapy.

Analysis of Differentiated Approach Effectiveness in Patients with Varying Degrees of Severity of Chronic Ocular Ischemic Syndrome Caused by Internal Carotid Artery Stenosis

Purpose: to study the effect of differentiated treatment approach in patients with varying degrees of severity chronic ocular ischemic syndrome (OIS) on clinical course of disease and hemodynamics of eyes in prospective research.Patients and methods. The research included 20 patients with chronic OIS. Patients were divided into 4 groups due to severity of chronic OIS and type of treatment. 1st group — 7 patients with moderate severity chronic OIS and hemodynamically significant of internal carotid artery stenosis (ICAS); only carotid endarterectomy (CE) of ICAS was performed. 2nd group — 6 patients with severe degree chronic OIS and hemodynamically significant stenosis of ICAS; 2 weeks before CE, panretinal photocoagulation (PRP) of retinal capillary non-perfusion areas was performed. 3rd group — 4 patients with severe degree chronic OIS, complicated by rubeosis iris and increased IOP on hypotensive regimen, on the background of hemodynamically insignificant ICAS; PRP of retina was performed. 4th group — 3 patients with moderate severity chronic OIS with hemodynamically insignificant ICAS; course of neuroprotective therapy was performed. All patients underwent standard and specialized ophthalmologic examination methods. Assessment of blood flow in brachiocephalic vessels, eye vessels was performed by ultrasound scan, spiral computed tomography, OCT-angiography with the AngioVue.Results. Monitoring of patients’ groups for 1 year after chronic OIS treatment allowed us to determine tactics of patient management depending on degree of ICAS and severity of chronic OIS. Reconstructive surgery at hemodynamically significant ICAS caused positive dynamic in intraocular blood flow, which contributed to improvement and preservation of BCVA in 71 % of patients. Preventive PRP of retina, before performing reconstructive surgery of ICAS, optimized and reduced the time of visual recovery. PRP of retina as independent method of treatment of chronic OIS, complicated by neovascular glaucoma, caused full or partial regression of neovascularization in iris, which increased possibilities of its effective treatment. Neuroprotective pharmacotherapy in early stages of chronic OIS, in absence of indications for reconstructive surgery and PRP of retina, improved the prognosis for patients’ vision.Conclusion. Differentiated treatment approach in patients with chronic OIS, due to changes of hemodynamics of internal carotid artery, has improved indexes of hemodynamic and visual acuity.

Targeted Retinal Photocoagulation for Diabetic Macular Edema with Peripheral Retinal Nonperfusion: Three-Year Randomized DAVE Trial

To evaluate the effect of targeted retinal photocoagulation (TRP) on visual and anatomic outcomes and treatment burden in eyes with diabetic macular edema (DME). Phase I/II prospective, randomized, controlled clinical trial. Forty eyes of 29 patients with center-involved macular edema secondary to diabetes mellitus. Eyes with center-involved DME and Early Treatment Diabetic Retinopathy Study (ETDRS) best-corrected visual acuity (BCVA) between 20/32 and 20/320 (Snellen equivalent) were randomized 1:1 to monotherapy with 0.3 mg ranibizumab (Lucentis, Genentech, South San Francisco, CA) or combination therapy with 0.3 mg ranibizumab and TRP guided by widefield fluorescein angiography. All eyes received 4 monthly ranibizumab injections followed by monthly examinations and pro re nata (PRN) re-treatment through 36 months. Targeted retinal photocoagulation was administered outside the macula to areas of retinal capillary nonperfusion plus a 1-disc area margin in the combination therapy arm at week 1, with re-treatment at months 6, 18, and 25, if indicated. Mean change in ETDRS BCVA from baseline and number of intravitreal injections administered. At baseline, mean age was 55 years, mean BCVA was 20/63 (Snellen equivalent), and mean central retinal subfield thickness (CRT) was 530 μm. Thirty-four eyes (85%) completed month 36, at which point mean BCVA improved 13.9 and 8.2 letters (P= 0.20) and mean CRT improved 302 and 152 μm (P= 0.03) in the monotherapy and combination therapy arms, respectively. The mean number of injections administered through month 36 was 24.4 (range, 10-34) and 27.1 (range, 12-36), with 73% (362/496) and 80% (433/538) of PRN injections administered (P= 0.004) in the monotherapy and combination therapy arms, respectively. Goldmann visual field isopter III-4e area decreased by 2% and 18% in the monotherapy and combination therapy arms, respectively (P= 0.30). In this 3-year randomized trial of 40 eyes with DME, there was no evidence that combination therapy with ranibizumab and TRP improved visual outcomes or reduced treatment burden compared with ranibizumab alone.

CORRELATION BETWEEN CYSTOID SPACES IN CHRONIC DIABETIC MACULAR EDEMA AND CAPILLARY NONPERFUSION DETECTED BY OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY.

To study the relationship between the location of cystoid spaces and retinal capillary nonperfusion areas in diabetic cystoid macular edema (DCME). In this retrospective study, 24 eyes of 21 patients with chronic DCME were followed using optical coherence tomography angiography. The capillary density of the superficial capillary plexus and deep capillary plexus was measured using AngioAnalytics software in all DCME eyes and in 20 healthy controls. Diabetic cystoid macular edema improved spontaneously or after treatment in 11 eyes. The intraretinal cystoid spaces were surrounded by capillary-flow void areas in the superficial capillary plexus in 71% of cases and in the deep capillary plexus in 96% of cases. The deep capillary plexus had lost its regular pattern in all cases. The capillary density was decreased in both plexus (mean decrease of -23.0% in the superficial capillary plexus and -12.4% in the deep capillary plexus vs. normal). In the 11 cases with DCME resolution, the capillary did not reperfuse in areas of resolved cystoid spaces, and the capillary density did not change significantly. In chronic DCME, cystoid spaces were located within capillary dropout areas. No reperfusion occurred after DCME resolution. The impact of the severity of this nonperfusion on the risk of recurrence of DCME remains to be clarified.

Retinal vascular nonperfusion in siblings with Dandy-Walker variant

We report the case of a 2-month-old girl with Dandy-Walker variant who presented with strabismus, pathologic myopia measuring -16.00 D in each eye, diffuse chorioretinal atrophy and pigment mottling in the macula of both eyes, and areas of retinal capillary nonperfusion in both eyes. The patient's brother also has Dandy-Walker variant and was found to have bilateral severe myopia, myopic fundi, tilted optic disks with peripapillary atrophy, extensive areas of white without pressure, areas of lattice degeneration, and several chronic-appearing atrophic retinal holes surrounded by pigmentation. We hypothesize that children with Dandy-Walker variant may present with refractive errors such as pathologic myopia and with diverse retinal findings, including retinal ischemia. A lower threshold for ophthalmologic examination may be considered in this population.

Ultra Wide Field Fluorescein Angiography Guided Targeted Retinal Photocoagulation (TRP)

We report two cases in which ultra wide field fluorescein angiography was used to direct targeted retinal photocoagulation (TRP) to areas of retinal capillary non-perfusion in an attempt to cause regression of diabetic neovascularization. By providing up to a 200 degree field of view, accurate delineation of retinal capillary non-perfusion and precise application of photocoagulation was possible. The application of TRP successfully led to the regression of the retinal neovascularization in our patients. Complications of conventional panretinal photocoagulation (PRP) such as visual field loss and macular edema may have been avoided. When TRP is used in conjunction with ultra wide field fluorescein angiography, preservation of functional retina may be possible while minimizing the amount of laser treatment that is applied to the retina.

Ocular neovascularization in a patient with Fanconi anemia

Case report: An 11-year-old girl diagnosed with Fanconi anemia was referred to us for redness and pain in her right eye. Findings in the right eye included visual acuity of counting fingers, neovascular glaucoma, vitreous hemorrhage, optic disc neovascularization, and features of peripheral ischemic retinopathy. Findings in the left eye included peripheral retinal neovascularization and areas of retinal capillary nonperfusion. Comments: Patients with Fanconi anemia may develop ocular neovascularization with subsequent severe visual loss due to vitreous hemorrhage or neovascular glaucoma. Regular ophthalmic examination, including ophthalmoscopy and fluorescein angiography in selected cases, is recommended in such patients.

Ocular structure and function in an aged monkey with spontaneous diabetes mellitus

Diabetes mellitus develops spontaneously in middle-aged, obese rhesus monkeys, thus making them a good model for examining the effects of co-morbid factors on the development of end-organ damage. Changes in structure and function in the eyes of one monkey who spontaneously developed type 2 diabetes are reported here. This animal had concomitant hypertension, high levels of triglycerides and serum cholesterol, and a low fraction of high-density lipoprotein. The eyes showed intraretinal hemorrhages and large areas of retinal capillary nonperfusion. Indo-cyanin green (ICG) angiography revealed a large area of non- or poorly perfused choriocapillaris in one eye, and immunohistochemistry showed loss of viable choriocapillaries in this region. Both basal laminar deposits and hard drusen were present on areas of Bruch's membrane adjacent to nonviable choriocapillaris. Blood flow via the nasal posterior ciliary arteries to this section of choroid was not detectable by color duplex Doppler ultrasound, indicating contribution of extraocular vascular disease to ischemia in this eye. There was a severe decline in number of photoreceptor inner and outer segments, and corresponding reductions in the multifocal electroretinogram (ERG), in the areas of choriocapillaris loss.The ganzfeld ERG indicated loss in both inner and outer retinal function. Much of the ganglion cell layer was absent throughout the retina, possibly reflecting the effect of diabetes as well as chronic open angle glaucoma; the latter diagnosis supported by elevated intraocular pressures and excavated optic disks. In summary, high resolution, enzyme histochemical and histopathological analyses of a diabetic hypertensive monkey retina and choroid after serial functional in vivo analyses have demonstrated the relationship between vascular dysfunction and visual function loss. Choroidal vascular dysfunction in both large and small vessels was associated with age-related macular degeneration-like changes in Bruch's membrane and photoreceptor degeneration.

Optic disk neovascularization in a patient with cytomegalovirus retinitis associated with renal transplantation

PURPOSE: To report the development of optic nerve head neovascularization during the recovery phase of cytomegalovirus (CMV) retinitis in a renal allograft recipient. CASE REPORT: A 46-year-old male renal allograft recipient developed CMV retinitis seven months after transplantation. At the time of the diagnosis, the patient was being immunosuppressed with prednisone, cyclosporine, and azathioprine, and was treated with repeated intravitreal and intravenous ganciclovir. Six weeks after the initiation of therapy, optic disk neovascularization developed. This was confirmed by fluorescein angiography, which showed no areas of retinal capillary nonperfusion. At this stage, active retinal lesions were partially resolved. Apart from intraocular inflammation, no other cause of neovascularization was detected. Over the following six months, optic disk neovascularization regressed spontaneously without causing vitreous hemorrhage or visual loss. There was no recurrence of CMV retinitis during follow-up. CONCLUSION: Optic disk neovascularization may develop in the healing phase of CMV retinitis in renal transplant recipients.

Indocyanine green angiographic findings in nonproliferative diabetic retinopathy

PURPOSE: To report angiographic findings of nonproliferative diabetic retinopathy patients by means of indocyanine green angiography. METHODS: Forty-two eyes (42 patients) with nonproliferative diabetic retinopathy were evaluated by indocyanine green angiography in addition to fluorescein angiography. Angiographic findings with the two imaging techniques were compared with the red-free fundus appearance. RESULTS: Among the 42 eyes, five (12%) had the appearance on indocyanine green angiography of lobular spotty hyperfluorescent and hypofluorescent areas (“salt and pepper” appearance) in the very late phase. Twenty eyes (48%) presented with diffuse late-phase hyperfluorescence on indocyanine green angiography, corresponding to areas of retinal capillary nonperfusion on fluorescein angiography, and retinal edema. A total of 3,564 microaneurysms were divided into three types: 58 (1.6%) appeared mainly on the fluorescein angiography and very faintly on the indocyanine green angiography, 3,029 (85%) appeared on the fluorescein angiography and the indocyanine green angiography, and 477 (13.4%) were uniquely hyperfluorescent on the indocyanine green angiography. CONCLUSIONS: Indocyanine green angiography in patients with nonproliferative diabetic retinopathy disclosed microvascular findings that were in addition to those shown on fluorescein angiography. These angiographic changes were not observed on fluorescein angiography because of imaging limitations. Indocyanine green angiography may be a useful adjunct to fluorescein angiography in the evaluation of chorioretinal vascular changes in nonproliferative diabetic retinopathy.

Photocoagulation for Ischemic Central Retinal Vein Occlusion

There is a difference of opinion in the ophthalmology community regarding whether prophylactic pan retinal photocoagulation should be applied to eyes with ischemic central retinal vein occlusions (CRVOs). Some investigators have recommended panretinal photocoagulation, while others have observed that panretinal photocoagulation is not helpful in preventing ocular neovascularization and neovascular glaucoma. 1-4 Because of the diversity of opinions, the optimum treatment of a patient with ischemic CRVO is uncertain. The Central Vein Occlusion Study (CVOS), a controlled clinical trial, was designed to determine whether prophylactic laser treatment is beneficial; patients are randomized either to undergo panretinal photocoagulation or to be observed without treatment. We believe that such randomization is the best and most ethical approach to the management of ischemic CRVO. Eyes with at least 10 disc areas of retinal capillary nonperfusion, as established by the CVOS photographic protocol, are randomized to panretinal photocoagulation or observation. Both groups are being

Experience With Photocoagulation in Behçet's Disease

Between 1973 and 1987 we examined both eyes of 300 patients with the uveoretinitis-type lesions characteristic of Behçet's disease. Of the 556 eyes whose fundus could be examined, 38 eyes (6.8%) in 33 patients (11%) had developed retinal capillary nonperfusion, branch retinal vein occlusion, or retinal or disc neovascularization. These eyes were treated by photocoagulation, primarily to forestall vitreous hemorrhage and the development of neovascular glaucoma, as well as to decrease the macular edema resulting from vein occlusion. The treatment, which was well tolerated, was successful in closing retinal capillary nonperfusion areas and eliminating retinal neovascularization. Disc neovascularization was resolved completely in some cases, and partially in others.