Capillary Nonperfusion Research Articles

Visual Acuity (VA) Outcomes and Impact of Baseline (BL) Perfusion Status in VIBRANT

PurposeReport additional VA outcomes from VIBRANT.MethodsVIBRANT was a phase 3 study of intravitreal aflibercept (IVT‐AFL) vs laser for macular edema (ME) due to branch retinal vein occlusion (BRVO). Patients received IVT‐AFL 2 mg every 4 weeks to week 24 (W24) and every 8 weeks thereafter or macular grid laser at BL. Eligible laser patients received IVT‐AFL rescue beginning at W24. Primary endpoint was the proportion of eyes gaining ≥15 letters in best corrected VA (BCVA) at W24. Retina was considered perfused for patients with ≤10 disc areas of capillary nonperfusion at baseline.ResultsThe proportion of eyes gaining ≥15 letters from BL to W24 and W52 was 52.7% vs 26.7% (P < 0.001) and 57.1% vs 41.1% (P < 0.03), for IVT‐AFL vs laser; 36.3% and 49.5% of eyes receiving IVT‐AFL gained ≥15 letters by W4 and W12. Overall mean BCVA gain from BL to W24 and W52 was 17.0 vs 6.9 letters (P < 0.0001) and 17.1 vs 12.2 letters (P < 0.004), for IVT‐AFL vs laser. W52 results for laser group include patients who received IVT‐AFL rescue. In the laser group, 80.7% received rescue IVT‐AFL between W24 and W48. In perfused patients, mean BCVA gain from BL to W24 and W52 was 14.3 vs 5.7 and 13.7 vs 11.9 letters; in nonperfused patients, it was 19.1 vs 11.3 and 20.0 vs 15.6 letters. The most common ocular AE, conjunctival hemorrhage, occurred in 24.2% (IVT‐AFL) and 15.2% (laser) of patients. Two APTC‐ATEs occurred, both in the laser group.ConclusionsHere, IVT‐AFL provided statistically and clinically significant VA benefits over laser at W24 that were maintained at W52. Benefits with AFL treatment were not dependent on baseline perfusion status.

Measuring the precise area of peripheral retinal non-perfusion using ultra-widefield imaging and its correlation with the ischaemic index

ObjectiveTo determine the calculated, anatomically correct, area of retinal non-perfusion and total area of visible retina on ultra-widefield fluorescein angiography (UWF FA) in retinal vein occlusion (RVO) and to compare...

Diagnostic accuracy of disorganization of the retinal inner layers in detecting macular capillary non-perfusion in diabetic retinopathy.

Disorganization of the retinal inner layers (DRIL) on optical coherence tomography (OCT) is thought to represent retinal capillary non-perfusion (CNP) in eyes with diabetic retinopathy. This study was designed to evaluate the ability of DRIL to accurately predict CNP. Retrospective masked reliability and diagnostic accuracy study performed in the National Institute for Health Research (NIHR) Moorfields Biomedical Research Centre, London, UK SAMPLES: Retinal images of patients with diabetic retinopathy The OCT images from 90 separate areas of angiographically confirmed perfused and non-perfused areas of the macula from 37 eyes of 31 patients were anonymized and coded. Two masked graders independently graded these OCT scans for the presence or absence of DRIL to determine the intergrader reliability. The diagnostic accuracy of DRIL in identifying CNP was evaluated from the results obtained. Sensitivity and specificity of DRIL in accurately detecting CNP RESULTS: The intergrader agreement was high with a Cohen's kappa of 0.909. DRIL was present in 84.4% (38/45) of non-perfused retina and none in perfused retina (0/45). The sensitivity and specificity of DRIL in detecting angiographic evidence of CNP was 84.4% and 100%, respectively. The positive predictive value was 100% and the negative predictive value was 86.5%. The presence of DRIL is a reliable predictor of areas of macular CNP. However, DRIL is not a universal finding of non-perfusion, with some cases exhibiting absence of DRIL despite angiographic CNP.

Chlorophyllin-M: A new substance for photodynamic therapy in the retina and choroid.

Chlorophyllin-M is a new chlorophyll-based derivative photosensitive compound developed by our research group with easy laboratorial synthesis and ideal properties for photodynamic therapy (PDT). It is intended for clinical treatments with simple and low cost techniques and reagents. The objective of this study is to evaluate if intravenous chlorophyllin-M is able to deliver a photosensitizer to rabbit retina and rabbit choroid and promote PDT after ocular irradiation with a 660 nm LASER. This is a pre-clinical study. Ten eyes of five pigmented Californian rabbits were included in the study. The right eyes served as the treatment group, and the left eyes served as the control group. All eyes had been ophthalmologically evaluated and were considered normal. Ophthalmic exam with anterior biomicroscopy, dilated fundus examination, and fluorescein angiography after the LASER procedure revealed normal anterior segment, retinal and choroid vessels occlusion, lumen narrowing, and capillary non-perfusion in the treated areas, indicating that PDT was successful in the treatment eyes group. The results of this pre-clinical study encourage future studies with this new compound. Chlorophyllin-M may become a new cost-effective agent in the retinal therapeutic arsenal.

The significance of fundus fluorescein angiography after panretinal photocoagulation

Objective To evaluate the application of fundus fluorescein angiography (FFA) in the follow-up of diabetic retinopathy patients after panretinal photocoagulation(PRP). Methods Forty-nine eyes of 28 patients with proliferative diabetic retinopathy were treated with PRP and subsequently followed up for 6 months. Two months after PRP, each eye was taken 9 pieces of fundus photography and then was examined with FFA. Two senior doctors analyzed the image data to find capillary nonperfusion and retinal neovascularization. Results According to retinal fundus photography, 9 eyes were found having neovascularization. While according to FFA, retinal or optic disc neovascularization exsited in 12 eyes, and 4 eyes had no neovascularization but had capillary non-perfusion area. Totally 16 eyes were treated with additional retinal photocoagulation again according to results of FFA. Conclusion The follow-up of patients with proliferative diabetic retinopathy after PRP can be based on fundus photography and should be supplemented by FFA. FFA can early, comprehensively and accurately discover retinal capillary non-perfusion and retinal neovascularization. which contribute to photocoagulation therapy. Key words: Retinopathy, diabetic, proliferative; Photocoagulation, panretinal; Angiography, fundus, fluorescein

Disorganized retinal lamellar structures in nonperfused areas of diabetic retinopathy.

To investigate morphologic changes on spectral-domain optical coherence tomography (SD-OCT) images in nonperfused areas (NPAs) in diabetic retinopathy (DR). One hundred eight consecutive eyes of 80 patients with diabetic ischemic maculopathy were retrospectively reviewed. The boundary between the nerve fiber layer (NFL) and the ganglion cell layer (GCL)/inner plexiform layer (IPL) and the status of Henle's layer were characterized on the vertical sectional images of SD-OCT. These findings were compared with the NPAs on the FA images and the logMAR visual acuity (VA). The SD-OCT images showed that most areas of capillary nonperfusion had an indistinct boundary between the NFL and GCL/IPL in DR, regardless of high or moderate OCT reflectivity. The total transverse length of the NPAs was correlated positively with that of the areas with no boundary between these layers in all 108 eyes (R = 0.860, P < 0.001). Sixty-four eyes that had center-involved diabetic macular edema (DME) also had a significant association between them (R = 0.764, P < 0.001), and the most significant correlation was seen in eyes without DME (R = 0.955, P < 0.001). The macular transverse length of the areas with no boundary between the NFL and GCL/IPL was associated modestly with the logMAR VA (R = 0.334, P < 0.001). The indistinct Henle's layer on SD-OCT images often was delineated specifically in the NPAs rather than in the perfused areas. Nonperfused areas were associated significantly with the absence of a boundary between the NFL and GCL/IPL on SD-OCT images in DR.

Quantitative Analysis of Peripheral Vasculitis, Ischemia, and Vascular Leakage in Uveitis Using Ultra-Widefield Fluorescein Angiography

To investigate the relationships between peripheral vasculitis, ischemia, and vascular leakage in uveitis using ultra-widefield fluorescein angiography (FA). Cross-sectional, consecutive case series. Consecutive ultra-widefield FA images were collected from 82 uveitis patients (82 eyes) in a single center. The extent of peripheral vasculitis, capillary nonperfusion, and vessel leakage were quantified. Parameters included: (1) foveal avascular zone area and macular leakage, (2) peripheral diffuse capillary leakage and ischemia, (3) peripheral vasculitis, and (4) leakage from neovascularization. Central macular thickness measurements were derived with optical coherence tomography. Main outcome measures were correlations between central and peripheral fluorangiographic changes as well as associations between visual function, ultra-widefield FA-derived metrics, and central macular thickness. Although central leakage was associated with peripheral leakage (r= 0.553, P= .001), there was no association between foveal avascular zone size and peripheral ischemia (r= 0.114, P= .324), regardless of the underlying uveitic diagnosis. Peripheral ischemia was, however, correlated to neovascularization-related leakage (r= 0.462, P= .001) and focal vasculitis (r= 0.441, P= .001). Stepwise multiple regression analysis revealed that a poor visual acuity was independently associated with foveal avascular zone size and central macular thickness (R(2)-adjusted= 0.45, P= .001). We present a large cohort of patients with uveitis imaged with ultra-widefield FA and further describe novel methods for quantification of peripheral vascular pathology, in an attempt to identify visually significant parameters. Although we observed that relationships exist between peripheral vessel leakage, vasculitis, and ischemia, it was only macular ischemia and increased macular thickness that were independently associated with a reduced visual acuity.

Screening for diabetic retinopathy: the optometrist&amp;rsquo;s perspective

Diabetic retinopathy (DR) is a micro-vascular complication of diabetes affecting nearly all persons with a duration of diabetes of $15 years; and is the most common cause of blindness in the working-age adult population in developed countries. Vision loss results mainly from macular edema, macular capillary nonperfusion, vitreous hemorrhage, and tractional retinal detachment. Timely and appropriate care at early stages of DR can significantly reduce visual loss over time, improve patients' quality of life, and reduce the financial burden associated with the complications of visual impairment. Treatment modalities such as retinal photocoagulation, intraocular injections of pharmacological agents, and vitreo-retinal surgery have been effective in the management of DR. Optometry is a health care profession that is concerned with eyes and related structures, vision, and the visual system. Apart from refraction and visual rehabili- tation, optometrists have a wide range of roles to play in DR management by performing new visual acuity tests, detecting DR early using dilated ophthalmoscopy and if required imaging modalities, monitoring disease progression, providing timely follow-up examinations and man- agement which are critical for early diagnosis and intervention, making referral for concurrent care when indicated, and, above all, educating the patient. The optometrist's participation in the shared care of DR management regimen is likely to result in improvement in patient outcomes. This review is aimed at highlighting what primary-care optometrists are doing to manage this sight-threatening disease, what they can and should do to improve their competence in providing eye care to patients with diabetes, and what guidelines they need to follow to improve visual outcomes in the management of DR and diabetes mellitus.

From pathobiology to the targeting of pericytes for the treatment of diabetic retinopathy.

Pericytes, the mural cells that constitute the capillaries along with endothelial cells, have been associated with the pathobiology of diabetic retinopathy; however, therapeutic implications of this association remain largely unexplored. Pericytes appear to be highly susceptible to the metabolic challenges associated with a diabetic environment, and there is substantial evidence that their loss may contribute to microvascular instability leading to the formation of microaneurysms, microhemorrhages, acellular capillaries, and capillary nonperfusion. Since pericytes are strategically located at the interface between the vascular and neural components of the retina, they offer extraordinary opportunities for therapeutic interventions in diabetic retinopathy. Moreover, the availability of novel imaging methodologies now allows for the in vivo visualization of pericytes, enabling a new generation of clinical trials that use pericyte tracking as clinical endpoints. The recognition of multiple signaling mechanisms involved in pericyte development and survival should allow for a renewed interest in pericytes as a therapeutic target for diabetic retinopathy.

Adult onset coats disease in a 56-year-old male: An atypical presentation

Coats disease is a congenital retinal vascular disease, which is seen commonly in childhood and remits and exacerbates throughout life. However, it is not rare for coats disease to present in adulthood for the first time. This has been referred to as adult onset coats disease. We do hereby present a rare case of adult onset coats disease in a 56-year-old male patient who presented with visual acuity of 20/200 in the left eye. Fundus findings typical of coats disease included telangiectasis, macular exudation and edema. Fluorescein angiography revealed peripheral capillary nonperfusion areas and telangiectasis. Optical coherence tomography showed cystoid macular edema. After the treatment with intravitreal injection of bevacizumab (1.25 mg in 0.05 ml) and sectoral panretinal photocoagulation to the area of capillary nonperfusion the macular edema was reduced by 100 microns, which translated to a visual acuity of 20/80, proving the point that the prognosis in these cases is not as grave as in classical coats disease.

Detection of retinal capillary nonperfusion in fundus fluorescein angiogram of diabetic retinopathy

Introduction: Retinal capillary nonperfusion (CNP) is one of the retinal vascular diseases in diabetic retinopathy (DR) patients. As there is no comprehensive detection technique to recognize CNP areas, we proposed a different method for computing detection of ischemic retina, non-perfused (NP) regions, in fundus fluorescein angiogram (FFA) images. Methods: Whilst major vessels appear as ridges, non-perfused areas are usually observed as ponds that are surrounded by healthy capillaries in FFA images. A new technique using homomorphic filtering to correct light illumination and detect the ponds surrounded in healthy capillaries on FFA images was designed and applied on DR fundus images. These images were acquired from the diabetic patients who had referred to the Nikookari hospital and were diagnosed for diabetic retinopathy during one year. Our strategy was screening the whole image with a fixed window size, which is small enough to enclose areas with identified topographic characteristics. To discard false nominees, we also performed a thresholding operation on the screen and marked images. To validate its performance we applied our detection algorithm on 41 FFA diabetic retinopathy fundus images in which the CNP areas were manually delineated by three clinical experts. Results: Lesions were found as smooth regions with very high uniformity, low entropy, and small intensity variations in FFA images. The results of automated detection method were compared with manually marked CNP areas so achieved sensitivity of 81%, specificity of 78%, and accuracy of 91%.The result was present as a Receiver operating character (ROC) curve, which has an area under the curve (AUC) of 0.796 with 95% confidence intervals. Conclusion: This technique introduced a new automated detection algorithm to recognize non-perfusion lesions on FFA. This has potential to assist detecting and managing of ischemic retina and may be incorporated into automated grading diabetic retinopathy structures.

Factors Related to Repeatability of Intravitreal Bevacizumab Injections in Branch Retinal Vein Occlusion Macular Edema

Purpose: To identify the factors related to repeatability of intravitreal bevacizumab injections in patients with macular edema secondary to branch retinal vein occlusion (BRVO). Methods: The present study included 26 patients with macular edema secondary to BRVO occurring within 1 month of diagnosis. Initial best corrected visual acuity, type of BRVO according to the involved vein branch, distance between fovea and occlusion vein, central macular thickness, type of macular edema, presence of macula hemorrhage, and presence of capillary nonperfusion were evaluated at the time of diagnosis. The patients received an intravitreal bevacizumab injection at the time of diagnosis and reinjections when macular edema and visual acuity were aggravated. According to the factors considered, the reinjection‐free rate which was considered a survival rate was evaluated for 1 year after the first injection. Results: The patients with initial visual acuity lower than log MAR 0.5 showed 52.6% survival rate within 1 year compared with 14.3% of the patients with visual acuity higher than log MAR 0.5 (p < 0.01). The patients with occluded vein closer than a distance of 2.5 disc diameters (DD) from the foveal center had a 57.1% survival rate and the patients with occluded vein farther than a distance of 2.5 DD from the foveal center had a 25.0% survival rate (p = 0.04). Macular BRVO and major BRVO patients had 64.3% and 16.7% survival rates, respectively (p = 0.01). Conclusions: The patients with BRVO may have less chance of repetitive intravitreal bevacizumab injections due to macular edema when initial visual acuity is lower than log MAR 0.5, occluded vein is closer than 2.5 DD from the foveal center, and macular branch is involved at the initial diagnosis. These factors can be utilized to predict the prognosis of BRVO patients and the probability of repetitive intravitreal bevacizumab injections. J Korean Ophthalmol Soc 2015;56(10):1580-1585

En face swept-source optical coherence tomography detecting thinning of inner retinal layers as an indicator of capillary nonperfusion.

To report en face swept-source optical coherence tomography (SS-OCT) as a noninvasive detection modality for regions of retinal layer thinning that are potential indicators of retinal nonperfusion areas (NPAs) in patients with branch retinal vein occlusion (BRVO). Thirty-one eyes of 46 patients with BRVO showing a definite retinal NPA larger than 1 disc in diameter within the vascular arcades were included in this study. We calculated the overlapping correspondence ratio between presumed NPA, which appeared as a dark area in en face SS-OCT, and definite NPA in corresponding fluorescein angiography (FA) images. The correlation between brightness in en face SS-OCT images and corresponding ganglion cell complex (GCC) thickness determined by SD-OCT GCC maps was evaluated as well. Measured NPA size in FA and presumed NPA size in en face SS-OCT showed strong correlation (r = 0.746, p&lt;0.001) and colocalization. Reliable agreement between the 2 methods was confirmed by size comparisons (p = 0.11), with an overlapping correspondence ratio of 0.73. The results suggest that en face SS-OCT is a noninvasive and relatively reliable method for delineating retinal thinning as an indicator of NPAs in eyes with BRVO. Because SS-OCT can be performed without mydriasis, this procedure may be an option for evaluating NPAs on a screening basis and during follow-up to reduce the number of FA examinations that carry very rare, but potentially fatal, allergic side effects.

Characteristics of fundus image in combined hamartoma of the retina and retinal pigment epithelium

Objective To investigate the characteristics of fundus image in patients with combined hamartoma of the retina and retinal pigment epithelium (CHRRPE).Methods Eight eyes of 8 cases with CHRRPE were included in this study.There were 5 males and 3 females,ranging from 6 to 21 years old (mean 14.13 years).In all cases,unilateral eye was affected.The best-corrected visual acuity (BCVA) was 0.02 to 0.2.The intraocular pressure in all eyes was normal.The ocular anterior segment in all cases was alright.For all cases,fundus photography,fundus autofluorescence (AF),fundus fluorescein angiography (FFA) and spectral-domain optical coherence tomography (SD-OCT) were taken.The characteristics of fundus image were analyzed.Results All the CHRRPE lesions located at posterior pole,presenting as yellow-white elevations,surrounded by hyperpigmentation.Retinal vascular tortuosity and proliferation of epiretinal membrane were found in all CHRRPE lesions.In 8 affected eyes,lesions were involved in macula and optic disc in 3 eyes (37.5％),lesions were located in macula in 5 eyes (62.5％).AF images showed lesion bulges and the surrounding hyperpigmentation corresponding to the local hypo-AF in 7 eyes (87.5％),dense epiretinal membrane corresponding to the local hyper-AF in 1 eye (12.5％).FFA showed local hypofluorescence of choroidal background corresponding to lesions and the surrounding hyperpigmentation,tortuous retinal vascular due to traction of shrinkage membranes.Retinal capillary leakage and the fluorescence brightness gradually increased in all lesions.No retinal hemorrhage,exudation,area of capillary non-perfusion,retinal and choroidal neovascularization could be found in 8 CHRRPE eyes.SD-OCT showed disorganized and elevated lesion with uneven reflectivity in inner retina,mild attenuation of the retinal pigment epithelium (RPE) and photoreceptor inner segment/outer segment junction in all CHRRPE eyes.Of the 8 CHRRPE eyes,cavernous hypo-reflective shadowing due to the shielded optical signal acquisition below dense epiretinal membranes in 2 eyes (25.0％),membrane-like hyper-reflective signals connecting with RPE in 1 eyes (12.5％).Conclusions Decreased AF appear in the location of CHRRPE lesion and the surrounding hyperpigmentation.Hypofluorescence of choroidal background can be found in the early phase of FFA,the fluorescence brightness of CHRRPE lesion gradually increases in FFA process.The retinal elevation,attenuated signal reflection of the RPE and photoreceptor inner segment/ outer segment junction in CHRRPE lesion can be verified by OCT. Key words: Retinal diseases; Hamartoma/diagnosis; Fluorescein angiography; Tomography, optical coherence

Assessment of perfused foveal microvascular density and identification of nonperfused capillaries in healthy and vasculopathic eyes.

To analyze the foveal microvasculature of young healthy eyes and older vasculopathic eyes, imaged using in vivo adaptive optics scanning light ophthalmoscope fluorescein angiography (AOSLO FA). AOSLO FA imaging of the superficial retinal microvasculature within an 800-μm radius from the foveal center was performed using simultaneous confocal infrared (IR) reflectance (790 nm) and fluorescence (488 nm) channels. Corresponding IR structural and FA perfusion maps were compared with each other to identify nonperfused capillaries adjacent to the foveal avascular zone. Microvascular densities were calculated from skeletonized FA perfusion maps. Sixteen healthy adults (26 eyes; mean age 25 years, range, 21-29) and six patients with a retinal vasculopathy (six eyes; mean age 55 years, range, 44-70) were imaged. At least one nonperfused capillary was observed in five of the 16 healthy nonfellow eyes and in four of the six vasculopathic eyes. Compared with healthy eyes, capillary nonperfusion in the vasculopathic eyes was more extensive. Microvascular density of the 16 healthy nonfellow eyes was 42.0 ± 4.2 mm(-1) (range, 33-50 mm(-1)). All six vasculopathic eyes had decreased microvascular densities. AOSLO FA provides an in vivo method for estimating foveal microvascular density and reveals occult nonperfused retinal capillaries. Nonperfused capillaries in healthy young adults may represent a normal variation and/or an early sign of pathology. Although limited, the normative data presented here is a step toward developing clinically useful microvascular parameters for ocular and/or systemic diseases.

Long-term Effects of Therapy with Ranibizumab on Diabetic Retinopathy Severity and Baseline Risk Factors for Worsening Retinopathy

To assess the effects of intravitreal ranibizumab on diabetic retinopathy (DR) severity when administered for up to 3 years, evaluate the effect of delayed initiation of ranibizumab therapy on DR severity, and identify baseline patient characteristics associated with the development of proliferative DR (PDR). Exploratory analyses of phase III, randomized, double-masked, sham-controlled multicenter clinical trials. Adults with diabetic macular edema (DME) (N= 759), baseline best-corrected visual acuity 20/40 to 20/320 Snellen equivalent, and central foveal thickness ≥275 μm. Patients were randomized to monthly 0.3 or 0.5 mg ranibizumab or sham injections. Sham participants could switch to 0.5 mg ranibizumab during the third year (sham/0.5 mg crossover). Baseline risk factors were evaluated to explore potential associations with development of PDR. Time to first development of PDR was analyzed by Kaplan-Meier methods to calculate cumulative probabilities by group. Study eye change on the Early Treatment Diabetic Retinopathy Study severity scale and a composite clinical outcome evaluating progression to PDR based on photographic changes plus clinically important events defining PDR. At month 36, a greater proportion of ranibizumab-treated eyes had ≥2- or ≥3-step DR improvement compared with sham/0.5 mg crossover. A ≥3-step improvement was achieved at 36 months by 3.3%, 15.0%, and 13.2% of sham/0.5 mg, 0.3 mg, and 0.5 mg ranibizumab-treated eyes, respectively (P < 0.0001). Through 36 months, 39.1% of eyes in the sham/0.5 mg group developed PDR, as measured by composite outcome, compared with 18.3% and 17.1% of eyes treated with 0.3 or 0.5 mg ranibizumab, respectively. The presence of macular capillary nonperfusion at baseline seems to be associated with progression to PDR in ranibizumab-treated eyes but did not meaningfully influence visual acuity improvement in eyes with DME after ranibizumab therapy. Ranibizumab, as administered to patients with DME for 12 to 36 months in these studies, can both improve DR severity and prevent worsening. Prolonged delays in initiation of ranibizumab therapy may limit this therapeutic effect. Although uncommon, the development of PDR still occurs in a small percentage of eyes undergoing anti-vascular endothelial growth factor therapy and may be related to the presence of macular nonperfusion.

Heidelberg Spectralis Ultra-Widefield Fundus Fluorescein Angiography in Infants

To describe the intraoperative use of the Heidelberg Spectralis for ultra-widefield fundus fluorescein angiography in infants. Retrospective observational case series. A modified Heidelberg Spectralis was used to perform ultra-widefield fundus fluorescein angiography in infants undergoing an examination under general anesthesia for a range of retinal vasculopathies. Peripheral angiographic findings, angiographic image acquisition time, and any complications were reviewed. A total of 22 eyes of 11 infants underwent intraoperative ultra-widefield fundus fluorescein angiography using the modified Heidelberg Spectralis. Ultra-widefield fundus fluorescein angiography was successfully performed in all infants and permitted capture of the posterior pole as well as the peripheral retina in a single shot centered on the macula. Peripheral retinal pathologies captured include neovascularization, capillary nonperfusion, and skip areas from previous laser treatment. Capturing of angiographic images took a mean time of 7.09 minutes. Image artifact from condensation of the ultra-widefield lens was noted during imaging of 1 infant. The modified Heidelberg Spectralis is an effective and reliable imaging tool for performing ultra-widefield fundus fluorescein angiography in infants. It is capable of capturing wide-angle images of high quality. The technique has advantages as an alternative to RetCam fluorescein angiography in infants undergoing an examination under general anesthesia.

Purtscher-like Retinopathy in Systemic Lupus Erythematosus

To investigate clinical characteristics of Purtscher-like retinopathy and its clinical implications among patients with systemic lupus erythematosus (SLE). Observational case series. setting: Tertiary medical center. patient population: Patients with SLE who were diagnosed with Purtscher-like retinopathy between 2002 and 2013. observation procedures: Assessment and follow-up in the ophthalmology department. main outcome measure: Visual acuity and funduscopic examination at presentation and at 6 month follow-up, with analysis of the association between Purtscher-like retinopathy and other systemic involvement of SLE and overall disease activity. Among 5688 patients with SLE evaluated, 8 cases of Purtscher-like retinopathy were diagnosed. Typical fundus abnormalities included Purtscher flecken, cotton-wool spots, retinal hemorrhages, macular edema, optic disk swelling, and a pseudo-cherry red spot. Fluorescein angiography abnormalities included areas of capillary nonperfusion corresponding to the retinal whitening, late leakage, peripapillary staining, precapillary occlusion, and slower filling of vessels. The prevalence of central nervous system lupus was significantly higher among those with Purtscher-like retinopathy (6/8) than among 240 patients randomly sampled from those without Purtscher-like retinopathy. A very high SLE Disease Activity Index (≥20) was present in all 8 patients with Purtscher-like retinopathy. All patients received corticosteroids combined with immunosuppressants. For the majority of patients, optic atrophy developed during follow-up with persistent low visual acuity. As a rare and severe ophthalmic complication of SLE, Purtscher-like retinopathy was associated with central nervous system lupus and highly active disease. Visual acuity recovery was usually poor despite prompt treatment.

Retinal vasculopathies

AbstractDrug‐induced retinal vasculopathies constitute a group of rare disorders, most often produced by quinine, aminoglycosides, hormone preparations, and interferon. IFN‐ associated retinopathy includes cotton wool spots, retinal hemorrhages and retinal micro aneurysms. Aminoglycosides were often used subconjunctivally after different ocular surgeries as a postoperative prevention of endophthalmitis and intravitreally as a method of endophthalmitis treatment. Both clinical and animal studies have shown vascular changes, including whitening of the retina, retinal hemorrhages, multiple areas of vascular leakage and macular infarction. Although the true pathogenesis remains unknown, the clinical presentation of capillary nonperfusion has suggested a primarily vascular mechanism. The mechanism of quinine‐induced retinal toxicity, although still not well understood, includes probably ischemic/ occlusive type of events occurring in the posterior retinal circulation with relative sparing of choroidal circulation. Hormone‐related retinopathy, mainly due to oral contraceptives, include among others retinal hemorrhage or emboli, macular edema, and papillary edema.

The Effect of Central Retinal Venous Pressure in Patients with Central Retinal Vein Occlusion and a High Mean Area of Nonperfusion

To evaluate the effect of central venous pressure (CVP) on visual outcomes and retinal ischemic consequences in patients with central retinal vein occlusion (CRVO). Prospective, single-center cohort study. Eighty-eight patients with CRVO and a high overall mean area (21.6 disc areas) of capillary nonperfusion (CNP) who were followed for 18 months before the availability of intravitreal therapy and who were offered standard care of the time. Patients were evaluated at baseline and at 3, 8, and 18 months. At each study visit, measurements of CVP, best-corrected visual acuity (BCVA), area of CNP, retinal fluorescein transit time (FTT), and an evaluation for rubeosis iridis were performed. Evaluation of the effect of different levels of CVP on BCVA, retinal blood flow, and the development of retinal ischemia and rubeosis iridis. Mean BCVA was significantly higher in patients with lower CVP at all time points (P<0.0001). The area of CNP increased significantly with higher levels of CVP and progressed with time. The development of rubeosis iridis was significantly associated with CVP at all time points and was present in 5.6%, 27.9%, and 88.9% of those with low, moderate, and high CVP levels, respectively (P<0.0001), at the 18-month conclusion. Retinal blood flow as measured by FTT was reduced with higher levels of CVP. Spontaneous lowering of CVP had beneficial effects on BCVA, although this diminished with time. Eyes with increased CVP after more severe CRVO demonstrate significantly reduced vision, reduced retinal blood flow, a higher incidence of rubeosis iridis, and larger areas of CNP that correlate with the degree of CVP elevation.