Early Treatment Diabetic Retinopathy Study Lines Research Articles

Analysis of association of bandage contact lens with serious vision-threatening diseases and their management

BackgroundBandage contact lenses are important aids for aftercare following ocular surgery and for a wide variety of ocular surface conditions. However, bandage contact lenses also bear the risk of fostering microbial infections of the cornea. We herein report the safety profile of bandage contact lenses from a comprehensive review of medical records in a tertiary care eye hospital in Germany.MethodsWe identified 638 consecutive patients who had been prescribed at least one bandage lens during the past 10 years. For these, we performed a computerized search for the following adverse events: (1) endophthalmitis, (2) emergency keratoplasty and (3) vision loss of at least 2 lines according to the Early Treatment Diabetic Retinopathy Study (ETDRS). We manually assessed the relatedness of each event to the bandage lens. Events later than 100 days following the bandage lens prescription were not considered to be related to bandage contact lenses.ResultsWe observed 267 adverse events, with 120 occurring within 100 days after bandage lens prescription. This left a total of 18 endophthalmitis events, 21 penetrating keratoplasties and 81 eyes with vision loss of at least 2 ETDRS lines (for individual review of relatedness). Only two episodes of endophthalmitis could be linked to bandage lens wear. All other adverse events were due to causative conditions that had already been present prior to bandage contact lens insertion.ConclusionsSevere adverse events after bandage contact lens wear are not uncommon because lenses are used in patients suffering from preexisting ocular conditions. However, severe adverse events were almost never caused by the bandage contact lenses directly in our hands. We therefore conclude that bandage contact lenses are safe given proper ophthalmological supervision.

Impact of Ocular Complications on Visual Outcomes in Adult Patients With Uveitis.

BackgroundIn this study, we aimed to assess the impact of ocular complications on visual outcomes in uveitis.MethodologyWe conducted a retrospective cohort study of 474 uveitis patients (655 eyes) with a mean age of 52.4 years who were followed for a median of 32 months (range: 8-80 months).ResultsAt least one ocular complication was found in 317 eyes (48.4%), 161 of which were present at the time of diagnosis (prevalent complication). Although having an ocular complication was associated with a mean loss of 1.7 Early Treatment Diabetic Retinopathy Study (ETDRS) lines, the best-corrected visual acuity increased at the end of the study. Complications causing a decrease of ≥2 ETDRS lines were prevalent macular and peripheral retinal diseases, as well as new-onset corneal lesions, intraocular pressure alterations, and peripheral retinal diseases.ConclusionsThe impact of the most frequent complications (cataract and macular edema) did not reach two ETDRS lines. Macular diseases at presentation were the main risk factor for visual loss at the end of follow-up.

Assessing clinical evidence for idebenone in the treatment of chronic Leber Hereditary Optic Neuropathy: a systematic literature review

AbstractPurposeLeber Hereditary Optic Neuropathy (LHON) is a mitochondrial genetic disorder causing severe, bilateral loss of visual acuity (VA). Idebenone is the only treatment for LHON currently approved in Europe. Due to the rarity of the disease, information about outcome in patients starting treatment >12 months since disease onset in the most recent eye (chronic LHON) is scarce.MethodsThe search for clinical evidence included any published study or conference abstract evaluating oral idebenone at the approved dose of 900 mg/day, in patients with confirmed diagnosis of LHON starting treatment >12 months since disease onset in the most recent eye. Literature search was carried out on Medline, Embase, InsightMeme and Cochrane Libraries up to March 2020.ResultsEvidence for idebenone treatment of chronic LHON is based on four uncontrolled, retrospective case series and one post‐hoc analysis of a randomized controlled study. All studies included patients (n = 4–53) with confirmed primary LHON mutations and evaluated changes in VA with the Early Treatment Diabetic Retinopathy Study (ETDRS) chart. The post‐hoc analysis (n = 53, idebenone:34; placebo:19) assessed efficacy as rate of clinically relevant recovery (CRR; defined as improvement from off‐chart to reading five letters, or improvement of 10 letters) from baseline (BL) after 6‐month therapy. 35.3% of idebenone‐treated versus 10.5% of placebo patients achieved CRR (p = 0.059); by eyes: 23.5% versus 5.3% (p = 0.016). All 4 retrospective studies (n = 4–16) assessed efficacy as average VA improvement (all eyes) from BL after 9 to 12 months of therapy. Improvements ranged from −0.20 to −0.31 logMAR (2–3 ETDRS lines). One retrospective study compared the effect of idebenone in two subgroups according to time from LHON onset (1–5 years, n = 7; >5 years, n = 8) showing no difference between groups.ConclusionsData presented indicates a potential therapeutic effect of idebenone in chronic LHON patients, which may be explained by the reactivation of dysfunctional retinal ganglion cells and deserved further investigation.

Safety and efficacy of selective retina therapy (SRT) for the treatment of diabetic macular edema in Korean patients

Selective retina therapy (SRT) stimulates retinal pigment epithelium (RPE) cell migration and proliferation into irradiated areas. The objective of this study was to evaluate the efficacy and safety of SRT in Korean patients with clinically significant diabetic macular edema (DME). Prospective non-randomized interventional case series study. Twenty-three eyes of 21 patients with clinically significant DME were treated with SRT and followed for 6months. Patients underwent an evaluation of best corrected visual acuity (BCVA) in Early Treatment Diabetic Retinopathy Study (ETDRS) letters. Microperimetry was employed to measure macular sensitivity within the central 10° field, and the central macular thickness (CMT) and maximum macular thickness (MMT) were measured. An improvement in BCVA of one to two ETDRS lines was observed in 41.2% of patients and an improvement of greater than two lines in 29.4%. Although there was no significant change in CMT (P > 0.05), MMT decreased from 465.8 ± 87.4μm to 434.3 ± 83.9μm (P = 0.006), and mean macular sensitivity increased from 20.8 ± 3.4dB to 22.5 ± 3.5dB (P = 0.02). The gains in BCVA and improvement in macular sensitivity demonstrated that SRT may be used as an effective and safe treatment modality in Korean patients with clinically significant DME.

Perfluorocarbon in vitreoretinal surgery and preoperative bevacizumab in diabetic tractional retinal detachment.

To describe the en bloc perfluorodissection (EBPD) technique and to demonstrate the applicability of using preoperative intravitreal bevacizumab during small-gauge vitreoretinal surgery (23-gauge transconjunctival sutureless vitrectomy) in eyes with advanced proliferative diabetic retinopathy (PDR) with tractional retinal detachment (TRD). This is a prospective, interventional case series. Participants included 114 (eyes) with advanced proliferative diabetic retinopathy and TRD. EBPD was performed in 114 eyes (consecutive patients) during 23-gauge vitrectomy with the utilization of preoperative bevacizumab (1.25 mg/0.05 mL). Patients mean age was 45 years (range, 21-85 years). Surgical time had a mean of 55 min (Range, 25-85 min). Mean follow up of this group of patients was 24 mo (range, 12-32 mo). Main outcome measures included best-corrected visual acuity (BCVA), retinal reattachment, and complications. Anatomic success occurred in 100% (114/114) of eyes. Significant visual improvement [≥ 2 Early Treatment Diabetic Retinopathy Study (ETDRS) lines] was obtained in 69.2% (79/114), in 26 eyes (22.8%) BCVA remained stable, and in 8 eyes (7%) BCVA decreased (≥ 2 ETDRS lines). Final BCVA was 20/50 or better in 24% of eyes, between 20/60 and 20/400 in 46% of eyes, and worse than 20/400 in 30% of eyes. Complications included cataract in 32 (28%) eyes, iatrogenic retinal breaks in 9 (7.8%) eyes, vitreous hemorrhage requiring another procedure in 7 (6.1%) eyes, and phthisis bulbi in 1 (0.9%) eye. This study demonstrates the usefulness of using preoperative intravitreal bevacizumab and EBPD during small-gauge vitreoretinal surgery in eyes with TRD in PDR.

Intravitreal Bevacizumab for Nonsubfoveal Choroidal Neovascularization Associated With Angioid Streaks

To evaluate the effects of intravitreal bevacizumab injections in the treatment of nonsubfoveal choroidal neovascularization (CNV) associated with angioid streaks. Nonrandomized, interventional, prospective case series. Fifteen patients (15 eyes) affected by juxtafoveal or extrafoveal CNV secondary to angioid streaks were enrolled in the study. All patients underwent a complete ophthalmologic examination, including best-corrected visual acuity (BCVA) measurement on Early Treatment Diabetic Retinopathy Study (ETDRS) chart, optical coherence tomography (OCT), and fluorescein angiography (FA). The protocol treatment included a first injection, followed by repeated injections over a 12-month follow-up period on the basis of the detection of new hemorrhage on biomicroscopic examination, any type of fluid on OCT, or presence of leakage on FA. Mean changes in BCVA and proportion of eyes gaining at least 10 letters (2 ETDRS lines) at the end of the follow-up. Mean changes of central macular thickness (CMT) and extension to the fovea. Mean BCVA did not change throughout the follow-up period, being 0.2 ± 0.2 logMAR at baseline and 0.2 ± 0.3 logMAR at the 12-month examination. A functional improvement of at least 2 ETDRS lines was achieved by 5 eyes (33%), with 3 eyes (20%) gaining 3 lines. Mean CMT at baseline was 215 ± 13 μm and 225 ± 85 μm at the 12-month examination. Two eyes (13.3%) showed CNV extension to the fovea. Intravitreal bevacizumab injection can be a beneficial approach for the management of nonsubfoveal CNV secondary to angioid streaks over a 1-year follow-up.

Intravitreal triamcinolone combined with grid laser photocoagulation for patients with cystoid macular edema and advanced diabetic retinopathy: Pilot study

BackgroundTo determine if primary intravitreal injection of triamcinolone acetonide (TA) plus grid laser photocoagulation (GLP) is effective in treating cystoid diabetic macular edema (DME). MethodsProspective comparative non-randomized clinical trial. Fourteen eyes (14 patients) diagnosed with cystoid DME were treated with GLP according to the Early Treatment Diabetic Retinopathy Study (ETDRS) guidelines, plus an intravitreal injection of 4mg of TA. A matched control group (16 eyes [16 patients]) treated with GLP was selected retrospectively from our medical records. Best-corrected visual acuity (BCVA), and quantitative change in optical coherence tomography (OCT) macular thickness were assessed. ResultsMean follow up was 14.9 months (12 to 19 months). In 3 (21.4%) eyes BCVA increased >2 ETDRS lines, in 5 (35.7%) eyes BCVA remained the same, and BCVA decreased >2 ETDRS lines in 6 (42.8%) eyes. Central macular thickness, as measured by OCT, decreased a mean of 106.2μm (30.2%). The difference with the control group was not statistically significant (p=0.2). Four (28.5%) eyes developed an increased in intraocular pressure in our study group. ConclusionsAlthough all of our patients showed an improvement of cystoid DME by means of OCT and fluorescein angiography, 42.8% (6 eyes) lost 2 or more lines in BCVA with primary intravitreal injection of TA plus GLP. Primary intravitreal injection of TA plus GLP may not be effective for cystoid DME at 12 months.

Triamcinolona intravítrea combinada con fotocoagulación láser en rejilla en pacientes con edema macular quístico y retinopatía diabética avanzada: estudio piloto

BackgroundTo determine if primary intravitreal injection of triamcinolone acetonide (TA) plus grid laser photocoagulation (GLP) is effective in treating cystoid diabetic macular edema (DME). MethodsProspective comparative non-randomized clinical trial. Fourteen eyes (14 patients) diagnosed with cystoid DME were treated with GLP according to the Early Treatment Diabetic Retinopathy Study (ETDRS) guidelines, plus an intravitreal injection of 4mg of TA. A matched control group (16 eyes [16 patients]) treated with GLP was selected retrospectively from our medical records. Best-corrected visual acuity (BCVA), and quantitative change in optical coherence tomography (OCT) macular thickness were assessed. ResultsMean follow up was 14.9 months (12 to 19 months). In 3 (21.4%) eyes BCVA increased > 2 ETDRS lines, in 5 (35.7%) eyes BCVA remained the same, and BCVA decreased >2 ETDRS lines in 6 (42.8%) eyes. Central macular thickness, as measured by OCT, decreased a mean of 106.2μm (30.2%). The difference with the control group was not statistically significant (P=.2). Four (28.5%) eyes developed an increased in intraocular pressure in our study group. ConclusionsAlthough all of our patients showed an improvement of cystoid DME by means of OCT and fluorescein angiography, 42.8% (6 eyes) lost 2 or more lines in BCVA with primary intravitreal injection of TA plus GLP. Primary intravitreal injection of TA plus GLP may not be effective for cystoid DME at 12-months.

Alprostadil infusion in patients with dry age related macular degeneration: a randomized controlled clinical trial

Background: Age-related macular degeneration is the leading cause of blindness among elderly individuals in industrialized countries. New drugs and advanced concepts for the treatment of dry AMD (dAMD) are needed. A new approach is the application of intravenous infusions of prostaglandin E1.Objective: The aim of this study was to assess efficacy and safety of intravenous alprostadil infusion in patients with dAMD.Methods: This was a prospective, randomized, multi-center study. Patients were treated with intravenous infusion of either 60 µg alprostadil or placebo over 3 weeks. Main efficacy outcomes were mean differences in best corrected visual acuity (BCVA) from baseline assessed in early treatment diabetic retinopathy study (ETDRS) lines immediately, 3 months and 6 months after treatment.Results: In the full analysis set (FAS) a mean difference of 0.89 ± 0.537 ETDRS lines according to analysis of variance-covariance (ANCOVA) resulted in the alprostadil group (n = 16) and a mean difference of -0.05 ± 0.578 in the placebo group (n = 17) 3 months after end of treatment. Thus, effectiveness of alprostadil infusion was numerically superior to placebo treatment by a mean of 0.94 lines after 3 months (1.51 lines after 6 months). These findings were more pronounced in the per protocol set (PPS). Safety results were in line with the good safety profile of alprostadil.Conclusion: A numerical treatment effect in favor of alprostadil was visible, which lasted until the end of follow up. These results provide further evidence that alprostadil probably has a therapeutic effect in the treatment of dAMD and justify further clinical studies.

Intravitreal Ranibizumab for Pigment Epithelium Detachment With Subfoveal Occult Choroidal Neovascularization: A Prospective 24-Month Case Series

To assess the effects of intravitreal ranibizumab injection in patients affected by pigment epithelial detachment associated with occult subfoveal choroidal neovascularization. Prospective, interventional case series. Forty eyes of 40 patients were considered for the purpose of the study. Consecutive patients were recruited for a 24-month study. All patients underwent a complete ophthalmic examination, including best-corrected visual acuity on Early Treatment Diabetic Retinopathy Study (ETDRS) charts. After a 3-monthly loading phase, further intravitreal ranibizumab injections were administered on the basis of detection of any type of fluid on optical coherence tomography. Changes in mean best-corrected visual acuity at 12 and 24months and the proportion of eyes losing fewer than 15 letters (corresponding to 3 ETDRS lines) from baseline visual acuity. Changes in central macular thickness on optical coherence tomography and variation in mean area of the entire lesion. Forty patients were included. Mean best-corrected visual acuity decreased from 20/66 (58 ETDRS letters) to 20/83 (53 letters) at 12months and 20/112 (489 ETDRS letters) at 24months (P= .003). Eighty percent and 67.5% of eyes lost fewer than 3 lines at 12 and 24months, respectively. Mean central macular thickness passed from 545μm to 428μm at 12months and 426μm at 24months. Mean lesion area changed from 6826μm(2) to 6312μm(2) at 12months and 6010μm(2) at 24months. The treatment of pigment epithelial detachment associated with occult subfoveal choroidal neovascularization with intravitreal ranibizumab injection after a 3-monthly loading phase and pro re nata strategy can lead to partial results over a 24-month follow-up. Further investigations are warranted to establish the best therapeutic approach to this disease.

SURGICAL TREATMENT OF LAMELLAR MACULAR HOLE ASSOCIATED WITH EPIMACULAR MEMBRANE

Although the surgical treatment of full-thickness macular hole is well established, the utility of pars plana vitrectomy in the treatment of lamellar macular hole (LMH) remains less clear. The purpose of the study is to report functional results of surgical treatment of LMH associated with epiretinal membrane. Retrospective chart review of patients undergoing pars plana vitrectomy and peeling of epiretinal membrane and internal limiting membrane, with or without air or gas tamponade, for symptomatic LMH associated with epimacular membrane. Forty-five eyes of 44 patients were operated for LMH associated with epimacular membrane between May 2000 and July 2009. Pars plana vitrectomy and membrane peeling were combined with air or gas tamponade in 43 of 45 cases. Mean logarithm of the minimum angle of resolution best-corrected visual acuity improved from 0.4 preoperatively to 0.13 postoperatively (P < 0.0001). Improvement in visual acuity ranged from 0 Early Treatment Diabetic Retinopathy Study (ETDRS) lines to 8.9 ETDRS lines (mean, 2.65 ETDRS lines). Visual acuity improved by ≥ 1 ETDRS line(s) in 40 of 45 eyes (89%) and by ≥ 2 ETDRS lines in 26 of 45 eyes (58%) after the surgical procedure. No patient lost vision. This small retrospective study suggests that surgical treatment of LMH associated with epimacular membrane may improve visual acuity in symptomatic patients.

A Randomized Controlled Trial of Alleviated Positioning after Small Macular Hole Surgery

To establish whether the success rate of surgery for small idiopathic macular holes (diameter, ≤ 400 μm) is significantly reduced if facedown positioning is replaced by simply taking care to avoid the supine position. Randomized, controlled, parallel-assignment, open-label, interventional, multicenter clinical trial. Sixty-nine patients from 6 specialized vitreoretinal units, randomized into 2 parallel groups and followed up after surgery for 3 months. All patients underwent pars plana vitrectomy, peeling of any epiretinal membrane, and 17% C₂F₆ gas filling. Patients then were advised randomly to observe either strict facedown positioning for 22 of 24 hours or simply to avoid the supine position for 10 days. The primary outcome measure was the rate of anatomic closure 3 months after surgery. Main secondary measurements included Early Treatment Diabetic Retinopathy Study (ETDRS) visual acuity, progression of cataract, and frequency of complications. The mean size of macular holes was approximately 300 μm in both groups. Closure rates were more than 90% in both groups: 32 (91.4%) of 34 eyes in the alleviated positioning group versus 32 (94.1%) of 35 eyes in the facedown positioning group (lower margin of 95% confidence interval of difference, -14.88%). The ETDRS scores at 3 months increased in both groups by 10.23 ± 14.64 and 10.52 ± 14.54 letters, respectively. Progression of cataract and the rate of other complications were not significantly different in the 2 groups. The success rate of surgery for idiopathic macular holes of 400 μm or smaller is not significantly reduced if facedown positioning is replaced by simply taking care to avoid the supine position. These macular holes can be treated by streamlined surgery, that is, with no internal limiting membrane peeling and no facedown positioning (only avoidance of the supine position) with a closure rate of more than 90% and a mean gain in visual acuity of more than 2 ETDRS lines at 3 months.

Primary intravitreal bevacizumab for the management of pseudophakic cystoid macular edema: Pilot study of the Pan-American Collaborative Retina Study Group

To determine the feasibility, safety, and clinical effect of primary intravitreal bevacizumab (Avastin) in patients with cystoid macular edema (CME) after cataract surgery. Five institutions in Venezuela, Costa Rica, Puerto Rico, Peru, and Brazil. Twenty-eight eyes of 25 patients treated with at least 1 intravitreal injection of 1.25 mg or 2.50 mg of Avastin participated in this interventional retrospective multicenter study at 5 institutions from 5 countries. Baseline and follow-up visits included Early Treatment Diabetic Retinopathy Study (ETDRS) visual acuity testing, optical coherence tomography (OCT) imaging, and ophthalmoscopic examination. The mean follow-up was 32 weeks (range 24 to 52 weeks). Twenty eyes (71.4%) had improved best corrected visual acuity (BCVA) (> or =2 ETDRS lines), and no eye had worse visual acuity (> or =2 ETDRS lines). The BCVA remained stable in 8 eyes (28.6%). The mean baseline BCVA was 20/160 (logMAR = 0.92) and the mean final BCVA, 20/63 (logMAR = 0.50); the difference was statistically significant (P<.0001). The mean central macular thickness at baseline (466.3 microm; range 208 to 784 microm) decreased significantly (264.5 microm; range 176 to 513 microm) by the end of follow-up (P<.0001). Eight eyes (28.6%) required a second injection and 4 (14.3%), a third injection. The mean interval between injections was 13 weeks (range 5 to 26 weeks). No ocular or systemic adverse events were observed. Short-term results suggest that primary intravitreal Avastin is well tolerated in patients with pseudophakic CME. Treated eyes had a significant improvement in BCVA and decrease in macular thickness by OCT.

Central Retinal Vein Occlusion as a Possible Presenting Manifestation of Sneddon Syndrome

We report a case of central retinal vein occlusion (CRVO) and livedo reticularis in a patient in whom Sneddon syndrome was subsequently diagnosed. A 61-year-old man presented with a sudden and painless decline in visual acuity of his right eye. Visual acuities evaluated with Early Treatment Diabetic Retinopathy Study (ETDRS) measurements were 0.62 ETDRS lines (20/60 Snellen equivalent) for the right eye and 0.9 ETDRS lines (20/30 Snellen equivalent) for the left eye, there was no relative afferent pupillary defect, and intraocular pressures were 18 mm Hg in both eyes. Examination of the right fundus revealed retinal edema, optic disc swelling, tortuous and dilated retinal veins, and extensive superficial hemorrhages in all four quadrants. A diagnosis of acute CRVO was made. Pre-fluorescein angiographic red-free fundus photography (Fig. 1) showed venous stasis but good retinal capillary perfusion, disc edema, tortuosity, and dilation of all branches of the central retinal vein and a few scattered peripheral fundus hemorrhages, consistent with nonischemic CRVO. The periphery of the eye showed no extensive areas of capillary nonperfusion or neovascularization.FIG. 1: Red-free fundus photography of the right eye at presentation shows tortuosity and dilation of all branches of the central retinal vein, mild disc edema, a few scattered peripheral fundus hemorrhages, and good retinal capillary perfusion. These are features consistent with nonischemic central retinal vein occlusion.The patient had no personal or family history of eye disease, systemic hypertension, diabetes mellitus, thrombophilia, or malignancy. Systemic examination revealed a generalized livid discoloration of the skin in a net-like pattern all over the body except on the face (Fig. 2). The patient had noted the skin discoloration 13 days earlier.FIG. 2: Left hip shows livedo reticularis, a reddish netlike discoloration of the skin.Results of ultrasound studies of the heart and extracranial vessels as well as laboratory serology analyses were negative, including antinuclear antibodies (ANAs), antineutrophilic cytoplasmic antibodies (ANCAs), complement C3 and C4, antiphospholipid antibodies, and lupus anticoagulant, prothrombin time, antithrombin III, fibrinogen, protein C, protein S, and activated protein C resistance. Brain MRI showed an old cerebral infarction in the left basal ganglia. Aortic arch, neck, and brain MRA revealed no evidence of atherosclerosis or vasculitis. A skin and skeletal muscle biopsy revealed endothelial thickening in the small vessels of the subcutis without signs of vasculitis, consistent with Sneddon syndrome. The patient was treated with 400 mg intravenous pentoxifylline daily and 7,500 IU dalteparin sodium subcutaneously for 7 days, followed by 100 mg aspirin per day. On re-examination 3 months later, visual acuity had increased to 0.71 ETDRS lines (20/50 Snellen equivalent) for the right eye and remained at 0.9 ETDRS lines (20/30 Snellen equivalent) for the left eye. The right fundus revealed persisting optic disc swelling and retinal hemorrhages but a reduction in retinal edema. Repeated fluorescein angiography showed no signs of ischemia of the right eye. Sneddon syndrome, first described in 1965, is characterized by generalized livedo reticularis and stroke (1,2). The etiology of this syndrome is unknown, although there are correlations with the antiphospholipid syndrome, systemic secondary vasculitis, and coagulopathies. It may start as an inflammatory and possibly immunologically mediated disorder and lead to a proliferation of smooth cells of small blood vessels and obstruction of the vessel lumen. Although central retinal artery occlusion (3-5) and peripheral retinal capillary occlusions and neovascularization (6) have been reported previously in Sneddon syndrome, CRVO has not. It is unclear whether the CRVO in our patient was directly related to Sneddon syndrome. Tina Aggermann, MD Ludwig Boltzmann Institute for Retinology and Biomicroscopic Laser Surgery Department of Ophthalmology Rudolf Foundation Clinic Vienna, Austria [email protected] Paulina Haas, MD Ludwig Boltzmann Institute for Retinology and Biomicroscopic Laser Surgery Vienna Austria Susanne Binder, MD Ludwig Boltzmann Institute for Retinology and Biomicroscopic Laser Surgery Department of Ophthalmology Rudolf Foundation Clinic Vienna, Austria

Intravitreal Triamcinolone Improves Recovery of Visual Acuity in Nonarteritic Anterior Ischemic Optic Neuropathy

The visual outcome in untreated nonarteritic anterior ischemic optic neuropathy (NAION) is dismal. Because intravitreal triamcinolone (IVTA) has shown promise in improving edematous retinal disorders, a pilot trial of this therapy in NAION was considered reasonable. Four eyes of 4 patients with severe visual loss due to NAION were treated with 4 mg IVTA (study group). The control group consisted of 6 consecutive patients with NAION who received no treatment. Patients were evaluated by the visual acuity and visual field measurements of the Early Treatment Diabetic Retinopathy Study (ETDRS) and fluorescein angiography. All patients completed at least 9 months of follow-up. In the study group, the mean improvement in visual acuity were 4, 5.8, and 6.2 ETDRS lines at the first and third weeks and final visit, respectively. Optic disc swelling and leakage had markedly decreased at the first postinjection week and had disappeared by the third week examination in all eyes. In the control group, the mean improvements in visual acuity were 0, 0.7, and 1.3 ETDRS lines at the first and third weeks and final visit, respectively. Control eyes showed resolution of the optic disc swelling between the fourth week and third month visits. No marked change in visual field defects was observed in either group. IVTA provided relatively improved recovery of visual acuity and relatively rapid resolution of optic disc swelling in a small sample of patients with acute NAION. It did not provide visual field improvement. A larger trial is merited by the results of this small pilot study.

OCCULT WITH NO CLASSIC CHOROIDAL NEOVASCULARIZATION SECONDARY TO AGE-RELATED MACULAR DEGENERATION TREATED BY INTRAVITREAL TRIAMCINOLONE AND PHOTODYNAMIC THERAPY WITH VERTEPORFIN

To examine combined treatment with intravitreal triamcinolone acetonide (IVT) and photodynamic therapy (PDT) for occult with no classic choroidal neovascularization (CNV) secondary to age-related macular degeneration. In this prospective, interventional case series, 11 eyes of 10 consecutive patients with occult with no classic CNV underwent a single injection (25 mg) of IVT followed 1 month later by PDT. Best-corrected visual acuity was measured by Early Treatment Diabetic Retinopathy Study (ETDRS) protocol refraction. Median best-corrected visual acuity was 20/160, 20/80, 20/80, 20/50, and 20/80 at baseline and 1, 3, 6, and 12 months, respectively. Best-corrected visual acuity at baseline was statistically different (P < 0.05) than best-corrected visual acuity at 1, 3, and 6 months. Of 11 eyes, 5 (45.5%), 7 (63.6%), 7 (63.6%), and 4 (36.3%) had improved best-corrected visual acuity of at least 3 ETDRS lines at 1, 3, 6, and 12 months, respectively, while 6 (54.5%), 9 (81.8%), 10 (91%), and 8 (73%) had improved best-corrected visual acuity of at least 2 ETDRS lines at 1, 3, 6, and 12 months, respectively. Two eyes (18%) lost >3 lines at 12 months. One eye had intraocular hypertension at 3 months and was treated with a combination of topical antiglaucomatous drugs. One eye developed a dense cataract at the last follow-up visit. No endophthalmitis, retinal detachment, or vitreous hemorrhage developed. Fluorescein leakage and retinal thickness reduced significantly after treatment. Improvement of best-corrected visual acuity and lack of fluorescein leakage suggest combination treatment with IVT and PDT for occult with no classic CNV merits further investigation.

Visual Acuity and Macular Hole Size After Unsuccessful Macular Hole Closure

To evaluate the visual acuity, change in macular hole size, and change in subretinal fluid cuff size after unsuccessful macular hole closure. Forty-two consecutive eyes with macular hole and unsuccessful surgery for macular hole were studied. Preoperative and postoperative best-corrected visual acuities were tested according to the Early Treatment Diabetic Retinopathy Study (ETDRS) protocol, and changes were compared. Preoperative and postoperative fundus photographs were analyzed on a photograph documenter for changes in diameter of the macular hole and surrounding subretinal fluid cuff. Mean visual acuity decreased from 20/133 preoperatively to 20/154 postoperatively (mean loss, 0.79 ETDRS line). Mean diameter of the macular hole enlarged 22%; mean diameter of the visible surrounding subretinal fluid cuff enlarged 36%. A decrease in best-corrected visual acuity postoperatively was correlated with better preoperative visual acuity, earlier macular hole stage, and shorter duration. Enlargement in the diameter of the macular hole and fluid cuff did not correlate with better preoperative best-corrected visual acuity, earlier macular hole stage, or shorter duration. In 23 eyes that had failed previous surgery, macular hole surgery was anatomically successful in 17 (65%) (mean improvement, 3.7 ETDRS lines; mean best-corrected final visual acuity, 20/74). After macular hole surgery, anatomically unsuccessful closure of the hole correlates with small enlargements in the diameter of the macular hole and its surrounding subretinal fluid cuff, and with a slight decrease in visual acuity. Macular hole closure after repeat surgery improves visual acuity outcome in the majority of retreated eyes.

The results of vitreous surgery for chronic macular holes

To evaluate the visual and anatomic results of macular hole surgery in eyes that have had symptoms of a macular hole for 2 years or longer. Fifty-one eyes with chronic macular holes (> or = 2 years' duration) were treated in a retrospective analysis of the results of vitrectomy, 16% perfluoropropane gas tamponade, and one of three adjunctive agents (bovine transforming growth factor beta-2, recombinant transforming growth factor beta-2, or autologous platelet extract). Of 51 eyes, 45 (88.2%) were examined 3 months after surgery. Visual acuity of these 45 eyes was measured preoperatively and 3 months postoperatively using the Early Treatment Diabetic Retinopathy Study (ETDRS) visual acuity chart. Twenty-eight eyes (62.2%) had no prior vitrectomy and 17 eyes (37.8%) had a prior vitrectomy for the macular hole that failed. The macular holes had a mean duration of 3.7 years and were successfully closed in 32 of 51 total eyes (62.7%) and 32 of 45 eyes (71.1%) that were examined 3 months after surgery. The mean preoperative visual acuity was 20/100 -2 and the mean visual acuity at 3 months was 20/80 for a mean gain of 6.6 ETDRS letters (+ 1.3 lines). Of 45 eyes, 17 (37.8%) were 20/63 or better 3 months after surgery; 21 (46.7%) gained 2 or more ETDRS lines. There was no statistically significant difference in macular hole closure (P = 0.311) or visual acuity change (P = 0.095) in eyes with or without prior vitreous surgery. Eyes with macular holes between 2-2.99 years experienced a somewhat better anatomic and functional result overall than eyes with macular hole from 3-14 years, duration, but the visual acuity change was not statistically significant (P = 0.187). There was substantial variability in visual improvement among eyes with successful closure of the chronic macular hole. Macular holes of > or = 2 years' duration may be more difficult to close successfully than are more recent macular holes, and the visual improvement appears to be less favorable. Many eyes with chronic macular holes in our study gained substantial visual acuity, so vitreous surgery can be considered in selected eyes with chronic macular holes based on visual needs.

Reoperation after failed macular hole surgery.

The authors determined the anatomic and visual success rates of vitrectomy in patients who have failed previous macular hole surgery. Standardized Early Treatment Diabetic Retinopathy Study (ETDRS)-style best-corrected visual acuity was measured in each patient pre- and postoperatively. Surgery was performed at two centers using a standardized protocol, as previously reported, using 1330 ng bovine-derived transforming growth factor-beta 2 (TGF-beta 2) and 16% perfluoropropane internal gas tamponade. Endpoint analyses were conducted for anatomic closure of the hole, visual improvement of three or more ETDRS lines, and final visual acuity of > or = 20/63 and > or = 20/40. Forty-eight failing macular hole surgery were reoperated. The anatomic results showed closure of the hole in 40 (83%) cases at the end of the mean follow-up interval of 7.4 months. The visual acuity improved in greater than or equal to three lines in 52%, was > or = 20/63 in 54%, and was > or = 20/40 in 25% of reoperated eyes. The only factor associated with a better final visual acuity was preoperative visual acuity better than 20/80. Nuclear sclerosis leading to cataract extraction was observed in 13 (30%) of 43 initially phakic eyes. Macular hole closure was induced in this subset of reoperated patients. Visual improvement occurred often, although in a lower percentage than has been reported for primary surgical eyes. Repeat vitrectomy should be considered in patients with persistent macular hole after failure of primary surgery.