Retinal Fluorescein Angiography Research Articles

Expressions of survivin and vascular endothelial growth factor in a Murine model of proliferative retinopathy.

To examine the expression of survivin and vascular endothelial growth factor(VEGF) during the development of retinal neovascularization (NV) in a mouse model. A well-characterized murine model of retinal NV was used to study the expression of survivin and VEGF. NV of the retina was induced in mice by exposure to 75% O(2) from postnatal day P7 to P12, followed by return to room air from P12 to P17. Expression of survivin and VEGF protein was analyzed by Immunohistochemistry. In addition, mouse model of proliferative retinopathy was analyzed by retinal fluorescein angiography and quantification analysis. The normal mice had both superfiekal and deep vascular layers that extended from the optic nerve to the periphery. In intraocular pressure(IOP) mice were characterized by represent a typical pattern of pathological retinal NV. There are less or little nuclei of new vessels vascular endothelial cell breaking through the inner retinal than in retinopathy of prematurity (ROP) mice, large clusters of blood vessels were adherent to the internal limiting membrane(ILM) (0.27±0.20 vs 23.38±1.027, t=9.454, P<0.001). During the angiogenic period from P13 to P17, survivin and VEGF protein expression increased in experimental retinas compared with control samples(2.56±0.46 vs 3.34±0.40, t=17.43, P<0.01: 2.18±0.75 vs 4.34±0.25, t=19.61, P<0.01). Protein levels of VEGF and survivn has significantly positive correlation (P<0.05, r=0.411). Correlation was made at the protein levels of survivin expression compared with that of VEGF in a murine model of retinal NV, which suggests a temporal role for survivin and VEGF in new vessel formation in response to hypoxic stimulation.

Topographic assessment of retinal pigment epithelium detachment in central serous chorioretinopathy by three-dimensional optical coherence tomography single-layer retinal pigment epithelium map

This study aims to compare the topographic distribution of retinal pigment epithelium detachment (PED) in central serous chorioretinopathy (CSC) on spectral domain optical coherence tomography (SD-OCT) single-layer retinal pigment epithelium (SL-RPE) map and fluorescein angiography for the first time. Twenty-seven eyes of CSC with PEDs were studied retrospectively. Topographic distribution of PEDs was documented on 50° fluorescein angiography and SD-OCT SL-RPE map on macular cube 512 × 128. Quantity of PEDs ranged from 1 to 5 on SD-OCT SL-RPE map macular cube 512 × 128 and corresponding macular cube area on 50° fluorescein angiography. Topographic distribution of PEDs on SL-RPE map matched with PEDs on fluorescein angiography in the corresponding macular cube area, in all the cases (interobserver correlation = 0.9). SD-OCT SL-RPE map is a noninvasive, three-dimensional advanced tool for documentation of topographic assessment of PEDs and obviates the need of fluorescein angiography for monitoring CSC.

MULTIFOCAL ELECTROPHYSIOLOGIC FINDINGS AFTER INTRAVITREAL BEVACIZUMAB (AVASTIN) TREATMENT

To determine the short-term safety of intravitreal bevacizumab by multifocal electroretinography testing. Thirty-one eyes with choroidal neovascularization, proliferative diabetic retinopathy, and retinal vein occlusion received intravitreal bevacizumab (2.5 mg/0.1 mL). All patients underwent best-corrected visual acuity measurement, retinal fluorescein angiography, optical coherence tomography, and multifocal electroretinography at baseline and 1 month after the treatment. Subjects undergoing multifocal electroretinography testing had no statistically significant changes in electrophysiologic responses 1 month after the intravitreal injection of bevacizumab. Multifocal electrophysiologic testing did not demonstrate any short-term cone photoreceptor toxicity after intravitreal bevacizumab.

The dexamethasone drug delivery system for the treatment of retinal venous occlusion with cystoid macular edema

AbstractPurpose To report our case report with sustained‐release dexamethasone 0.7 mg intravitreal implant (Ozurdex®; Allergan, Inc., Irvine, CA) in retinal vein occlusion with macular edema.Methods A 67‐years old female patient with recent retinal vein occlusion with macular edema treated with sustained‐release dexamethasone 0.7 mg intravitreal implant was performed. On initial examination, the right best‐corrected visual acuity (BCVA) was 0,3. Right fundoscopy revealed dilatation and tortuosity of the retinal veins and retinal hemorrhage in the superior quadrant of the retina. The fluorescein retinal angiography showed a delay of filling time and spectral domain optical coherence tomography (Spectralis SD‐OCT; Heidelberg Engineering, Heidelberg, Germany) showed macular edema.Results The patient was treated with two intravitreal ranibizumab injections but two moths later the visual acuity was 0,2 and then we treated with sustained‐release dexamethasone 0.7 mg intravitreal implant and six moths later the right BCVA was improved to 0.7. Funduscopy and optical coherence tomography confirmed reduction of edema and tolerability of the implant was assessed.Conclusion The dexamethasone drug delivery system is one of the most recent additions to the armamentarium against macular edema, and is intriguing for its potency, dose consistency, potential for extended duration of action, and favorable safety profile. In patients with macular edema in retinal vein occlusion, sustained‐release dexamethasone 0.7 mg intravitreal implant may be an effective treatment option to control macular edema

Comparison of the use of minimized cardiopulmonary bypass with conventional techniques on the incidence of retinal microemboli during aortic valve replacement surgery

Minimized cardiopulmonary bypass (MCPB) circuits have been shown to reduce cerebral and retinal microembolisation during coronary artery bypass graft (CABG) surgery compared to conventional CPB (CCPB) circuits. Our aim was to evaluate whether the reduction of microembolisation is sustained in aortic valve surgery, as well as to evaluate the effects of MCPB on inflammatory, endothelial, and platelet activation markers. Patients were randomized to undergo aortic valve replacement (AVR), with or without CABG, with MPCB (n=20) or CCPB (n=20). After anaesthesia induction and termination of CPB, standardized digital retinal fluorescein angiography images were obtained on both eyes and analyzed in a blinded fashion. Blood samples were collected at eight time points until the third postoperative day. Fewer patients in the MCPB group showed evidence of microembolic perfusion defects on postperfusion retinal fluorescein angiographs compared to the CCPB group (37% vs. 63%, absolute difference 26%, 95% CI -5% -51%, P = 0.194). Polymorphonuclear leukocyte (PMN) elastase and von Willebrand factor release were statistically significantly reduced in the MCPB group, but there were no significant differences in other markers of inflammation, coagulation or endothelial activation. A significantly higher three-fold increase in the amount of shed blood was collected to the cell saver with a higher rate of intraoperative platelet transfusion in the MCPB group compared to CCPB. The use of MCPB was associated statistically insignificantly with less retinal microemboli compared to CCPB. MCPB was complicated by excess bleeding and need for transfusion. The feasibility of MCPB techniques in valve surgery requires further studies.

Implantation of ultrathin, biofunctionalized polyimide membranes into the subretinal space of rats

Subretinal implants aim to replace the photoreceptor function in patients suffering from degenerative retinal disease by topically applying electrical stimuli in the subretinal space. Critical obstacles in the design of high-resolution subretinal implants include the proximity of stimulating electrodes to the target cells and enabling nutrient flow between the retina and the choroid. The present work evaluates the adhesion, migration and survival of retinal cells on an ultrathin (5 μm), highly porous (Ø 1 μm spaced 3 μm), gelatin-coated polyimide (PI) membrane. The biocompatibility was examined in mice indicating a good tolerance upon subcutaneous implantation with only a mild inflammatory response. In addition, organotypic cultures of rat retina evidenced that the porous membrane allowed the necessary nutrient flow for the retinal cell survival and maintenance. A transscleral implantation technique was applied to position the membrane into the subretinal space of rats. The effect on the obtained retinal integration was investigated in vivo using scanning laser ophthalmoscopy (SLO) and optical coherence tomography (OCT). In 12 out of 18 rat eyes, the implant was successfully placed subretinally. SLO and OCT demonstrated complete retinal attachment and fluorescein angiography showed no retinal vascular abnormalities over and around the implant, immediately after and up to four weeks after the implantation. Histological examination of the eyes showed a close attachment of a thin fibrocyte layer to the implant, the occlusion of the pores by living cells and the survival of some photoreceptors at the implantation site.

Amelanotic choroidal melanoma

In February, 2010, a 43-year-old woman presented to our clinic complaining of visual floaters in her left eye for the previous 2 months. She had a history of systemic hypertension, but was currently not on medication. Our patient was otherwise healthy. On examination, her visual acuity was 20/20 in each eye. Anterior segment examination was unremarkable. Ophthalmoscopy of the left eye showed an amelanotic, vascularised choroidal lesion with a basal diameter of about 9·0×9·5 mm, located at the superotemporal vascular arcade. Vitreous condensations (floaters) were present in the vitreous cavity (figure A). The lesion presented a mushroom-shaped configuration that is typically seen when choroidal melanomas grow and cause rupture of the Bruch's membrane (figure B), which is the innermost layer of the choroid. Fluorescein retinal angiography revealed the characteristic double circulation within the lesion (figure C). Ultrasonography showed a lesion thickness of 5·7 mm, a medium to low internal reflectivity and choroidal excavation (figure D). The patient was diagnosed with a choroidal melanoma and underwent brachytherapy with an iodine-125 plaque. In February, 2010, a 43-year-old woman presented to our clinic complaining of visual floaters in her left eye for the previous 2 months. She had a history of systemic hypertension, but was currently not on medication. Our patient was otherwise healthy. On examination, her visual acuity was 20/20 in each eye. Anterior segment examination was unremarkable. Ophthalmoscopy of the left eye showed an amelanotic, vascularised choroidal lesion with a basal diameter of about 9·0×9·5 mm, located at the superotemporal vascular arcade. Vitreous condensations (floaters) were present in the vitreous cavity (figure A). The lesion presented a mushroom-shaped configuration that is typically seen when choroidal melanomas grow and cause rupture of the Bruch's membrane (figure B), which is the innermost layer of the choroid. Fluorescein retinal angiography revealed the characteristic double circulation within the lesion (figure C). Ultrasonography showed a lesion thickness of 5·7 mm, a medium to low internal reflectivity and choroidal excavation (figure D). The patient was diagnosed with a choroidal melanoma and underwent brachytherapy with an iodine-125 plaque.

Les vascularites rétiniennes : profils épidémiologiques, cliniques et étiologiques

To study the epidemiological and clinical features of noninfectious retinal vasculitis (NIRV). We analyzed 128 consecutive patients with NIRV, collected over 15 years (1993-2007) in an ophthalmological reference university hospital in Tunis, Tunisia. Data were analyzed regarding associated systemic disease, ocular syndromes, anatomic features (type and topography of vessel and type of capillaropathy), age and sex. The results of the etiologic work-up were based on the Levy-Clarke and Perez classification. A total of 240 cases of NIRV (128 patients) were collected (mean age: 32; sex ratio: 2.6). It was bilateral in 93.7% of cases. The mean visual acuity (VA) was 20/50 (range: 20/800-20/20). NIRV was mainly venous (84.1%), diffuse (57%), with a mixed capillaropathy (40.2%). There were complications in 56.25% of the cases, mainly macular edema (48.1%), vascular occlusion (25.9%), optic atrophy (22.2%) and cataract (19.2%). NIRV was idiopathic in 15.6% of the cases, characterized by a predominance of young subjects (mean: 38 years old), males (sex ratio: 4), VA at 20/25, and edematous periphlebitis in 100% of cases. There were ocular disorders in 12.5% of the cases and systemic disease in 72% of the cases, with a predominance of Behçet disease (BD): 53.9% of all patients and 81% of systemic disease with predominant venous features. In 48.3% of cases, VA was less than 20/200, due to BD in 48% of the cases. In NIRV, the etiologic work-up is oriented on anatomic presentation, based on fluorescein retinal angiography, and requires an interdisciplinary approach. In young adults with retinal phlebitis, BD is suggested first.

Combined intravitreal anti‐vascular endothelial growth factor (Avastin®) and photodynamic therapy to treat retinal juxtapapillary capillary haemangioma

Retinal capillary haemangioma complications are characterized by progressive exudation with consecutive intraretinal and subretinal leakage. A successful therapy without side-effects has not been found. We report a case of retinal juxtapapillary capillary haemangioma causing consecutive leakage with macular involvement. The tumour was treated with a combination of anti-vascular endothelial growth factor (VEGF) and photodynamic therapy (PDT) and was followed for 1 year. A 44-year-old woman with retinal juxtapapillary capillary haemangioma in the right eye experienced a decrease of visual acuity from 20/20 to 20/60 because of a severe leakage from the tumour involving the macula with lipid depositions. Two sessions of PDT (sparing the part of the haemangioma located within the optic disc) and five injections of bevacizumab were applied in a period of 5 months. Visual acuity, visual field testing, retinal thickness measurements, fundus photography and fluorescein angiography were performed to evaluate the treatment effect. One year after the last injection, visual acuity increased to 20/40. All lipid exudates at the posterior pole resolved. Retinal thickness decreased from 490 to 150 microm with the restoration of normal central macular architecture. Leakage in fluorescence angiography reduced significantly, but hyperfluorescence of the tumour was still evident. Visual field testing and angiography did not show any treatment-related vaso-occlusive side-effects. In this single case, the combination of anti-VEGF and PDT appeared to be an effective strategy for the treatment of retinal juxtapapillary capillary haemangioma without side-effects. Further studies with a greater number of eyes and adequate follow-up are necessary to support these first clinical results.

Triamcinolone-Associated Crystalline Maculopathy

To describe the findings of a new crystalline maculopathy exclusively affecting individuals who have previously received intravitreous triamcinolone acetonide injections. In a retrospective, observational, noncomparative case series, 21 eyes of 13 patients referred over a 9-year period were identified as having a characteristic crystalline maculopathy. Each patient underwent detailed historical questioning and comprehensive ocular evaluation, including formal retinal examination, fundus photography, fluorescein angiography, and optical coherence tomography. Each of the 21 eyes was treated with intravitreous triamcinolone (preserved in all but 2 eyes) for macular edema (18 eyes due to diabetes, 2 due to pseudophakic cystoid macular edema, and 1 due to a vein occlusion). The crystals were superficial, refractile, white or yellow-green, asymmetric in distribution, and deposited as a cluster in the central macula or in a perifoveal distribution. The crystals were benign and unassociated with visual deficit. Preretinal hyperreflective deposits were noted with optical coherence tomography. Two eyes underwent vitrectomy with membrane peeling, and the crystals were no longer present postoperatively. We describe a novel syndrome of crystalline maculopathy associated with a history of intravitreous triamcinolone injections. The crystals are refractile, multicolored, located in the posterior pole, and unassociated with obvious visual deficit or retinal sequelae. The predominantly white color and superficial location of the crystals indicate that they may result from aggregation and clumping of insoluble components of triamcinolone.

Apoptotic factors (Bcl-2 and Bax) and diabetic retinopathy in type 2 diabetes

The expression of apoptotic factors Bcl-2 and Bax were studied in the conjunctiva of diabetic patients with and without retinopathy. All patients underwent a complete ophthalmic examination including ocular fundus and retinal fluorescein angiography. The indirect immunoperoxidase method was performed on 15 normal conjunctiva taken during cataract surgery (group 1), on 40 eyes of 40 patients with type 2 diabetes without diabetic retinopathy (group 2) and 13 eyes of 13 patients with diabetic retinopathy (group 3). In normal human conjunctiva, Bax showed positive expression in epithelial, vascular and stromal cells whereas Bcl-2 staining was negative. In the conjunctiva of diabetic patients without diabetic retinopathy, Bax was widely, and strongly, expressed in epithelial cells, vascular endothelial cells, fibroblasts and infiltrating cells such as macrophages. For patients with diabetic retinopathy, Bax was consistently strong to very strong. Bcl-2 protein expression became weak to negative for diabetic patients both with and without diabetic retinopathy. Immunoreactivity was not correlated between Bcl-2 and Bax in the conjunctiva of diabetic patients. Bax was always localized in tissues characterized by a high rate of apoptosis, whereas, Bcl-2 was absent. Our results suggest that diabetic human conjunctiva, with its inflammatory phenomena, is considered as a privileged target for programmed cell death.

The Central Retinal Vein Bypass Study: A Trial of Laser-induced Chorioretinal Venous Anastomosis for Central Retinal Vein Occlusion

To evaluate the effectiveness of a laser-induced chorioretinal venous anastomosis (L-CRA) as a treatment for nonischemic central retinal vein occlusion (CRVO). Prospective, randomized, controlled, multicenter clinical trial. A total of 113 consecutive patients with a nonischemic CRVO of >3 months' duration and visual acuity of < or =20/50. Patients were randomized to L-CRA (58 patients) or conventional care (55 patients). They underwent standardized retinal photography, fluorescein angiography, and ophthalmic examinations, together with standardized assessments of best-corrected visual acuity, performed by masked visual acuity assessors using Early Treatment Diabetic Retinopathy Study protocols. Analysis was performed by intention-to-treat. The primary outcome measure was change in visual acuity at 18 months. Secondary outcomes were progression of retinal ischemia and rates of adverse events. A total of 53 control patients and 55 treatment patients completed the study. The 2 groups were comparable for age, age- and gender-adjusted mean visual acuity, and most other parameters. In the treated group of 55 patients, 42 (76.4%) developed an L-CRA. Over the 18-month follow-up period, treated eyes had an 8.3 letter mean improvement from baseline compared with control eyes (P = 0.03). Treated eyes that developed a functional L-CRA achieved an 11.7 letter mean improvement from baseline over the control group after 18 months (P = 0.004). Conversion to the ischemic CRVO category occurred in 20.8% of control eyes and in 9.6% of treated eyes overall (P = 0.33). Of the treated group who developed an L-CRA where the retinal ischemia was due to progression of the CRVO, 4.9% progressed to the ischemic category (P = 0.03). Neovascularization developed at the site of the L-CRA in 10 of 55 treated eyes (18.2%). Vitrectomy surgery was required by 5 of 55 treated eyes (9.1%) because of macular traction or nonresolving vitreous hemorrhage. Chorioretinal venous anastomosis was created in 76.4% of eyes with nonischemic CRVO in this study. Eyes that developed an anastomosis had a significant improvement (11.7 letters) in final visual acuity after 18 months, compared with eyes in the control group (P = 0.004). Complications were managed successfully with careful follow-up and early intervention.

Peripapillary Dark Choroid Ring as a Helpful Diagnostic Sign in Advanced Stargardt Disease

To investigate the prevalence of a peripapillary dark choroid ring on fluorescein angiography (FA) and the associated clinical features in patients with Stargardt disease. Retrospective review of 135 patients with Stargardt disease. The presence or absence of a peripapillary dark choroid ring on FA was noted and was compared with patient demographics and clinical features. Thirty-seven percent (50/135) had a peripapillary dark choroid ring on FA. When evaluated in subgroups, this sign was present in 41% (9/22) of patients with 2 causative ABCA4 mutations, in 28% (5/18) of patients with 1 causative ABCA4 mutation and a clinical diagnosis of Stargardt disease, and in 38% (36/95) of patients with a clinical diagnosis of Stargardt disease pending mutational analysis. Ninety-four percent (44/47) of patients for whom mutational testing confirmed the presence of ABCA4 mutations demonstrated a dark choroid sign. The peripapillary dark choroid ring sign was associated with diffuse flecks (P < .001), worse logarithm of the minimal angle of resolution visual acuity (P = .03), larger central scotoma size (P = .0146), and the presence of complete macular atrophy (P = .0017) compared with patients without this sign. The presence of a peripapillary dark choroid ring on FA should prompt further evaluation for Stargardt disease by examination of peripheral retinal FA images for a dark choroid sign, followed by subsequent ABCA4 mutation screening.

Peripapillary choroidal neovascularization associated with kenny syndrome.

To report a case of Kenny-Caffey syndrome with peripapillary choroidal neovascularization. An observational case report with clinical findings demonstrated by wide-field retinal photographic and angiographic evaluation of a patient with Kenny-Caffey syndrome. Wide-field retinal photography and fluorescein angiography showed characteristic findings seen in Kenny-Caffey syndrome (crowded optic nerves, retinal vascular tortuosity). In addition, the previously undocumented finding of peripapillary choroidal neovascularization is demonstrated. The development of peripapillary choroidal neovascularization can occur in patients with Kenny-Caffey syndrome. The development of this finding may be secondary to abnormalities of the optic nerve inherent in this rare disorder.

Retinal Angiography and Optical Coherence Tomography Disclose Focal Optic Disc Vascular Leakage and Lipid-Rich Fluid Accumulation Within the Retina in a Patient With Leber Idiopathic Stellate Neuroretinitis

A 52-year-old woman with clinical features of Leber idiopathic stellate neuroretinitis (LISN) underwent retinal fluorescein and indocyanine green angiography that revealed lipid-containing fluid leakage from a single arteriole in the superficial nerve fiber layer of the optic disc. The fluid expanded gradually into the upper half of the optic disc and the adjacent peripapillary retina. Optical coherence tomography (OCT) demonstrated fluid accumulation in two separate subretinal spaces and in the outer nuclear-plexiform layer, which extended from the optic disc margin to the fovea. These angiographic and OCT findings support the hypothesis that LISN develops from focally increased permeability of an optic disc surface arteriole from which lipid-rich fluid flows through the outer nuclear-plexiform layer space to pool in these retinal areas.

Serous retinal detachment caused by a choroidal metastasis treated with subtenon triamcinolone injection

Abstract Purpose Ocular metastases are becoming less and less rare. Choroidal metastases are recognized as the most common intraocular malignancy. Most ocular tumors metastasize from systemic origins in breast carcinoma in females, and bronchial carcinoma in males Methods CASE REPORT A 44 years‐old woman with an history of breast adenocarcinoma three years ago, who complained of visual disturbance of the left eye. On initial examination, the left best‐corrected visual acuity (BCVA) was 0,3. Left fundoscopy revealed several elevated yellowish masses with peripapillary serous retinal detachment. The fluorescein retinal angiography showed a choroidal lesion highly suggestive of choroidal metastasis Results The patient was treated with subtenon triamcinolone intection. Five moths later the left BCVA was improved to 0.8. Funduscopy and optical coherence tomography confirmed reduction of edema Conclusion CONCLUSIONS Subtenon triamcinolone inyection reduced subretinal edema. Optical coherence tomography (OCT) is useful in the follow‐up of choroidal metastasis after treatment. However, some limitations result from the choroidal location of the metastasis.

Serial retinal fluorescein angiography and immune therapy in Susac's Syndrome

We report a patient with Susac's disease presenting classically in a young female with an encephalopathy and visual disturbance with later deafness and tinnitus. Her encephalopathy settled, but subsequent serial fluorescein angiograms allowed sensitive monitoring of continuing sub-clinical disease activity, and provide evidence of a clear therapeutic response to immune suppression with tacrolimus (but not steroids alone) — and of a lack of efficacy of nimodipine and aspirin. We believe this single case study has both pathogenetic and useful practical implications: the apparently favourable response to immunosuppression lends support to the hypothesis that Susac's Syndrome is an immune-mediated disease; while the presence during symptomatic clinical remission of sporadic, multi-focal episodes of hyper-fluorescence, suggestive of breakthrough vasculopathy despite treatment, underlines the fact that the natural history of this rare condition is still not fully understood. Fluorescein angiography is proposed as a sensitive and important approach to the monitoring of sub-clinical disease activity, and so optimising immune suppressive treatment.

Loss of vision after anaesthesia for nonophthalmic surgery: a persistent problem

Loss of vision after anaesthesia for nonophthalmic surgery: a persistent problem

Anterior Ischemic Optic Neuropathy After Intravitreal Injection of Bevacizumab

Bevacizumab, an anti-vascular endothelial growth factor (VEGF) agent widely used for intravitreal treatment of neovascular and exudative ocular diseases, is generally free of complications, but lens injury, endophthalmitis, retinal detachment, subconjunctival hemorrhage, cataract progression, acute vision loss, central retinal artery occlusion, new or progressive subretinal hemorrhages, and tears of the retinal pigment epithelium have been reported (1). We describe a case of nonarteritic ischemic optic neuropathy (NAION) after intravitreal injection of bevacizumab, a complication not heretofore reported. A 72-year-old woman presented with vision loss in her right eye from exudative age-related macular degeneration (ARMD). She had had an episode of NAION 10 years earlier in the right eye. Best-corrected visual acuity was light perception in the right eye and finger counting at 1 m in the left eye. An afferent pupillary defect was present in the right eye. Intraocular pressures were 12 mmHg in both eyes. Slit-lamp examination was unremarkable except for a nuclear cataract in both eyes. Fundus examination and retinal fluorescein angiography revealed optic disc pallor and dry ARMD in right eye and an active subfoveal choroidal neovascularization in left eye (Fig. 1).FIG. 1: Fluorescein angiography performed 14 days before intravitreal bevacizumab injection shows optic disc hypoperfusion andmacular pigmentary changes in the right eye and a classic subfoveal choroidal neovascular membrane in the left eye (arrow).The left eye underwent an intravitreal injection of 2.5 mg/0.1 mL bevacizumab. Four weeks later, visual acuity was light perception in the right eye and finger counting at 2 m in the left eye with decreased activity of the neovascular complex. Two weeks later, she underwent an additional intravitreal injection of 2.5 mg/0.1 mL bevacizumab. One week after the injection, she reported visual loss in the left eye on awakening. On our examination, visual acuity was light perception in both eyes. Intraocular pressure was normal. Pupils were sluggishly reactive without afferent defect. The left optic nerve was now edematous with peripapillary hemorrhages (Fig. 2). She reported no symptoms of giant cell arteritis. Results of laboratory tests, including complete blood count, erythrocyte sedimentation rate, and serum C-reactive protein, were within the normal range.FIG. 2: Fundus photography and fluorescein angiography of the left eye performed 8 days after intravitreal bevacizumab injection show disc swelling with adjacent splinter hemorrhages and blockage of the peripapillary background fluorescence.Risk factors of NAION include crowding of the optic disc, systemic hypertension, diabetes, smoking, hyperlipidemia, and surgery (2). We propose the following possible mechanisms for NAION in our patient: Impaired autoregulatory and microcirculatory mechanisms of optic nerve circulation due to pan-VEGF blockade. The exact mechanism responsible for blood flow autoregulation in the optic nerve remains enigmatic (3). Recent studies have shown that vascular endothelial vasoactive agents play an important role in modulating the local vascular tone and perhaps in blood flow autoregulation (3). Impaired autoregulation of the optic disc circulation by atherosclerosis, with a possible contribution from serotonin and endothelin-mediated vasospasm, may play a role in the pathogenesis of idiopathic NAION (4). Inhibition of VEGF may influence this autoregulation in the microcirculation. In addition, a sudden drop in effective VEGF concentration may be responsible for closure of normal capillaries (5). Transient intraocular pressure (IOP) elevation after intravitreal injection of bevacizumab. A transient increase in IOP can lead to ischemia of the optic nerve head because of a decrease in perfusion pressure (6). Elevations in IOP immediately after intravitreal injections are common (7). However, this mechanism seems less likely because NAION occurred 7 days after the injection. The NAION is an incidental occurrence. The risk of fellow eye involvement in NAION is 15-24% within 5 years (8). Because our patient had an attack of NAION in right eye, she was susceptible to this event in the fellow eye. Given the widespread use of intravitreal anti-VEGF agents, a possible effect of VEGF blockade on optic nerve circulation merits further exploration. Hamid Hosseini, MD Mohammad Reza Razeghinejad, MD Poostchi Ophthalmic Research Center Shiraz University of Medical Sciences Shiraz, Iran [email protected]

Central Retinal and Posterior Ciliary Artery Occlusion After Intralesional Injection of Sclerosant to Glabellar Subcutaneous Hemangioma

The aim of this study is to describe vision loss caused by central retinal artery and posterior ciliary artery occlusion as a consequence of sclerotherapy with a polidocanol injection to a glabellar hemangioma. An 18-year-old man underwent direct injection with a 23-gauge needle of 1 mL of a polidocanol-carbon dioxide emulsion into the glabellar subcutaneous hemangioma under ultrasound visualization of the needle tip by radiologists. He developed lid swelling the next day, and 3 days later at referral, the visual acuity in the left eye was no light perception. Funduscopy revealed central retinal artery occlusion and fluorescein angiography disclosed no perfusion at all in the left fundus, indicating concurrent posterior ciliary artery occlusion. The patient also showed mydriasis, blepharoptosis, and total external ophthalmoplegia on the left side. Magnetic resonance imaging demonstrated the swollen medial rectus muscle. In a month, blepharoptosis and ophthalmoplegia resolved but the visual acuity remained no light perception. Sclerosing therapy for facial hemangioma may develop a severe complication such as permanent visual loss.