Ischemic Maculopathy Research Articles

Paracentral Acute Middle Maculopathy: A Case Report

Paracentral Acute Middle Maculopathy (PAMM) is an optical coherence tomography finding observed in patients with retinal capillary ischaemia. It is a type of ischaemic maculopathy that affects the intermediate and deep retinal capillary plexuses. PAMM has been associated with various retinal vascular disorders such as retinal artery and venous occlusions, diabetic retinopathy, sickle cell anaemia, and Purtscher retinopathy. It can also occur following a flu-like illness and transorbital compression. The authors present a case of a 37-year-old healthy female patient who exhibited signs and symptoms suggestive of PAMM a few days after experiencing a self-limiting flu-like illness.

Evaluation of Automated Measurement of Macular Ischemic Changes in Retinal Vein Occlusion With Optical Coherence Tomography Angiography.

The foveal avascular zone (FAZ) is altered in patients with retinal vein occlusion (RVO) and correlates inversely with visual acuity. Optical coherence tomography angiography (OCTA) is an imaging tool to visualize FAZ safely and easily. Automated measurements can facilitate interpretation of OCTA images. In this comparative cross-sectional study, we compare the results of manual measurement of the FAZ with automated measurement by built-in application (Metrix). The study included patients with RVO who underwent OCTA. Manual measurement was compared with automated evaluation by Metrix in 3 mm x 3 mm and 6 mm x 6 mm scan sizes and correlations of the circularity, circumference, and size of the FAZ were calculated. Forty-seven eyes were included in the study. A reliable measurement result in both Metrix 3 mm x 3 mm and 6 mm x 6 mm was found in only 25 of 47 eyes. The mean FAZ in these eyes by manual measurement was 0.50 mm2 compared with 0.20 mm2 and 0.24 mm2, respectively, by automated measurement. A statistically significant inverse correlation was found in both the automated 3 mm x 3 mm and 6 mm x 6 mm measurements for FAZ circumference with FAZ circularity but not FAZ area. The two automated measurements showed no significant bias regarding the size of the FAZ, but the plausibility of the data should be checked on a case-by-case basis. The manual measurements were higher, indicating limited agreement of manual and automated measurements. The information on circularity can point to ischemic maculopathy early in the course of the disease. [Ophthalmic Surg Lasers Imaging Retina 2023;54:462-469.].

OCT Angiography in Noninfectious Uveitis: A Description of Five Cases and Clinical Applications.

Optical coherence tomography angiography (OCTA) is a noninvasive imaging modality used to analyze the retinochoroidal vasculature and detect vascular flow. The resulting images can be segmented to view each vascular plexus individually. While fluorescein angiography is still the gold standard for the diagnosis of posterior uveitis, it has limitations, and can be replaced by OCTA in some cases. This case series describes five patients with posterior noninfectious uveitis and their description by OCTA. Cases included lupus retinopathy (n = 1) for which OCTA showed ischemic maculopathy as areas of flow deficit at the superficial and deep capillary plexus; choroidal granulomas (n = 1) with a non-detectable flow signal in the choroid; active punctate inner choroiditis and multifocal choroiditis (n = 1) with OCTA that showed active inflammatory chorioretinal lesions as non-detectable flow signals in choriocapillaris and choroid; dense type 2 inflammatory secondary neovascularization (n = 1) associated with active choroiditis; and acute posterior multifocal placoid pigment epitheliopathy (APMPPE) (n = 1) without flow abnormalities at the superficial and deep retinal plexuses but non-detectable flow at the levels of the choriocapillaris and choroid. Ophthalmologists can use OCTA to identify inflammatory changes in retinal and choroidal vasculature, aiding in the diagnosis, management, and monitoring of posterior uveitis.

Post-COVID ischemic maculopathy – A case report

We report a case of post-COVID ischemic maculopathy, which has not been seen previously in COVID-associated retinal findings. The patient presented with sudden onset loss of vision following COVID infection and was treated at a local hospital. Fundus examination revealed ischemic patches interspersed with blot hemorrhages around the macula. Fundus fluorescein angiography demonstrated delayed filling of macular vessels and nonperfusion of the macula. There were signs of hyperreflectivity of the nerve fiber layer and disorganization of the inner retinal layers with foveal atrophy on optical coherence tomography. The patient responded to steroids with improvement in visual acuity. Coronavirus disease 2019 can cause vascular events such as macular infarction in healthy young people.

Optical coherence tomography angiography versus fluorescein angiography in diagnosis of ischemic diabetic maculopathy

Objectives: To compare between the use of Fundus Fluorescein Angiography (FFA) and Optical Coherence Tomography Angiography (OCTA) in the diagnosis and quantification of diabetic macular ischemia (DMI) diagnosed according to the Early Treatment Diabetic Retinopathy Study (ETDRS) classification based on Foveal avascular zone (FAZ) parameters. Patients and Methods: The presented study is a prospective randomized observer blind observational study that included 40 eyes of 25 diabetic patients who were diagnosed as having ischemic diabetic maculopathy. Diabetic patients (type 1 or type 2) having different severities of diabetic retinopathy with and without previous treatment (laser or intravitreal injections). FA and OCTA images were independently graded by 2 observers that reached agreement regarding quantitative DMI according to established protocols. Quantitative analysis of the FAZ area was performed using custom software. Results: Demographic data of the studied cases were comparable between groups. OCTA images closely correlated with FA regarding area of FAZ (mm2).

English

BACKGROUND Screening of Diabetic retinopathy is essential for detection of diabetic retinopathy and its management. Diabetic retinopathy is a common and preventable cause of blindness in adults. Laser pan-retinal photocoagulation has been proven to have established efficacy in treating diabetic visual loss. Since India has a wide geographical area and there is a lack of trained ophthalmologists in peripheral India, there is an immense need for telemedicine in diabetic retinopathy screening. This study was done to evaluate the comparability of non-stereoscopic fundus photography with conventional fundoscopy for detection of diabetic maculopathy. METHODS All patients with diabetic retinopathy and mixed retinopathy presenting to Ophthalmology OPD at Sri Siddhartha Medical College between June 2020 and June 2021, were included in the study. The patients were evaluated for visual acuity on Snellen Visual Acuity Chart, Anterior Segment evaluation on a slit-lamp examination. Fundus was evaluated with 90 Diopter Volk lens with Slit Lamp biomicroscopy, Direct Ophthalmoscopy with Welch Allyn ophthalmoscope with medium size aperture, and the peripheral fundus was seen by an Indirect Ophthalmoscope with 20 Diopter lens Volk lens. ETDRS 7 Field Picture on Carl Zeiss Meditec AG VISUCAM SN model AA107 was taken. The observations were subjected to the statistical analysis of Cohen’s Kappa and the percentile description. RESULTS The commonest retinopathy was moderate non-proliferative diabetic retinopathy (NPDR), seen in 41.667 %. The commonest maculopathy found was the absence of maculopathy seen in 78.3 % of cases. There was perfect agreement (Kappa k-1.00) in the evaluation of background retinopathy on Conventional Fundoscopy and Fundus imaging, P-value < 0.001. There was moderate agreement (Kappa k-0.5) in the evaluation of maculopathy on Conventional Fundoscopy and Fundus imaging, Pvalue < 0.001, only for CSME and No maculopathy. However diffuse macular oedema and Ischemic Maculopathy were missed on Fundus Photography. CONCLUSIONS Non-Stereoscopic Fundus Photography is a good telemedicine tool for diabetic retinopathy screening, but there is under-diagnosis of it, though it can detect diabetic maculopathy. As a diagnosis”Absence of maculopathy” is inconclusive until and unless screened by Conventional Ophthalmoscopy. KEY WORDS Diabetic Retinopathy, Maculopathy, Clinically Significant Macular Oedema, NonStereoscopic Fundus Imaging, Ophthalmoscopy.

English

BACKGROUND The increased prevalence of diabetes mellitus (DM) worldwide has resulted in worsening diabetic retinopathy (DR) and nephropathy. The pathophysiological changes that occur at a cellular and anatomical level are similar in DR and DN. The risk factors for DR and DN are common hence investigating both is paramount to reduce morbidity. We wanted to study the association of diabetic retinopathy and diabetic nephropathy, their ophthalmic features, patterns of vision loss and extent of ocular morbidity. METHODS This is a retrospective observational study performed on 100 diabetic patients over 2 years. Patients with a confirmed diagnosis of DN based on clinical evaluation and laboratory tests were included. Ophthalmic evaluation and investigations were done and DR was classified based on early treatment diabetic retinopathy study (ETDRS). RESULTS Mild non-proliferative diabetic retinopathy (NPDR) occurred in 60 %, moderate to severe NPDR in 9 %, proliferative diabetic retinopathy (PDR) in 4 % and no diabetic retinopathy in 27 %. Macula was involved in 48 % with clinically significant macular edema (CSME) in 33 % and ischemic maculopathy in 5 %. Retinopathy occurred in 3 % after 5 years and in 40 % after 20 years of DM. The incidence of DN +DR was 65 % and statistical significance was noted with longer duration of diabetes, higher serum creatinine, proteinuria, lower haemoglobin, decreased GFR, higher age and higher lipid levels (P = 0.04). Improvement in vision was seen in 63 % after blood sugar control with laser photocoagulation, 27 % with laser alone and 7 % of patients with intravitreal anti-VEGF CONCLUSIONS DR and DN have an overlapping significant association and all patients have to be screened for both to prevent ocular morbidity. KEY WORDS Diabetic Retinopathy, Diabetic Nephropathy, Vision, Glomerular Filtration Rate, Macular Edema.

Diabetic Macular Edema

Diabetic macular edema (DME) is a chronic retinal disease, which requires intensive clinical monitoring. Within the last ten years the intravitreal anti-VEGF (vascular endothelial growth factor) therapy has become the standard of care to improve and stabilize vision in patients with centre involving DME. Long-acting intravitreal corticosteroids can achieve similar visual results with fewer injection rates. Because of steroid-induced side effects (progression of cataract, glaucoma) these drugs are regarded as second-line medication. Since the introduction of anti-VEGF-medication the focal laser photocoagulation is no longer considered as first-line therapy for DME. However, a focal laser treatment can sometimes be a possible alternative in specific situations. In patients with proliferative diabetic retinopathy and DME, the intravitreal anti-VEGF therapy is approved for both conditions. In ischemic maculopathy the functional outcome is restricted. For the indication of anti-VEGF-treatment for DME with accompanying central ischemia not only visual acuity and optical coherence tomography parameters should be considered, the amount of ischemia seen on fluorescein angiography should also be taken into account. In tractional macular edema due to epiretinal membranes and vitreomacular adhesions a pars-plana vitrectomy with membrane peeling is indicated.

Choroidal assessment in diabetic maculopathy

Background and aim Diabetic maculopathy is a leading cause of visual loss in diabetic patients. The choroid is the outer retina's primary source of oxygen and nourishment and the only blood supply to the avascular fovea. Angiopathy of the choroid seems to have a role in the pathophysiology and progression of diabetic maculopathy. It has been theorized that unexplained visual acuity loss in diabetic patients might be linked to diabetic choroidopathy. The aim of this study was to evaluate choroidal changes in eyes with diabetic maculopathy using optical coherence tomography. Patients and methods In all, 20 eyes of 10 normal individuals and 94 eyes of 50 diabetic patients suffering from diabetic maculopathy were recruited in this study. The diabetic patients were categorized according to the type of maculopathy as demonstrated by fluorescein angiography into four subgroups: the focal edema group, the diffuse edema group, the ischemic maculopathy group, and the mixed maculopathy group. Choroidal thickness was measured subfoveally, 1 mm away from the fovea nasally, temporally, superiorly, and inferiorly using optical coherence tomography. Results There was a significant difference among the different groups in all the measured regions (P=0.001). The more severe the maculopathy, the thinner the choroid in all the measured regions. Conclusion The results of this study suggest a negative relationship between macular choroidal thickness and severity of diabetic maculopathy.

Clinical Study of Risk Factors for Diabetic Maculopathy

Aim: To determine the association between various systemic risk factors with diabetic maculopathy. Methodology: A prospective observational study was conducted on 50 patients having diabetic maculopathy. Patients with maculopathies secondary to Vitreous Haemorrhage, Ocular disorders like Glaucoma, Uveitis, Advanced Diabetic Eye Disease, Vitreo-macular traction, maculopathy along with proliferative diabetic retinopathy, ischemic maculopathy, and history of laser treatment in last six months were excluded from the study. Data was collected using a structured proforma that included name, age, sex, occupation, height, weight, history of other systemic diseases like hypertension, investigations and treatment taken in past, family history, duration of DM, smoking, hyperlipidemia, hyperglycemia and nephropathy. Results: Out of 50 patients, 38 (76%) were males and 12 (24%) were females suggestive of male predominance. Mean age of the patient was 57.36±11.65 years in males and 56.67±10.17 years in females. Among 50 patients, 19 patients had diabetes mellitus for 6-10 years duration, 14 patients had diabetes mellitus for 1-5 years, in 12 patients for 11-15 years, in 2 patients for 16-20 years, in 2 patients for 21-25 years and only 1 patient more than 25 years. Mean duration of DM was 12.2±6.1 years. Majority of patients having maculopathy had duration of DM up to 20 years. Among 50 patients, 27 patients (54%) had systemic hypertension, 37 patients (74%) had uncontrolled blood sugar level, 29 patients (58%) were found to have hyperlipidemia and 20 patients (40%) had nephropathy. Among 50 patients, pseudophakia was noted in 7 patients (14%), obesity was noted in 21patients (42%). Eleven patients (22%) were found to have anemia, 6 patients (12%) had family history of DM and 13 patients (26%) had history of smoking. Conclusion: Hyperglycemia, hypertension, duration of DM, hyperlipidemia are the major risk factors for the development and progression of diabetic maculopathy. While anemia, smoking, and obesity, family history of DM are the less significant risk factors.

Managing Challenges of Phacoemulsification in Vitrectomized Eyes: A New Technique.

AIM:This study aimed to describe a novel approach to manage the challenges of phacoemulsification in vitrectomized eyes.METHODS:Intraoperative titrated intravitreal injection of balanced salt solution (BSS) through pars plana was done using a 30G needle hooked to a 1 cc syringe to build up the vitreous pressure.RESULTS:Five eyes of five patients who had previous vitrectomy were given intraoperative injection. This led to the prevention of lens–iris diaphragm retropulsion and routine completion of phacoemulsification. The preoperative visual acuity was < 6/60 in all patients. The postoperative visual acuity was 6/9 or better in all patients, except in one patient which was 6/60, which is explained by diabetic ischemic maculopathy. Neither injection-related intraoperative nor postoperative complications were noted.CONCLUSION:Challenges of phacoemulsification in vitrectomized eyes can be prevented by a simple titrated intraoperative injection of BSS intravitreally through pars plana.

Role of Rho kinase pathway in diabetic retinopathy: from a diabetic rat model to human eye pathology

AbstractDiabetic macular oedema is the main cause of visual loss in diabetic retinopathy, particularly in type 2 diabetic patients. The pathogenic mechanisms are not fully elucidated. Rho/Rock1 pathway is activated in diabetes and is responsible for cellular contraction. ROCK1 activation induces actin cytoskeleton remodeling. We hypothesized that Rho/Rock1 diabetes‐induced activation could contribute to cytoskeleton remodelling especially in retinal vessels subsequently altering retinal perfusion.MethodsWe used 12 months old Goto‐Kakizaki (GK) type 2 diabetic rats. Rho/Rhock1 pathway activation effects on retinal vasculature was analysed and ROCK inhibition by Fasudil administered into the vitreous was tested in rats in vivo on vascular perfusion.ResultsIn diabetic rats, activation of ROCK‐1 induces focal vascular constrictions, endoluminal blebbing and subsequent retinal hypoxia. Intraocular injection of fasudil, significantly reduces retinal hypoxia. Diabetes‐induced cell blebbing may contribute to ischemic maculopathy and represent an intervention target.

The Correlation between Macular Ischemia by Fundus Fluorescein Angiography and Spectral Domain Optical Coherence Tomography Findings in Diabetic Macular Edema

AbstractBackground: To study the association between the OCT structural changes, and vascular changes around the fovea in FFA in the detection of ischemic diabetic maculopathy.Material and Methods: A 35 eyes of 25 patients with ischemic and mixed diabetic maculopathy were included as determined by irregular margins of the FAZ in fluorescein angiography. We measured the best-corrected visual acuity (BCVA), central macular thickness, inner retinal layer thickness and the lateral extent of inner segment-outer segment (IS-OS) disruption on SD-OCT images, as well as the FAZ to optic nerve head (FAZ/ONH) area ratio using the Image J program.Results: The central macular thickness and the inner retinal layer thickness showed no significant correlation with FAZ/ONH area ratio (p=0.161, 0.480 respectively). The mean horizontal and vertical extents of IS-OS disruption were not significantly correlated with FAZ/ONH area ratio (p=0.630 and p=0.732 respectively. The horizontal and vertical extents of IS-OS disruption showed a significant correlation with Log MAR BCVA (r=0.798 and 0.795 respectively, p<0.001 in both). The FAZ/ONH area ratio was positively correlated with LogMAR BCVA but was not statistically significant (p=0.815, r=–0.041).Conclusion: In patients with diabetic retinopathy, it is not possible to predict FAZ area based solely on the measure-ments assessing volume and thickness or retinal structure evaluation on OCT. Consequently, at present OCT cannot replace FA in the detection of ischemic or mixed diabetic maculopathy.

ROCK-1 mediates diabetes-induced retinal pigment epithelial and endothelial cell blebbing: Contribution to diabetic retinopathy

In diabetic retinopathy, the exact mechanisms leading to retinal capillary closure and to retinal barriers breakdown remain imperfectly understood. Rho-associated kinase (ROCK), an effector of the small GTPase Rho, involved in cytoskeleton dynamic regulation and cell polarity is activated by hyperglycemia. In one year-old Goto Kakizaki (GK) type 2 diabetic rats retina, ROCK-1 activation was assessed by its cellular distribution and by phosphorylation of its substrates, MYPT1 and MLC. In both GK rat and in human type 2 diabetic retinas, ROCK-1 is activated and associated with non-apoptotic membrane blebbing in retinal vessels and in retinal pigment epithelium (RPE) that respectively form the inner and the outer barriers. Activation of ROCK-1 induces focal vascular constrictions, endoluminal blebbing and subsequent retinal hypoxia. In RPE cells, actin cytoskeleton remodeling and membrane blebs in RPE cells contributes to outer barrier breakdown. Intraocular injection of fasudil, significantly reduces both retinal hypoxia and RPE barrier breakdown. Diabetes-induced cell blebbing may contribute to ischemic maculopathy and represent an intervention target.

Clinical relevance of reduced decorrelation signals in the diabetic inner choroid on optical coherence tomography angiography

Diabetes induces lesions of the retinal and choroidal capillaries, which promote the pathogenesis of diabetic retinopathy (DR). The decorrelation signals in optical coherence tomography angiography (OCTA) represent the blood flow and vascular structure, and three-dimensional OCTA images enable individual capillary layers to be evaluated separately. The current study documented that en-face OCTA images revealed spots of flow void in the choriocapillaris layer in eyes with DR. Quantitative investigation demonstrated that non-flow areas within the central subfield (CSF) increased in eyes with more severe DR grades. The non-flow areas in the choriocapillaris layer were also associated with poorer visual acuity (VA) in all 108 eyes. A modest correlation was noted between the areas of flow void and poorer VA in 69 eyes without DME, whereas the non-flow areas were not related to VA or to CSF thickness measured by OCT in 39 eyes with DME. In 12 eyes with ischemic maculopathy, the choriocapillaris layer beneath the disrupted ellipsoid zone of the photoreceptor (EZ) had greater areas of flow void than did the area beneath an intact EZ. These data suggested that disrupted choroidal circulation has clinical relevance and contributes to the pathogenesis of DR.

Diagnostic value OF oct-angiography AND regional hemodynamic assesSment in patients with retinal vein occlusion

Introduction. Ischemic maculopathy is the main cause of irreversible vision loss due to retinal vein occlusion (RVO). Fluorescein angiography (FA), which is the gold standard for evaluating retinal capillary plexuses, does not allow for the visualization of separate intraretinal capillary networks. Optical coherence tomography angiography (OCT-angiography) enables the possible visualization of four capillary plexi and allows for the quantitative analysis of microcirculation to quantitatively estimate capillary network density and non-perfusion areas.&#x0D; Aim. To investigate microcirculation changes using OCT-angiography data and to compare the changes with opthalmoplethysmography indices in patients with RVO.&#x0D; Material and methods. The study included 12 patients with RVO. In all patients, a routine ophthalmic examination was performed, and ocular blood flow was estimated using FA, OCT-angiography, and ophthalmoplethysmography.&#x0D; Results. Ischemia in the macular area was detected in four patients (25%) according to FA results, and in eight (67%) accor ding to OCT-angiography data. Compared with the unaffected eye, significant decrease in the density of both superficial and deep capillary plexuses as well as a decrease in flow area and enlargement of foveal avascular zone were observed. A significant close direct correlation was established between capillary density in the superficial capillary plexus (r 0.8) and the deep capillary plexus (r 0.7), choroidal thickness, and opthalmoplethysmography indices (r 0.6).&#x0D; Conclusion. Compared with FA, OCT-angiography is a more sensitive method to detect macular capillary perfusion. In cases with RVO, the combination of the above mentioned methods with ophthalmoplethysmography allows for the comprehensive evaluation of regional hemodynamics.

Improvement in distance and near visual acuities using low vision devices in diabetic retinopathy

Purpose:The aim of this study is to elucidate the causes and level of visual impairment (VI) in patients with different pathologies of diabetic retinopathy (DR) who presented to a low vision care (LVC) clinic, to analyze the type of distant and near devices prescribed to them and the visual benefits thereof.Methods:A retrospective chart review was done for 100 consecutive patients with DR who were referred to the LVC clinic from June 2015 to June 2016. The reason for referral was assessed from the electronic medical records and available fundus photographs, fundus fluorescein angiograms, and optical coherence tomography images by a retina specialist. The details of low-vision devices and subsequent improvements were noted.Results:Of the 100 patients, 52% had moderate VI, 19% mild VI, 16% severe VI, and 13% had profound VI or blindness. The most commonly prescribed low vision device was half-eye spectacles (38.4%). The pathologies which had statistically significant improvement (P < 0.05) in distance vision with low vision devices were DR with disc pallor (4.4% improvement), ischemic maculopathy (11.9% improvement), and plaque of hard exudate (10.1% improvement). However, in all pathologies, there was statistically significant improvement (P < 0.05) in near vision.Conclusion:Usually, the patients with DR presented to the LVC clinic with moderate VI. The use of low vision devices can help these patients in cases where medical and surgical treatment have no or a limited role in restoring useful vision.

Outcomes of using intravitreal ranibizumab to treat patients with ischaemic diabetic maculopathy

PurposeTo report the functional and anatomical outcomes of using intravitreal ranibizumab (IR) for patients with ischaemic diabetic maculopathy (IDM).MethodsRetrospective analysis of 11 consecutive patients treated with IR for IDM from Nov 2008 to May 2015. The number of injections, fluorescein fundus angiography (FFA) results, visual acuity (VA) and central retinal thickness (CRT) prior to commencing IR were recorded. VA was assessed with logMAR.ResultsThree eyes were excluded as one had a history of vein occlusion, one was amblyopic and the other patient had multiple vitreous haemorrhages and vitrectomy.There were equal numbers of females and males, the average age was 67 (34–82 years) and patients had on average 5 (range 3–11) injections of IR. Average length of follow up was 13 months (5–18 months). On FFA 4 patients had enlargement of foveal avascular zone (FAZ), 1 patient had fragmentation of FAZ, 1 patient had deregulation of FAZ and 1 patient had an increase in FAZ. The average initial VA was +0.9 (+0.3 to +1.78) and the average final VA was +1.05 (+0.6 to +1.78). The average change between initial and final VA was +0.15. Initial average CRT was 558 (306–785) reducing to an average of 447 (197–892) at the final follow up. The average CRT reduction was 111 between initial and final CRT.ConclusionsAnatomical thickness appears to be reduced with IR injections, but without improvement in visual acuity. No adverse complications were noted with this regimen.

This issue of ACTA, printed and electronic

The cover illustration shows senile scleral plaques which is reported by Beck et al. in the electronic part of this issue of ACTA. Grzybowski points out that the various disciplines in medicine and science differ in size and that this effects the impact factor calculation. Scheerlinck et al. in the Netherlands found that the preoperative vision predicts postoperative visual acuity in many studies on epiretinal membrane surgery. OCT characteristics, metamorphopsia and autofluorescence may also have a prognostic role. Fernandes et al. in the United Kingdom and China reviewed smoking during pregnancy and vision difficulties in children. There were higher rates of strabismus, refractive errors and retinopathy among children of women who smoked during pregnancy. Leivo et al. in Helsinki describe a considerable risk of eye injury in sports, such as ice hockey and tennis. Klefter et al. in Denmark used motion-contrast velocimetry to study the regulation of retinal perfusion. Faber et al. in Denmark found increased plasma levels of tumour necrosis factor to be associated with age-related macular degeneration. They suggest that this supports low-grade inflammation. Knaapi et al. in Finland refine an old method to determine the actual size of retinal features on a fundus photograph. Carreno et al. in the United Kingdom, Australia and Spain describe panuveitis with nodular peripapillary changes in juvenile systemic granulomatous disease also known as Blau syndrome. Fledelius et al. in Copenhagen describe corneal deposits and abnormal vessel morphology in patients with Fabry disease. Holmström et al. in Sweden evaluated new Swedish guidelines for screening for retinopathy of prematurity and found the guidelines adequate. Zetterberg et al. in Sweden used anterior chamber angle surgery and in some cases tube implantation to treat paediatric glaucoma. Pärssinen et al. in Finland studied the prevalence of and changes in astigmatism from the onset of myopia at school age. They found that the prevalence and mean amount of refractive astigmatism associated with corneal astigmatism increased, and the axis of astigmatism changed among myopics during the 23-year follow-up. Koefoed et al. in Norway found that contrast sensitivity is not diminished by sleep deprivation. Talebizadeh et al. Uppsala describe the distribution of caspase-3 in the rat lens and suggest this enzyme may be involved in cataract formation. Mollazadegan and Lundström in Sweden analysed the relationship between patient-reported outcome measures and clinical outcome measures in 42 individual Swedish cataract surgery settings. For some clinics, up to 50% of the patients stated that they were very satisfied with their vision before surgery. The following articles are published electronically only. They are available on www.actaophthalmologica.com. On actaopthalmologica.com, you can find all the articles of this issue of ACTA and indeed all articles published in ACTA from the beginning. Eppig et al. in Germany found that the aberration-correcting intraocular lenses are associated with better contrast sensitivity. Beck et al. in Switzerland study senile scleral plaques with imaging and anterior segment OCT. They point out that these plaques have gained increased interest since the advent of intravitreal injections. These plaques are depicted on the cover of this issue of ACTA. Pérez-Rico et al. in Spain found the poor glucose control affects corneal biomechanics in patients with diabetes. Steinberg et al. in Germany and the United Kingdom validated a previously described algorithm as well as Scheimpflug tomography for the diagnose and classification of keratoconus. Rao et al. in India found that the spectral domain OCT imaging of the neuroretinal rim of the optic nerve did not adequately differentiate between glaucomatose and non-glaucomatose discs. Tanito et al. in Japan found no association between exfoliation and central retinal vein occlusion even when they used the LOXL1 gene as a marker for exfoliation. Maestroni et al. in Italy found that vasostatin-1 prevents choroidal neovascularization in mice. Zhang et al. in China found gene polymorphisms which are associated with increased risk of proliferative diabetic retinopathy in a Chinese population. Kessel et al. in Denmark review ocular injuries from ammonium hydroxide sprayed into eyes. Massamba et al. in France found that the pain associated with intravitreal injection was greater in the inferior quadrants of the eye and in the right eye. Rantala and Majander in Helsinki used OCT to image cornea plana. Iribarren et al. in Norway describe the loss of refractive power of the lens in early adulthood. Fleischman et al. in USA reviewed cerebrospinal fluid pressure trends in diseases associated with glaucoma. Sung et al. in Korea found OCT reliable in assessing nerve fibre layer thickness regardless of refractive error. Tanito et al. in Japan describe a bidirectional flow of aqueous following glaucoma tube surgery. Introini et al. in Italy describe ischaemic maculopathy associated with cocaine use. I hope that the current issue of ACTA provides pleasant and educational reading in your summer house and elsewhere.

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.