Pseudophakic Macular Edema Research Articles

OPTICAL COHERENCE TOMOGRAPHY BIOMARKERS TO DISTINGUISH DIABETIC MACULAR EDEMA FROM PSEUDOPHAKIC CYSTOID MACULAR EDEMA USING MACHINE LEARNING ALGORITHMS.

In diabetic patients presenting with macular edema (ME) shortly after cataract surgery, identifying the underlying pathology can be challenging and influence management. Our aim was to develop a simple clinical classifier able to confirm a diabetic etiology using few spectral domain optical coherence tomography parameters. We analyzed spectral domain optical coherence tomography data of 153 patients with either pseudophakic cystoid ME (n = 57), diabetic ME (n = 86), or "mixed" (n = 10). We used advanced machine learning algorithms to develop a predictive classifier using the smallest number of parameters. Most differentiating were the existence of hard exudates, hyperreflective foci, subretinal fluid, ME pattern, and the location of cysts within retinal layers. Using only 3 to 6 spectral domain optical coherence tomography parameters, we achieved a sensitivity of 94% to 98%, specificity of 94% to 95%, and an area under the curve of 0.937 to 0.987 (depending on the method) for confirming a diabetic etiology. A simple decision flowchart achieved a sensitivity of 96%, a specificity of 95%, and an area under the curve of 0.937. Confirming a diabetic etiology for edema in cases with uncertainty between diabetic cystoid ME and pseudophakic ME was possible using few spectral domain optical coherence tomography parameters with high accuracy. We propose a clinical decision flowchart for cases with uncertainty, which may support the decision for intravitreal injections rather than topical treatment.

Cystoid macular edema with prostaglandin analogue use after uneventful cataract surgery in glaucoma patients

To evaluate the effect of postoperative latanoprost administration on central macular thickness (CMT) after uneventful cataract surgery in glaucoma patients. Farabi Eye Hospital, Tehran, Iran. Prospective randomized clinical trial. In this single-masked trial, glaucoma patients treated with latanoprost who had no other risk factor for the development of pseudophakic macular edema were randomly allocated to continuation of latanoprost or discontinuation of the drop after uneventful cataract surgery. At baseline and postoperatively at 1month and 3months, patients had complete ocular examinations and CMT measurements using optical coherence tomography. The main outcome measure was the change in the CMT between baseline measurements and postoperative measurements at 1month and 3months. One hundred fifty-six eyes (latanoprost 76; discontinuation 80) finished the trial. There were no differences in baseline patient demographics or characteristics, including the CMT, between the two groups. There was transient increase in the mean CMT by 12μm±49 (SD) in the latanoprost group at 1month (P=.03); however, the value returned to baseline by 3months (6±55μm; P=.27). The between-group difference in the mean change in the CMT from baseline was -3.1μm (95% confidence interval [CI], -18.4 to 12.0; P=.68) after 1month and -10.5μm (95% CI, -26.6 to 5.5; P=.19) after 3months; the differences were not significant. Latanoprost administration after cataract surgery had no measurable effect on macular thickness.

Development of "Predict ME," an online classifier to aid in differentiating diabetic macular edema from pseudophakic macular edema.

Differentiating the underlying pathology of macular edema in patients with diabetic retinopathy following cataract surgery can be challenging. In 2015, Munk and colleagues trained and tested a machine learning classifier which uses optical coherence tomography variables in order to distinguish the underlying pathology of macular edema between diabetic macular edema and pseudophakic cystoid macular edema. It was able to accurately diagnose the underlying pathology in 90%-96% of cases. However, actually using the trained classifier required dedicated software and advanced technical skills which hindered its accessibility to most clinicians. Our aim was to package the classifier in an easy to use web-tool and validate the web-tool using a new cohort of patients. We packaged the classifier in a web-tool intended for use on a personal computer or mobile phone. We first ensured that the results from the web-tool coincide exactly with the results from the original algorithm and then proceeded to test it using data of 14 patients. The etiology was accurately predicted in 12 out of 14 cases (86%). The cases with diabetic macular edema were accurately diagnosed in 7 out of 7 cases. Of the pseudophakic cystoid macular edema cases, 5 out of 6 were correctly interpreted and 1 case with a mixed etiology was interpreted as pseudophakic cystoid macular edema. Variable input was reported to be easy and took on average 7 ± 3 min. The web-tool implementation of the classifier seems to be a valuable tool to support research into this field.

RESPONSE OF INFLAMMATORY CYSTOID MACULAR EDEMA TO TREATMENT USING ORAL ACETAZOLAMIDE.

To determine the treatment effect of oral acetazolamide on refractory inflammatory macular edema. A retrospective review of identified patients with uveitic or pseudophakic macular edema treated using acetazolamide between 2007 and 2014. Visual acuity and central macular subfield thickness was determined at baseline and at first follow-up. Baseline optical coherence tomography features were analyzed as predictors of acetazolamide response. Sixteen patients (19 eyes) of 61 screened met all criteria. Mean age was 57.9 years (19.7-81.1). The most common diagnosis was idiopathic uveitis (n = 6, 31.6%). Mean uveitis duration was 4.4 years (0.2-27.5). Average central macular subfield thickness decreased significantly (from 471.8 ± 110.6 μm to 358.3 ± 50.4 μm) (P < 0.0001). Average visual acuity (logarithm of the minimum angle of resolution) improved significantly from 20/54 (0.43 ± 0.25) to 20/37 (0.27 ± 0.16) (P = 0.003). Pretreatment optical coherence tomographies demonstrated intraretinal fluid (n = 19, 100%), subretinal fluid (n = 8, 42.1%), epiretinal membrane (n = 13, 68.3%), and vitreomacular traction (n = 1, 5.2%). No optical coherence tomography characteristic was predictive of a response to therapy. There is a significant benefit to vision and central macular subfield thickness after acetazolamide treatment in patients with inflammatory macular edema. In patients with refractory inflammatory macular edema, treatment using acetazolamide can provide anatomical and visual benefit without corticosteroid-related adverse effects.

Comparison of topical nepafenac 0.1% with intravitreal dexamethasone implant for the treatment of Irvine-Gass syndrome.

To compare safety and efficacy of intravitreal dexamethasone (IVD) implant with topical nepafenac (TN) 0.1% in previously untreated Irvine-Gass syndrome (IGS) in clinical practice. This was a retrospective study of 62 eyes with IGS after phacoemulsification with posterior chamber intraocular lens (IOL) implantation. None of the patients used treatment before IVD or TN. Best-corrected visual acuity (BCVA) with Early Treatment Diabetic Retinopathy Study chart (ETDRS), slit-lamp, intraocular pressure (IOP) measurement, fundus examination, spectral-domain optical coherence tomography (OCT) and fundus florescein angiography were performed to all subjects at baseline, 1, 3 and 6mo. The mean BCVA of the IVD group was 49.3±6.8, and the mean BCVA of the TN group was 32.9±7.3 ETDRS letters in post-treatment month 6. The mean central macular thickness (CRT) of IVD group was 266.6±53.5 µm and the mean CRT of TN group was 364.9±56.3 µm in post-treatment month 6. Baseline BCVA has correlation with final BCVA in TN group however there was no correlation between baseline BCVA and final BCVA in IVD group. IVD is found to be better than TN in controlling pseudophakic macular edema and improving visual acuity. IVD group also has significantly lower CRT however IOP is not significantly different between two groups in post-treatment month 6.

MACULAR EDEMA AFTER CATARACT SURGERY IN EYES WITH PREOPERATIVE RETINAL VEIN OCCLUSION.

To evaluate the incidence of pseudophakic macular edema (PME) in eyes with a history of retinal vein occlusion before cataract surgery and to identify any associated risk factors. The records of 21,332 eyes that underwent cataract surgery were retrospectively reviewed. Eyes that had retinal vein occlusion preoperatively with no evidence of macular pathology on optical coherence tomography at the time of surgery and no macular edema treatment at least 6 months before surgery were included. Eyes with diabetes or diabetic retinopathy, those with a history of previous intraocular surgery or with intraoperative complications, and those administered glaucoma and nonsteroidal antiinflammatory eye drops were excluded. Pseudophakic macular edema developed in 31 (27.4%) of 113 eyes within 3 months of cataract surgery. Mean visual acuity for eyes with PME (0.48 logarithm of the minimum angle of resolution [logMAR; 20/60 Snellen equivalent]) at 3 months after surgery was significantly worse than that for eyes without PME (0.28 logMAR; 20/38, P = 0.020). However, there was no significant difference in the visual acuity between the 2 groups 6 months after the surgery. Taking into consideration various baseline factors, a history of previous treatment of macular edema was significantly associated with an increased risk of PME (odds ratio, 11.022; 95% confidence interval, 7.258-17.712; P = 0.009). A higher number of intravitreal injections used to treat macular edema also significantly increased the risk of PME (odds ratio, 1.902; 95% confidence interval, 1.032-4.227; P = 0.031). Pseudophakic macular edema frequently developed after phacoemulsification cataract surgery in patients with a history of retinal vein occlusion. The risk of PME further increased when the patient had undergone macular edema treatment and had a higher prevalence of intravitreal injection treatment.

Nepafenac in the Treatment of Ocular Inflammation Following Cataract Surgery (Pseudophakic Macular Oedema) – an Update

Cataract surgery is a hugely important means of preventing poor-quality vision or vision loss, especially in the elderly and people with diabetes. Pseudophakic macular oedema (PMO) is a comparatively infrequent complication occurring in 0.2–2.35% of patients, but the increasing scale of cataract surgeries worldwide makes it a widespread and significant problem. PMO can affect vision and, if untreated, can damage the retina and, less commonly, cause pain. Effective and convenient treatment for PMO, therefore, is an important issue. The pathophysiology of PMO is not fully understood, but may result from multiple factors including traction, irritation and disturbance of the blood-retinal barrier, leading to secretion of inflammatory factors which affect the posterior segment. Among the non-steroidal anti-inflammatory drugs used in the management of PMO is nepafenac (NPF). NPF is a unique prodrug and use of the 0.1% formulation given three times daily is supported by several key phase II and III clinical trials, in which prophylactic use resulted in lower incidence of PMO, better visual outcomes and lower central subfield macular thickness than vehicle alone. Several studies have also shown that 0.1% NPF provided superior efficacy compared with bromfenac, fluorometholone or ketorolac in the treatment of PMO. More recently, a 0.3% NPF formulation has been developed to provide more convenient once daily dosing. A phase III trial (n=819) showed that 0.3% NPF was non-inferior to 0.1% NPF in terms of inflammation and proportion or patients who were pain-free with similar safety profiles for both doses. Other evidence from phase II and III vehicle-controlled, non-comparative trials also indicate the equivalence of frequent 0.1% NPF and the less frequent 0.3% NPF dosing. Greater use of the more convenient 0.3% NPF formulation may help improve patient adherence and consequently provide better outcomes in PMO.

Pseudophakic Macular Edema in Primary Open-Angle Glaucoma: A Prospective Study Using Spectral-Domain Optical Coherence Tomography

To determine the incidence of and risk factors for pseudophakic macular edema (PME) after uncomplicated cataract surgery in primary open-angle glaucoma (POAG) using spectral-domain optical coherence tomography (SDOCT). Cohort study. Macular retinal thickness was evaluated using SDOCT at 1week before surgery and at 1, 3, 6, and 12months postoperatively, in 70 POAG and 68 control eyes. Forty-three healthy subjects without impaired vision or cystoid PME were recruited separately as pilot samples to define significant PME. Significant PME was defined as an increase in the average thickness exceeding the mean+ 3 standard deviations of the increase shown in the pilot samples. Significant PME (increase in the foveal 3-mm zone thickness of >19.5μm) was observed in 31 (44%) eyes with POAG and in 14 (21%) control eyes (P=.003). The extent of PME was maximal at 3months postoperatively and decreased gradually until 12months. Regression tree analysis revealed that the risk of PME was the greatest in the POAG group using prostaglandin analogue (PGA) (odds ratio [OR]= 5.51), followed by POAG not using PGA (OR= 1.70), and control group (OR= 1.0). Risk factors for PME were younger age in all groups (OR= 1.07), systemic hypertension in PGA users (OR= 6.42), higher untreated IOP in PGA nonusers (OR= 1.09) and male sex (OR= 14.06) and diabetes mellitus (OR= 16.71) in the control group. The incidence of PME as observed by SDOCT was higher than previously reported after uncomplicated cataract surgery. Eyes with POAG were at greater risk for PME, which was mainly associated with perioperative PGA use.

Risk Factors and Incidence of Macular Edema after Cataract Surgery: A Database Study of 81984 Eyes

To define the incidence of pseudophakic macular edema (PME) after cataract surgery and to identify contributory risk factors. Retrospective database study of electronic medical records (EMRs). A total of 81984 eyes undergoing cataract surgery between December 2010 and December 2014 from 8 independent United Kingdom clinical sites. Structured clinical data mandated by the EMR were anonymized and extracted for each eye undergoing cataract surgery including: perioperative visual acuity, copathologic features, simultaneous surgical procedures, and the presence or absence of a specified list of intraoperative complications. Diabetic status with matched Early Treatment Diabetic Retinopathy Study (ETDRS) grading also was mandated by the EMR. Eyes receiving prophylactic nonsteroidal anti-inflammatory drugs were excluded. Diagnosis of cystoid macular edema or new-onset macular edema in patients with diabetes, recorded by a healthcare professional within 90 days of surgery. Baseline incidence of PME in eyes without operative complications, diabetes, or risk factors was 1.17%. Eyes in which PME developed were more likely to be male, older, and to demonstrate risk factors. The relative risk (RR) was increased in eyes with capsule rupture with or without vitreous loss (RR, 2.61; 95% confidence interval [CI], 1.57-4.34), a previous diagnosis of epiretinal membrane (RR, 5.60; 95% CI, 3.45-9.07), uveitis (RR, 2.88; 95% CI, 1.50-5.51), retinal vein occlusion (RR, 4.47; 95% CI, 2.56-5.92), or retinal detachment repair (RR, 3.93; 95% CI, 2.60-5.92). High myopia, age-related macular degeneration, or prostaglandin analog use were not shown to increase risk. Eyes with PME on average had poorer postoperative visual acuity, which persisted to the latest time point assessed, up to 24 weeks. Eyes from patients with diabetes, even in the absence of retinopathy, had an increased RR (RR, 1.80; 95% CI, 1.36-2.36) of new macular edema after surgery. The risk was higher in the presence of any diabetic retinopathy (DR; RR, 6.23; 95% CI, 5.12-7.58) and rose proportionately with increasing severity of DR. Pseudophakic macular edema occurs commonly after phacoemulsification cataract surgery, even in the absence of complications and risk factors. This large retrospective study using structured EMR data quantified the RRs of PME and the risk with increasing ETDRS severity of DR. It highlights the need for prophylactic therapy, especially in those groups of eyes with the highest RRs.

Resolution of postoperative macular hole with topical nepafenac: a case report

PurposeMacular hole (MH) is a rare complication of cataract extraction. Various etiologies are discussed but it seems that the combination of vitreous traction and pseudophakic macular edema are the causes most likely involved in its pathogenesis. Pars plana vitrectomy (PPV) and internal limiting membrane peeling is the gold standard treatment option for patients with postoperative MH. Medical treatment has not been very effective in resolving this pathology. We present a case of post‐surgical MH treated with topical Nepafenac.MethodsInterventional case report showing the role of topical Nepafenac as a therapeutic tool in post‐surgical MH.ResultsAn 81‐year‐old female with a history of uncomplicated cataract surgery in RE. Four weeks after surgery there was a progressive visual deterioration with a best corrected visual acuity (BCVA): 0.05. SD‐OCT revealed a full‐thickness MH. Nepafenac 0.1 mg/ml, 3 times a day, was administered for 8 weeks in RE. Four months later, an improvement of her visual acuity (BCVA: 0.4) and a recovery of the retinal structure were observed. No recidive has been observed in a follow‐up of 1 year.ConclusionsWe propose the therapeutic use of topical NSAIDs as a possible alternative to surgery for macular holes whose etiology is related to inflammatory processes.

Dexamethasone implant as an effective treatment option for macular edema due to Irvine-Gass syndrome

To investigate the effectiveness and safety of a dexamethasone implant (Ozurdex) to treat pseudophakic macular edema (Irvine-Gass syndrome). Department of Ophthalmology, Ludwig-Maximilians-University Munich, Munich, Germany. Prospective nonrandomized study. Preoperatively and in 12 monthly postoperative intervals, a complete ophthalmic examination was performed in study patients, including measurement of corrected distance visual acuity (CDVA) using the standard Early Treatment Diabetic Retinopathy Study chart, intraocular pressure, foveal thickness using spectral-domain optical coherence tomography (SD-OCT), and retinal sensitivity (mean defect depth) using microperimetry. Morphological aspects of the inner segment-outer segment junction and visual function were correlated. Twenty-three eyes (23 patients) with pseudophakic macular edema after uneventful cataract surgery were included. The mean duration of macular edema before treatment with a dexamethasone implant was 5.4 months (range 2 to 8 months). The CDVA increased in all patients from 30.2 letters ± 4.3 (SD) at baseline to 50.4 ± 4.9 letters at 12 months (P = .0016), regardless of the time of macular edema duration. Foveal thickness decreased from 520.8 ± 71.4 μm to 232.7 ± 26.6 μm (P < .002). Retinal sensitivity (mean defect depth) increased significantly over a 12-month follow-up, correlating positively with a restored inner segment-outer segment junction on SD-OCT analyses. No relevant adverse events were reported, and 9 recurrences occurred with a peak after 3 months and required a second dexamethasone implant injection. The dexamethasone implant was safe and effective in treating pseudophakic macular edema regardless of the duration of the edema. Drs. Mayer and Haritoglou are consultants to Allergan, Inc. No author has a financial or proprietary interest in any material or method mentioned.

Study of the effect of intravitreal dexamethasone implant in pseudophakic macular edema. Preliminary

ObjectiveTo evaluate the efficacy of intravitreal dexamethasone implant on the treatment of pseudophakic macular edema (PME). Materials and methodsA retrospective, observational, descriptive study was conducted on 4 patients who received an intravitreal injection of dexamethasone implant due to PME in the period from 1st January 2013 to 31st December 2013 in the Hospital Universitario de La Ribera (Alzira, Valencia, Spain). A complete ophthalmic examination was performed on these patients. Best-corrected visual acuity (BCVA), macular thickness, and duration of the effect of the treatment were studied. ResultsAt baseline, the mean MT was 414μm. After dexamethasone implant, mean values of MT decreased to 330.25μm at month one. The mean change from baseline MT was 83.75μm. The baseline mean BCVA was 0.3 and improved to 0.575 at month one and 3. The mean duration of the effect of the treatment was 3.5 months. ConclusionsIntravitreal dexamethasone implant is a possible treatment for Irvine-Gass syndrome as it improved visual acuity and reduced the macular thickness of these patients.

Estudio de la eficacia del implante intravítreo de dexametasona en el edema macular pseudofáquico. Resultados preliminares

ObjectiveTo evaluate the efficacy of intravitreal dexamethasone implant on the treatment of pseudophakic macular edema (PME). Material and methodsA retrospective, observational, descriptive study was conducted on 4 patients who received an intravitreal injection of dexamethasone implant due to PME in the period from 1st January 2013 to 31st December 2013 in the Hospital Universitario de La Ribera (Alzira, Valencia, Spain). A complete ophthalmic examination was performed on these patients. Best-corrected visual acuity (BCVA), macular thickness), and duration of the effect of the treatment were studied. ResultsAt baseline, the mean MT was 414μm. After dexamethasone implant, mean values of MT decreased to 330.25μm at month one. The mean change from baseline MT was 83.75μm. The baseline mean BCVA was 0.3 and improved to 0.575 at month one and 3. The mean duration of the effect of the treatment was 3.5 months. ConclusionsIntravitreal dexamethasone implant is a possible treatment for Irvine-Gass syndrome as it improved visual acuity and reduced the macular thickness of these patients.

Prophylaxis and treatment of cystoid macular edema after cataract surgery

O edema macular cistoide e uma das principais causas de baixa de visao apos cirurgia de catarata. O processo inflamatorio parece ser o principal fator causal do edema. Sao considerados fatores de risco complicacoes cirurgicas, doencas retinianas previas, diabetes, uveites e uso de colirios de prostaglandinas. O diagnostico e feito clinicamente, mas a angiografia fluoresceinica e a tomografia de coerencia optica tambem sao ferramentas importantes para detectar o edema e auxiliar no diagnostico diferencial. Apesar da profilaxia pre-operatoria nao ter evidencia cientifica, ela e preconizada especialmente nos casos com fatores de risco. O tratamento inicial e realizado com associacao de corticoide e anti-inflamatorio nao hormonais topicos. Os casos cronicos e refratarios tem diversas alternativas de tratamento, sendo o uso de triancinolona e antiangiogenicos intravitreos as mais utilizadas. Este artigo se propoe a discutir diversos aspectos do edema macular cistoide pseudofacico.

Macular edema after uncomplicated cataract surgery: a role for phacoemulsification energy and vitreoretinal interface status?

To study postoperative macular thickness fluctuations measured by spectral-domain optical coherence tomography (SD-OCT) and to investigate a potential correlation among macular edema (ME) incidence, cumulative dissipated energy (CDE) released during phacoemulsification, and vitreoretinal interface status. This is a prospective, cross-sectional study of 106 cataract patients with no macular disorder who underwent phacoemulsification. Best-corrected visual acuity measurement, slit-lamp examination, OCT scans were performed preoperatively and 30 and 90 days postoperatively. The intraoperative parameters measured were CDE and total phacoemulsification time. The SD-OCT parameters assessed were central subfield thickness (CST), cube average thickness (CAT), cube macular volume, vitreoretinal interface status, and presence of cystoid or diffuse ME. Four patients (3.8%) developed subclinical ME. Regarding ME, there was no significant difference between patients with presence or absence of posterior vitreous detachment (chi-square, p = 0.57), although 75% of ME cases were observed in patients with attached posterior vitreous. With regard to comparison between eyes with and without subclinical CME incidence, CDE (p = 0.05), phacoemulsification time (p = 0.001), CST at month 1 (p = 0.002), cube macular volume at month 1 (p = 0.039), and CAT at month 1 (p = 0.050) were significantly higher in the subclinical CME group. This study provides evidence that OCT macular thickness parameters increase significantly at first and third month postoperatively and that the incidence of pseudophakic ME can be affected by CDE.

Corticosteroid intravitreal implants vs. ranibizumab for the treatment of vitreoretinal disease

Three long-acting corticosteroid implants are now available for the treatment of retinal disease, offering control of macular edema and inflammation for between 6 months and up to 3 years. This review evaluates their efficacy and side-effect profile in comparison with the antivascular endothelial growth factor agent ranibizumab in diabetic macular edema, retinal vein occlusion, pseudophakic macular edema, and uveitis. Trials of ranibizumab in diabetic macular edema have demonstrated excellent efficacy without serious safety concerns to date. Fluocinolone acetonide implants can be considered, but have a high risk of cataract and sequelae from intraocular pressure rise. In retinal vein occlusion, both ranibizumab and Ozurdex have been shown to be effective, although their relative efficacy has not been determined in head-to-head clinical trials. In pseudophakic and uveitic macular edema, steroid implants are probably the first choice therapy, although there is evidence that ranibizumab is effective. For choroidal neovascularization secondary to inflammatory disease, ranibizumab is indicated, whereas Retisert has been shown to reduce the risk of uveitis relapse. In diabetic macular edema, ranibizumab has shown greater efficacy with fewer side-effects than steroid implants. Both ranibizumab and steroid implants can be considered in retinal vein occlusion, but trials are awaited to determine their relative efficacy.

Macular hole formation in a patient with Irvine-Gass syndrome: coincidence or rare complication?

BackgroundMacular edema (ME) is caused by abnormal retinal capillary permeability and has also been described as a postoperative complication of cataract surgery (Irvine-Gass syndrome).ObjectiveTo present a patient with Irvine-Gass syndrome in the right eye complicated with a macular hole (MH) in the same eye and possible associations between these two entities.Case reportA 72-year-old male with a history of uneventful bilateral cataract surgery was followed-up with biomicroscopy and optical coherence tomography (OCT). Four weeks after cataract surgery oculus dexter (OD), there was progressive visual deterioration (best corrected visual acuity [BCVA]: 0.5). OCT disclosed cystoid ME. A parabulbar triamcinolone injection, dexamethasone 0.1% and ketorolac 0.4% eye drops, both 4 times per day OD were administered. Six weeks later (BCVA OD: 0.2), OCT revealed cystoid ME and full-thickness MH.ConclusionME secondary to diabetes or central retinal vein occlusion may lead to MH by inducing focal vitreomacular traction and by triggering inflammatory mechanisms which facilitate a marked thinning of the fovea. MH may occur even in cases of pseudophakic ME, representing a rare complication of Irvine-Gass syndrome.

Differential Optical Density of Subretinal Spaces

We investigated the optical density characteristics of 3subretinal spaces in neovascular age-related macular degeneration (AMD), diabetic retinopathy (DR), rhegmatogenous retinal detachment (RRD), central serous retinopathy (CSR), retinoschisis (RS), and pseudophakic cystoids macular edema (PCME). Patients in whom subretinal fluid (SRF) was detected by optical coherence tomography (OCT), and whose earliest OCT scans showed sufficient SRF for sampling that did not include tissue edges, were chosen for study. The highest quality B-scan containing SRF (as graded by the OCT image acquisition software) was analyzed. Optical density measurements were obtained using ImageJ, an open code Java-based image processing software. The diagnoses of the 71 patients who met the inclusion criteria were AMD in 17, DR in 7, RRD in 18, CSR in 17, RS in 8, and PCME in 4. Optical density ratios (ODRs) were calculated as SRF OD divided by vitreous OD. ODRs were significantly higher in patients with AMD, DR, CSR, and PCME than in those with RRD and RS. No significant difference in vitreous reflectivity was detected between the former and latter patients. The finding that disease states produce significant changes in optical density ratios calls for further investigation of the possible usefulness of the parameter in differentiating between disease states, determining the outcome of various retinal diseases, and designing therapies aimed at treating the disease by correcting the abnormal density.

Anterior chamber migration of dexametasone intravitreal implant (Ozurdex®)

Dear Editor, Ozurdex® (Allergan Inc., Irvine, CA, USA) is an intravitreal implant containing the dexamethasone. It uses NOVADUR® drug delivery technology, in which a biodegradable material is combined with the active drug dexamethasone to form a small rod-shaped implant of 0.46 mm in diameter and 6 mm in length. Inside the eye, the implant is progressively dissolved in the vitreous gel, as it slowly releases dexamethasone (0.7 mg). This biodegradable device is indicated for the treatment of macular edema following branch or central retinal vein occlusions. In large clinical trials, Ozurdex® has also proved effective in the treatment of posterior non-infectious uveitis, and diabetic and macular edema to and pseudophakic macular edema [1, 2]. Herein we report the case of a 68-year-old male diagnosed with macular edema following branch retinal vein occlusion in his left eye. Visual acuity was 0.6 logMAR. The patient had undergone cataract surgery years before, with intraoperative violation of the lens posterior capsula, anterior vitrectomy assisted with triamcinolone and iris-claw intraocular lens implantation. An intravitreous injection of Ozurdex® (Allergan Inc., Irvine, CA, USA) was performed without remarkable complications. Three weeks later, the patient attended our emergency department complaining of blurred vision in his left eye. Slit-lamp examination revealed the presence of diffuse corneal edema, and anterior migration of the implant (Fig. 1). The intraocular pressure measured 18 mmHg. The implant was surgically removed from the anterior chamber 48 hours later. However, corneal edema did not resolve, and the patient finally underwent corneal transplantation. The anterior chamber transit has been previously described for triamcinolone acetonide, resulting in pseudohypopion [3, 4]. Probably due to a similar mechanism, the dexamethasone implant may also migrate into the anterior chamber, with secondary corneal descompensation due to the contact of the implant with the endothelium. This may be more frequent in pseudophakic cases with Nd-YAG capsulotomy, or posterior capsule violation during phacoemulsification. Nevertheless, pseudohypopion after intravitreal triamcinolone injection has been described in both phakic or pseudophakic patients with posterior capsule integrity, it being presupposed then that the zonula is not complete or that the crystals are capable of crossing through it [3, 4]. In this particular case, the lack of anterior hyaloid may facilitate the penetration of Ozurdex into the anterior chamber too. In our opinion, the state of anterior hyaloid can be assessed by slit-lamp examination only. However, ecography could be useful in cases of uncertain anterior hyaloid status. The authors certify that they have not been published or are being considered for publication elsewhere. The authors also transfer property rights (copyright) of this work to Graefe’s Archive for Clinical and Experimental Opthalmology. D. Pardo-Lopez : E. Frances-Munoz :R. Gallego-Pinazo : M. Diaz-Llopis Department of Ophthalmology, University and Polytechnic Hospital La Fe, Valencia, Spain

Pseudophakic Cystoid Macular Edema Associated with Extrafoveal Vitreoretinal Traction

Purpose: To describe an association between extrafoveal vitreoretinal traction and intractable chronic pseudophakic cystoid macular edema (CME) by the use of optical coherence tomography (OCT).Methods: In a retrospective case series study, charts and OCT findings of patients who had postoperative recalcitrant pseudophakic CME for at least 6 months and vitreoretinal traction membranes were analyzed. Excluded were eyes that either had another vitreoretinopathy that could affect the analysis or had undergone an intravitreal intervention.Results: Three eyes (three patients) with macular edema following uneventful cataract surgery were detected to be associated with multifocal extrafoveal vitreoretinal traction sites in each. Retinal edema that was underlying each of the traction sites in all eyes was in continuum in at least one site per eye with the central macular edema, thus manifesting as diffuse macular edema.Conclusion: Chronic pseudophakic macular edema may be related to extrafoveal vitreoretinal traction.