Treatment Diabetic Retinopathy Study Lines Research Articles

A Novel Artificial Endothelial Replacement Membrane for the Treatment of Chronic Corneal Edema.

The purpose of this study was to report the safety and efficacy results of an artificial lamellar implant for the treatment of chronic corneal edema. The EndoArt (EyeYon Medical, Ness Ziona, Israel), an artificial endothelial replacement membrane designed to treat corneal edema, was implanted in 24 eyes of 24 patients with low-to-normal visual potential. We present the safety and efficacy results from a prospective, open-label, single-arm, multicenter study conducted over a 12-month period. Twenty-four patients were enrolled, with no device-related serious adverse events reported. Seventeen patients completed 12-month follow-up, showing a reduction in average central corneal thickness from 759 ± 116 μm to 613 ± 135 μm. Best-corrected distance visual acuity improved from 1.88 ± 0.79 logarithmic minimum angle of resolution (logMAR) to 1.34 ± 0.57 logMAR. Sixty percent gained at least 3 early treatment diabetic retinopathy study (ETDRS) lines. The EndoArt was removed in 5 cases due to incomplete attachment and replaced by corneal transplants; 1 patient was lost to follow-up, and 1 had a procedure failure. No device-related long-term complications, infections, or inflammations were reported. The implants remained transparent throughout the study. The first-in-human results of EndoArt implantation demonstrated the device's potential to treat patients suffering from corneal edema with a favorable safety profile and effective edema reduction in most subjects, with no device-related serious adverse event. The EndoArt may offer a viable solution in regions facing a shortage of donor corneas, as well as for patients who have poor prognosis with human tissue.

CLINICAL CHARACTERISTICS AND VISUAL OUTCOMES IN ENDOPHTHALMITIS AFTER KERATOPROSTHESIS IMPLANTATION.

To describe the presentation, microbiology, management, and prognosis of eyes with endophthalmitis after Boston keratoprosthesis implantation. Retrospective case series with history, diagnostics, management, and outcomes data in endophthalmitis after keratoprosthesis implantation presenting to a tertiary center between 2009 and 2020. Of 137 keratoprosthesis-implanted eyes, 7 eyes of 7 patients (5%) developed endophthalmitis. On presentation, 6 (86%) reported decreased visual acuity, and only 1 (14%) reported pain. Peripheral corneal ulcers were present in 2 eyes (29%). Seidel testing was negative in all cases. Six eyes (86%) had retroprosthetic membranes. One (14%) underwent initial pars plana vitrectomy with mechanical vitreous biopsy, whereas 6 (86%) received a needle vitreous tap-half of which were dry. Organisms were isolated after vitreous tap in two eyes: Streptococcus intermedius and Mycobacterium abscessus. The mean visual acuity preendophthalmitis, at presentation, and at 6 months were 20/267, 20/5,944, and 20/734, respectively. The visual acuity improved 9.08 ± 11.78 Early Treatment Diabetic Retinopathy Study lines from presentation to 6 months. Six-month visual acuity was correlated with preendophthalmitis visual acuity (r = 0.92, P = 0.003) but not presenting visual acuity (P = 0.838). Visual acuity at 6 months is correlated with preendophthalmitis visual acuity, not presenting visual acuity. Endophthalmitis should be considered in the differential diagnosis of painless intraocular inflammation any time after keratoprosthesis implantation, even if Seidel negative.

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

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

Treatment Patterns and Clinical Outcomes for Branch Retinal Vein Occlusion: An 8-Year Experience at a Tertiary Eye Center.

This work aims to investigate real-world treatment patterns and outcomes in eyes with branch retinal vein occlusion in the antivascular endothelial growth factor (anti-VEGF) era. A retrospective, nonrandomized, comparative study was conducted on eyes diagnosed with branch retinal vein occlusion at a single tertiary center between 2009 and 2017. Medical history, treatment patterns, and visual acuity outcomes were examined. Subanalysis was performed for eyes that met the eligibility criteria for the BRAVO (Ranibizumab for the Treatment of Macular Edema Following Branch Retinal Vein Occlusion) trial. A total of 315 eyes were included, of which 244 were treatment naive. In all eyes, the most common first treatment was the following: intravitreal bevacizumab (38.4%), aflibercept (15.1%), ranibizumab (8.1%), sectoral scatter laser (6.2%), and triamcinolone (3.1%). At 1 year, treatment-naive eyes had received an average of 2.43 anti-VEGF injections. During follow-up, treatment-naive eyes gained an average of 0.21 Early Treatment Diabetic Retinopathy Study lines. Forty eyes that met BRAVO trial criteria received an average of 5.05 anti-VEGF injections in the first year and gained an average of 1.83 Early Treatment Diabetic Retinopathy Study lines. This real-world cohort received fewer anti-VEGF injections at year 1 and experienced less improvement in visual acuity during the course of treatment than clinical trial participants. Trial-eligible patients received more injections and had greater visual gains than those who would not have been eligible for the trial.

Factors Associated With Improvement in Vision Following Femtosecond Astigmatic Keratotomy in Post-Keratoplasty Keratoconus Patients

To evaluate factors associated with improvement in vision following femtosecond astigmatic keratotomy (FSAK) in patients with keratoconus post-keratoplasty. Retrospective, interventional case series. The study took place in an institutional setting. This was a retrospective study that included patients with keratoconus who underwent FSAK for astigmatism following penetrating (PKP) or deep anterior lamellar keratoplasty (DALK). Success was defined as improvement in 3 Early Treatment Diabetic Retinopathy Study lines (doubling of the visual angle) of uncorrected distance visual acuity (UDVA) or best spectacle-corrected visual acuity (BSCVA). A total of 56 eyes in 56 patients with keratoconus were included. Following FSAK, there was a significant improvement in UDVA (1.30 ± 0.49 to 0.87 ± 0.58 logarithm of minimal angle of resolution [logMAR]; P < .001), BSCVA (0.40 ± 0.26 to 0.27 ± 0.29 logMAR; P <.001), and corneal astigmatism (8.69 ± 2.72 to 3.92 ± 2.13 diopter [D]; P < .001). Success was achieved in 60.7% (34/56) of cases, and this group had a higher proportion of previous PKP (73.5% vs 45.5%; P= .03), worse preoperative UDVA (1.42 ± 0.47 vs 1.11 ± 0.47 logMAR; P= .03), and a greater preoperative manifest cylinder (7.56 ± 2.26 vs 5.72 ± 2.12 D; P= .01). In multiple regression analysis, PKP (vs DALK) (odds ratio [OR]: 8.52; P= .009), worse preoperative UDVA (OR: 9.08, P= .02), and greater preoperative cylinder (OR: 1.51; P= .04) were independently associated with success, and, when combined, led to a sensitivity and specificity of 84.6% and 93.8%, respectively, in predicting success. The optimal cutoff predicting success with a preoperative cylinder was a cylinder >6.75 D. Approximately 60% of patients with keratoconus post-keratoplasty experience doubling of the visual angle following FSAK. Patients with previous PKP and a greater cylinder are more likely to benefit from this procedure. Separate nomograms for DALK and PKP patients may be warranted.

Comparison of platelet-rich plasma and inverted internal limiting membrane flap for the management of large macular holes: A pilot study.

Purpose:To compare the safety and efficacy of 25-gauge pars plana vitrectomy (PPV) with either platelet-rich plasma (PRP) or inverted internal limiting membrane (ILM) flap for the treatment of large macular hole.Methods:Pseudophakic patients with idiopathic macular holes with a minimum diameter (MD) of 600–1500 μm were randomized into two groups (30 patients each): 25-gauge PPV with either inverted ILM flap (group A) or PRP (group B).Results:Mean MD in groups A and B were 803.33 ± 120.65 μm and 784.73 ± 120.10 μm, respectively (P = 0.552). Mean base diameter in groups A and B was 1395.17 ± 240.57 μm and 1486.90 ± 281.61 μm, respectively (P = 0.180). The median presenting best-corrected visual acuity (BCVA) was logMAR 0.78 (range 0.78–1.00) and logMAR 0.78 (Range 0.60–1.00) in groups A and B, respectively (P = 0.103). Anatomical closure was achieved in 90% (n = 27/30) and 93.3% (n = 28/30) eyes in groups A and B, respectively (P = 0.158). Type 1 closure was achieved in 76.7% (n = 23/30) and 83.3% (n = 25/30) eyes in groups A and B, respectively. Median BCVA at postoperative 3-month in groups A and B was logMAR 0.60 (range 0.48–0.60) and logMAR 0.60 (range 0.48–0.78), respectively (P = 0.312). The average visual improvement was 2.0 and 2.5 early treatment diabetic retinopathy study (ETDRS) lines in groups A and B, respectively (P = 0.339). None of the patients developed postoperative exaggerated inflammatory reactions.Conclusion:Using platelets for the treatment of large macular holes is as safe and effective as an inverted ILM flap.

INTRAVITREAL ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR INJECTIONS FOR EXUDATIVE RETINAL ARTERIAL MACROANEURYSMS.

There is no established therapy for exudative-hemorrhagic complications in primary retinal arteriolar macroaneurysm (RAM). Retrospective multicenter interventional study of anti-vascular endothelial growth factor in symptomatic RAMs. Central macular thickness in μm and best-corrected visual acuity in logMar were correlated with the RAM size and distance to the macula. Statistical analyses were performed using paired comparisons and Pearson correlation. Thirty-two eyes (32 patients) were treated with a mean of 2.7 injections over a mean follow-up of 16.6 months. Initial best-corrected visual acuity correlated with the RAM size and distance to the macula (P = 0.02). Central macular thickness decreased by 131,180, and 211 μm at 1, 2, and 3 months after the first injection (P < 0.001). Best-corrected visual acuity improved by 0.47 and 0.38 Early Treatment Diabetic Retinopathy Study lines at 2 and 3 months (P = 0.005). Anti-vascular endothelial growth factor response correlated with the RAM size (P = 0.04) and the distance to the macula (P = 0.009). Symptomatic RAMs can be treated successfully with anti-vascular endothelial growth factor injections, leading to a decrease in macular edema.

Pegaptanib: choroidal neovascularization in patients with age-related macular degeneration and previous arterial thromboembolic events.

To evaluate the efficacy and the rate of side effects of the pegylated aptamer pegaptanib in the treatment of patients with choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD) and a history of previous arterial thromboembolic events (ATEs). Twenty-three eyes of 23 patients with subfoveal CNV due to AMD and cerebrovascular accidents (n = 12) and myocardial infarction (n = 11) in the previous 6 months received intravitreal pegaptanib 0.3 mg according to a pro re nata regimen and were followed for 12 months. The paired Student t test was used to evaluate mean changes in best-corrected visual acuity (BCVA; primary outcome measure) and central foveal thickness (CFT). The mean patient age was 71.5 ± 4.6 years; there were 14 women and 9 men. The CNV was type 1, 2, and 3 in 18, 3, and 2 eyes, respectively. The mean BCVA improved from 0.67 ± 0.23 logMAR at baseline to 0.52 ± 0.31 logMAR at the end of 12-month follow-up (p = 0.044). Thirty-five percent of patients achieved ≥3 Early Treatment Diabetic Retinopathy Study lines improvement at 12 months. Mean CFT at baseline (381 ± 111 µm) decreased to 304 ± 82 µm at 12 months (p = 0.008). Patients received a mean of 4.3 ± 1.3 (range 3-7) injections. No systemic or ocular side effects occurred; no patient experienced further ATEs. Intravitreal pegaptanib can be considered a viable treatment option for patients with AMD-related CNV who are at high risk of ATEs.

Intravitreal Injection of Sulfamethoxazole and Trimethoprim Associated with Dexamethasone as an Alternative Therapy for Ocular Toxoplasmosis

ABSTRACTPurpose: To evaluate intravitreal injections of sulfamethoxazole/trimethoprim in association with dexamethasone for treating toxoplasmic retinochoroiditis.Methods: Thirteen patients with active, recurrent ocular focal toxoplasmic retinochoroiditis and visual acuity worse than 20/63 in the affected eye were included. Ocular toxoplasmosis was diagnosed according to the classic clinical findings. The primary end point was the change in the final best-corrected visual acuity (BCVA).Results: The intraocular inflammation decreased within 2 weeks after injection in all eyes and resolved in 8 (62%) eyes with only one injection after 30 days; the remaining eyes received two injections. In all eyes, the retinitis was inactive and no patient had decreased early treatment diabetic retinopathy study lines of BCVA at the final examination.Conclusion: The combination of intravitreal trimethoprim/sulfamethoxazole and dexamethasone might be an alternative treatment strategy in patients with toxoplasmic retinochoroiditis.

INTRAVITREAL RANIBIZUMAB FOR CHOROIDAL NEOVASCULARIZATION IN ANGIOID STREAKS

To analyze retrospectively the efficacy of intravitreal ranibizumab injections for the management of choroidal neovascularization in patients with angioid streaks over a long term. In this "nonrandomized," double-center, retrospective, interventional case series, a consecutive series of patients affected with choroidal neovascularization associated with angioid streaks were treated with intravitreal ranibizumab injections (0.5 mg/0.05 mL). Best-corrected visual acuity, fundus photography, optical coherence tomography, and fluorescein angiography were examined before and after treatment. The primary endpoint was the percentage of eyes with stable or improved visual acuity at the end of follow-up (loss of less than 3 Early Treatment Diabetic Retinopathy Study lines). Secondary endpoints were the percentage of eyes with stable or decreased macular thickness on optical coherence tomography (less than a 10% increase in macular thickness) and the percentage of eyes with persistent leakage on fluorescein angiography at the last observation carried forward. Thirty-five eyes of 27 patients were treated with repeated intravitreal ranibizumab injections (mean of 9.9 ± 7.2 injections, range 2-26) for a mean of 48.6 ± 17.1 months (range 8-66). At the end of follow-up, best-corrected visual acuity was stabilized or improved in 22 of 35 eyes (62.9%). Macular thickness had stabilized or decreased in 16 of 35 eyes (45.7%). At the last follow-up examination, on fluorescein angiography, no further leakage was observed in 27 of 35 eyes (77.1%). In this large series of patients with choroidal neovascularization associated with angioid streaks followed for 4 years, ranibizumab injections allowed stabilization of best-corrected visual acuity in most eyes. Ranibizumab appear as an effective therapeutic option in CNV associated with angioid streaks over long time.

DEXAMETHASONE IMPLANT FOR MACULAR EDEMA SECONDARY TO CENTRAL RETINAL VEIN OCCLUSION IN PATIENTS YOUNGER THAN 50 YEARS.

To evaluate the effects of dexamethasone implant for macular edema secondary to central retinal vein occlusion in patients younger than 50 years. Patients with no previous treatment, macular edema with central foveal thickness >250 μm and best-corrected visual acuity between 1.30 LogMAR and 0.30 LogMAR were prospectively recruited for a 12-month follow-up study. After baseline dexamethasone implant, re-treatment was performed starting from the fourth month if a best-corrected visual acuity deterioration with central foveal thickness >250 μm occurred after an initial improvement. The primary outcome was the change in the best-corrected visual acuity. Secondary outcomes included the proportion of eyes gaining at least 3 Early Treatment Diabetic Retinopathy Study lines, the change in the central foveal thickness, and the number of treatments. Mean best-corrected visual acuity changed significantly from 0.60 ± 0.38 LogMAR at baseline to 0.43 ± 0.48 at the 12-month examination (P = 0.03). Eight of 16 eyes (50%) gained 3 Early Treatment Diabetic Retinopathy Study lines. Mean central foveal thickness improved significantly from 705 ± 202 μm at baseline to 408 ± 196 μm at 12-month visit (P < 0.001). The patients received a mean of 1.8 ± 0.9 implants with 8/16 eyes and 3/16 receiving 1 and 2 implants, respectively. This present investigation indicates that dexamethasone implant can provide a 3-line improvement in half of the patients younger than 50 years and affected by macular edema secondary to central retinal vein occlusion.

Local treatment of toxoplasmic retinochoroiditis with intravitreal clindamycin and dexamethasone.

To report the clinical outcomes of local treatment of toxoplasmic retinochoroiditis (TRC) with intravitreal injections of clindamycin and dexamethasone. 16 eyes (16 patients) with active TRC sparing the macula and juxtapapillary area treated with intravitreal injections of clindamycin (1 mg) and dexamethasone (1 mg) without concomitant systemic antitoxoplasmic or anti-inflammatory therapy. Measured parameters: Best-corrected visual acuity (BCVA) was measured by an Early Treatment Diabetic Retinopathy Study (ETDRS) chart. BCVA and clinical characteristics of retinochoroiditis were assessed at baseline and at 1, 3, 6, and 12 months. Resolution of retinochoroiditis and changes in BCVA. Control of TRC was achieved in all cases with a mean interval of 2.48 ± 1.03 weeks (2-6 weeks). A single injection of intravitreal clindamycin and dexamethasone was performed in 12 patients, and four patients required two intravitreal injections, during the follow-up period. Fourteen eyes (87.5%) improved ≥ 2 ETDRS lines of BCVA, of two or more Early Treatment Diabetic Retinopathy Study lines, BCVA remained stable in two eyes (12.5%), and no patient had decreased BCVA at the end of the follow-up period. No ocular or systemic adverse events were observed. Local treatment with intravitreal injections of clindamycin and dexamethasone without concomitant systemic therapy was associated with resolution of TRC in patients without macular or juxtapapillary involvement. Intravitreal clindamycin and dexamethasone may represent a viable treatment option in patients with allergies or inadequate responses to oral medications.

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

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

INTRAVITREAL BEVACIZUMAB FOR JUXTAFOVEAL CHOROIDAL NEOVASCULARIZATION SECONDARY TO MULTIFOCAL CHOROIDITIS

To assess the effects of intravitreal bevacizumab injections in the treatment of juxtafoveal choroidal neovascularization associated with multifocal choroiditis. Prospective interventional case series. Fourteen patients (14 eyes) affected by juxtafoveal choroidal neovascularization secondary to multifocal choroiditis were examined. All patients underwent a complete ophthalmologic examination, including measurement of best-corrected visual acuity using Early Treatment Diabetic Retinopathy Study charts, optical coherence tomography, and fluorescein angiography. The protocol treatment included a first injection, followed by repeated intravitreal bevacizumab injections over a 12-month follow-up period on the basis of optical coherence tomography parameters and angiographic features. Mean best-corrected visual acuity changed from 0.41 logarithm of the minimum angle of resolution (approximately corresponding to 20/51 Snellen equivalent), at baseline, to 0.16 ± 0.13 logarithm of the minimum angle of resolution (approximately corresponding to 20/28 Snellen equivalent), at the 12-month examination (P < 0.002). A functional improvement of at least 3 Early Treatment Diabetic Retinopathy Study lines was achieved by 6 eyes (43%) at the 12-month examination. Mean central macular thickness at baseline was 318 μm, reducing to 239 μm at the 12-month examination (P < 0.001). No eye showed choroidal neovascularization extension to the fovea. Intravitreal bevacizumab is a beneficial treatment for juxtafoveal choroidal neovascularization associated with multifocal choroiditis. Further studies are warranted to confirm these preliminary results.

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

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

SURGICAL TREATMENT OF LAMELLAR MACULAR HOLE ASSOCIATED WITH EPIMACULAR MEMBRANE

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

MACULAR HOLES AFTER RHEGMATOGENOUS RETINAL DETACHMENT REPAIR

To review the surgical management and functional outcome of macular holes (MHs) developing after rhegmatogenous retinal detachment repair. Retrospective, interventional, noncomparative case series. Twenty patients with MH developing after rhegmatogenous retinal detachment repair were included. Pars plana vitrectomy with internal limiting membrane peeling and gas tamponade was performed. Macular attachment status and number of best-corrected visual acuity lines of improvement after MH repair were evaluated. The fovea had been detached in all eyes at the time of rhegmatogenous retinal detachment repair. Six MHs developed after scleral buckling surgery and 14 MHs after vitrectomy with an encircling band. In 5 of the 20 patients, ≥ 2 operations had been required to achieve retinal reapplication. The mean time to MH diagnosis was 38 weeks. Preoperative best-corrected visual acuity was ≤ 20/100 in all but one case. Single-operation MH closure rate was 100%, with a mean of 4 Early Treatment Diabetic Retinopathy Study lines of visual improvement (P < 0.001). Mean postoperative Snellen best-corrected visual acuity was 20/70 (± 0.15) (P < 0.001). In this small retrospective study, standard surgical treatment for idiopathic MH was effective in achieving anatomical closure of these secondary MHs, but visual acuity gain was limited by the previous macula-involving rhegmatogenous retinal detachment status.

Compassionate use of dexamethasone implant for the treatment of macular edema secondary to central retinal vein occlusion in a clinical setting

Editor, The GENEVA trial has demonstrated the beneficial effects of a sustained-release, dexamethasone delivery system for macular oedema (ME) secondary to retinal vein occlusion (Haller et al. 2010). We report the results in patients with ME related to central retinal vein occlusion (CRVO) treated with dexamethasone implant in a clinical setting. An open-label, compassionate use program case series was approved by the local IRB. Written informed consent was obtained from all patients. Patients affected by CRVO-related ME were prospectively enrolled from January 2008. Inclusion criteria were as follows: nonischemic CRVO, ME with central foveal thickness (CFT) ≥250 μm on optical coherence tomography (OCT), best-corrected visual acuity (BCVA) between 1.30 and 0.30 logMAR (approximately 20/400–20/40 Snellen equivalent). Exclusion criteria included any other ocular disorder, ocular hypertension or glaucoma, media opacities, and signs of ocular infection. A 700 μg dose of dexamethasone was implanted in the operating theater. The protocol included a monthly complete ocular examination over a 12-month follow-up, with retreatments carried out on a pro-re-nata (PRN) basis starting from the fourth month. Retreatment criteria: documented positive response after the first treatment (BCVA improvement of at least five letters, CFT reduction by at least 20%), at least five letter-BCVA deterioration, associated with CFT >250 μm. Best-corrected visual acuity measurement and OCT were performed by an ophthalmologist masked to the patient’s condition. Primary outcome was the BCVA change at the end of the follow-up. Overall, 10 patients (six men) were enrolled, (mean age of 61.8 ± 6.2, mean CRVO duration of 29.6 ± 11 months and mean ME duration of 26.4 ± 9.3 months). Mean BCVA was 1.10 ± 0.26 logMAR at baseline, changing to 0.79 ± 0.30 logMAR at the end of the follow-up, with a statistically significant difference with respect to the baseline value from the third month on (Fig. 1). The mean number of Early Treatment Diabetic Retinopathy Study (ETDRS) lines gained was 3.10 ± 1.45 (9 patients gaining at least three lines at the end of the follow-up). Mean CFT passed from 620 to 273 μm at the 12-month examination, with a statistically significant difference. The mean number of treatments was 1.7 ± 0.4 (range: 1–2). Two patients developed a nuclear cataract, while one patient experienced increased intraocular pressure, which was effectively controlled with topical antiglaucoma therapy. Change in the mean best-corrected visual acuity (BCVA) (LogMAR) and in central foveal thickness (CFT, μm) during the 12 months of follow-up. With regard to the BCVA, a statistically significant difference in comparison with the baseline value was registered from the 3-month examination up to the end of the scheduled follow-up. Considering the CFT, a statistically significant improvement in the mean CFT in comparison with the baseline value was registered at 1-month examination and following in each time-point until the end of the scheduled follow-up. The most appropriate management of ME related to CRVO is a matter of debate. Intravitreal anti-VEGF drugs have yielded promising results, as has intravitreal injection of triamcinolone acetonide (Ferrara et al. 2007; Ip et al. 2009, Brown et al. 2010). The GENEVA trial has demonstrated that dexamethasone implant can both reduce the risk of vision loss and improve the incidence of visual improvement (Haller et al. 2010). Nevertheless, the effect in the CRVO subgroup turned out to be partially unsatisfactory. Indeed, BCVA improvement was statistically significant for both 350 and 700 μg subgroups at the second month and for the 350 μg subgroup at the third month too, losing the statistically significant difference afterwards. A possible explanation may emerge from the study design, which provides for retreatment only after the sixth month. The design of this compassionate program study provided for retreatment from the fourth month on a PRN basis. Our results show that a sustained effect can be obtained for both functional and anatomical aspects. It is worth remarking that our patients displayed older CRVO forms, with longer ME duration in comparison with the GENEVA trial (13 versus 5 months, respectively), lower mean BCVA at baseline (20/320, versus 20/80, respectively) and higher CFT (620 versus 550 μm, respectively) (Haller et al. 2010). Although obvious limitations include small number of patients and absence of a control group, this study illustrates, with all due caution, the positive effect of dexamethasone implant for ME secondary to CRVO in a clinical setting, demonstrating a sustained effect if a PRN basis is followed. Further studies are needed to ascertain the best therapeutic approach and the most appropriate timing of the treatment.

Outcomes of different management options for malignant glaucoma: a retrospective study

To assess the outcomes of the various medical and surgical treatment options for malignant glaucoma. Design Retrospective, comparative case series. Participants Twenty-four eyes of 21 patients with malignant glaucoma. Intervention Nine eyes were treated medically. Twenty-one eyes underwent surgery, 15 of which had the full vitrectomy-(phaco)-iridectomy-zonulectomy procedure. Main outcome measures Intraocular pressure (IOP), best-corrected visual acuity (BCVA) and number of glaucoma medications were measured. The relapse rate was 100% after medical therapy, 75% after a Yag laser capsulotomy and a hyaloidotomy, 75% after a conventional vitrectomy and 66% after an anterior vitrectomy in combination with an iridectomy-zonulectomy. All patients who underwent a full vitrectomy combined with an iridectomy and a zonulectomy (and phacoemulsification if phakic) had postoperative relief of malignant glaucoma without relapse within the follow-up period. After this vitrectomy-tunnel technique, the IOP ranged from 10 to 22 mmHg (mean 16 mmHg) after a mean follow-up of 61 days. Mean BCVA improved by 5 Early Treatment Diabetic Retinopathy Study (ETDRS) lines, and mean number of glaucoma medications decreased from two to one. Complete vitrectomy combined with iridectomy and zonulectomy (and phacoemulsification, if applicable) most successfully managed aqueous misdirection syndrome in our retrospective case series.

TWELVE-MONTH OUTCOME AFTER ONE INTRAVITREAL INJECTION OF BEVACIZUMAB TO TREAT MYOPIC CHOROIDAL NEOVASCULARIZATION

To report the changes during a 1-year follow-up in visual acuity and macular thickness in a series of highly myopic eyes with choroidal neovascularization treated with bevacizumab. Retrospective and multicenter study including 107 highly myopic eyes from 107 patients (mean age, 55 years) with subfoveal or juxtafoveal choroidal neovascularization. All cases were treated by one intravitreous injection of 1.25 mg bevacizumab. Best-corrected visual acuity and macular thickness with the optical coherence tomography were evaluated at baseline and then monthly during 1 year. Logarithm of the minimum angle of resolution best-corrected visual acuity at baseline averaged 0.72 (standard deviation [SD], 0.43) versus 0.53 (SD, 0.41) at 1 year after treatment (P < 0.001). Logarithm of the minimum angle of resolution best-corrected visual acuity was 0.30 or better in 49 of 107 eyes (45%) at 1 year. Thirty-three eyes (30%) gained at least 3 Early Treatment Diabetic Retinopathy Study lines (15 letters) during the follow-up. In 43 eyes (40%), reinjections were necessary because signs of choroidal neovascularization activity were still evident. The mean number of reinjections was 0.8 (SD, 1.3). Best-corrected visual acuity improvement was better in the younger group (younger than 50 years). No adverse reactions were reported. One intravitreal bevacizumab injection seems to be an effective therapeutic approach to treat choroidal neovascularization in highly myopic eyes. Careful monitoring is necessary to assess the need for reinjections.