The effect of latanoprost and influence of changes in body position on patients with glaucoma and ocular hypertension.

BACKGROUND AND OBJECTIVES: Some patients have an elevation of intraocular pressure (IOP) in the supine position (IOPSP). It has been suggested that topical latanoprost 0.005% (LP) has an attenuating effect on these IOP elevations. The Authors report a simple procedure to evaluate the change in the IOPSP. This paper presents the results of the change in the IOPSP in normals, in patients with ocular hypertension (OH) and in patients with primary open angle glaucoma (POAG). The study also evaluates the effect of the addition of topical LP on those patients with an elevation of their IOPSP. PATIENTS AND METHODS: Part 1 evaluated the change in the IOPSP in the morning in 40 eyes of normals, 82 eyes in patients with OH and 77 eyes in patients with POAG. The IOP was measured before and after lying in the supine position (SP) for 90 minutes. In part 2 the patients with OH or POAG with an increase in their IOPSP were selected and the test was repeated again after the addition of topical LP. RESULTS: When compared with normals, the patients with OH and POAG had significantly greater IOPSP increases. The patients with POAG had significantly greater IOPSP increases than did those with OH. The addition of LP partially decreased but did not eliminate the IOP increases in the SP. CONCLUSIONS: Patients with OH and POAG have a larger increase in their IOPSP than do normals. The addition of topical LP partially decreased but did not totally eliminate these pressure increases.

Optical coherence tomography findings in a case of acute multifocal posterior placoid pigment epitheliopathy (AMPPPE).

PURPOSE: To report the optical coherence tomography (OCT) findings in a case of acute multifocal posterior placoid pigment epitheliopathy (AMPPPE). DESIGN: Case report. METHODS: A 26-year-old woman was seen for a mild loss of visual acuity in both eyes. The fundus examination revealed yellow-white placoid lesions in the posterior pole suggesting AMPPPE. Fluorescein and indocyanine green (ICG) angiography and optical coherence tomography (OCT) were performed 2 days, 9 days, and 1 month after the first examination. RESULTS: In the acute phases the OCT revealed a mild hyperreflective area above the retinal pigmented epithelium (RPE) in the photoreceptor layer. In the later phases the OCT scan revealed a nodular hyperreflective lesion on the plane of the RPE with mild underlying backscattering. CONCLUSIONS: In AMPPPE, the OCT demonstrates hyperreflective lesions that may indicate inflammatory tissue and inflammatory cells or the presence of ischemic edema in the outer retinal layers.

Pycnogenol® and Centella asiatica in the management of asymptomatic atherosclerosis progression.

AIM: The aim of the study was to evaluate the effect of the nutritional supplements Pycnogenol® and total triterpenic fraction of Centella asiatica (TTFCA) on atherosclerosis progression in low-risk asymptomatic subjects with carotid or femoral stenosing plaques. METHODS: This was an observational pilot, substudy of the San Valentino epidemiological cardiovascular study. The study included 824 subjects aged 45-60 without any conventional risk factors who had a stenosing atherosclerotic plaque (>50-60%) in at least one carotid or common femoral bifurcation, allocated into 6 groups: Group 1 (Controls): management was based on education, exercise, diet and lifestyle changes. This same management plan was used in all other groups; group 2: Pycnogenol® 50 mg/day; group 3: Pycnogenol® 100 mg/day; group 4: Aspirin® 100 mg/day or ticlopidine 250 mg/day if intolerant to aspirin; group 5: Aspirin® 100 mg/day and Pycnogenol® 100 mg/day; group 6: Pycnogenol® 100 mg/day plus TTFCA 100 mg/day. The follow-up lasted 42 months. Plaque progression was assessed using the ultrasonic arterial score based on the arterial wall morphology and the number of plaques that progressed and on the number of subjects that had cardiovascular events. A secondary endpoint was to evaluate the changes in oxidative stress at baseline and at 42 months. RESULTS: The ultrasonic score increased significantly in groups 1, 2, and 4 (>1%) but not in groups 3, 5 and 6 (<1%) suggesting a beneficial effect of Pycnogenol® 100 mg. Considering the percent of patients that progressed from class V (asymptomatic) to VI (symptomatic) there was a progression of plaques in 48.09% of controls. In the Pycnogenol® 100 (group 3, 10.4%) and in the Aspirin®+ Pycnogenol® (group 5, 10.68%) progression was half of what observed with antiplatelet agent (group 4, 20.93%); in the TTFCA+ Pycnogenol®group (group 6) progression was 7.4 times lower than in controls; 3.22 times lower than in the antiplatelet agents group (4). Events (hospital admission, specialized care) were observed in 16.03% of controls; there were 8.83% of subjects with events with Pycnogenol® 50 mg and 8% in group 3 (Pycnogenol® 100 mg). In group 4 (antiplatelets), 8.52% of subjects had events; in group 5, 6.87% of subjects had events and in group 6 (TTFCA+ Pycnogenol®) only 4.41% had events (this was the lowest event rate; P<0.05). All treatment groups had a significantly lower event rate (P<0.05) in comparison with controls. Considering treatments groups 2, 3, 5, 6 had a lower number (P<0.05) of subjects in need of cardiovascular management in comparison with controls. The need for risk factor management was higher in controls and lower in group 6 (P<0.05). In groups 2 to 6 the need for risk factor management was lower than in controls (P<0.05). Including all events (hospital admission, need for treatment or for risk management) 51.9% of controls were involved. In the other groups there was a reduction (from a -9.28% reduction in group 2 to a -26% in group 6) (P<0.002). The most important reduction (higher that in all groups; P<0.05) was in group 6. At 42 months, oxidative stress in all the Pycnogenol® groups was less than in the control group. In the combined group of Pycnogenol® and TTFCA the oxidative stress was less than with Pycnogenol® alone (P<0.001). CONCLUSION: Pycnogenol® and the combination of Pycnogenol® +TTFCA appear to reduce the progression of subclinical arterial plaques and the progression to clinical stages. The reduction in plaque and clinical progression was associated with a reduction in oxidative stress. The results justify a large, randomized, controlled study to demonstrate the efficacy of the combined Pycnogenol® and TTFCA prophylactic therapy in preclinical atherosclerosis.

Doppler ultrasonography in giant cell arteritis.

A patient with biopsy negative giant cell arteritis was examined and treated by our group. Since in some cases the visual loss in this disease is due to a central retinal artery occlusion, a technique to evaluate the blood flow velocity in this artery would be useful. The Duplex scanner was utilized by us in this patient to study the blood flow velocity of the central retinal artery. The flow velocity was reduced. The patient was treated with systemic steroids which lead to clinical and symptomatic improvement. After the treatment with steroids the Duplex scanner was again used to study the flow velocity of the central retinal artery. The blood flow velocity improved. We think that Doppler ultrasonography may be useful in the diagnosis of and in monitoring the treatment of some cases of giant cell arteritis.

Ocular and orbital blood flow velocity in patients with peripheral vascular disease and diabetes treated with intravenous prostaglandin E1.

The purpose of this study was to evaluate the effect of intravenous prostaglandin E1 (PGE1) on the flow velocity of the ophthalmic artery and the central retinal artery in patients with peripheral vascular disease manifested by intermittent claudication. The flow velocity of these vessels is frequently decreased in vascular patients. Since these patients were already being treated with PGE1 for their intermittent claudication, the authors wanted to evaluate the effect on the flow velocity of the ocular vessels as well. A randomized 21-week study of two groups of vascular patients was performed. The first group had intermittent claudication. The second group had intermittent claudication and were also diabetics. Both groups were treated with intravenous PGE1 for their intermittent claudication. Using the color Doppler, the flow velocities of the ophthalmic artery and central retinal artery were measured before and after the intravenous treatment. Before treatment, the flow velocity of the ophthalmic artery and the central retinal artery was decreased when compared to that in the normals. After treatment, there was a significant increase in the systolic and diastolic phases of the flow velocity in both arteries. The systolic flow velocity increased by as much as 40%, and the diastolic flow velocity increased by as much as 80%. The flow velocities of the ophthalmic artery and the central retinal artery are frequently decreased in certain ocular diseases, and this decreased flow may contribute to the ocular pathology. If intravenous PGE1 is able to increase the flow velocity of these vessels in patients with peripheral vascular disease, it is possible that it is also able to increase the flow velocity of these vessels in patients with ocular disease as well. Intravenous PGE1 may prove to be a useful adjunct therapy in eyes when ischemia is part of the pathology.

Ocular and retrobulbar blood flow in ocular hypertensives treated with topical timolol, betaxolol and carteolol.

The purpose of this study was to evaluate the effect of topical timolol 0.5%, betaxolol 0.5% and carteolol 2% on the blood flow velocity of the central retinal artery (CRA), the posterior ciliary artery (PCA) and the ophthalmic artery (OA) in patients with ocular hypertension. A group of 14 patients with ocular hypertension and a group of 11 normals were studied. The color Doppler was used to measure the peak systolic flow velocity (PSFV) and the end diastolic flow velocity (EDFV) of the CRA, the PCA and the OA in the normals and in the patients. The normals were under no treatment, while the patients were studied before and after treatment with topical timolol 0.5%, betaxolol 0.5% and carteolol 2%. In the systolic phase, there was a significant increase in the flow velocity of the CRA with all three drugs. In the diastolic phase of the CRA, the increase was significant for timolol 0.5% and carteolol 2% but not for betaxolol 0.5%. The flow velocity of the PCA and OA remained unchanged. In this study of 14 patients with ocular hypertension, topical timolol 0.5%, betaxolol 0.5% and carteolol 2% led to a significant increase in the flow velocity of the CRA without creating a steal or decrease in the flow velocity of the PCA.

Retrospective study of glaucoma and closed-eyelid test: long-term outcomes in an Italian native population.

AIM: To establish a threshold value of intraocular pressure (IOP) increase after the closed-eyelid test (CET) that correlates with the highest probability of developing overt primary open-angle glaucoma (OAG) in an Italian native population from 1980 to 2010. METHODS: Retrospective analysis of data obtained from 161 patients with ocular hypertension who performed the CET in 1980, and were subsequently followed to see whether they developed OAG. CET was performed always in the morning Eyelids were closed by bandaging for 1 h in a quiet environment, with the patient seated and not sleeping. IOP was measured again 8 to 10s after opening the eyelids. RESULTS: Accurate statistical analysis of the obtained values indicated that 77% of the subjects showing an IOP increase after 1 hour of eyelid closure in a sitting position developed OAG in the following 30 years and that IOP increase values above 4 mmHg led to a subsequent diagnosis of glaucoma in more than 80% of the patients. CONCLUSION: Eyelid closure for 60 minutes results in a net elevation of IOP the extent of which depends on the balance between the increase of aqueous humour secretion and its outflow. Therefore, the CET may discriminate individuals with a normal outflow from individuals with a less functional outflow, which are evidently those at a higher risk of developing glaucoma.

Forskolin and rutin prevent intraocular pressure spikes after Nd:YAG laser iridotomy.

AIM: the purpose of this research was to evaluate whether an oral treatment with an association of forskolin and rutin can blunt the intraocular pressure (IOP) spikes and avoid the damage that may occur after laser iridotomy. METHODS: Ten patients underwent bilateral Neodymium:YAG (Nd:YAG) laser iridotomy (Visulas YAG III Laser, Zeiss), for the prevention of primary closed-angle glaucoma. IOP was measured in subjects before and after 7 days of pretreatment with placebo or forskolin and rutin by Goldman applanation tonometry. The IOP was measured before surgery and after surgery at 30-60-120 minutes, and 4-7 days. RESULTS: Analysis of variance indicated a significant increase of the postoperative values in patients receiving treatment with placebo (p < 0.001), but not in those who received treatment with the forskolin and rutin association. T test analysis confirmed that IOP still remained significantly elevated 7 days after laser intervention in placebo treated patients, whereas it stayed within normal values in forskolin/rutin treated patients. CONCLUSION: Forskolin and rutin can blunt the increase of IOP that occurs after Nd-YAG laser iridotomy. This can avoid serious risk to the optic nerve of the patients under laser treatment for iridotomy.

Idiopathic juxtafoveal retinal telangiectasis and retinal macroaneurysm treated with indocyanine green dye-enhanced photocoagulation.

This case report presents the use of indocyanine green dye-enhanced photocoagulation (ICG-DEP) for the treatment of idiopathic juxtafoveal retinal telangiectasis and a retinal macroaneurysm. A 35-year-old male with 20/20 vision had been followed for 5 years for a retinal macroaneurysm with retinal telangiectasis outside the macular area. He then presented with a recently decreased vision in his right. He had macular edema with a new area of idiopathic juxtafoveal retinal telangiectasis. After 4 focal argon laser treatments, angiographic closure of the lesions was not obtained and the retinal edema remained. After 3 sessions of ICG-DEP, the lesions were closed and the edema absorbed. The 810 nm infrared laser with ICG-DEP should be considered for the treatment of idiopathic juxtafoveal retinal telangiectasis and retinal macroaneurysms. In this case the procedure appears to be safe and well tolerated. It may allow for more direct energy absorption than that of the argon laser to these types of retinal lesions with better tissue closure.

Ocular and optic nerve ischemia: recognition and treatment with intravenous prostaglandin E1.

Ischemia of the optic nerve, the retina and the choroid are common problems in ophthalmology. This paper presents the different types of ischemia and their treatment with prostaglandin E1 (PGE1), a powerful vasodilator of the microcirculation. This is a review article of various previously published case reports and studies presenting patients with different types of ocular and optic nerve ischemia. Their treatment with intravenous (IV) PGE1 is described. Treatment for acute and chronic problems is presented. The visual acuity and/or the visual fields improved in almost all the treated patients. When measured, the blood flow velocities also improved. No complications due to the use of PGE1 were seen. Treatment with IV PGE1 should be considered in cases of ocular and optic nerve ischemia to immediately restore blood flow to these structures and improve the visual acuity. Intravenous prostaglandin E1 is an effective treatment for ocular and optic nerve ischemia leading to immediate visual improvement.

Optical coherence tomography findings in a case of an acute multifocal posterior placoid pigment epitheliopathy (AMPP).

PURPOSE: To report the optical coherence tomography (OCT) findings in a case of acute multifocal posterior placoid pigment epitheliopathy (AMPPPE). METHODS: A 26-year-old woman was seen for a mild loss of visual acuity in both eyes. The fundus examination revealed yellow-white placoid lesions in the posterior pole suggesting AMPPPE. Fluorescein and indocyanine green (ICG) angiography and optical coherence tomography (OCT) were performed 2 days, 9 days, and 1 month after the first examination. RESULTS: In the acute phases the OCT revealed a mild hyperreflective area above the retinal pigmented epithelium (RPE) in the photoreceptor layer. In the later phases the OCT scan revealed a nodular hyperreflective lesion on the plane of the RPE with mild underlying backscattering. CONCLUSIONS: In AMPPPE, the OCT demonstrates hyperreflective lesions that may indicate inflammatory tissue and inflammatory cells or the presence of ischemic edema in the outer retinal layers. (Eur J Ophthalmol 2005; 15: 143-7).

Fusidic acid vs ofloxacin prophylaxis before cataract surgery.

PURPOSE: To evaluate the safety and efficacy of two self-administrated antibiotics in eliminating conjunctival microbial flora. METHODS: A total of 133 patients operated for cataract surgery were divided into three groups. The first group (A), 55 patients, received fusidic acid drops (1%) two times per day during the 3 days before the surgery; a second group (B), 55 patients, received ofloxacin (0.3%) four times per day during the 3 days before the surgery; and the third group (C), 23 patients, did not receive any topical antibiotic before the surgery. On the day of the surgery, cultures were taken from the lower fornix. RESULTS: In Group A, 28 cultures (50.9%) were sterile, and 27 (49.1%) were positive for the presence of microbial agents. In Group B, 25 cultures (45.4%) were sterile, and 30 (54.5%) were positive for the presence of microbial agents. In Group C, 5 cultures (21.7%) were sterile, and 18 (78.2%) were not. Staphylococcus epidermidis was the most common micro-organism isolated in all the groups. Statistical analysis does not reveal a significant difference between Groups A and B for the sterile cultures (p=0.7) (chi-square test), but a statistically significant difference is present between the treated and not treated patients (p= 0.05) (chi-square test). CONCLUSIONS: A preoperative prophylaxis is useful in eliminating conjunctival micro-organism, and both antibiotics (fusidic acid and ofloxacin) are efficient.

Doppler ultrasonography of the central retinal artery in normals treated with topical timolol.

Using high-resolution Duplex scanning it is possible to evaluate the blood flow velocity in the central retinal artery of eyes of normal individuals. The flow velocity can be divided into its systolic and diastolic phases. Topical timolol maleate 0.5%, a non-selective beta-adrenergic receptor blocking agent, was then administered to one eye in each of the normals and the flow velocity was again recorded. The flow velocity improvement was significant, with a 43.58% increase in the systolic phase and a 61.53% increase in the diastolic phase. The diastolic component increased from 49.29% to 55.56%. The increased flow velocity may be due to a vasodilatory effect of timolol. The technique is briefly described and the significance of the results discussed.

Ocular and orbital blood flow in cigarette smokers.

OBJECTIVE: To report the effect of cigarette smoking on the blood flow velocity of the ophthalmic artery (OA), central retinal artery (CRA), and posterior ciliary artery (PCA) in patients who smoke at least 20 cigarettes a day. METHODS: The color duplex scanner was used to measure the systolic and diastolic flow velocity of the OA, CRA, and PCA in 10 smokers and 11 nonsmokers. RESULTS: Both the systolic and diastolic flow velocity decreased in the OA, CRA, and PCA in smokers compared with nonsmokers. The systolic flow decreased by as much as 36% and the diastolic flow by as much as 52%. This decrease was significant for the flow velocity of the CRA and PCA but not for the OA. An increase in the resistance index was also found. CONCLUSION: The authors believe that the decrease in the flow velocity of these vessels may be due to an increase in the vascular resistance of the vessels of the retina and optic nerve head in smokers. This may be important in patients with eye disease in whom altered blood flow already contributes to the ocular or orbital pathology.

Doppler ultrasonography of the central retinal artery in patients with diabetes and vascular disease treated with topical timolol.

Using high-resolution duplex scanning it is possible to evaluate the blood flow velocity in the central retinal artery of the eye. Four different patient groups were studied with this technique: normals, diabetics with a decreased flow, diabetics with an increased flow and vascular patients with a decreased flow. The eyes of these patients were then treated with topical timolol and the flow measured again. An increase in the flow was found in three of the four groups. This increased flow velocity may be due to a vasodilatory effect of timolol. The results are presented and discussed.

Ocular and orbital blood flow in patients with essential hypertension treated with trandolapril.

PURPOSE: To study the effect of essential hypertension on flow velocity in the central retinal (CRA) and posterior ciliary arteries (PCA). Flow velocity was also evaluated in these arteries in patients with hypertension treated with trandolapril, an oral angiotensin-converting enzyme inhibitor. METHODS: Using the duplex scanner, flow velocity of the CRA and PCA was measured in 12 medication-free patients with hypertension and 10 normal controls. The hypertensive patients were then treated with oral trandolapril, 1 mg/day for 1 week. After 1 week of treatment, flow velocity was again measured in the arteries of the patients with hypertension. RESULTS: There was a significant reduction in systolic and diastolic flow velocity of the vessels tested in the medication-free hypertensive patients when compared with those in the normal controls. In controls, the CRA had a peak systolic flow velocity (PSFV) of 34 cm/sec and an end diastolic flow velocity (EDFV) of 14 cm/sec; the PCA had a PSFV of 38 cm/sec and an EDFV of 16 cm/sec. In the hypertensive patients off medication, the CRA had a PSFV of 16 cm/sec and an EDFV of 6 cm/sec; the PCA had a PSFV of 17 cm/sec and an EDFV of 5 cm/sec. The diastolic component also was significantly decreased in the patients with hypertension. Flow velocity significantly increased in the hypertensive patients treated with trandolapril for 1 week, but did not reach the level of flow measured in normal controls. CONCLUSION: The decreased flow velocity in hypertensive patients may result from a peripheral vasospasm in the vessels of the eye and orbit. This decreased flow velocity may be important in eyes that already have ocular disease. Improvement in flow velocity was noted with oral trandolapril but it did not reach the levels seen in normal controls.

Doppler ultrasonography of the central retinal artery by duplex scanning.

PURPOSE: To present duplex scanning of the central retinal artery, which the authors have termed duplex scanner imaging, as an alternative to color Doppler imaging in the evaluation of retinal blood flow velocity, and to show the difference in measurements obtained with the two different techniques. METHODS: The high-resolution ATL-Ultramark 4 duplex scanner (Advanced Technology Laboratories, Bothell, WA) with the variable focus access probe was used to measure blood flow velocity of the central retinal artery in the eyes of 48 healthy volunteers. RESULTS: Using this technique the peak systolic flow velocity (+/- standard deviation [SD]) of the central retinal artery was 36.6 +/- 10.8 cm/sec, and the end diastolic flow velocity was 12.6 +/- 3.7 cm/sec. CONCLUSION: The flow velocity measurements of the central retinal artery obtained with this technique were much higher than those obtained by other authors using color Doppler imaging (9.6 cm/sec for the peak systolic flow velocity, and 4.7 cm/sec for the end diastolic flow velocity). The authors propose duplex scanner imaging as an alternative to color Doppler imaging for evaluating retinal blood flow velocity. The duplex scanner also can be used to measure the flow velocity of orbital vessels.