Vitreous composition modification after transpalpebral electrical stimulation of the eye: Biochemical analysis.

Electrical stimulation (ES) of the eye represents a therapeutic approach in various clinical applications ranging from retinal dystrophies, age-related macular degeneration, retinal artery occlusion and nonarteritic ischemic optic neuropathy. In clinical practice, ES of the eye is mainly performed with a transcorneal or transpalpebral approach. These procedures are non-invasive and well-tolerated by the patients, reporting only minimal and transient adverse events, while serious adverse effects were not observed. Despite the growing literature on animal models, only clinical parameters have been investigated in humans and few data are available about biochemical changes induced by ES of the eye. The purpose of this study is to investigate the possible mechanism that regulates the beneficial effects of ES on retinal cells function and survival in humans. 28 patients undergoing pars plana vitrectomy (PPV) for idiopathic epiretinal membrane (iERM) were randomly divided in two groups: 13 patients were treated with transpalpebral ES before surgery and 15 underwent surgery with no prior treatment. Vitreous samples were collected for biochemical analysis during PPV. ES treatment leads to a reduction in the vitreous expression of both proinflammatory cytokines, namely IL-6 and IL-8, and proinflammatory lipid mediators, such as lysophosphatidylcholine. Indeed, we observed a 70% decrease of lysophosphatidylcholine 18:0, which has been proven to exert the greatest proinflammatory activities among the lysophosphatidylcholine class. The content of triglycerides is also affected and significantly decreased following ES application. The vitreous composition of patients undergoing PPV for iERM displays significant changes following ES treatment. Proinflammatory cytokines and bioactive lipid mediators expression decreases, suggesting an overall anti-inflammatory potential of ES. The investigation of the mechanism by which this treatment alters the retinal neurons leading to good outcomes is essential for supporting ES therapeutic application in various types of retinal diseases.

ANATOMICAL CHANGES BETWEEN ARGUS II RETINAL PROSTHESIS AND INNER RETINAL LAYERS DETECTED BY SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHY IN FIRST YEAR: A CASE REPORT.

PURPOSE: To report and describe the anatomical changes detected by spectral domain optical coherence tomography between an Argus II retinal prosthesis and the inner retinal layers during 1-year follow-up. METHODS AND RESULTS: A patient presented with epiretinal fibrosis 12 months after implant of an Argus II epiretinal prosthesis. One month after uneventful surgery in March 2016, an evident hyporeflective space was detected between the epiretinal prosthesis and the inner retinal surface by spectral domain optical coherence tomography. An epiretinal hyperreflective band was noticed during follow-up and 1 year after surgery. Spectral domain optical coherence tomography showed close contact of the band with the array, which greatly increased the electrical threshold of stimulation for most of the electrodes. Some electrodes were no longer functioning. No changes in visual performance were detected. CONCLUSION: Argus II epiretinal prosthesis implant may be complicated by the formation of a hyperreflective epiretinal band, detectable by spectral domain optical coherence tomography. The band may alter prosthesis function; to date, the patient did not scored any decrease in visual function.

EPIRETINAL FIBROSIS REMOVAL IN AN ARGUS II-IMPLANTED EYE: Histological Characteristics and Functional Results.

PURPOSE: 1) To investigate morphologic and histochemical characteristics of an epiretinal fibrosis removed in an Argus II-implanted eye; 2) to evaluate the Argus II function before and after the fibrosis removal, and 3) to compare morphologic and functional data. METHODS: Fibrosis, which developed between the Argus II prosthesis and the retina two years after implant, was surgically removed. Its morphologic and histochemical characteristics were evaluated both in light and transmission electron microscopy, with special stains and immunohistochemistry. The Argus II function was evaluated during the follow-up before surgical removal and 1 month later. RESULTS: Fibrosis was successfully removed. It was composed of a fibrotic tissue with spindle cells arranged in nodular aggregates with a symmetric distribution, mixed with an inflammatory infiltrate. Extra- and intracellular, irregular, small iron particles were found and confirmed ultrastructural characterization with degenerative cellular changes. The repositioned Argus II restored, and its function was partially nearly to normal values 1 month after surgery. CONCLUSION: Fibrosis can develop between the Argus II and the retina with increasing reduced function. Morphologic characteristics of the removed fibrosis suggested a pathogenesis based on an inflammatory process involved in a foreign body reaction with progressing connective tissue deposition leading to sclerosis. Adequate clinical follow-up is critical to successful removal of the fibrosis with reactivation of the Argus II function.

Comparison of 5-year progression of retinitis pigmentosa involving the posterior pole among siblings by means of SD-OCT: a retrospective study.

BACKGROUND: The aim of this study is to analyze and compare the progression of photoreceptor atrophy among siblings affected by retinitis pigmentosa by means of spectral SD-OCT. METHODS: Fifty three eyes of 27 patients belonging to 12 family clusters were analyzed. To assess the annual progression rate of photoreceptor atrophy, the ellipsoid zone (EZ) line was measured in OCT sections through the fovea. We used multivariate generalized mixed effects to model the rate of progression and its relation to the initial ellipsoid zone line width. RESULTS: During our 4.84 years (± 1.44) mean follow up time (range 3-7) 53 eyes were examined. The ellipsoid zone line width declined with a yearly average rate of 76.4 µm (4.16% / year) (p-value < 0.0001). Progression rates were poorly correlated within family clusters (p-value = 0.23) and showed statistical difference between affected siblings (p-value = 0.007). There was no correlation between inter-familiar progression rate and mode of inheritance (p-value = 0.98) as well as between age and ellipsoid zone line width among siblings (p-value = 0.91). CONCLUSION: RP could be extremely heterogeneous even among siblings: an accurate and sensitive method to follow the progression of the disease is fundamental for future development of clinical trials and therapy strategies.

Diabetic macular edema.

Diabetic macular edema (DME) is one of the most common causes of visual loss in patients with diabetes mellitus. Many patients continue to lose vision despite laser photocoagulation and medical therapies. The two major categories of medications currently used to treat DME are corticosteroids and anti-VEGF agents. The vitreous has been implicated as a cause of macular edema in people with diabetes via several mechanical and physiologic mechanisms, all of which are postulated to lead to increased vascular permeability. Vitrectomy can release the mechanical traction on the macula and increase oxygenation with subsequent reduction in DME. Early vitrectomy even in nontractional DME results in significant macular thinning and may lead to rapid improvement in vision with long-term stabilization. Unfortunately, a randomized trial pitting vitrectomy against the methods currently employed has not yet been performed.

Renal cell carcinoma with invasion of the tricuspid valve apparatus.

A right atrial in-growth of renal carcinoma occurs in 1% of cases. A traditional approach to removal of the tumor using cardiopulmonary bypass (CPB) and deep-hypothermic circulatory arrest (DHCA) has been challenged in favor of techniques that allow tumor removal without CPB and DHCA. To the best of the present authors' knowledge, no report has yet been made of an invasion by the tumor of the tricuspid valve leaflets and subvalvular apparatus. The details of such a case are reported herein, where CPB + DHCA was used to completely remove the neoplasm, and to preserve tricuspid valve competence.

Pulsatile pulmonary perfusion with oxygenated blood ameliorates pulmonary hemodynamic and respiratory indices in low-risk coronary artery bypass patients.

OBJECTIVE: Acute lung injury still accounts for postoperative mortality after cardiopulmonary bypass (CPB). The safety and the efficacy of pulsatile pulmonary perfusion (PPP) during CPB were analyzed. Preliminary results of the first PPP trial in human beings are reported. METHODS: Thirty low-risk coronary artery bypass grafting (CABG) patients were prospectively randomized to receive PPP with oxygenated blood during CPB and aortic cross-clamping (15 patients, PPP-group) or to conventional CPB (15 patients, control group). Alveolo-arterial oxygen gradient (A-aDO(2)) was set as the primary end point and collected preoperatively, at intensive care unit (ICU) arrival (T1), 3h postoperatively (T2), and post extubation (T3). Secondary end points were collected at the same time points and consisted of respiratory indices (partial pressure of arterial oxygen/fraction of inspired O(2) (PaO(2)/FiO(2)), lung compliance, mixed-venous partial pressure of oxygen (pO(2))) and hemodynamic pulmonary parameters (indexed pulmonary vascular resistances (PVRI), pulmonary arterial pressure (PAP), pulmonary capillary wedge pressure (PCWP), and cardiac index (CI)). Bronchoalveolar lavage (BAL) fluid was collected preoperatively, at ICU arrival (T1-BAL) and after 4h. RESULTS: There were no PPP-related complications. Patients undergoing PPP showed a better preserved A-aDO(2) (group-p=0.001) throughout the study period (group × time-p = 0.0001). PaO(2)/FiO(2) and lung compliance were better preserved by PPP (group-p and group × time-p ≤ 0.05 for all). Pulmonary hemodynamic status was positively influenced by PPP, as shown by the higher CI (group-p=0.0001, group × time-p = 0.0001), and the lower PVRI, PAP, and PCWP (group-p ≤0.001, group × time-p=0.0001 for all). Postoperative BAL specimens demonstrated a lower absolute count of white blood cells (group-p=0.0001), a higher percentage of monocytes/macrophages (group-p=0.027), and a lower percentage of neutrophils (group-p=0.015) after PPP. CONCLUSIONS: Oxygenated blood PPP proved safe and significantly ameliorated pulmonary hemodynamic parameters and respiratory indices in low-risk CABG.

Surgical treatment of postinfarction left ventricular free wall rupture.

BACKGROUND: Left ventricular free wall rupture (LVFWR) is still one of the often fatal complications of acute myocardial infarction. Surgical repair is mandatory even with high operative mortality. The optimal surgical technique is controversial since the results depend on type of rupture. We present our mid-term surgical experience according to the status of the left ventricular tear and type of surgical repair. METHODS: From January 1997 to December 2007, 19 consecutive patients with LVFWR were treated at our institution. The mean age was 72 +/- 8 ranging from 53 to 81 years; there were eight males and 11 females. According to the intraoperative findings, patients were divided into two groups: group 1 (eight patients), where no macroscopic tear of the LVFW could be detected with blood oozing from infarcted zone (Oozing type LVFWR); and group 2 (11 patients), where a macroscopic defect of the epicardium, with free communication between left ventricular cavity and pericardial space, was identified (Blow-out type LVFWR). The patch covering and glue technique was applied for group 1 patients, while closure of the ventricular tear either by direct suture or by patch repair was used for group 2 patients. RESULTS: The interval between diagnosis of LVFWR and surgery was 2.9 +/- 1.1 hours. However, reevaluation of echocardiographic studies showed an early missed diagnosis of LVFWR in three patients of group 1 and in eight of group 2. Thus, the mean interval between initial signs of rupture and surgery was 9 +/- 8 hours and 21 +/- 15 hours, respectively, for oozing and blow-out type rupture. On arrival in the operating room, four patients were on cardiopulmonary resuscitation, while four were in cardiogenic shock. The hospital mortality was 12% (one death) in group 1 and 36% (four deaths) in group 2 mainly due to multiorgan failure. Fourteen patients were discharged with a mean follow-up of 3.8 +/- 3.5 years. During follow-up, one patient in group 1 died after 7.5 years. No recurrence of free wall rupture or aneurysm formation was demonstrated in all cases. At last follow-up, all survivors showed excellent clinical results with a preserved left ventricular function. Patients with oozing type LVFWR and patch covering technique repair showed an absence of left ventricular-restricted motion at the echocardiographic study. CONCLUSION: In patients with LVFWR, early diagnosis and surgical treatment are crucial for successful outcome when excellent results can be achieved with a simple glued patch covering technique.

A 20-year experience with mitral valve repair with artificial chordae in 608 patients.

OBJECTIVE: Mitral valve repair with artificial chordae for degenerative mitral regurgitation is widely adopted. We evaluated long-term results of mitral repair with expanded polytetrafluoroethylene sutures (GORE-TEX CV-5; W. L. Gore & Associates, Inc, Flagstaff, Ariz). METHODS: Between November 1986 and November 2006, 608 consecutive patients underwent mitral repair with artificial neochordae. Mean age was 55 +/- 11 years (15-85 years); 433 (71.2%) were male. Valve disease was purely degenerative in 555 patients (91.3%). Prolapse of anterior, posterior, or both leaflets was present in 47 (7.7%), 308 (50.7%), and 253 (41.6%), respectively. Atrial fibrillation was associated in 117 (19.2%). In 125 cases (20.5%), additional surgical procedures were performed. Follow-up was complete at a median of 5.7 years (interquartile range 2.2-9.8 years, range 0-19.4 years). RESULTS: In-hospital mortality was less than 1% (6 deaths). Overall and cardiac late mortalities were 6.6% and 3.9% (34 and 24 deaths). Kaplan-Meier survival at 15 years was 84% (95% confidence interval 75%-90%). Freedoms from endocarditis, thromboembolic events, reoperation, and recurrent mitral regurgitation at 15 years were 97% (95% confidence interval 93%-99%), 92% (87%-95%), 92% (88%-95%), and 85% (78%-91%), respectively. Sinus rhythm was restored in 75% (33 patients) after surgical atrial fibrillation correction. Calcification of GORE-TEX neochordae was never reported. CONCLUSION: Mitral valve repair with GORE-TEX artificial chordae is effective, safe, and associated with low operative mortality and low rates of valve-related complications at long-term follow-up. Artificial chordae showed excellent biologic adaptation, retaining flexibility and tension with time.

25-gauge macular surgery: results and complications.

PURPOSE: To report the safety and surgical outcome of 25-gauge transconjunctival sutureless vitrectomy for macular conditions. METHODS: In a single-center, retrospective, noncomparative case series, 160 eyes of 150 patients underwent 25-gauge vitrectomy for different macular conditions: 108 eyes for idiopathic macular pucker, 24 for idiopathic macular hole, and 28 for tractional diabetic macular edema. Main outcome measures were surgical time, preoperative and 1-day intraocular pressure (IOP), preoperative and 1-month, 3-month, and 6-month visual acuity, intraoperative and postoperative complications, anatomical results, and cataract progression. All patients were observed up for at least 6 months. RESULTS: Mean follow-up was 10 months (range, 6-20 months). Mean operative time +/- SD was 21 +/- 11 minutes. Mean 1-day IOP was 14 +/- 4 mmHg. No IOP was <8 mmHg on postoperative day 1. Mean overall preoperative visual acuity was 20/70, and mean overall postoperative visual acuity was 20/40 (P or=2 Snellen lines of visual acuity at 1 month; 74%, at 3 months; and 67%, at 6 months (P

Time course of changes in retinal thickness and visual acuity after intravitreal triamcinolone acetonide for diffuse diabetic macular edema with and without previous macular laser treatment.

PURPOSE: To describe the changes in retinal thickness (RT) and visual acuity over time in patients with clinically significant diffuse diabetic macular edema (DME) after intravitreal injection of triamcinolone acetonide (IVTA) and to compare patients with and without previous laser treatment. METHODS: A total of 23 eyes with clinically significant DME received a 4-mg IVTA injection. Twelve eyes were refractory to macular laser treatment (group 1), and 11 eyes received IVTA as primary therapy (group 2). Visual acuity and changes in macular thickening shown by optical coherence tomography were evaluated 48 hours after injection, every 7 days for 1 month, and at 3 months and 6 months of follow-up. RESULTS: RT decreased in all eyes in both groups. The reduction of edema was maximal in the first 7 days after IVTA and tended to remain stable for 3 months. The decrease in RT over time was significant in both groups (P < 0.001). At 6 months, RT had increased in almost all eyes. Visual acuity improved quickly, to a maximum at 2 weeks in both groups, after which it remained stable for 3 months and then decreased. Improvement in visual acuity over time was significant in both groups (P < 0.001). The temporal characteristics of the changes in RT and visual acuity were similar in the two groups (P < 0.05). CONCLUSIONS: IVTA was effective in reducing clinically significant DME and improving visual acuity in eyes with and without previous laser treatment. Its action was maximal in the first week and lasted approximately 3 months in this study.

Optical coherence tomography evaluation of macular edema after radial optic neurotomy in patients affected by central retinal vein occlusion.

PURPOSE: To evaluate the characteristics of macular edema (ME) before and after radial optic neurotomy (RON) detected by optical coherence tomography (OCT), in patients with central retinal vein occlusion (CRVO). DESIGN: Interventional case series. METHODS: Five eyes of 5 patients affected by CRVO underwent RON. Complete ocular examination including best corrected snellen visual acuity (VA), fluorescein angiography (FA) and OCT were performed before RON and at 1, 3 and 6 months of follow-up. RESULTS: The OCT characteristics of macular edema are similar in all the eyes affected by CRVO. Mean retinal thickness (RT) before RON was 858 microns, mean VA was 20/640. By FA 3 eyes were evaluated as being perfused and 2 as indeterminate. No complications occurred during and after surgery. At 6 months of follow-up the RT decreased in all the patients (100%) with a mean value of 289 microns. The VA increased in 3 patients and remained stable in 2. CONCLUSIONS: OCT demonstrated resolution of the macular edema in all the eyes. This resolution is not always accompanied with an improvement in VA. Further studies are needed to better understand the efficacy of this procedure.

Transient visual loss after amyl Isobutyl nitrite abuse.

PURPOSE: To report retinal alterations after Isobutyl nitrite (popper) inhalation. METHODS: Case Report. RESULTS: A 30-year-old man presented a sudden visual decrease following the use of Isobutyl nitrite (popper) while he was at a discotheque. His visual acuity (VA) was 20/50 in the right eye (RE) and 20/63 in the left eye (LE). Ophthalmoscopy revealed symmetric alteration of the foveal reflex with a small yellowish-white spot in the foveal area, much more evident in the RE. Fluorescein angiography and OCT were normal. Visual field showed a mild reduction of central differential light sensitivity. A progressive recovery was noted and at one month's follow-up VA was 20/25 in OU with very faint yellowish-white spots. CONCLUSIONS: The inhalation of drugs as "popper" may cause a visual loss by unclear mechanisms.

OCT findings in patients with retinopathy after watching a solar eclipse.

PURPOSE: To evaluate the optical coherence tomography (OCT) findings in patients with solar retinopathy after watching a solar eclipse. METHODS: Complete ocular examinations and OCT were done in 4 patients presenting with acute solar retinopathy soon after observation of an eclipse. All 4 patients repeated the examinations about 1 month and 1 year after the first visit. RESULTS: The symptoms and fundus findings were similar in all patients; all eyes were emmetropic. However, the OCT images were different in all patients, and the alterations were at different levels. The most evident alterations shown by OCT were: a reduction in the intensity of reflectiveness of the retinal pigment epithelium in 3 cases; intraretinal nonreflective spaces between the inner retinal layers in 2 cases; increased reflectiveness of the inner retinal layers in 2 cases, and a round hyperreflective formation in the vitreous just in front of the fovea in 1 case. All these OCT alterations disappeared after 1 month. CONCLUSIONS: The retinal damage arising soon after exposure to sunlight showed many different aspects in the OCT images of the 4 cases examined. All retinal layers seemed to be altered, but these alterations disappeared after 1 month, and the OCT findings remained the same after 1 year.