Aflibercept in persistent neovascular AMD: comparison of different treatment strategies in switching therapy.

PurposeTo evaluate the effects of aflibercept administered according to a pro re nata (PRN) or Fixed Regimen to patients with neovascular AMD and persistent intraretinal/subretinal fluid (IRF/SRF) despite three consecutive ranibizumab injections.MethodsPatients were switched to aflibercept injection (IVA) administered according to a PRN or to a fixed regimen for 1 year in two different retina centers. At baseline each patient underwent a complete ophthalmologic evaluation, including best-corrected visual acuity assessment (BCVA ETDRS chart), fluorescein, and indocyanine green angiography and OCT.ResultsEach group included 36 eyes. After 1 year the PRN group showed BCVA stabilization (63 vs 60 letters, P=0.33), whereas fixed regimen group showed significant BCVA improvement (68 vs 71, P=0.008). The median central retinal thickness decreased by 94 µm in the PRN (P=0.002) and by 148 µm in the fixed regimen group (P≤0.001). Complete IRF/SRF reabsorption was found in 58% of eyes in the PRN and in 42% of eyes in the fixed regimen group. At 1-year visit, the percentage of eyes with pigment epithelium detachment did not significantly decrease, but a height reduction was recorded in both groups. The median number of IVA was 3.5 in the PRN and 7 in the fixed regimen group.ConclusionThe switch to aflibercept with both treatment strategies enabled improvement in morphological parameters and stabilization of visual acuity. BCVA improvement and reduction in vision loss with reduction in retinal thickness, fluid and PED height was achieved with the fixed regimen in previously treated nAMD after 1 year.

Indocyanine green enhanced subthreshold diode-laser micropulse photocoagulation treatment of chronic central serous chorioretinopathy.

PURPOSE: To assess the efficacy and safety of indocyanine green (ICG) dye-enhanced subthreshold diode-laser micropulse (SDM) photocoagulation in patients with chronic central serous chorioretinopathy (CCSC) with no spontaneous resolution 6 months after the onset of the disease. STUDY DESIGN: Interventional prospective non-comparative case series of seven patients presenting with CCSC with well-defined active leaking sites (ALS) suitable for laser treatment and with serous neuroepithelial detachment persisting for 6 or more months. METHODS: SDM treatment was performed 15 minutes after the injection of 25 mg of ICG in 2 cc of 5% glucose solution. ALS were treated with a series of 50 500-ms exposures separated by 500-ms pauses. Each 500-ms exposure delivered a train of 250 micropulses at 10% duty cycle and 500 mW power. ICG angiographic images were taken after the treatment without new ICG injection, to check for the presence of laser-induced spots of background hypofluorescence at the treated leakage sites. RESULTS: Within 7-14 days after treatment, all the patients showed improved visual acuity and reduction of serous neuroepithelial detachment on OCT. No signs of laser lesions were visible at fundus examination and on fluorescein angiography. In a period ranging from 4 to 8 weeks, the neuroepithelial detachment was completely resolved in five patients and reduced in two patients. At the 12-month follow-up visits, no recurrence had occurred in the patients, with resolution of the serous neuro-epithelial detachment, and no worsening of the serous detachment or of VA was noted in the patients with incomplete recovery. CONCLUSIONS: These preliminary results suggest that ICG dye-enhanced SMD photocoagulation appears to be an effective treatment, and can represent a viable approach for the management of CSCC with persistent serous neuroepithelial detachment. Post-treatment ICG angiography, without new ICG dye injection, can be used to verify the placement of the SDM laser applications.

Neuroprotection: VEGF, IL-6, and clusterin: the dark side of the moon.

Growth factors and their respective receptors are key regulators in development and homeostasis of the nervous system, and changes in the function, expression, or downstream signaling of growth factors are involved in many neuropathological disorders. Recently, research has yielded a rich harvest of information about molecules and gene, and currently the assumption "a gene-a protein", where each gene encodes the structure of a single protein, is becoming a paradox. In the past years, the discovery of synergic or antagonistic proteins deriving from the same gene is a novelty upsetting. In some way, the conventional function of proteins involved in DNA repair, cell death/growth induction, vascularization, and metabolism is inhibited or shifted toward other pathways by soluble mediators that orchestrate such change depending on the microenvironment conditions. In this chapter, we focus on the antithetic properties that proteins could exert, depending on the microenvironment that orchestrates the complex networks among proteins and their respective partners.

Subjective visual halos after sildenafil (Viagra) administration: Electroretinographic evaluation.

PURPOSE: The ophthalmologic and electroretinographic (ERG) findings in one subject with subjective visual disturbances after sildenafil administration are described. DESIGN: Interventional case report. METHODS: A complete ophthalmologic examination was performed, including best-corrected visual acuity and ERG, repeated 1 and 2 hours after administration of 100 mg of sildenafil. MAIN OUTCOME MEASURES: Rod responses were obtained over a range of retinal illuminances from those producing a minimum detectable response to those producing rod saturation. Intensity amplitude function was determined. RESULTS: At 2 hours after 100 mg of oral sildenafil, we observed significant variations from baseline in parameters of best-fit Naka-Rushton function; V(max) was notably higher, and K was 0.14 log units lower than baseline. CONCLUSIONS: Sildenafil administration resulted in a higher rod response to light stimuli and in a higher rod sensitivity. These findings are consistent with the weak PDE-6 inhibition induced by sildenafil.

Excimer laser photorefractive keratectomy for high myopia and myopic astigmatism.

BACKGROUND AND OBJECTIVE: To determine the efficacy, safety, and predictability of excimer laser photorefractive keratectomy of high myopia and myopic astigmatism. PATIENTS AND METHODS: 76 eyes of 52 patients with myopia from -8.00 to -23.50 diopters (D) with or without astigmatism up to -5.50D were treated with the VISX 20/20 excimer laser (VISK, Santa Clara, CA) and a multi-zone ablation technique. Visual acuity, manifest refraction, corneal haze, and topography were evaluated at 1 week and 1, 3, 6, 12, and 18 months postoperatively. RESULTS: Postoperative refractions were generally stable after 12 months. At the last follow-up all patients were within - 1.96 D of the intended correction. Eighteen months postoperatively, 68% of patients undergoing photorefractive keratectomy (PRK), and 65% of patients undergoing photo astigmatic refractive keratectomy (PARK), were within 1 D of planned refraction. Furthermore, 87% of patients after PRK and 80% of patients after PARK had a visual acuity of 20/40 or better. CONCLUSIONS: High myopia with or without astigmatism was successfully treated in most of the patients using PRK. The stability of the postoperative refraction during the first 18 months seems to be good. The incidence of adverse effects was low but improvements in the future should further reduce complications, thus increasing the safety of refractive procedures.

'Minimal-change hypertensive retinopathy' and 'arterial pre-hypertension', illustrated via ambulatory blood-pressure monitoring in putatively normotensive subjects.

PURPOSE: To investigate the 24 h blood-pressure (BP) pattern in subjects who were found to show some incipient signs of hypertensive retinopathy but had been diagnosed as normotensives by means of casual sphygmomanometry. METHODS: Non-invasive ambulatory BP monitoring was performed in 25 caucasian subjects (16 M, 9 F; mean age 46 +/- 16 years) showing this type of retinal problem. A comparable number of controlled normotensive Caucasian subjects (15 M, 10 F; mean age: 48 +/- 15 years) without funduscopic signs of hypertensive retinopathy were investigated as a reference group. A series of BP tests over time was analysed by means of conventional biometry and chronobiological methods. RESULTS: The biometric estimates suggest that the investigated subjects with incipient hypertensive retinopathy, although characterized by BP values below 140/90 mmHg, show a significantly higher daily systolic BP. The increase, however, is within WHO reference limits and is not associated with the abolition of the circadian BP rhythm. CONCLUSIONS: The results suggest that the initial signs of hypertensive retinopathy may appear before BP elevation above WHO reference limits occurs. Because of this, it can be assumed that there is such a condition as 'minimal-change hypertensive retinopathy' associated with a haemodynamic picture of 'arterial pre-hypertension'.

Work-related accidents of ophthalmologic interest in Italy during 1986-1991.

The authors analysed accidents of ophthalmological interest obtaining information from the database of the INAIL (National Insurance Institute for Professional Casualties) concerning the period of 1986-1991. The INAIL registers all casualties that cause work disabilities exceeding 3 days. The investigation included all job types grouped into two major categories: agriculture (16% of all insured labour) and industry/craftsmanship (84%). Over 78% of the cases examined were in the industry/craftsmanship category. Approximately 22% of the cases were in the agriculture category. Every year in Italy, about 6% of regularly employed workers suffer casualties. The incidence of casualties of ocular interest has been a stable 0.37% in the years examined; 2.88% of these casualties produce permanent consequences (1/10,000 workers per year). The risk in 3 times higher in agriculture.

Cardiovascular reactivity of mitral valve prolapse patients during experimental stress exposure: evidence for a functional nature of cardiovascular symptoms.

We studied a group of 18 patients with mitral valve prolapse (MVP) and a group of 20 healthy controls. Subjects in both groups were subjected to a 1-h experimental stress exposure during which Holter-ECG monitoring was performed and was then continued for the following 24 h. MVP patients complained of significant cardiac palpitation during the stress session, but ECG examination did not reveal significant inter-group differences. However, the two groups did show statistically significant differences in some psychometric measurements (Toronto Alexithymia Scale, Anxiety Sensitivity Index, Fear Questionnaire, Beck Depression Inventory, and Harm Avoidance subscale of Tridimensional Personality Questionnaire) that underlie personality traits known to be important in the process fostering functional somatic symptoms, according to the somatosensory amplification model. As no objective signs of cardiac rhythm modification were found in MVP patients under stress, we postulate that the symptoms for which these patients were referred have a functional nature, and that there is no pathogenetic link with the underlying valvular defect.

Macula halo syndrome and non-pitting lid oedema in an Italian family.

We report an undocumented association of macula halo syndrome and mechanical ptosis secondary to nonpitting oedema in two members of an Italian family. Macula halo syndrome is universally recognised to be variant of Niemann-Pick disease type B, a lipid storage disorder which is ultimately diagnosed by measuring sphingomyelinase activity levels. Although the diagnosis could not be confirmed because of our patients' refusal to undergo enzymatic investigation, the clinical picture proved to be highly compatible with the suggested diagnosis. We discuss the possible clinical differential diagnosis of lipid storage diseases involving the retina.