Diabetic Macular Edema: State of Art and Intraocular Pharmacological Approaches.

Diabetic macular edema (DME) is the main cause of vision loss in diabetic retinopathy (DR). Although it is one of the main complications of diabetes, the pathogenesis of DME is not completely understood. The hyperglycemic state promotes the activation of multiple interlinked pathways leading to DME. Different classifications have been proposed: based on clinical features, on pathogenesis or on diagnostic tests (optical coherence tomography - OCT and fluorescin angiography - FA). The multimodal imaging allows a better analysis of the morphological features of the DME. Indeed, new inflammatory biomarkers have been identified on OCT. Also, several studies are evaluating the role of the morphological features, identified on multimodal imaging, to find new prognostic factors. Over the past decade, great progresses have been made in the management of DME. Therapeutic alternatives include intraocular injection of anti-vascular endothelial grow factor agents (anti-VEGF) and steroid molecules, focal/grid laser photocoagulation and vitreo-retinal surgery. This review is focused on the description and analysis of the current intravitreal therapeutic pharmacological strategies. Current guidelines recommend anti-VEGF as first line therapy in DME. Corticosteroids are becoming increasingly relevant blocking the inflammatory cascade and indirectly reducing VEGF synthesis.

Case report: Cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy (CADASIL) as a risk factor for central serous chorioretinopathy.

Purpose: To describe an atypical case of central serous chorioretinopathy (CSC) in a patient with cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy (CADASIL). Methods: A retrospective case report. Results: A 43-year-old white man with a genetic diagnosis of CADASIL was referred to our hospital because of reduced visual acuity in his right eye (20/30). In the previous 2 months, he developed CSC with subretinal fluid (SRF) and damage to the retinal pigmented epithelium without pachychoroid and pachyvessels or known risk factors for CSC. The patient was treated with transfoveal subthreshold micropulse yellow laser (577 nm) therapy. One month later, there were no signs of SRF, and visual acuity improved to 20/20. Conclusions: Cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy (CADASIL) is a genetic condition that primarily affects vascular smooth cells in small cerebral vessels and retinal arterioles. However, we hypothesize that CADASIL could also be responsible for an alteration of the vascular smooth cells in the choroidal arterioles, leading to choriocapillaris ischemia and CSC, even in the absence of a pachychoroid spectrum.

Is choriocapillaris the early target in acute maculopathy secondary to hand, foot, and mouth disease? A case report.

PURPOSE: To report the case of a 33-year old man who disclosed the first case of bilateral ocular involvement of hand, foot, and mouth disease (HFMD) with a different stage of the disease in each eye. METHODS: Retrospective case report. RESULTS: The study included a patient who incurred in a bilateral HFMD maculopathy. During 6 months follow-up period persistent abnormalities in fundus examination and in OCT scans were reported. CONCLUSION: We consider that our case shows that choriocapillaris is the primary target of HFMD maculopathy, for this reason we consider that ICGA is mandatory for early diagnosis and an effective treatment.

Role of Statins and Ascorbic Acid in the Natural History of Diabetic Retinopathy: A New, Affordable Therapy?

BACKGROUND AND OBJECTIVE: Diabetic retinopathy (DR) is a worldwide health problem, and intravitreal injections of anti-inflammatory and antiangiogenic agents represent the leading therapy to effectively treat DR and its complications. However, they are expensive, invasive, and stressful for patients. This study aims to demonstrate that statins and vitamin C (alone or in combination with statins) as complementary therapy could have an impact on the nonproliferative DR (NPDR) complication rate. PATIENTS AND METHODS: A retrospective review was conducted with 479 patients with NPDR. Statins and vitamin C intake were analyzed, along with the rate of diabetic macular edema (DME), vitreous hemorrhage (VH), circinate maculopathy (CM), and proliferative DR (PDR). RESULTS: Lower DME (P = .07) and VH (P = .018) rates were observed in patients who took statins compared with those who were statin-naïve. This difference was significant after accounting for vitamin C intake, with a lower rate of DME (P = .01) and VH (P = .008) in patients with statin-vitamin C combination therapy. CONCLUSION: Statins, alone or with vitamin C, appear to reduce the complication rate of NPDR. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:S23-S27.].

Intravitreal vs. subtenon triamcinolone acetonide for the treatment of diabetic cystoid macular edema.

BACKGROUND: To assess the efficacy of the intravitreal (IVT) injection of Triamcinolone Acetonide (TA) as compared to posterior subtenon (SBT) capsule injection for the treatment of cystoid diabetic macular edema. METHODS: Fourteen patients with type II diabetes mellitus and on insulin treatment, presenting diffuse cystoid macular edema were recruited. Before TA injection all focal lakes were treated by laser photocoagulation. In the same patients one eye was assigned to 4 mg IVT injection of TA and the fellow eye was then treated with 40 mg SBT injection of TA. Before and one, three and six months after treatment we measured visual acuity with ETDRS chart as well as thickness of the macula with optical coherence tomography (OCT) and intraocular pressure (IOP). RESULTS: The eyes treated with an IVT injection displayed significant improvement in visual acuity, both after one (0.491 +/- 0.070; p < 0.001) and three months (0.500 +/- 0.089; p < 0.001) of treatment. Significant improvement was displayed also in eyes treated with an SBT injection, again after one (0.455 +/- 0.069; p < 0.001) and three months (0.427 +/- 0.065; p < 0.001). The difference between an IVT injection (0.809 +/- 0.083) and SBT injection (0.460 +/- 0.072) becomes significant six months after the treatment (p < 0.001). Macular thickness of the eyes treated with IVT injection was significantly reduced both after one (222.7 +/- 13.4 microm; p < 0.001) and after three months (228.1 +/- 10.6 microm; p < 0.001) of treatment. The eyes treated with SBT injection displayed significant improvement after one (220.1 +/- 15.1 microm; p < 0.001) and after three months (231.3 +/- 10.9 microm; p < 0.001). The difference between the eyes treated with IVT injection (385.2 +/- 11.3 microm) and those treated with SBT injection (235.4 +/- 8.7 microm) becomes significant six months after the treatment (p < 0.001). Intraocular pressure of the eyes treated with IVT injection significantly increased after one month (17.7 +/- 1.1 mm/Hg; p < 0.020), three (18.2 +/- 1.2 mm/Hg; p < 0.003) and six month (18.1 +/- 1.3 mm/Hg; p < 0.007) when compared to baseline value (16.1 +/- 1.402 mm/Hg). In the SBT injection eyes we didn't display a significant increase of intraocular pressure after one (16.4 +/- 1.2 mm/Hg; p < 0.450), three (16.3 +/- 1.1 mm/Hg; p < 0.630) and six months (16.2 +/- 1.1 mm/Hg; p < 0.720) when compared to baseline value (16.2 +/- 1.3 mm/Hg). CONCLUSION: The parabulbar subtenon approach can be considered a valid alternative to the intravitreal injection. TRIAL REGISTRATION: Current Controlled Trials ISRCTN67086909.

Long-lasting corneal endothelial graft rejection successfully reversed after dexamethasone intravitreal implant.

Graft rejection is the most significant complication corneal transplantation and the leading indication for overall corneal transplantation. Corticosteroid therapy represents the mainstay of graft rejection treatment; however, the optimal route of administration of corticosteroid remains uncertain. We report herein for the first time the multimodal imaging of a case of long-lasting corneal endothelial graft rejection successfully reversed 3 months after dexamethasone intravitreal implant. A 29-year-old Asian female presented with a long-lasting corneal endothelial graft rejection in her left phakic eye. She underwent penetrating keratoplasty for advanced keratoconus 24 months before presentation. Hourly dexamethasone eyedrops, daily intravenous methylprednisolone, and one parabulbar injection of methylprednisolone acetate were administered during the 5 days of hospitalization. However, the clinical picture remained approximately unchanged despite therapy. By mutual agreement, we opted for the off-label injection of dexamethasone 0.7 mg intravitreal implant in order to provide therapeutic concentrations of steroid for a period of ~6 months. No other concomitant therapies were prescribed to the patient. Visual acuity measurement, slit lamp biomicroscopy, anterior segment photography, confocal microscopy, anterior segment optical coherence tomography, laser cell flare meter, intraocular pressure measurement, and ophthalmoscopy were performed monthly for the first postoperative 6 months. Three months after injection, both clinical and subclinical signs of rejection disappeared with a full recovery of visual acuity to 20/30 as before the episode. Currently, at the 12-month follow-up visit, the clinical picture remains stable without any sign of rejection, recurrence, or graft failure. Dexamethasone intravitreal implant seems to be a new potential effective treatment for corneal graft rejection, particularly in case of poor compliance or lack of response to conventional treatment. In addition, it could be especially useful in diabetic patients unable to receive systemic steroids.

Vitrectomy without laser treatment for macular serous detachment associated with optic disc pit: long-term outcomes.

PURPOSE: To evaluate the clinical outcome of surgical treatment for macular serous detachment associated with optic disc pit with pars plana vitrectomy (PPV) without laser photocoagulation on the temporal edge. METHODS: Vitrectomy was performed in 8 eyes of 8 patients (mean age 27.25 years; range 12-57 years) with unilateral macular detachment associated with optic disc pit. All patients underwent pars plana vitrectomy (cases 1, 2, 3, and 4, PPV 20 G; cases 5, 6, 7, and 8, PPV 25 G), internal limiting membrane (ILM) peeling, and SF6 20% gas tamponade (case 1 was treated with silicone oil tamponade). Endolaser on the temporal margin of the optic disk was not performed. Every patient was observed for a follow-up period of 59.25 months after surgery. Statistical analysis was carried out using Student t test paired data. p Value <0.05 was considered to be significant. RESULTS: Complete retinal reattachment was achieved in 7 of 8 patients. Case 8 was operated 11 months ago and he still has a small area of subretinal fluid not completely reabsorbed. Mean preoperative best-corrected visual acuity (BCVA) was 20/83 and the mean postoperative BCVA was 20/40. Mean preoperative foveal thickness was 973 µm and mean postoperative foveal thickness was 363.5 µm. Case 7 developed a macular hole after treatment. CONCLUSIONS: Pars plana vitrectomy, ILM peeling, and endotamponade (SF6 20% gas) without endolaser on the temporal edge of optic disc is an effective treatment. This procedure achieved successful anatomical and functional results.