Fatal ischemic stroke complicating acute multifocal placoid pigment epitheliopathy: histopathological findings.

A previously healthy 29-year-old man was admitted to a tertiary referral center with acute left hemiparesis followed shortly by de novo convulsive status epilepticus. This was in the context of a 2-month history of flu-like symptoms, severe headaches, and retinopathy recently diagnosed as acute multifocal placoid pigment epitheliopathy. Neuroimaging demonstrated bilateral, multiple territory cerebral infarction. Despite intravenous methylprednisolone and craniotomy for the management of raised intracranial pressure, the patient deteriorated and died 14 days later. At autopsy, multiple infarcts of varying ages within a 10-day period were seen in association with a segmental giant cell vasculopathy of meningeal arteries.

Nanosecond-laser application in intermediate AMD: 12-month results of fundus appearance and macular function.

BACKGROUND: A novel, ultra-low energy nanosecond laser (retinal rejuvenation therapy) has been developed with the aim to slow progression of early age-related macular degeneration (AMD). The safety, changes in fundus characteristics and macular function in a cohort of participants with bilateral intermediate AMD are reported. DESIGN: Prospective non-randomised, pilot intervention study. PARTICIPANTS OR SAMPLES: Subjects with bilateral intermediate AMD (n = 50, aged 50-75 years). METHODS: Ultra-low energy laser pulses applied in 12 spots around the macula of one eye (0.15-0.45 mJ), using 400 µm diameter spot, 3 nanosecond pulse length, 532 nm wavelength and energy titrated to each patient. MAIN OUTCOME MEASURES: Best corrected visual acuity, drusen area and macular sensitivity (flicker perimetry) at baseline and at 3, 6 and 12 months post-laser. RESULTS: Treatment was painless with no clinically visible lesions. No participant developed choroidal neovascularization, while two with thin central retinal thickness at baseline developed atrophy at 12-month follow up. Drusen area was reduced in 44% of treated eyes and 22% of untreated fellow eyes, with changes in drusen and function not being coincident. Improvement in flicker threshold within the central 3° was observed in both the treated and untreated fellow eyes at 3 months post-laser. Of the 11 eyes at greatest risk of progression (flicker defect >15 dB), seven improved sufficiently to be taken out of this high-risk category. CONCLUSIONS: A single unilateral application of nanosecond laser to the macula produced bilateral improvements in macula appearance and function. The nanosecond retinal rejuvenation therapy laser warrants ongoing evaluation as an early intervention for AMD.

Prandial presbyopia.

Loss of accommodation amplitude during eating (prandial presbyopia) is a rare phenomenon that has been reported in only 1 patient who had had head trauma. We report 2 patients who had not had head trauma and whose accommodative amplitudes, measured by dynamic retinoscopy, became markedly diminished within 1 minute of starting a meal and did not recover for 55-60 minutes. Apart from this abnormality, there appeared to be no autonomic or other neurologic dysfunction. The cause of this isolated disturbance in these patients is a mystery.

Failure of prophylactic retinopexy in fellow eyes without a posterior vitreous detachment.

OBJECTIVE: To describe adverse sequelae of retinal prophylaxis in fellow eyes of patients with rhegmatogenous retinal detachment. DESIGN: Records were reviewed for 17 patients who had retinal breaks or detachment subsequent to prophylactic retinopexy applied to the fellow eye (without posterior vitreous detachment) at the time of primary rhegmatogenous retinal detachment surgery. Subsequent treatment included cryotherapeutic and laser retinopexy, scleral buckling, and vitrectomy. RESULTS: Of the 17 patients, 12 were male (mean age, 49 years). Laser retinopexy alone was used in 6 cases. Sixteen (94%) developed retinal tears related to acute posterior vitreous detachment, of which 8 (47%) were at the edge of retinopexy and 8 (47%) were in the normal or untreated retina. Thirteen (76%) developed a retinal detachment, of which 11 (85%) did not involve the fovea. Median visual acuity following treatment was 0.18 logMAR (6/9 Snellen equivalent). CONCLUSIONS: Prophylactic retinopexy in fellow eyes without posterior detachment is not completely successful and may cause breaks to develop at the edge of treated areas during subsequent acute posterior vitreous detachment. Patient education alone regarding the symptoms of retinal tear and detachment may be preferable to prophylactic retinopexy of the fellow eye in the absence of a posterior vitreous detachment.

Delay to treatment and visual outcomes in patients treated with anti-vascular endothelial growth factor for age-related macular degeneration.

PURPOSE: To investigate the potential influences that affect visual acuity (VA) outcome in a clinic-based cohort of age-related macular degeneration (AMD) patients undergoing anti-vascular endothelial growth factor (anti-VEGF) treatment for choroidal neovascularization. DESIGN: Prospective interventional case series. METHODS: Patients with subfoveal choroidal neovascularization (CNV) secondary to AMD were prospectively recruited. A detailed questionnaire was given to patients at time of enrollment, to collect information relating to demographics, history of visual symptoms, visual acuity (VA), and treatment scheduling. Delay from symptoms to treatment ("Treatment delay") was measured in terms of weeks and analyzed in tertiles. Information pertaining to treatment outcomes was collected over a 6-month period. RESULTS: One hundred eighty-five eyes of 185 patients were recruited into the study. Longer delay from first symptoms suggestive of CNV to first injection was a significant predictor (P=.015) of poorer treatment outcome, when controlling for age, sex, and baseline VA. Patients with a delay in treatment of 21 weeks or more compared to a delay of 7 weeks or less had an odds ratio of 2.62 (1.20, 5.68) for worsening vision after treatment. CONCLUSIONS: Patients experiencing a longer delay between their first symptoms of CNV and their first anti-VEGF treatment have a significantly lower chance of improving vision at 6 months following anti-VEGF therapy. It is critical that this information reach those at potential vision loss from AMD, in order that prompt treatment may be instituted, to maximize the benefits of anti-VEGF treatment.

Variants in the APOE gene are associated with improved outcome after anti-VEGF treatment for neovascular AMD.

PURPOSE: Anti-vascular endothelial growth factor (anti-VEGF) drugs have dramatically improved the treatment of neovascular AMD. In pivotal studies, almost 90% of patients maintain vision, with approximately 30% showing significant improvement. Despite these successes, 10% to 15% of patients continue to lose vision, even with treatment. It has been reported that variants in some AMD-associated genes influence treatment outcome. This study showed an association of treatment outcome with variants in the apolipoprotein E (APOE) gene. METHODS: One hundred ninety-two patients receiving anti-VEGF treatment for subfoveal choroidal neovascularization secondary to AMD were enrolled. Information on demographics, lesion characteristics, delay until treatment, visual acuity (VA), and number of treatments was collected, and variants of APOE were assessed in all patients at baseline. Best corrected logarithm of the minimum angle of resolution (logMAR) VA was recorded in all patients. RESULTS: The presence of the APOE ε4 allele was associated with improved treatment outcome at 3 (P = 0.02) and 12 (P = 0.06) months, compared with the presence of the ε2 allele, after adjustment for baseline acuity, treatment delay after first symptoms, age, and sex. Patients with an APOE ε4 allele had an odds ratio (OR) of 4.04 (95% confidence interval [CI], 1.11-14.70) for a 2-line gain in vision from baseline at 3 months (P = 0.03) and an OR of 2.54 (95% CI, 0.61-10.52; P = 0.20) at 12 months after treatment, based on multivariate analysis. CONCLUSIONS: In patients with neovascular AMD, the presence of the APOE ε4 allele conferred significantly better visual outcomes after anti-VEGF treatment than did the ε2 allele. These findings suggest a possible role for a personalized approach to treatment with anti-VEGF.

Erectile dysfunction following intravitreal bevacizumab.

Despite initial concerns regarding systemic complications, the use of intravitreal antivascular endothelial growth factor (anti-VEGF) agents for ocular disease is rapidly expanding worldwide, in terms of both the number of patients injected and its indications. To our knowledge, there are no cases in the literature reporting erectile dysfunction following the use of intravitreal bevacizumab. We postulate an organic mechanism for impaired erectile function due to systemically absorbed intravitreal bevacizumab. We describe a case of erectile dysfunction following intravitreal bevacizumab administration. Color fundus photos, fluorescein angiogram and optical coherence tomography images are presented. A 40-year-old male underwent intravitreal bevacizumab therapy for macular edema secondary to a branch retinal vein occlusion. He subsequently developed transient erectile dysfunction after each of his two bevacizumab injections. His only comorbidity was mild hypertension. Erectile dysfunction may be a side effect of intravitreal bevacizumab. The erectile dysfunction could be organic and/or psychogenic in etiology.