QUANTITATIVE AND QUALITATIVE ANALYSIS OF THE THREE CAPILLARY PLEXUSES AND CHORIOCAPILLARIS IN PATIENTS WITH TYPE 1 AND TYPE 2 DIABETES MELLITUS WITHOUT CLINICAL SIGNS OF DIABETIC RETINOPATHY: A Prospective Pilot Study.

PURPOSE: To separately evaluate the three retinal capillary plexuses and the choriocapillaris in patients with diabetes mellitus (DM) Type 1 and Type 2, without clinical signs of diabetic retinopathy. METHODS: The study was prospective and cross-sectional. Only patients with age ≤55 years were included. We used a swept-source optical coherence tomography angiography device (Triton; Topcon, Tokyo, Japan) to obtain both quantitative and qualitative analysis of the retinal capillary plexuses (superficial capillary plexus; middle capillary plexus; and deep capillary plexus) and the choriocapillaris. RESULTS: We included 17 patients with DM Type 1 (age 34.52 ± 11.05 years, 29 eyes), 17 patients with DM Type 2 (age 48.76 ± 3.26 years, 32 eyes), and 23 healthy control subjects (age 41.82 ± 8.97 years, 43 eyes). When compared with controls, vessel density in the central 1 mm was reduced in both DM Type 1 and DM Type 2 groups in the superficial capillary plexus (P = 0.05 and P = 0.02, respectively), and in DM Type 2 in the deep capillary plexus (P = 0.03). Foveal avascular zone was increased in the middle capillary plexus and deep capillary plexus of DM Type 2 group compared with controls (P = 0.03 and P = 0.02, respectively). Choriocapillary voids were more frequent in DM Type 1 and DM Type 2 compared with controls (P = 0.003 and P < 0.001, respectively). CONCLUSION: Microvascular modifications are present in the three retinal capillary plexuses and the choriocapillaris in both DM Type 1 and DM Type 2 even in the absence of clinical signs of diabetic retinopathy.

EVALUATION OF PHOTORECEPTORS, RETINAL CAPILLARY PLEXUSES, AND CHORIOCAPILLARIS IN PATIENTS WITH BIRDSHOT CHORIORETINOPATHY.

PURPOSE: To assess the status of the cone photoreceptors using adaptive optics flood illumination ophthalmoscopy in patients with birdshot chorioretinopathy and to study their relationship with optical coherence tomography (OCT) angiography. METHODS: Seventeen patients with birdshot chorioretinopathy were studied using standard automated perimetry, color vision testing, fluorescein angiography, indocyanine green angiography, spectral domain OCT, enhanced depth imaging OCT, and adaptive optics flood illumination ophthalmoscopy (rtx1, Imagine Eyes, Orsay, France) in a 90 × 90-µm area at 1.5° temporal of the fovea and OCT angiography (Spectralis OCT2, Heidelberg Engineering, Heidelberg, Germany). For adaptive optics flood illumination ophthalmoscopy, spectral domain OCT, and OCT angiography, a control group of 12 healthy patients (12 eyes) matched for age, sex, and refractive error was included. RESULTS: After excluding low-quality adaptive optics flood illumination ophthalmoscopy images, 12 eyes (12 patients, 7 women, mean age 53.5 ± 10.8 years) were analyzed. Best-corrected visual acuity was 0.01 ± 0.03 LogMAR (20/25 Snellen equivalent), and foveal threshold at standard automated perimetry was 35.2 ± 3.0. Cone density at 1.5° of the fovea in the birdshot chorioretinopathy group (11,435.25 ± 4,342.9 cells/mm) was significantly smaller than in the control group (24,594.04 ± 4,764.3 cells/mm, P < 0.001). In the same area, birdshot chorioretinopathy eyes showed disruption of the ellipsoid/interdigitation zone and vascular abnormalities, such as capillary loops (58.3%), increased superficial intercapillary spaces (75%), increased deep intercapillary spaces (58.3%), capillary dilations (58.3%), telangiectatic vessels (66.6%), and absence of choriocapillary flow (58%). Cone density at 1.5° was associated with duration of the disease (Spearman's rho -0.8, P = 0.01), although it was not associated with OCT angiography abnormalities in the same area. CONCLUSION: Birdshot chorioretinopathy can result in a reduction in cone density and development of macular vascular abnormalities even in the presence of preserved visual function.

Choroidal Thickness in Birdshot Retinochoroiditis Over a 2-Year Period.

PURPOSE: To evaluate 2-year choroidal changes in eyes with birdshot retinochoroiditis (BRC). METHODS: Thirteen patients (26 eyes) with BRC were prospectively evaluated during a 2-year period with standard automated perimetry (SAP), fluorescein angiography, indocyanine green angiography and optical coherence tomography (Spectralis Heidelberg Retinal Angiograph + optical coherence tomography). Enhanced-depth imaging optical coherence tomography was performed. RESULTS: Eight patients (61%) were females; the patients mean age was 60 ± 4.7 (range 49-66) years. At baseline, best-corrected visual acuity (BCVA) was 0.08 ± 0.2 and foveal sensitivity threshold (FST) at SAP was 34.04 ± 2.6; at 2-year visit, no significant changes were observed (BCVA 0.06 ± 02, p = 0.1 and FST 34.36 ± 2.6, p = 0.1). In all cases, at the 2-year visit, a significant reduction of choroidal thickness was present only at the fovea (p = 0.01). The rate of foveal choroidal thinning was 1.8 ± 1.6 µm per month. When compared to baseline, suprachoroidal fluid (SCF) was more frequent (42.3 vs. 23%; p = 0.002). The amount of foveal choroidal thinning was associated with the presence of SCF at baseline (p = 0.005). CONCLUSION: In patients with BRC, foveal choroidal thinning and increase of SCF at 2-year follow-up can be observed, even in the absence of visual loss.

Epilutein for Early-Stage Age-Related Macular Degeneration: A Randomized and Prospective Study.

PURPOSE: The hypothesis that oral supplementation of the epilutein/lutein combination could augment the macular pigment optical density (MPOD) in patients with age-related macular degeneration (AMD) was tested. METHODS: In a prospective randomized interventional study, 40 consecutive patients with early-stage AMD were recruited. After a 2-week run-in period, patients were randomly treated with a daily oral administration of 8 mg epilutein and 2 mg lutein (group 1) or 10 mg lutein (group 2) for 2 months. At baseline (BL) and 1-month (M1) and 2-month visits (M2), all patients underwent a complete ophthalmological examination, including measurement of MPOD in a 7° area (Visucam 200; Carl Zeiss Meditec, Milan, Italy). Xanthophylls were quantified in plasma, as well as the HDL, non-HDL, and erythrocyte fractions at each study visit. RESULTS: Twenty-one patients (mean age 69.4 ± 6.7 years, 35 eyes) were included in group 1. Mean MPOD was 0.203 ± 0.02 optical density units (ODU) at BL, and increased to 0.214 ± 0.04 ODU at M1 (p = 0.008) and 0.206 ± 0.03 ODU at M2 (p = 0.04). Sixteen patients (mean age 72.0 ± 6.3 years, 29 eyes) were included in group 2. Mean MPOD was 0.215 ± 0.03 at BL, which reduced to 0.202 ± 0.03 ODU at M1 (p = 0.003) and 0.207 ± 0.02 ODU at M2 (p < 0.001). A rise in the systemic level of total xanthophylls was observed at M1 for both groups. At M2, total xanthophylls were significantly increased only in group 1 and decreased in group 2. CONCLUSION: In patients with early-stage AMD, the administration of lutein in combination with epilutein was associated with an increased MPOD compared to the administration of lutein alone.

Multimodal analysis of the progression of Best vitelliform macular dystrophy.

PURPOSE: To investigate the multimodal morphological features in the different stages of Best vitelliform macular dystrophy (VMD) in subjects harboring mutations in the BEST1 gene, and their changes during the progression of the disease. METHODS: In this retrospective observational study performed between January 2007 and December 2012, 21 patients (42 eyes) with Best VMD from eight families with the BEST1 mutation were included. Best-corrected visual acuity (BCVA), fundus autofluorescence (FAF), and spectral domain optical coherence tomography (SDOCT) were evaluated at study entry and at last visit. RESULTS: The mean age of patients was 26.3±17.4 years. Seven new missense mutations in BEST1 were identified. Mean follow-up was 41.1±18.5 months. Mean BCVA was 0.34±0.34 LogMAR at study entry and 0.32±0.33 LogMAR at last follow-up visit (p = 0.2). The overall lesion area on FAF increased from 6.62±4.9 mm² to 7.34±6.1 mm² (p = 0.05). At study entry, on SD-OCT, photoreceptor inner segment ellipsoid portion (ellipsoid zone, EZ) was normal in 15 eyes, disrupted in 14 eyes, and absent in 13 eyes. In two eyes, EZ changed from normal to disrupted during follow-up. Three eyes of three patients showing pseudohypopyon lesions at study entry progressed to vitelliruptive lesions at the last follow-up visit. Three eyes of three patients showing vitelliruptive lesion at study entry reverted to pseudohypopyon lesion with overall enlargement of the lesion size. CONCLUSIONS: Multimodal analysis allowed documenting a continuous material accumulation and reabsorption in Best VMD progression. Blue FAF and SD-OCT could represent noninvasive imaging techniques to monitor Best VMD.

Refractive surgery for accommodative esotropia: 5-year follow-up.

PURPOSE: To assess the long-term effectiveness and safety of refractive surgery with LASIK or photorefractive keratectomy (PRK) for treating accommodative esotropia in adults. METHODS: All patients with accommodative esotropia treated with LASIK or PRK until December 2007 and with a minimum follow-up of 5 years were retrospectively included. RESULTS: LASIK was performed on 44 eyes of 22 patients (12 women, 10 men; mean age: 22.7 ± 2.9 years). Mean postoperative follow-up was 62.1 ± 3.2 months. PRK was performed on 16 eyes of 8 patients (4 women, 4 men; mean age: 23.7 ± 1.7 years). Mean postoperative follow-up was 61.3 ± 2.8 months. At the 5-year follow-up, the mean cycloplegic refraction was more hyperopic in the PRK group (0.3 ± 0.8 vs 0.06 ± 0.3 diopters, P = .01). Correction of esotropia to esophoria or orthotropia was present in 21 patients (95.4%) treated with LASIK and in all patients treated with PRK. CONCLUSIONS: Both LASIK and PRK were effective in the long-term reduction of accommodative esotropia.

Microperimetry of subretinal drusenoid deposits.

PURPOSE: To investigate light sensitivity in eyes presenting with subretinal drusenoid deposits (SDD). METHODS: All consecutive patients with SDD only seen between January 2012 and July 2012 were included. A control group of consecutive age- and sex-matched control subjects presenting at least one eye with early age-related macular degeneration was considered. In all cases best-corrected visual acuity (BCVA), color fundus photography, fundus autofluorescence imaging and spectral-domain-optical coherence tomography with integrated microperimetry were performed. RESULTS: Twenty-one eyes (21 patients, 9 females, 12 males, mean age 69.2 ± 5.3 years, mean BCVA 0.18 ± 0.14 LogMAR) were included in the SDD group. Twenty eyes of 20 patients (13 females, 7 males, mean age 69.1 ± 3.9 years, mean BCVA 0.16 ± 0.15 LogMAR) were included in the control group. In eyes with SDD the choroid was thinner at the subfoveal location, and at 1,500 µm superior, inferior, temporal and nasal to the fovea (p < 0.05). In eyes with SDD, the overall mean light sensitivity in the central macula (4.21 ± 2.46 dB) was significantly reduced when compared to the control group (6.81 ± 2.12 dB, p = 0.001), while stable fixation was present in both groups. Correlation between BCVA and mean light sensitivity in the central 7 × 7 mm square was low in the SDD group (Pearson's rho = 0.4, p = 0.01), while it was good in the control group (Pearson's rho = 0.7, p = 0.001). CONCLUSIONS: Eyes with SDD showed reduced sensitivity despite preserved BCVA. Reduced choroidal thickness could be involved in reduction of light sensitivity.

Long-term outcome of primary versus secondary intraocular lens implantation after simultaneous removal of bilateral congenital cataract.

BACKGROUND: Long-term outcomes of intraocular lens (IOL) implantation for congenital cataract in children under 2 years old are still undetermined. METHODS: We retrospectively reviewed all cases of bilateral congenital cataract who had undergone simultaneous bilateral cataract removal with posterior capsulotomy and central anterior vitrectomy between 1990 and 2010. Patients randomly underwent primary IOL implantation or secondary IOL implantation after a period of contact lens wear. The two groups were compared for visual outcome and complications during follow-up. RESULTS: Cataract removal and primary IOL implantation was performed in 30 eyes (15 patients; nine males, six females) at a mean age of 6.8 ± 4.2 months. After 79.31 ± 63.4 months, best-corrected visual acuity (BCVA) was 0.53 ± 0.36 EDTRS LogMAR. In 36 eyes (18 patients, 11 males, seven females) the lens was removed at a mean age of 5.42 ± 2.80 months, and after 32.0 ± 6.1 months of contact lens utilization, secondary IOL implantation was performed. After 109.0 ± 33.8 months, BCVA was 0.54 ± 0.4 ETDRS LogMAR. The association between age at surgery and final visual acuity and the difference between the two groups concerning type of cataract at baseline, BCVA and refractive error at last visit, incidence of posterior capsular opacification, glaucoma, strabismus, and nystagmus during follow-up were not significant (p > 0.05). Myopic shift was more frequent in eyes undergone primary IOL implantation (p < 0.001). CONCLUSIONS: Similar visual outcome and complications were observed during long-term follow-up after both primary and secondary IOL implantation following simultaneous bilateral congenital cataract removal with posterior capsulotomy and central anterior vitrectomy.

Adalimumab for juvenile idiopathic arthritis-associated uveitis.

PURPOSE: To assess the long-term outcomes and complications of patients with uveitis from juvenile idiopathic arthritis (JIA) treated with adalimumab. METHODS: Prospective interventional case series. All patients who underwent treatment with adalimumab for JIA and anterior uveitis were prospectively included in the study. The anterior chamber inflammation was evaluated according to the Standardization of Uveitis Nomenclature criteria. RESULTS: Twenty-one patients (16 females, five males, 38 eyes) were included in the study. Mean age of patients at referral was 11.1 ± 3.8 (5-17) years. Before initiation of treatment, mean duration of arthritis was 7.0 ± 5.5 (median, 6) months, mean duration of uveitis was 7.0 ± 4.4 (median, 7) months. Oligoarticular arthritis was present in 15 cases (71 %), polyarticular arthritis in six cases (28 %). After a mean follow-up of 18.2 ± 7.7 (9-41) months, resolution of anterior chamber inflammation was obtained in 29/38 eyes (76 %). The anterior uveitis flare rate during the 12 months prior to enrollment was 1.6 ± 0.4/year, and was reduced during adalimumab treatment to 0.7 ± 0.3/year (p<0.001). A significant decrease of the number of relapses/month was present after onset of treatment with adalimumab (0.18 ± 0.2 before versus 0.02 ± 0.1 after treatment onset, p<0.001). No significant correlation was found between relapse number and age, sex, type of JIA and doses of previous steroid treatment (p>0.05). CONCLUSION: Adalimumab showed to be effective and relatively safe for treatment of JIA-associated uveitis.

Multimodal evaluation of foveal sparing in patients with geographicatrophy due to age-related macular degeneration.

PURPOSE: To compare the ability of spectral domain optical coherence tomography (SD-OCT), blue light fundus autofluorescence (FAF), and near-infrared fundus autofluorescence (NIR-FAF) to evaluate foveal involvement in geographic atrophy as a result of age-related macular degeneration. METHODS: All consecutive patients with geographic atrophy underwent FAF (excitation λ = 488 nm; emission λ > 500 nm), NIR-FAF (excitation λ = 787 nm; emission λ > 800 nm), and simultaneous SD-OCT scanning (Spectralis HRA + OCT; Heidelberg Engineering). Two readers independently graded foveal involvement on FAF, NIR-FAF, and SD-OCT and measured the width of foveal sparing. In eyes with an intergrader agreement of foveal sparing by at least one among FAF, NIR-FAF, and SD-OCT, microperimetry (Spectral OCT/SLO; OPKO-OTI) was analyzed. RESULTS: A total of 158 eyes (83 patients; 53 women, 30 men, mean age 69.2 ± 4.8 years) with geographic atrophy were included. Spectral domain OCT showed the highest intergrader agreement of foveal involvement (k = k' = 0.8, P = 0.001 vs. k = k' = 0.7, P = 0.01 for NIR-FAF and k = k' = 0.5, P = 0.01 for FAF). In 74 eyes (46.8%) foveal sparing was present according to interobserver agreement. Width of the foveal sparing was larger on SD-OCT than on NIR-FAF and FAF (1,334 ± 943 µm vs. 1,228 ± 912 µm, P < 0.001 and 1,201 ± 922 µm, P < 0.001, respectively). Retinal fixation was predominantly central and stable in 97.3% of eyes with foveal sparing. CONCLUSION: Spectral domain OCT is an appropriate imaging modality for evaluating the presence and extent of foveal sparing, followed by NIR-FAF and FAF.

Precursors of type 3 neovascularization: a multimodal imaging analysis.

PURPOSE: To study the advent of exudative age-related macular degeneration in uninvolved fellow eyes of patients with unilateral Type 3 neovascularization and to investigate the precursors at the site of lesion development. METHODS: We studied 37 consecutive patients with the diagnosis of unilateral Type 3 neovascularization, for the advent of exudative age-related macular degeneration in uninvolved fellow eyes (study eyes). Looking for the precursors of Type 3 neovascularization, we reviewed the multimodal imaging (fundus autofluorescence, fluorescein angiography, indocyanine green angiography, and spectral-domain optical coherence tomography) in the study eyes and interpreted the changes over time at the site of lesion development. RESULTS: Of the 37 patients, 12 (32%) developed exudative age-related macular degeneration in the study eye, after a mean of 19.6 ± 9.5 months (range, 9-36 months) from the diagnosis of Type 3 neovascularization in the first involved eye (baseline). All these patients (12 of 12 eyes; 100%) developed Type 3 neovascularization in the study eye. Retrospective analysis of the precursors of these lesions revealed, at baseline, a focal hyperautofluorescence (fundus autofluorescence) that turned to focal hypoautofluorescence over time. In all eyes, a focal hyperfluorescence (fluorescein angiography and indocyanine green angiography) appeared over time at the site of Type 3 neovascularization development. The corresponding spectral-domain optical coherence tomography showed a localized retinal pigment epithelial (RPE) elevation characterized by a focal disruption of the RPE and photoreceptors and by the overlying outer plexiform layer that progressively took contact with the RPE. Based on these findings, it seems that a small, localized RPE elevation might be the lesion before the development of Type 3 neovascularization. This precursor lesion progresses over time to focal atrophy of RPE and photoreceptor. CONCLUSION: Type 3 neovascularization presents a predictable symmetry and bilaterality. Identification of the precursors of Type 3 neovascularization looks particularly useful for clinicians to detect the earliest changes in the vasogenic process in the fellow eye.

Surgical management of benign tumors of the parotid gland: extracapsular dissection versus superficial parotidectomy--our experience in 232 cases.

PURPOSE: The purpose of this study was to retrospectively analyze all cases of benign parotid tumors treated at our institution from 2002 to 2009. MATERIALS AND METHODS: We carried out a retrospective review of 232 patients with benign primary parotid tumors. Extracapsular dissection or superficial parotidectomy was performed. Clinical and histopathologic data were analyzed, and management was described. The statistical difference between the 2 techniques as concerns evaluated recurrence rate and complications was measured with the log-rank (Cox-Mantel) test. The chosen level of statistical significance was P < .05. RESULTS: A total of 232 patients were enrolled, 107 women and 125 men, whose mean age was 53.2 ± 11.3 years. Extracapsular dissection was performed in 176 cases (76%) (mean age, 52.82 ± 11.55 years), and superficial parotidectomy was performed in 56 cases (24%) (mean age, 54.59 ± 10.56 years). The mean lesion size was 1.89 ± 0.52 cm for extracapsular dissection and 3.49 ± 0.43 cm for superficial parotidectomy (P < .001). Mean follow-up was 52.6 ± 4.5 months for the group of patients treated with superficial parotidectomy and 46 ± 5.2 months for the group treated with extracapsular dissection. No significant differences as concerns capsular rupture and recurrence were observed after extracapsular dissection and superficial parotidectomy (3.4% vs 1.8% [P = .1] and 4.5% vs 3.6% [P = .1], respectively). Transient facial nerve injury, facial paralysis, and Frey syndrome were significantly more frequent after superficial parotidectomy than after extracapsular dissection (26.8% vs 3.9% [P = .001], 8.9% vs 0% [P < .001], and 5.3% vs 0% [P < .001], respectively). CONCLUSIONS: Extracapsular dissection showed similar effectiveness and fewer side effects than superficial parotidectomy and could be considered as the treatment of choice for tumors located in the superficial portion of the parotid gland.

Anatomic response of occult choroidal neovascularization to intravitreal ranibizumab: a study by indocyanine green angiography.

BACKGROUND: To investigate changes in indocyanine green angiography (ICGA) features of occult choroidal neovascularization (CNV) after intravitreal ranibizumab injections. METHODS: We reviewed the charts of all consecutive patients with newly diagnosed occult CNV secondary to age-related macular degeneration (AMD) treated by intravitreal ranibizumab. In all patients, optical coherence tomography (OCT) and ICGA were performed at baseline, after 3 months and 12 months. RESULTS: Fifty-one eyes of 44 patients (ten males, 34 females, mean age 77.8 ± 7.3 years) were included. Mean follow-up was 20.3 ± 6.2 months. During the first 12 months, patients received 5.5 ± 2.7 intravitreal ranibizumab injections. When compared with baseline, best-corrected visual acuity (BCVA) significantly improved at the 3-month follow-up visit (60.5 ±22.0 vs 50.9 ±20.7 letters, p = 0.04), and stabilized at 12-month visit (55.7 ±18.2 letters; p = 0.05). Central macular thickness (CMT) significantly improved during follow-up (229.0 ±54.7 µm vs 281.0 ±61.3 µm at baseline, p = 0.003). An overall stabilization was observed on ICGA in both the lesion area (5.27 ± 3.9 mm(2) at baseline vs 4.60 ± 3.5 mm(2) at month 12, p = 0.4), and greatest linear dimension (GLD 2.66 ± 1.2 mm at baseline vs 2.55 ± 1.0 mm at month 12, p = 0.3). Eight eyes (15.7%) showed CNV growth on ICGA (lesion area 3.98 ± 3.2 mm2 at baseline vs 4.3 ± 2.7 mm2 at month-12, p = 0.6; GLD 2.11 ± 1.0 mm at baseline vs 2.70 ± 0.8 mm at month-12, p = 0.05). CONCLUSION: ICGA suggests that functional outcomes after intravitreal ranibizumab is related to CMT reduction rather than CNV regression.

Longitudinal anatomical response of retinal-choroidal anastomosis to anti-vascular endothelial growth factor therapy.

PURPOSE: To evaluate the longitudinal anatomical response of retinal-choroidal anastomosis (RCA) to intravitreal ranibizumab injection using spectral-domain optical coherence tomography (SD-OCT). METHODS: We reviewed the medical records of 21 consecutive patients with RCA who underwent intravitreal ranibizumab injections at the University Eye Clinic of Creteil between January 2009 and June 2010. The SD-OCT features at baseline, at 3 months, and at 12 months were retrospectively analyzed. Based on SD-OCT, RCAs were classified as showing a focal retinal pigment epithelium (RPE) erosion ("erosion sign") over a small, localized RPE elevation; a focal RPE break leaving two free RPE flaps ("flap sign") at the level of a small, localized RPE elevation; or a large convex RPE prominence and a focal funnel-shaped RPE kissing an inverted focal funnel-shaped inner neuroepithelium ("kissing sign"). RESULTS: Twenty-one eyes of 21 patients (3 men and 18 women, aged 81.6 ± 6.8 years) diagnosed with RCA naive to any treatment were included for analysis. Spearman ρ correlation between best-corrected visual acuity and lesion classification was 0.54 (P = 0.01) at Month 3 and 0.85 (P < 0.001) at Month 12. Eyes showing the flap sign at baseline underwent significantly less ranibizumab injections after the loading phase (2.14 ± 0.89 vs. 3.40 ± 0.96, P = 0.007) and showed a greater improvement in best-corrected visual acuity at Month 12 (from 0.52 ± 0.14 to 0.38 ± 0.15, P = 0.03) compared with eyes showing the kissing sign. At 12 months, 3 of 10 eyes with flap sign at baseline showed RCA activity, whereas 7 of 10 regressed to erosion sign phase. Of the 10 eyes with kissing sign at baseline, 6 progressed to a fibroglial scar. CONCLUSION: A flap sign of RCA at baseline seems a favorable prognostic factor as concerns best-corrected visual acuity improvement and the need for retreatment.

Combined fluorescein angiography and spectral-domain optical coherence tomography imaging of classic choroidal neovascularization secondary to age-related macular degeneration before and after intravitreal ranibizumab injections.

PURPOSE: To evaluate the combined fluorescein angiography and spectral-domain optical coherence tomography features in a consecutive series of exudative age-related macular degeneration eyes with classic choroidal neovascularization before and after anti-vascular endothelial growth factor treatment. METHODS: Retrospective interventional study. All consecutive patients with exudative age-related macular degeneration because of newly diagnosed classic choroidal neovascularization visited during 3 months and treated by intravitreal ranibizumab injection on "as-needed" basis were analyzed. Combined fluorescein angiography and spectral-domain optical coherence tomography examination (Spectralis Heidelberg Retina Angiograph OCT) was performed at baseline and at the 12-month follow-up visit. RESULTS: Twenty-nine treatment-naive eyes (29 patients, 10 men and 19 women, mean age 76.28 ± 10.86 years) were included. A mean of 5.3 ± 3.5 injections was administered during 12 months. At Month 12 visit, patients showed an improved best-corrected visual acuity (P = 0.01), a reduction of linear dimension of the entire lesion on fluorescein angiography (P = 0.02), and a reduction of the entire lesion width on spectral-domain optical coherence tomography (P < 0.001). At baseline, in all cases we distinguished on spectral-domain optical coherence tomography scan a highly reflective subretinal lesion, above and separate from the retinal pigment epithelium. The highly reflective subretinal lesion showed a significant reduction of width along the length of a single B-scan, at Month 12 follow-up visit (P < 0.001). It is notable that a small "discreet" pigment epithelial detachment associated with the highly reflective subretinal lesions was present in 28 of 29 eyes at baseline and after treatment (at Month 12 follow-up visit). CONCLUSION: A discreet pigment epithelial detachment represents a common associated finding of classic choroidal neovascularization. Our study demonstrated that anti-vascular endothelial growth factor treatment may not only stop the growth of the highly reflective subretinal lesion that colocalize with the classic choroidal neovascularization but also determine its regression.

Retinal micropseudocysts in diabetic retinopathy: prospective functional and anatomic evaluation.

AIM: To evaluate the prevalence, progression and functional predictive value of retinal micropseudocysts (MPCs) in diabetic patients. METHODS: Prospective controlled observational study. From among all the type 2 diabetic patients evaluated during a period of 5 months between September 2009 and January 2010, we enrolled all patients with retinal MPCs at spectral-domain scanning laser ophthalmoscope/optical coherence tomography (SD-SLO/OCT) not previously treated for diabetic retinopathy. Forty diabetic patients without MPCs served as the control group. Best-corrected visual acuity (BCVA), central retinal thickness (CRT), macular sensitivity and stability of fixation at SD-SLO/OCT microperimetry were measured monthly for 12 months. RESULTS: 22/156 patients with type 2 diabetes (14.1%, 32 eyes) met the inclusion criteria. The 95% confidence interval for the prevalence estimate of MPCs was 12.3-16.6%. Mean BCVA, CRT and central retinal sensitivity at baseline were 77.53 ± 2.2 Early Treatment Diabetic Retinopathy Study letters, 242.31 ± 31.0 µm and 15.95 ± 0.61 dB, respectively. Fixation was stable in all cases. Compared to the control group, eyes with MPCs had similar BCVA but greater CRT (p = 0.01) and reduced macular sensitivity (p = 0.001) at baseline and at each follow-up visit. Over time, CRT remained stable in eyes with MPCs, whereas macular sensitivity progressively decreased. CONCLUSION: MPCs in diabetic retinopathy are associated, temporally or causally, with a progressive reduction of macular sensitivity despite a stable BCVA, CRT and fixation.

Bilateral methicillin-resistant Staphylococcus aureus keratitis following hyperopic photorefractive surgery.

To report clinical manifestations of a female patient with bilateral bacterial keratitis following photorefractive keratectomy (PRK). Bilateral PRK was performed for moderate hyperopia. Bandage contact lenses were fitted at the conclusion of the surgery. Bilateral infectious keratitis with hypopion was diagnosed within 4 days after surgery. Smear and culture were obtained and showed the presence of methicillin-resistant Staphylococcus aureus (MRSA). The patient was treated with systemic prednisone and topical antibiotics (vancomycin, tobramycin and netylmicin) and betamethasone. After 1 month corneal leukoma was still present and remained unchanged during the following 7 months. Infectious keratitis is a rare complication of PRK that appears early in the postoperative period. MRSA keratitis may determine long-term visual impairment despite prompt therapeutic intervention.

Intravitreal ranibizumab and bevacizumab in combination with full-fluence verteporfin therapy and dexamethasone for exudative age-related macular degeneration.

PURPOSE: To evaluate the efficacy and safety of triple therapy with intravitreal anti-vascular-endothelial-growth-factor (VEGF) antibody, dexamethasone and verteporfin photodynamic therapy (PDT) for exudative age-related macular degeneration (AMD). METHODS: Retrospective, comparative, interventional study. Records of treatment-naïve patients who received intravitreal bevacizumab or ranibizumab in monotherapy or in combination with dexamethasone and full-fluence verteporfin PDT in triple therapy were reviewed. logMAR visual acuity, foveal thickness (FT) on optical coherence tomography, intraocular pressure and endophthalmitis occurrence were recorded. RESULTS: Sixty-one eyes were included in the triple-therapy group, 40 eyes were included in the monotherapy group. The mean follow-up was 14.1 ± 3.4 months in the triple-therapy group and 16.3 ± 4.1 months in the monotherapy group. The triple-therapy group enjoyed a lower total number of treatments (1.92 ± 0.44 vs. 3.12 ± 0.37, p < 0.001) and a longer time before first retreatment (5.4 ± 3.3 vs. 3.6 ± 2.5 months, p = 0.001). A significant improvement of visual acuity and FT was present in both groups during the 12 months following first treatment. No adverse effects were observed. CONCLUSION: The combination of intravitreal bevacizumab or ranibizumabwith dexamethasone and full-fluence PDT for exudative AMD provided visual and anatomic improvement and a good safety profile. Triple therapy may reduce the number of retreatments when compared to anti-VEGF alone.

Spectral-domain versus time domain optical coherence tomography before and after ranibizumab for age-related macular degeneration.

PURPOSE: To study the ability to appreciate qualitative features that indicate disease activity in patients with neovascular age-related macular degeneration (AMD) and to analyze the differences in automated retinal thickness measurement, using 1 time domain optical coherence tomography (TD-OCT) and 2 different spectral-domain OCT (SD-OCT) machines. METHODS: Thirty-three consecutive naïve patients with neovascular AMD underwent Stratus TD-OCT, Cirrus SD-OCT and Spectralis SD-OCT, at baseline, 1 h, 1 day, 1 week and 1 month after intravitreal ranibizumab injection. RESULTS: As regards the ability to detect retinal cysts, subretinal fluid and pigment epithelium detachment, at each follow-up visit, there was a significant correlation among all 3 OCT devices (p < 0.05), even though Cirrus SD-OCT and Spectralis SD-OCT showed the highest level of intermachine agreement. At each follow-up visit, automated retinal thickness measurements showed a greater mean central macular thickness (CMT) for both Spectralis SD-OCT and Cirrus SD-OCT, compared with Stratus TD-OCT. However, the mean paired differences in CMT among the 3 OCT devices were not statistically significant (p > 0.05). Overall, Cirrus SD-CT showed fewer segmentation errors, compared with both Spectralis SD-OCT and Stratus TD-OCT. CONCLUSION: SD-OCT showed a greater ability to evaluate qualitative features indicating disease activity and fewer errors in automated segmentation. However, differences in CMT changes were similar between TD-OCT and SD-OCT systems during follow-up.

Lower eyelid surgery for lagophthalmos in Möbius and Poland-Möbius syndromes.

BACKGROUND: Patients with Möbius and Poland-Möbius syndromes may experience paralytic lagophthalmos. METHODS: This is a retrospective interventional case series. We report 1 case of Möbius syndrome and 2 cases of Poland-Möbius syndrome, wherein patients underwent lower blepharoplasty for lagophthalmos with 2 different surgical techniques. RESULTS: Two patients with Poland-Möbius syndrome presenting with bilateral lower eyelid entropion and paralytic lagophthalmos underwent lower eyelid elongation using right auricular cartilage via a transcutaneous approach. One patient with Möbius syndrome presenting with monolateral lower eyelid ectropion and lagophthalmos underwent lower eyelid elongation with Tessier cheek rotation flap. In all cases, lagophthalmos disappeared, and no complications were reported after a mean follow-up period of 19.6 months. CONCLUSIONS: A good functional correction of lagophthalmos was obtained at long-term follow-up with 2 different surgical techniques. In patients with Möbius and Poland-Möbius syndromes, correction of lagophthalmos should be rapidly undertaken to prevent consequences of exposure keratopathy.