Long-Term Follow-Up of Macular Perfusion Evaluated by Optical Coherence Tomography Angiography after Rhegmatogenous Retinal Detachment Surgery.

BACKGROUND: The goal of this study was to investigate macular microvascular changes using optical coherence tomography angiography (OCTA) at one year after successful rhegmatogenous retinal detachment (RRD) surgery. METHODS: We performed a cross-section study including RRD treated by pars plana vitrectomy (PPV) with or without scleral buckling and SF6 tamponade. After 12 months, DRI-Triton SS-OCTA was performed. Superficial and deep retinal capillary plexuses (SCP and DCP), choriocapillaris (CC) vessel density (VD), and foveal avascular zone (FAZ) morphology were analyzed. Results were compared with the unaffected contralateral eye. RESULTS: Sixty eyes were included. We observed an increase in VD in the central area of both the SCP and DCP in macula-off eyes treated with PPV + SB and in the SCP of macula-off eyes treated with PPV. Macula-off eyes had a diminished VD for both plexuses in the superior quadrant and in the SCP inferior quadrant in those treated with PPV + SB. The CC flow was diminished in the temporal quadrant of macular-off eyes treated with PPV + SB. Healthy eyes presented higher diameter values than macula-off eyes treated with PPV + SB. FAZ horizontal and vertical diameters were smaller in patients with macula-off RRD vs. macula-on RRD and control groups. CONCLUSION: Macular vascularity remains almost unchanged one year after successful RRD surgery, irrespective of the surgical technique or prior macular status.

Assessment of the Effectiveness of Obstructive Sleep Apnea Treatment Using Optical Coherence Tomography to Evaluate Retinal Findings.

Retinal findings may change in patients with obstructive sleep apnea syndrome (OSAS). The present study aims to evaluate several retinal findings, such as macula layer thickness, the peripapillary retinal nerve fiber layer, and the optic nerve head in patients with OSAS, using optical coherence tomography (OCT); it also aims to monitor the result of several types of treatment of OSAS with OCT. A prospective comparative study was designed. Patients were recruited at a Sleep Unit of a University Hospital and underwent comprehensive ophthalmological examinations. Following exclusion criteria, fifty-two patients with OSAS were finally included. Patients were examined by OCT twice: once before treatment, and again after six months of treatment. In mild-moderate patients, where retinal swelling had been demonstrated, retinal thicknesses decreased [fovea (p = 0.026), as did inner ring macula (p = 0.007), outer ring macula (p = 0.015), and macular volume (p = 0.015)]. In severe patients, where retinal atrophy had been observed, retinal thickness increased [fovea (p < 0.001)]. No statistically significant differences in efficacy between treatments were demonstrated. In conclusion, OCT can evaluate the retina in patients with OSAS and help to monitor results after treatment. In severe OSAS, retinal thickness increased six months after treatment.

José Morón was the first to introduce the retinal light photocoagulation.

Regarding the early history of laser, it is generally accepted that the technique of retinal light photocoagulation was first pioneered by Gerd Meyer-Schwickerath in 1949. The renowned German ophthalmologist developed the technique to obtain clinically useful results and is worldwide considered the father of retinal photocoagulation. Nevertheless, we believe that the Spanish ophthalmologist José Morón (Seville, 1918-2000) was really the author of the first known experience of therapeutic photocoagulation of the retina, because he had previously used a similar technique in rabbit and human eyes in 1945 and 1946, respectively. These experiences already appeared in his doctoral dissertation, which was defended in Madrid in 1946, almost three years before the pioneering presentation of Meyer-Schwickerath. Despite this, Morón was permanently forgotten in the history of retinal photocoagulation. We would like to highlight his earlier experimental studies and reclaim the figure of this Spanish ophthalmologist, which deserves international recognition. This case is an example of a common phenomenon that inventors of new ideas are often not cited appropriately.

Clinical characteristics of full thickness macular holes that closed without surgery.

PURPOSE: To ascertain the anatomic factors that help achieve non-surgical sealing in full thickness macular hole (FTMH). METHODS: Retrospective collaborative study of FTMH that closed without surgical intervention. RESULTS: A total of 78 patients (mean age 57.9 years) included 18 patients with blunt ocular trauma, 18 patients that received topical or intravitreal therapies and 42 patients with idiopathic FTMH. Mean±SD of the initial corrected visual acuity (VA) in logMAR improved from 0.65±0.54 to 0.34±0.45 (p<0.001) at a mean follow-up of 33.8±37.1 months. FTMH reopened in seven eyes (9.0%) after a mean of 8.6 months. Vitreomacular traction was noted in 12 eyes (15.8%), perifoveal posterior vitreous detachment in 42 (53.8%), foveal epiretinal membrane in 10 (12.8%), cystoid macular oedema (CME) in 49 (62.8%) and subretinal fluid (SRF) in 20 (25.6%). By multivariate analysis, initial VA correlated to the height (p<0.001) and narrowest diameter of the hole (p<0.001) while final VA correlated to the basal diameter (p<0.001). Time for closure of FTMH (median 2.8 months) correlated to the narrowest diameter (p<0.001) and the presence of SRF (p=0.001). Mean time for closure (in months) was 1.6 for eyes with trauma, 4.3 for eyes without trauma but with therapy for CME, 4.4 for eyes without trauma and without therapy in less than 200 µm in size and 24.7 for more than 200 µm. CONCLUSION: Our data suggest an observation period in new onset FTMH for non-surgical closure, in the setting of trauma, treatment of CME and size <200 µm.

The role of retinal fluid location in atrophy and fibrosis evolution of patients with neovascular age-related macular degeneration long-term treated in real world.

PURPOSE: To assess the effect of clinical factors on the development and progression of atrophy and fibrosis in patients with neovascular age-related macular degeneration (nAMD) receiving long-term treatment in the real world. METHODS: An ambispective 36-month multicentre study, involving 359 nAMD patients from 17 Spanish hospitals treated according to the Spanish Vitreoretinal Society guidelines, was designed. The influence of demographic and clinical factors, including the presence and location of retinal fluid, on best-corrected visual acuity (BCVA) and progression to atrophy and/or fibrosis were analysed. RESULTS: After 36 months of follow-up and an average of 13.8 anti-VEGF intravitreal injections, the average BCVA gain was +1.5 letters, and atrophy and/or fibrosis were present in 54.8% of nAMD patients (OR = 8.54, 95% CI = 5.85-12.47, compared to baseline). Atrophy was associated with basal intraretinal fluid (IRF) (OR = 1.87, 95% CI = 1.09-3.20), whereas basal subretinal fluid (SRF) was associated with a lower rate of atrophy (OR = 0.40, 95% CI = 0.23-0.71) and its progression (OR = 0.44, 95% CI = 0.26-0.75), leading to a slow progression rate (OR = 0.34, 95% CI = 0.14-0.83). Fibrosis development and progression were related to IRF at any visit (p < 0.001). In contrast, 36-month SRF was related to a lower rate of fibrosis (OR = 0.49, 95% CI = 0.29-0.81) and its progression (OR = 0.50, 95% CI = 0.31-0.81). CONCLUSION: Atrophy and/or fibrosis were present in 1 of 2 nAMD patients treated for 3 years. Both, especially fibrosis, lead to vision loss. Subretinal fluid (SRF) was associated with good visual outcomes and lower rates of atrophy and fibrosis, whereas IRF yields worse visual results and a higher risk of atrophy and especially fibrosis in routine clinical practice.

Challenges in Diabetic Macular Edema Management: An Expert Consensus Report.

PURPOSE: This paper aimed to present daily-practice recommendations for the management of diabetic macular edema (DME) patients based on available scientific evidence and the clinical experience of the consensus panel. METHODS: A group of Spanish retina experts agreed to discuss different aspects related with the clinical management of DME patients. RESULTS: Panel was mainly focused on therapeutic objectives in DME management; definition terms; and role of biomarkers as prognostic and predictive factors to intravitreal treatment response. The panel recommends to start DME treatment as soon as possible in those eyes with a visual acuity less than 20/25 (always according to the retina unit capacity). Naïve patient was defined, in a strict manner, as a patient who, up to that moment, had never received any treatment. A refractory DME patient may be defined as the one who did not achieve a complete resolution of the disease, regardless of the treatment administered. Different optical coherence tomography biomarkers, such as disorganization of the retinal inner layers, hyperreflective dots, and cysts, have been identified as prognostic factors. CONCLUSION: This document has sought to lay down a set of recommendations and to identify key issues that may be useful for the daily management of DME patients.

Microperimetry-Assessed Functional Alterations and OCT-Changes in Patients after Retinal Detachment Surgery Using Pars Plana Vitrectomy and SF6 Tamponade.

BACKGROUND: We study the retinal function measured by macular integrity assessment microperimetry (MAIA) and structural changes assessed by scanning swept source optical coherence tomography (SS-OCT) between healthy individuals and patients undergoing pars plana vitrectomy (PPV) after rhegmatogenous retinal detachment (RRD). METHODS: Cross-sectional study. Early Treatment Diabetic Retinopathy Study (ETDRS) grids were measured by SS-OCT and compared with the MAIA parameters. RESULTS: Thirty-eight eyes with RRD (19 macula-on and 19 macula-off) were compared with 113 healthy eyes. The retinal sensitivity and average total threshold were reduced in all sectors in the RRD group; macular integrity index was increased. Macular thicknesses in total retina and ganglion cell layer (GCL)++ protocols were higher in the RRD group in nasal outer (NO) and central (C) sectors and only in C sector for GCL+ protocol. Thicknesses were lower in total retina, GCL++ protocols in the temporal outer (TO) sector and in the GCL+ protocol in NO sector. Best-corrected visual acuity (BCVA) correlated moderately with retinal sensitivity in all sectors and in just several sectors with time between the date of surgery and the test. The central nasal (CN) sector thickness and the average total threshold were higher in the macula-on subgroup. CONCLUSIONS: RRD and subsequent surgery results in functional and structural changes, especially in individuals with macular detachment.

Prepapillary vascular loop-a new classification.

BACKGROUND/OBJECTIVES: To analyze the ophthalmic characteristics of congenital prepapillary vascular loop (PVL) and to propose a new morphologic classification dividing the loops into six types. SUBJECTS/METHODS: Collaborative multinational multicentre retrospective study of PVL cases. RESULTS: There was a total of 49 cases (61 eyes), 37 unilateral (75.5%) and 12 bilateral (24.5%), 32 arterial type (65.3%) and 18 venous type (36.7%) (one patient had either kind in each eye). The mean number of loops per eye was 2.7 (range, 1-7). The loops were asymptomatic in 42 cases (85.7%). Other findings included: the presence of cilioretinal artery (14 cases), retinal vascular tortuosity (26 cases), amaurosis fugax (1 case), branch retinal artery occlusion (1 case) and vitreous haemorrhage (3 cases). Six morphologic loop types could be discerned based on elevation (flat vs. elevated), shape (figure of 8 or corkscrew with hyaline sheath), number (multiple or single), location (central or peripheral), lumen size (arterial vs. arteriolar) and presence of vascular tortuosity or vitreous traction. CONCLUSIONS: PVL are usually asymptomatic and can be divided into six morphologic types with different pathogenesis during early embryogenesis.

Clinical-Decision Criteria to Identify Recurrent Diabetic Macular Edema Patients Suitable for Fluocinolone Acetonide Implant Therapy (ILUVIEN®) and Follow-Up Considerations/Recommendations.

Current management of diabetic macular edema (DME) predominantly involves treatment with short-acting intravitreal injections of anti-vascular endothelial growth factors (anti-VEGFs) and/or corticosteroids; however, short-acting therapies (lasting between 1 and 6 months) require frequent injections to maintain efficacy, meaning a considerable treatment burden for diabetic patients with multiple comorbidities. Continuous injections needed in some cases are an economic burden for patients/healthcare system, so real-life clinical practice tends to adopt a reactive approach, ie, watch and wait for worsening symptoms, which consequently increases the risk of undertreatment and edema recurrence. On March 7th 2019, a group of experts in retinal medicine and surgery held a roundtable meeting in Madrid, Spain to discuss how to (1) optimize clinical outcomes through earlier use of fluocinolone acetonide (FAc) implant (ILUVIEN®) in patients with persistent or recurrent DME despite therapy; and, (2) to provide guidance to assist physicians in deciding which patients should be treated with ILUVIEN. In this regard, a 36-month follow-up consensus protocol is presented. In conclusion, patients that achieve a complete or partial anatomical, and preferably functional, response following one or two intravitreal dexamethasone implants, but with recurrence of edema after 3-4 months, are deemed by the authors most likely to benefit from ILUVIEN, and the switch to FAc implant should not be delayed more than 12 months after the initiation of at least the first dexamethasone implant.

An Update on Corneal Biomechanics and Architecture in Diabetes.

In the last decade, we have witnessed substantial progress in our understanding of corneal biomechanics and architecture. It is well known that diabetes is a systemic metabolic disease that causes chronic progressive damage in the main organs of the human body, including the eyeball. Although the main and most widely recognized ocular effect of diabetes is on the retina, the structure of the cornea (the outermost and transparent tissue of the eye) can also be affected by the poor glycemic control characterizing diabetes. The different corneal structures (epithelium, stroma, and endothelium) are affected by specific complications of diabetes. The development of new noninvasive diagnostic technologies has provided a better understanding of corneal tissue modifications. The objective of this review is to describe the advances in the knowledge of the corneal alterations that diabetes can induce.

Diabetes and Phacoemulsification Cataract Surgery: Difficulties, Risks and Potential Complications.

Diabetes mellitus is one of the most prevalent chronic diseases worldwide. Diabetic patients are at risk of developing cataract and present for surgery at an earlier age than non-diabetics. The aim of this study was to review the problems associated with cataract surgery in a diabetic patient. Corneal complications in diabetic patients include delayed wound healing, risk of developing epithelial defects or recurrent erosions due to the impairment of epithelial basement membranes and epithelial-stromal interactions. Diabetic patients present lower endothelial cell density and their endothelium is more susceptible to trauma associated with cataract surgery. A small pupil is common in diabetic patients making cataract surgery technically challenging. Finally diabetic patients have an increased risk for developing postoperative pseudophakic cystoid macular edema, posterior capsule opacification or endophthalmitis. In patients with pre-proliferative or proliferative diabetic retinopathy, diabetic macular edema or iris neovascularization adjunctive therapy such as an intravitreal anti-vascular endothelial growth factor injection, can inhibit exacerbation related to cataract surgery.

Did poor eyesight influence Goya's late works? Medicine and art history in search for an interpretation of Goya's late paintings.

PURPOSE: The aim of this article is to 'determine' the scope of Goya's eyesight difficulties and assess the extent to which those difficulties might explain his style of painting in the last years of his life. METHODS: We analyse the correspondence and late works of the Aragonese painter Francisco de Goya y Lucientes (1746-1828), who has been admired for his use of colour, his energetic loose brushstrokes, his disregard for details and his bold compositions, as well as for his different artistic styles throughout his life. RESULTS: The evolution of Goya's style of painting in his later works seems to have been the consequence of an eyesight condition, probably age-related cataracts at an advanced stage. The faded dark backgrounds, which become blurred with the silhouette of the person portrayed, could indicate a certain degree of eye strain. This can be traced in all these works, but is especially evident in the unfinished portrait of Pío de Molina (1827-1828), as well as in the portraits of Mariano Goya, the artist's grandson (1827), and Jacques Galos (1826). CONCLUSION: It has been considered that the late and isolated Goya's sight problems were a belated consequence of his severe illness of 1792. Nevertheless, in our opinion, this is a simplistic explanation and, given the painter's age, it is logical to presume that their cause could be age-related lens opacities. This article argues that medicine may become a subsidiary science to art history, as it can provide empirical evidence of the way painters' illnesses may have a strong impact on their artworks.

Visual field defects and retinal nerve fiber imaging in patients with obstructive sleep apnea syndrome and in healthy controls.

BACKGROUND: To assess the retinal sensitivity in obstructive sleep apnea hypopnea syndrome (OSAHS) patients evaluated with standard automated perimetry (SAP). And to correlate the functional SAP results with structural parameters obtained with optical coherence tomography (OCT). METHODS: This prospective, observational, case-control study consisted of 63 eyes of 63 OSAHS patients (mean age 51.7 ± 12.7 years, best corrected visual acuity ≥20/25, refractive error less than three spherical or two cylindrical diopters, and intraocular pressure < 21 mmHg) who were enrolled and compared with 38 eyes of 38 age-matched controls. Peripapillary retinal nerve fiber layer (RNFL) thickness was measured by Stratus OCT and SAP sensitivities and indices were explored with Humphrey Field Analyzer perimeter. Correlations between functional and structural parameters were calculated, as well as the relationship between ophthalmologic and systemic indices in OSAHS patients. RESULTS: OSAHS patients showed a significant reduction of the sensitivity for superior visual field division (p = 0.034, t-student test). When dividing the OSAHS group in accordance with the severity of the disease, nasal peripapillary RNFL thickness was significantly lower in severe OSAHS than that in controls and mild-moderate cases (p = 0.031 and p = 0.016 respectively, Mann-Whitney U test). There were no differences between groups for SAP parameters. We found no correlation between structural and functional variables. The central visual field sensitivity of the SAP revealed a poor Pearson correlation with the apnea-hipopnea index (0.284, p = 0.024). CONCLUSIONS: Retinal sensitivity show minor differences between healthy subjects and OSAHS. Functional deterioration in OSAHS patients is not easy to demonstrate with visual field examination.

Calculation of iris-claw IOL power for correction of late in-the-bag IOL complex dislocation.

BACKGROUND: To assess the constants and formula for aphakia correction with iris-claw IOLs to achieve the best refractive status in cases of late in-the-bag IOL complex dislocation. METHODS: A literature search was performed. The following data were obtained: Iris-claw IOL model, Iridal or retroiridal enclavation, A-constant, ultrasound or optical biometry, formula employed and refractive outcomes. Acceptable emmetropia was considered if the resulting spherical equivalent (SE) was within ±1.00 D. RESULTS: The majority of the studies used SRK/T formula (66.6%). The 88.9% of the reports obtained a SE within ±1.00 D. Using A-115 for ultrasound biometry and A-115.7 for optical biometry and SRK/T formula, the emmetropia (±1.00 D) of SE, was able to get near 100% of reported cases over the pupil implantation. However, the emmetropia decreased to 80% when the enclavation is retropupilar using the same formula. The A-constant can vary from 116.7 to 117.5 for retropupilar enclavation. CONCLUSIONS: Using A-115 for ultrasound biometry and A-115.7 for optical biometry and SRK/T formula, ±1.00 D of SE, is able to get near 100% of cases. Nevertheless, ±1.00 D of SE decreased to 80% of the cases when the enclavation is retropupilar.

Optical Coherence Tomography in Patients with Chronic Migraine: Literature Review and Update.

Migraine is a chronic disease characterized by unilateral, pulsating, and often moderate-to-severe recurrent episodes of headache with nausea and vomiting. It affects approximately 15% of the general population, yet the underlying pathophysiological mechanisms are not fully understood. Optical coherence tomography (OCT) is a safe and reproducible diagnostic technique that utilizes infrared wavelengths and has a sensitivity of 8-10 µm. It can be used to measure thinning of the retinal nerve fiber layer (RNFL) in some neurological disorders. Although ophthalmologists are often the first specialists to examine patients with migraine, few studies have addressed the involvement of the optic nerve and retino-choroidal structures in this group. We reviewed the literature on the etiological and pathological mechanisms of migraine and the relationship between recurrent constriction of cerebral and retrobulbar vessels and ischemic damage to the optic nerve, retina, and choroid. We also assessed the role of OCT for measuring peripapillary RNFL thickness and macular and choroidal changes in migraine patients. There is considerable evidence of cerebral and retrobulbar vascular involvement in the etiology of migraine. Transitory and recurrent constriction of the retinal and ciliary arteries may cause ischemic damage to the optic nerve, retina, and choroid in patients with migraine. OCT to assess the thickness of the peripapillary RNFL, macula, and choroid might increase our understanding of the pathophysiology of migraine and facilitate diagnosis of retino-choroidal compromise and follow-up of therapy in migraine patients. Future studies should determine the usefulness of OCT findings as a biomarker of migraine.