Comparison between "early" or "late" intravitreal injection of dexamethasone implant in branch (BRVO) or central (CRVO) retinal vein occlusion: six-months follow-up.

AIM: The aim of this study was to compare early and late injections of intravitreal dexamethasone implant in patients affected by central retinal vein occlusion (CRVO) or branch retinal vein occlusion (BRVO) with a six-months follow-up. We assessed whether an earlier treatment start (within seven days from diagnosis) could be more beneficial than a delayed (or late) treatment start (after seven days). MATERIALS AND METHODS: The study included 81 patients (81 eyes) affected by retinal vein occlusion. Best corrected visual acuity was assessed through Early Treatment Diabetic Retinopathy Study (ETDRS) while central macular thickness (CMT) was measured by spectral-domain optical coherence tomography. RESULTS: Both types of patients had a positive therapeutic response to dexamethasone, with an increase in visual acuity (ETDRS) and CMT reduction. CRVO patients were characterized by lower ETDRS values at baseline and at the end of the follow-up as compared to BRVO. CRVO patients showed higher CMT values at baseline, after three and six months from injection. No significant differences in therapeutic response to dexamethasone were observed between patients treated early or late, regardless of RVO type. CONCLUSIONS: This study demonstrates that the therapeutic properties of dexamethasone implant are not significantly influenced by an early or late treatment start in patients affected by BRVO and CRVO, although its therapeutic efficacy seems greater in the former type.

Three episodes of non-arteritic posterior ischemic optic neuropathy in the same patient treated with intravenous prostaglandin E1.

Non-arteritic posterior ischemic optic neuropathy (NA-PION) is a disorder involving reduced blood flow to the retrobulbar portion of the optic nerve. This disorder usually develops acutely, and research has suggested that high-dose steroid therapy soon after the onset of visual loss can result in significant visual improvement. This treatment, however, is not universally successful. The addition of a potent vasodilator could help to restore ocular blood flow. This case report describes the use of prostaglandin E1 (PGE1), a powerful vasodilator of the microcirculation, to treat three separate episodes of NA-PION over five years in the same patient. A 68-year-old white male was first seen in June 2009 with NA-PION in the left eye, and the condition was treated with steroids and PGE1. The patient had a subsequent episode in July 2010 that was treated with steroids and PGE1 and another in May 2014 that was treated with PGE1 alone. Visual acuity improved from 4/10 to 11/10 in 2009, from 4/10 to 11/10 in 2010, and from 5/10 to 10/10 in 2014. No complications due to the use of PGE1 were noted. PGE1 should be considered as a treatment for NA-PION to immediately restore blood flow and potentially improve vision.

An ultra-low-molecular-weight heparin, fondaparinux, to treat retinal vein occlusion.

Retinal vein occlusions may decrease visual acuity. There is no known therapy to treat ocular thrombosis. The authors used fondaparinux, an ultra-low-molecular-weight heparin, to treat 13 consecutive cases of recent-onset retinal vein occlusions. Two patients with renal insufficiency were not included. Eight central retinal vein occlusions and 5 branch retinal vein occlusions in 13 patients were treated with subcutaneous fondaparinux 2.5 mg once a day. The patients were seen every 2 weeks. Macular edema was treated with intravitreal injections of anti-vascular endothelial growth factor or steroids. Two patients elected to discontinue treatment. Of the remaining 11, 9 occlusions resolved in 1.5 to 13.5 months with rapid resolution of retinal edema and hemorrhage as soon as the occlusions resolved. One patient had a retinal vein that was still occluded after 8 months of therapy and 1 had retinal vein occlusion that partially resolved after 15 months of treatment. Of the 9 eyes with occlusions that resolved, visual acuity improved in 7. In 2, visual acuity decreased due to macular ischemia. Occlusion recurred in 1 2.5 months after the suspension of initial treatment. This patient is again being treated with fondaparinux 2.5 mg. No hemorrhaging occurred. Fondaparinux 2.5 mg can be given subcutaneously once a day to patients with recent-onset retinal vein occlusions without renal insufficiency. An occlusion may take a number of months to resolve. Once the vein occlusion has resolved, retinal edema and hemorrhage rapidly resolve and vision improves. Macular edema should be treated while waiting for the vein occlusion to resolve.

An ischemic diabetic eye treated with intravenous prostaglandin E1.

PURPOSE: To present the use of intravenous prostaglandin E1 (PGE1), a powerful vasodilator of the microcirculation, in the treatment of an ischemic diabetic eye. METHODS: A 27-year-old diabetic man with ischemic diabetic retinopathy and glaucoma had a decreased visual acuity of no light perception in his right eye and hand motions in his left eye. He was started on intravenous PGE1 and has been treated for over 4.5 years. RESULTS: The visual acuity in his right eye remained unchanged and in his left eye improved gradually to 1.5/30. He has been stable for 4.5 years. CONCLUSION: Intravenous PGE1 may be useful in ischemic diabetic eyes to improve the ocular blood flow and visual acuity. It is safe and tolerated well.

Non-arteritic Posterior Ischaemic Optic Neuropathy Treated with Intravenous Prostaglandin E1 and Oral Corticosteroids.

Intravenous prostaglandin E1 and oral corticosteroids were used to treat the ischaemic phase of a non-arteritic posterior ischaemic optic neuropathy with immediate visual improvement. Non-arteritic posterior ischaemic optic neuropathy is a disorder of reduced blood flow to the retrobulbar optic nerve, usually of acute onset. It has been suggested that high-dose steroid therapy given soon after the onset of visual loss can result in significant visual improvement. This treatment, however, is not universally successful. The addition of a potent vasodilator to the corticosteroids could help restore ocular blood flow and improve visual acuity. This paper presents the use of prostaglandin E1 (PGE1), a powerful vasodilator of the microcirculation, to treat non-arteritic posterior ischaemic optic neuropathy. In this case report a 68-year-old white male with hereditary haemochromatosis was seen 8 hours after sudden loss of visual acuity in his left eye (OS) to 4/10. The diagnosis of non-arteritic posterior ischaemic optic neuropathy was made and he was immediately given oral corticosteroids. Intravenous PGE1 was given the next morning, 24 hours after the sudden loss of vision, once ischaemia of the optic nerve was confirmed by colour Doppler imaging. The visual acuity in the OS improved from 4/10 to 11/10 within 1 day. A visual field (VF) post treatment showed a peripheral scotoma without a central scotoma. At 12 months post treatment the vision OS remained 11/10. No complications due to the use of PGE1 were seen. The authors conclude that PGE1 should be considered in addition to steroids in cases of NA-PION to immediately restore blood flow to the optic nerve and improve visual acuity.

Branch retinal arterial occlusion treated with intravenous prostaglandin e1 and steroids.

PURPOSE: To present the use of 6-methylprednisolone IV and prostaglandin E1 IV, a powerful vasodilator of the microcirculation, in the treatment of a branch retinal arterial occlusion. METHODS: A 63-year-old man presented with a 3-hour history of a sudden loss of vision in the right eye. On ophthalmic examination, the diagnosis of a superior temporal branch retinal arterial occlusion was made. The patient was immediately given 40 mg of 6-methylprednisolone IV for more than 5 minutes followed by 80 µg of prostaglandin E1 with 2 milliequivalents of potassium IV for more than 3 hours. The same treatment was repeated the following morning. RESULTS: The visual acuity in the right eye improved from 2/10 at presentation to 7/10 at the end of the second day of treatment. Clinically, there was a reduction of the posterior pole edema. Eleven days after treatment, the visual acuity was 9/10 with no retinal edema. CONCLUSION: Immediate prostaglandin E1 IV and steroids should be considered in cases of recent-onset branch retinal arterial occlusion to restore retinal blood flow and improve visual acuity.

Retinal Angiomatous Proliferation Successfully Treated with Indocyanine Green Dye-Enhanced Photocoagulation.

This case series presents the use of indocyanine green dye-enhanced photocoagulation (ICG-DEP) for the treatment of retinal angiomatous proliferation (RAP). Five RAP lesions in 4 eyes of 3 patients were identified by fluorescein and indocyanine green dye angiography. The RAP lesions were treated with focal ablation of the intraretinal component using a ICG-DEP protocol. The 810-nm infrared laser in the pulsed millipulsed mode was used. The visual acuity and angiographic findings in the 3 patients with a follow-up from 18 months to 4 years are reported. The five RAP lesions were closed angiography in the 4 eyes of the 3 patients. All of the eyes had visual improvement for at least 8 months. In one stage 3 RAP lesion, there was visual improvement for 8 months until the choroidal neovascular membrane grew again. In this limited series, the procedure appeared to be safe and well tolerated with stable or improved visual acuity.

Arteritic anterior ischemic optic neuropathy treated with intravenous prostaglandin E(1) and steroids.

Arteritic anterior ischemic optic neuropathy (AAION) is an acute ischemia of the posterior ciliary arteries and/or ophthalmic artery due to inflammation. Therapy is immediate intervention with systemic steroids, especially to protect against vision loss in the other eye. The addition of a potent vasodilator to the steroids could help restore ocular blood flow and improve visual acuity. The objective of the current report was to present the use of prostaglandin E(1) (PGE(1)) - a powerful vasodilator of the microcirculation - in the treatment of AAION. Two patients with AAION were treated with intravenous steroids and PGE(1). The visual acuity improved from 4/50 (less than 20/200) to 6/10 (20/35) in one patient and from 1/50 (20/400) to 1/10 (20/200) in the second patient. The visual fields in both patients maintained small central islands of vision. No complications due to the use of PGE(1) were seen. Intravenous PGE(1) should be considered in addition to steroids in cases of AAION to immediately restore blood flow to the optic nerve and improve visual acuity while the steroids reduce the inflammation.

Ocular ischemia in high myopia treated with intravenous prostaglandin e1.

BACKGROUND: High myopia is associated with a decreased ocular blood flow. In some cases this ocular ischemia may be the cause of severe visual loss. METHODS: Three patients with high myopia and progressive loss of visual acuity had a diagnosis of ocular ischemia by color Doppler. Intravenous prostaglandin E1, a powerful vasodilator of the microcirculation, was used to treat the ocular ischemia in all 3 patients. RESULTS: The visual acuity improved in all three cases with one patient improving from 20/100 to 20/30. The mean deficit of the visual fields in this patient improved from -19.08 to -9.52 after treatment. The treatment was repeated every 6 weeks to 8 weeks. CONCLUSION: Patients with high myopia and progressive visual acuity loss should be evaluated for ocular ischemia. Intravenous prostaglandin E1 should be considered in those cases of ocular ischemia with visual loss. Unfortunately the effect does not last for more than 6 weeks to 8 weeks and needs to be repeated at this interval for extended periods.

Retinal and orbital venous occlusions treated with enoxaparin.

BACKGROUND: Retinal and orbital vein occlusions may cause a decrease in visual acuity. There is no known therapy to resolve ocular thrombosis. The authors used enoxaparin, a low-molecular-weight heparin, to treat 8 consecutive cases of retinal vein occlusions in 7 patients and 1 case of a superior orbital vein occlusion. METHODS: Four (4) central retinal vein occlusions in 3 patients, 4 branch retinal vein occlusions in 4 patients, and 1 superior orbital vein occlusion in 1 patient were treated with subcutaneous (SC) enoxaparin 100 IU/kg twice a day. The treatment lasted from 2 to 19 weeks. Eight (8) patients with retinal vein occlusions treated with ticlopidine were used as controls. RESULTS: The 8 retinal vein occlusions opened up in all 7 patients with the absorption of the retinal edema and hemorrhage as soon as the occlusions were open. The orbital vein occlusion resolved with the absorption of the orbital edema. Visual acuity improved in 7 of the venous occlusions and was unchanged in 2. Visual acuity in the 8 controls improved in 4, was unchanged in 2, and was worse in 2. CONCLUSIONS: Enoxaparin can be given SC twice a day in patients with retinal or orbital vein occlusions. The occlusions may take from 2 to 19 weeks to open up. Once the vein occlusions are open, the retinal edema, hemorrhage, and the orbital edema can rapidly absorb with visual improvement.

Nonarteritic anterior ischemic optic neuropathy treated with intravenous prostaglandin E1 and steroids.

BACKGROUND: Acute nonarteritic anterior ischemic optic neuropathy (NAION) is considered to be acute ischemia of the posterior ciliary arteries. Prostaglandin E1 (PGE1), a powerful microcirculation vasodilator, has been shown to improve ocular blood flow. DESIGN: A nonrandomized, comparative trial. METHODS: Eight consecutive cases of NAION were treated with intravenous steroids and PGE1. Seven control cases of NAION were treated with acetylsalicylic acid and oral steroids. Fisher's exact test was used for statistical analysis. RESULTS: The visual acuity improved in seven cases of NAION treated with PGE1 and was unchanged in one. Of the seven control cases, four had no change in vision and three lost further visual acuity on follow-up visits. CONCLUSIONS: Intravenous PGE1 and steroids should be considered in cases of NAION to immediately restore blood flow to the optic nerve and improve visual acuity.

Photodynamic therapy for nonsubfoveal choroidal neovascularization in 100 eyes with pathologic myopia.

PURPOSE: To evaluate the visual and anatomic outcome of photodynamic therapy (PDT) in eyes with nonsubfoveal choroidal neovascularization (CNV) associated with pathologic myopia (PM). DESIGN: Interventional, noncomparative cases series. METHODS: Ninety-seven patients (100 eyes) who were treated with PDT at three centers and followed up for three to 44 months (mean 16.5 months). Outcome measures were visual acuity, lesion size, and the occurrence of subfoveal invasion. RESULTS: Median baseline visual acuity was 20/40(-2) and ranged from 20/20 to 20/160(+2). On average, visual acuity was stable throughout follow-up after a modest increase of about 0.5 lines between three and six months. The probability of losing 3 or more lines was 10% to 15% during the second year. Lesion size (median: 710 microns) slightly decreased after the first PDT and tended to increase later, but not to a statistically significant extent compared with baseline. The probability of developing subfoveal CNV stabilized at 10% in the second year. The mean number of PDTs per individual was 2.9 in the first year and 0.6 in the second. CONCLUSIONS: Visual and anatomic outcomes of PDT, in this large group of patients with nonsubfoveal myopic CNV and good visual acuity, suggest that it may halt the progression of the disease in most cases.

Macular function after PDT in myopic maculopathy: psychophysical and electrophysiological evaluation.

PURPOSE: To evaluate the effects of photodynamic therapy (PDT) on macular function in myopic subfoveal choroidal neovascularization (CNV). METHODS: Fourteen eyes of 14 patients (mean age, 48.1 +/- 13.3 years) with myopic CNV (myopia ranging from -6.50 to -20 D) were enrolled. In each eye, at baseline and at 15 and 90 days after PDT with verteporfin, logMAR visual acuity (logarithm of the minimum angle of resolution VA), macular sensitivity by scanning laser ophthalmoscope microperimetry, and focal (central 9 x 9 degrees ) ERGs (FERGs) and pattern ERGs (PERGs) were assessed. RESULTS: At 15 days after PDT, myopic CNV eyes showed, in relation to baseline values, a significant (ANOVA, P < 0.01) reduction in the diameter of the lesion that correlated (Pearson test, P < 0.01) with the significant (ANOVA, P < 0.01) increase in FERG and PERG amplitudes, VA, and scanning laser ophthalmoscopy (SLO) microperimetry results obtained from the central 1 degrees to 2 degrees of the macular area (SLO-CM). At 90 days after PDT, myopic CNV eyes showed, in comparison with baseline values, a nonsignificant (ANOVA, P > 0.01) reduction in the diameter of the lesion, a nonsignificant increase in VA and SLO-CM, and a still significant increase in FERG and PERG amplitudes. CONCLUSIONS: In myopic CNV eyes, PDT induces an increase, though not significant, in VA and macular sensitivity. These changes may be related to a reduction in the diameter of the lesion, with an improvement in the function of both ganglionic and preganglionic elements of the macular region, as suggested by the improvement in FERG and PERG responses.