Angiographic biomarkers are significant predictors of treatment response to intravitreal aflibercept in diabetic macular edema.

This prospective single-center study aims to identify biomarkers that predict improvement in best-corrected visual acuity (BCVA) and central retinal thickness (CRT) at 6 months, in 76 eyes with diabetic macular edema (DME) treated monthly with intravitreal aflibercept. At baseline, all patients underwent standardized imaging with color photography, optical coherence tomography (OCT), fluorescein angiography (FA) and OCT angiography (OCTA). Glycosylated hemoglobin, renal function, dyslipidemia, hypertension, cardiovascular disease and smoking were recorded. Retinal images were graded in a masked fashion. Baseline imaging, systemic and demographic variables were investigated to detect associations to BCVA and CRT change post aflibercept. Predictors of BCVA improvement included greater macular vessel density quantified using OCTA (p = 0.001) and low-density lipoprotein (LDL) ≥ 2.6 mmol/L (p = 0.017). Lower macular vessel density eyes showed a significant reduction in CRT but no BCVA improvement. Predictors of CRT reduction included peripheral non-perfusion seen on ultrawide-field FA (p = 0.005) and LDL ≥ 2.6 mmol/L (p < 0.001). Retinal angiographic biomarkers derived from OCTA and ultrawide-field FA may help predict functional and anatomic response to anti-vascular endothelial growth factor (VEGF) therapy in patients with DME. Elevated LDL is associated with treatment response in DME. These results may be used to better-select patients who will benefit from intravitreal aflibercept for treatment of DME.

Giant pars plana cysts and a diagnostic approach to peripheral retinal elevation with the assistance of multimodal imaging.

A man in his 50s was referred for a suspected superotemporal retinal tear in the right eye. Fundus examination showed multiple areas of elevated retina temporally in both eyes which were immobile and did not reappose with scleral depression. No retinal breaks were present. Ultra-widefield colour fundus photography with Optos captured these areas of elevated retina in both eyes temporally, which on fundus autofluorescence where hypoautofluorescent with no leading hyperautofluorescent edge. On ultrasound biomicroscopy, an immobile lesion with a single hyperechoic convexity towards the vitreous body was noted. The patient was diagnosed with bilateral giant pars plana cysts which were managed conservatively.The multimodal imaging in our case is its distinguishing feature which can be used to help ensure accurate diagnosis when one is presented with an area of peripheral retina elevation.

Introduction of diabetic retinopathy screening into an antenatal clinic: Impact on maternal screening and diagnosis rates.

Pregnancy is a risk factor for the development and progression of diabetic retinopathy (DR) in women with pre-gestational diabetes. However, a minority of pregnant women with diabetes adhere to retinal screening recommendations. The introduction of an onsite retinal camera at our tertiary maternity hospital significantly increased the proportion of women who received at least one retinal screen during pregnancy (93.0% vs 54.3%, P < 0.001) and the identification of both DR and DR progression. We conclude that the use of a retinal camera in similar clinics is a feasible option to improve DR screening and diagnosis rates in pregnancy.

ACUTE RETINAL NECROSIS ASSOCIATED WITH HERPES ZOSTER VACCINATION.

PURPOSE: To report a case of Zostavax-associated acute retinal necrosis in a patient with chronic lymphocytic leukemia. METHODS: Case report. PATIENTS: A 76-year-old white man. RESULTS: Unilateral acute retinal necrosis with obliterative angiopathy developed in close proximity of a Zostavax vaccine. Treatment with valacyclovir hydrochloride (1 g orally three times a day) and intravitreal ganciclovir (4 mg/0.1 mL) was initiated on presentation. Because of continuous increase of the retinal necrosis, patient was switched to intravenous acyclovir (7.5 mg/kg body weight, adapted to reduced glomerular filtration rate) and given intravitreal foscarnet (2.4 mg/0.1 mL). Despite being on maximal antiviral therapy, the patient suffered a central retinal artery occlusion. DISCUSSION: Acute retinal necrosis is a severe complication and potentially blinding disease of herpes zoster, and can occur in association with herpes zoster immunization, in particular, in immune suppressed patients.

First and second eye cataract surgery and driver self-regulation among older drivers with bilateral cataract: a prospective cohort study.

BACKGROUND: Driving a car is the most common form of transport among the older population. Common medical conditions such as cataract, increase with age and impact on the ability to drive. To compensate for visual decline, some cataract patients may self-regulate their driving while waiting for cataract surgery. However, little is known about the self-regulation practices of older drivers throughout the cataract surgery process. The aim of this study is to assess the impact of first and second eye cataract surgery on driver self-regulation practices, and to determine which objective measures of vision are associated with driver self-regulation. METHODS: Fifty-five older drivers with bilateral cataract aged 55+ years were assessed using the self-reported Driving Habits Questionnaire, the Mini-Mental State Examination and three objective visual measures in the month before cataract surgery, at least one to three months after first eye cataract surgery and at least one month after second eye cataract surgery. Participants' natural driving behaviour in four driving situations was also examined for one week using an in-vehicle monitoring device. Two separate Generalised Estimating Equation logistic models were undertaken to assess the impact of first and second eye cataract surgery on driver-self-regulation status and which changes in visual measures were associated with driver self-regulation status. RESULTS: The odds of being a self-regulator in at least one driving situation significantly decreased by 70% after first eye cataract surgery (OR: 0.3, 95% CI: 0.1-0.7) and by 90% after second eye surgery (OR: 0.1, 95% CI: 0.1-0.4), compared to before first eye surgery. Improvement in contrast sensitivity after cataract surgery was significantly associated with decreased odds of self-regulation (OR: 0.02, 95% CI: 0.01-0.4). CONCLUSIONS: The findings provide a strong rationale for providing timely first and second eye cataract surgery for older drivers with bilateral cataract, in order to improve their mobility and independence.

Do older drivers with bilateral cataract self-regulate their driving while waiting for first eye cataract surgery?

OBJECTIVES: To analyze the association between visual impairment and driver self-regulation among a cohort of older drivers waiting for first eye cataract surgery. METHODS: Ninety-six drivers with bilateral cataract aged 55+ years were assessed before first eye cataract surgery. Data collection consisted of a researcher-administered questionnaire, objective visual measures (visual acuity, contrast sensitivity and stereopsis), a visual attention test (the useful field of view test) and a cognitive test (the Mini-Mental State Examination). Driver self-regulation practices were collected using the Driving Habits Questionnaire and were also measured with an in-vehicle monitoring device. Characteristics of self-regulators and non-self-regulators were compared and a logistic regression model was used to examine the association between 3 objective visual measures and driver self-regulation status. RESULTS: After controlling for potential confounding factors, only binocular contrast sensitivity (p=0.01), age (p=0.03) and gender (p=0.03) were significantly associated with driver self-regulation status. The odds of participants with better contrast sensitivity scores (better vision) self-regulating their driving in at least 1 driving situation decreased (odds ratio [OR]: 0.01, 95% CI: 0.00-0.28) while those of increasing age reported an increased odds of self-regulating their driving (OR: 1.08, 95% CI: 1.01-1.15). The odds of males self-regulating their driving was decreased compared with females (OR: 0.28, 95% CI: 0.09-0.86). CONCLUSIONS: Worse binocular contrast sensitivity scores, increasing age and being female were significantly associated with driver self-regulation. The study highlighted that while self-regulation was common among cataract patients, a proportion of those with poor vision did not self-regulate. Further research should determine how cataract patients could benefit from self-regulation strategies while waiting for cataract surgery.

Extraocular seeding of choroidal melanoma after a transretinal biopsy with a 25-gauge vitrector.

PURPOSE: To report an isolated case of extraocular seeding of choroidal melanoma after a transretinal biopsy. METHODS: A 74-year-old man with a choroidal melanoma in the left eye underwent a 3-port transconjunctival 25-gauge transretinal biopsy (for cytogenetic prognostication) followed by proton beam radiotherapy. Biopsy showed the melanoma to be predominantly of spindle cell type with chromosome 3 loss. He presented 14 months later with two pigmented conjunctival lesions, corresponding to the site of the pars plana sclerotomy. RESULTS: Excision biopsy of the conjunctival lesions confirmed subconjunctival seeding of melanoma cells at the sites of sclerotomy. CONCLUSION: The seeding of melanoma corresponded to the sites of sclerotomy, indicating extraocular seeding of the primary tumor after transretinal biopsy. We discuss the possible reasons for this occurrence and strategies to prevent extraocular seeding of melanoma after transretinal biopsy.

Cross-linked actin networks (CLANs) are present in lamina cribrosa cells.

AIMS: A study was undertaken to determine and compare the F-actin staining patterns in the cells of the lamina cribrosa (LC) of normal, dexamethasone (DEX)-treated and glaucomatous dissected tissue and cell cultures. METHODS: About 30 dissected donor eyes and nine cell lines provided the human specimens; 25 eyes and 20 primary cell cultures provided the bovine material. Appropriate samples were exposed to 1×10⁻7 M DEX for up to 14 days. LC tissue and cells were stained with Phalloidin-Alexa 488 to identify F-actin, and all samples were examined by confocal or epifluorescent microscopy. RESULTS: Both in the LC tissue and LC cell cultures the dominant actin arrangement was bundles of stress fibres. However, cross-linked actin networks (CLANs) were identified in the tissue and in culture. These were markedly increased by steroid treatment and were particularly large and abundant in cultures from glaucoma donors. CLANs were not associated with optic nerve head astrocytes. CONCLUSIONS: The presence of abundant stress fibres in situ and in vitro highlights the biomechanical contribution of LC cells. However, the identification of CLANs in these cells shows that they are not exclusive to the trabecular meshwork, the only other place they have been found, and may have a role in glaucoma pathology.

The role of visually evoked potentials in the management of hemispheric arachnoid cyst compressing the posterior visual pathways.

We report a case of an occipital arachnoid cyst in an infant, managed on the basis of changes in visually evoked potentials (VEPs). A significant asymmetry of VEP responses prompted neurosurgical intervention, which improved visual behavior and electrical response to both pattern and flash stimuli.

Periorbital necrotising fasciitis: delay in diagnosis results in loss of lower eyelid.

Necrotising fasciitis (NF) is an extremely rare skin and soft tissue infection with extensive necrosis of the subcutaneous tissue and underlying fascia, which usually affects the limbs and trunk. It rarely affects the head and neck region because of the excellent blood supply in this region. We report a case of NF initially misdiagnosed as a traumatic pre-septal cellulitis following self-puncture of a hordeolum externum (stye) and its resistance to aggressive antibiotic therapy resulting in the loss of the lower eyelid.

Radiation retinopathy: a mistaken diagnosis of hypertensive retinopathy.

Radiation retinopathy is a vision-threatening complication following therapeutic irradiation of ocular, orbital, facial, nasopharyngeal and cranial structures. It is characterised by a delayed onset, slowly progressive, occlusive retinal microangiopathy that develops several years after initial radiotherapy. We present the case of a 44-year-old man who developed radiation retinopathy, initially diagnosed as a case of hypertensive retinopathy, following irradiation of a nasopharyngeal carcinoma. A careful history along with classical clinical features and fundus fluorescein angiography helped establish the diagnosis.

Latanoprost-related transient incontinence.

Latanoprost has increasingly become the first choice in topical anti-glaucoma therapy. Local adverse events like hypertrichosis and increased iris pigmentation are common whereas systemic adverse events have been rare and mild in intensity. The authors would like to report a case of transient urge incontinence after initiation of latanoprost therapy confirmed by challenge-rechallenge tests and speculate on the causal relationship.