Efficacy and safety of bimatoprost in patients with uncontrolled glaucoma as alternative to filtration surgery.

PURPOSE: To evaluate the efficacy and safety of bimatoprost 0.03% as an alternative to filtration surgery in patients with uncontrolled glaucoma. DESIGN: Interventional study. METHODS: A total of 83 consecutive patients (83 eyes) awaiting glaucoma surgery were enrolled in eight ophthalmic centers. Reasons for listing were inadequate intraocular pressure (IOP) control despite medical therapy and documented progression of visual field loss. All patients discontinued the previous treatment and were switched to bimatoprost 0.03% QD (one drop at 9 pm). The primary efficacy outcome was a 20% IOP reduction from baseline at each timepoint. IOP was measured at day 7, day 30, day 60, and day 90 of treatment; less than 20% IOP reduction was considered as a failure. RESULTS: An IOP reduction of at least 20% was achieved in 74 patients (89.1%) after 7 days and in 64 patients (86.5%) after 30 days. Sixty-two patients (74.6%) maintained IOP readings 20% lower than baseline after 60 and 90 days. In these patients, visual field indices improved in 8 eyes (13%), and remained unchanged in 54 eyes (87%). Ocular side effects were conjunctival injection (15.6%), burning sensation (9.6%), foreign body sensation (4.8%), and eyelash growth (2.4%). CONCLUSIONS: This preliminary study shows that bimatoprost 0.03% could represent a useful therapeutic tool that might defer filtration surgery.

Combined surgical ablation and intravitreal triamcinolone acetonide for retinal angiomatous proliferation.

PURPOSE: Neovascular age-related macular degeneration (ARMD) with retinal angiomatous proliferation (RAP) has a poor natural history and the efficacy of any treatment has not yet been established. The authors describe a combined surgical treatment. METHODS: A 76-year-old woman presented with a best-corrected visual acuity (BCVA) of 20/600 in the right eye and macula with stage 3 RAP as identified by fluorescein angiography (FA), indocyanine green angiography (ICGA), and optical coherence tomography (OCT). After a standard three-port pars plana core vitrectomy (PPV), endodiathermy of the arteriolar and venous feeder vessels of each lesion was performed, intraretinal RAP feeder vessels were cut with manual vertical intraocular scissors, and 0.1 mL of triamcinolone acetonide (TAAC) was injected intravitreally. At 1 and 4 weeks and at the sixth month, the patient underwent a complete eye examination, FA, ICGA, and OCT to assess outcomes and complications. RESULTS: Six months later, BCVA was stable at 20/300, intraocular pressure was 15 mmHg, anterior segment and vitreous cavity were clear without evidence of TAAC granules, and retina was attached. FA and ICGA showed a complete occlusion of the RAP and absence of leakage or ischemia and OCT demonstrated decreased macular thickness with resolution of both intraretinal edema and pigment epithelium detachment, and the restoration of the normal macular profile. At the end of follow-up, the authors did not observe any ocular or systemic complication. CONCLUSIONS: Surgical approach to RAP stage 3 with intravitreal injection of 4 mg of TAAC was safe and anatomically effective.

Variable outcome of photodynamic therapy for choroidal neovascularization associated with choroidal nevus.

PURPOSE: To report five cases of classic choroidal neovascularization (CNV) associated with choroidal nevus treated with photodynamic therapy (PDT) with verteporfin. METHODS: The patients underwent an ophthalmologic evaluation, including fluorescein angiography and indocyanine green angiography. Clinical and angiographic data were retrospectively analyzed to evaluate visual acuity outcomes and both clinical evolution and angiographic evolution. RESULTS: Two patients presented with subfoveal CNV, and three had juxtafoveal CNV. The mean follow-up was 25.8 months. Visual outcomes were extremely variable. Indeed, best-corrected visual acuity decreased in three eyes, stabilized in one case, and improved in the other case. The number of PDT sessions necessary to obtain CNV stabilization with cessation of fluorescein leakage varied from one to six. CONCLUSION: Bearing in mind that both the natural history and the post-PDT outcome may be extremely variable, further studies are needed to assess the real benefit of PDT for classic CNV secondary to choroidal nevus.

Intravitreal triamcinolone acetonide in refractory pseudophakic cystoid macular edema: functional and anatomic results.

PURPOSE: To evaluate safety and efficacy of intravitreal triamcinolone acetonide (TAAC) injections in the treatment of refractory pseudophakic cystoid macular edema (CME). METHODS: Seven eyes of six patients (age range: 50-74) with pseudophakic CME resistant to standard treatment received intravitreal injections of 4 mg of TAAC with all vehicle. Mean preinjection duration of CME was 18.3 months. A mean of 2.1+/-1.2 (range 1 to 4) treatments were performed in four eyes (57.1 %) when visual acuity deteriorated towards baseline levels. Visual acuity assessment, optical coherence tomography (OCT), and fluorescein angiography (FFA) were performed pre- and postoperatively to evaluate results of TAAC injections. Intraocular pressure (IOP) and complications related to treatment were assessed. RESULTS: After 11.1+/-3.9 months, mean best-corrected visual acuity (BCVA) increased (p =0.019) from 20/132 to a best value of 20/38. Mean macular thickness decreased from 517.29+/-146.98 mm to a best value of 263.71+/-83.13 mm (p=0.0018). Area of fluorescein leakage decreased (p<0.0001) from 11.84+/-0.93 mm2 at baseline to a minimal value of 3.86+/-0.98 mm2. The anatomic and functional improvement appeared after 1 month from the intravitreal injection and persisted through at least 3 months of follow-up. At the end of follow-up BCVA, macular thickness, and area of fluorescein leakage did not differ from baseline. Four eyes (57.1 %) developed IOP values higher than 21 mmHg, controlled by topical treatment. Two patients developed an endophthalmitis-like reaction. CONCLUSIONS: Intravitreal TAAC was relatively safe and effective in resistant cases of pseudophakic CME with a temporary beneficial effect on visual acuity and macular edema.

Intravitreal triamcinolone acetonide: valuation of retinal thickness changes measured by optical coherence tomography in diffuse diabetic macular edema.

PURPOSE: The authors studied the efficacy of intravitreal triamcinolone acetonide in a case series of patients with diffuse diabetic macular edema without evidence of vitreous-macular traction refractory to laser photocoagulation. METHODS: Six eyes with clinically diffuse diabetic macular edema that failed to respond to at least two previous sessions of laser photocoagulation were included. The mean age of selected patients was 72.5+/-13.8 years, with a preoperative best-corrected visual acuity reduced to 1.48+/-0.18 logMar and a mean baseline intraocular pressure (IOP) of 15.17+/-2.64 mmHg. The authors also studied macular thickness measured by optical coherence tomography (OCT 2000 scanner, Humphrey Instruments, San Leandro, CA) - in the preoperative period it was 640.8+/-171.1 microm - and the fluorangiographic (Heidelberg Retina Angiograph, Heidelberg Engineering GmbH, Heidelberg, Germany) patterns, which showed pooling in tardy phases and leakage. Mean follow-up was 4 months. RESULTS: In each patient the authors observed a significant improvement, both functionally and anatomically. Mean best-corrected visual acuity increased in the postoperative period to 0.94+/-0.53 logMar. No patient showed decline of visual acuity at the end of follow-up. Base line macular thickness was reduced in the postoperative period to 312.2+/-157.65 microm measured by OCT and fluorangiographic patterns showed a reduction of pooling and of leakage. The most common complications described in the literature were not observed and the increase of mean IOP in the postoperative period to 18.76+/-5.72 mmHg was not significant. CONCLUSIONS: Intravitreal triamcinolone acetonide may decrease macular edema and improve visual acuity in eyes with diffuse diabetic macular edema.

Effect of cataract surgery and foldable intraocular lens implantation on retinal nerve fiber layer as measured by scanning laser polarimetry with variable corneal compensator.

PURPOSE: Scanning laser polarimetry (SLP) enables the measurement of retinal nerve fiber layer (RNFL) thickness in vivo. As SLP measurements can be influenced by several conditions such as corneal birefringence, the new version GDx Access is implemented by the variable corneal compensator (VCC). The aim of this study was to evaluate the influence of cataract extraction and foldable intraocular lens (IOL) implantation on SLP parameters measured by GDx Access. METHODS: Sixty-eight eyes of 68 patients undergoing phacoemulsification with foldable IOL implantation (silicone and acrylic) were examined by SLP before and after surgery. SLP was performed using GDx Access (with VCC). Mean values for SLP parameters were compared before and after 30 days from surgery with paired two-tailed Student's t-test. RESULTS: No statistically significant differences were found between SLP parameters before and after cataract surgery, and regardless of the type of IOL implanted. CONCLUSIONS: Phacoemulsification and foldable IOL implantation do not influence RNFL parameters, as measured by GDx Access.

LDL-apheresis in acute anterior ischemic optic neuropathy.

Acute anterior ischemic optic neuropathy (AION) is a disabling disease which impairs visual function. Standard treatment is unable to affect the outcome and the visual damage persists. We describe the case of a 64-year-old patient affected by AION, whose only known risk factor was hypercholesterolemia. After a first onset of involvement of the right eye (RE), the patient presented four weeks later with an analogous episode affecting the left eye (LE). Since standard treatment, started at involvement of the RE, had not yielded any beneficial effect, the patient underwent three sessions of LDL apheresis. The scotomatous portion of the visual field reduced even after the first session, there was further improvement after the third, and after six months the condition remained stable. Corrected vision improved from 2/10 to 6/10 after the third session. LDL cholesterol and fibrinogen decresade after the third session from 239 mg/dL to 31 mg/dL and from 289 mg/dL to 92 mg/dL, respectively. In conclusion, thanks to its effect of antagonizing hemorheologic disorders of the ocular microcirculation, LDL apheresis seems to be an efficacious treatment of AION, especially in patients suffering from hypercholesterolemia.

Intravitreal triamcinolone acetonide: valuation of retinal thickness changes measured.

PURPOSE: The authors studied the efficacy of intravitreal triamcinolone acetonide in a case series of patients with diffuse diabetic macular edema without evidence of vitreous-macular traction refractory to laser photocoagulation. METHODS: Six eyes with clinically diffuse diabetic macular edema that failed to respond to at least two previous sessions of laser photocoagulation were included. The mean age of selected patients was 72.5 13.8 years, with a preoperative best-corrected visual acuity reduced to 1.48 0.18 logMar and a mean baseline intraocular pressure (IOP) of 15.17 2.64 mmHg. The authors also studied macular thickness measured by optical coherence tomography (OCT 2000 scanner, Humphrey Instruments, San Leandro, CA) in the preoperative period it was 640.8 171.1 m and the fluorangiographic (Heidelberg Retina Angiograph, Heidelberg Engineering GmbH, Heidelberg, Germany) patterns, which showed pooling in tardy phases and leakage. Mean follow-up was 4 months. RESULTS: In each patient the authors observed a significant improvement, both functionally and anatomically. Mean best-corrected visual acuity increased in the postoperative period to 0.94 0.53 logMar. No patient showed decline of visual acuity at the end of follow-up. Base line macular thickness was reduced in the postoperative period to 312.2 157.65 m measured by OCT and fluorangiographic patterns showed a reduction of pooling and of leakage. The most common complications described in the literature were not observed and the increase of mean IOP in the postoperative period to 18.76 5.72 mmHg was not significant. CONCLUSIONS: Intravitreal triamcinolone acetonide may decrease macular edema and improve visual acuity in eyes with diffuse diabetic macular edema. (Eur J Ophthalmol 2004; 14: 321-4).

Macular hole following conventional repair of bullous retinal detachment using air injection (D-ACE procedure).

PURPOSE: Sequential drainage of subretinal fluid (D), injection of air (A), cryotherapy (C), and application of local explants (E) (D-ACE) sequence was introduced in order to overcome the problems encountered in managing superior bullous detachments from multiple large equatorial breaks. The authors recently observed the occurrence of a full-thickness macular hole in one patient developing the day after he underwent a D-ACE procedure. METHODS: A 61-year-old man presented a bullous retinal detachment in the right eye extending from the 9:30 to the 2 o'clock position, and posteriorly to the vascular arcades two retinal tears were noted, at the equator at 11 o'clock, and anterior to the equator at 12 o'clock. The patient underwent a D-ACE procedure. Subretinal fluid was drained above the lateral rectus muscle at the equator. One and a half milliliters of air were injected 3.5 mm from the limbus midway between the superior and the medial rectus insertions. Cryotherapy was applied to the retinal breaks. A 240 encircling band was used in conjunction with a 276 tyre segment at the level of the tears. RESULTS: One day after surgery, the retina was flat, but a full-thickness macular hole could be seen with a surrounding cuff of subretinal fluid. CONCLUSIONS: The mechanisms proposed to explain the occurrence of full-thickness macular holes after D-ACE may involve the concurrence of scleral elongation and vitreofoveal traction by means of previous partial posterior vitreous detachment with persistent posterior attachments at the fovea.

Eyedrop-induced allergy: clinical evaluation and diagnostic protocol.

BACKGROUND: In the last few years, adverse reactions to mydriatic eyedrops have been investigated. However, is not still available a standardized protocol, capable of identify the pathogenetic mechanism. In the light of these findings we have evaluated the reliability of a protocol with well established concentration of specific allergens. METHODS: The diagnostic method includes the application of patch test series Gruppo Italiano Ricerca Dermatiti da Contatto e Ambientali (GIRDCA), medicaments, corticosteroids, local anesthetics, main eyedrops' excipients, pure active principles and extemporaneous preparations with mydriatic eyewashes. At the same time, skin prick test with a solution of atropine sulfate at 1 per thousand and an intradermal test with injection of atropine at 0.01 per thousand were carried out. RESULTS: After patch tests were removed, we detected seven positiveness to the phenylephrine, two to the benzalkonium chloride, one to thiomersal, one to the ethylendiamine and one to the atropine sulfate 1 per thousand. With intradermal tests we obtained three positiveness in patients who reported adverse reactions to atropine. CONCLUSIONS: Our results show that phenylephrine is frequently responsible for allergic conjunctivitis (53.8%). In the case of atropine, even though the limited number of patients suggests to perform more extensive studies, it emerges that our diagnostic protocol is safe and might be able to screen allergic reactions in the field of ophthalmopathies.

Combined cyclosporin-A /prednisone therapy of patients with active uveitis suppresses IFN-gamma production and the function of dendritic cells.

In this study, we assessed the Th1/Th2 polarization of the immune response and the involvement of dendritic cells (DC) and Th1 lymphocytes in the pathogenesis of uveitis. Thirty-seven patients with chronic idiopathic uveitis were enrolled: 21 of them had active uveitis and the remaining 16 were in complete remission. Patients with active uveitis were characterized as follows: 5 had intermediate uveitis, 5 panuveitis and the remaining 11 posterior uveitis. Thirteen healthy subjects were also studied as controls. Patients with active uveitis were treated with cyclosporin-A (CsA) associated to low doses of prednisone (PDS) and studied at baseline and after 6 months of therapy. Analysis of cytokine-producing CD3+ lymphocytes revealed a strong Th1 polarization of the immune response in patients with active uveitis. Th1 lymphocytes paralleled serum IL-12 levels and the response to therapy, which greatly reduced both IFN-gamma+/CD3+ lymphocytes and serum IL-12 levels, associated with a general clinical improvement. In vitro studies demonstrated that DC from untreated patients with active uveitis were mature and functionally active. In fact, they showed a higher ability to stimulate cell proliferation of allogeneic T cells in primary mixed lymphocyte reaction (MLR) and produced larger amounts of IL-12 than DC from CsA/PDS-treated patients and those in remission. These results demonstrate that CsA/PDS therapy impairs the capacity of mature DC to secrete IL-12 and inhibits their MLR activity.

Choroidal neovascularization secondary to vitrectomy for idiopathic epiretinal membrane: report of an unusual case.

PURPOSE: Epiretinal membranes (ERM) are a common finding in old patients. Pars plana vitrectomy is effective for removing ERM from the macula, but some postoperative complications are relatively frequent. In the present report, we describe a 73-year-old man in whom extrafoveal choroidal neovascularization developed four months after surgery. METHODS: Choroidal neovascularization was treated by argon laser photocoagulation. RESULTS: Six months after treatment, the choroidal neovascularization was obliterated, with no recurrence of ERM. CONCLUSIONS: Choroidal neovascularization can be an unusual complication of ERM surgery, and should be suspected in case of poor visual outcome or recurrence of symptoms.

Corneal interactive programmed topographic ablation customized photorefractive keratectomy for correction of postkeratoplasty astigmatism.

OBJECTIVE: This study evaluated the efficacy, predictability, stability, and safety of a software program (Corneal Interactive Programmed Topographic Ablation [CIPTA], LIGI, Taranto, Italy), which, by transferring programmed ablation from the corneal topograph to a flying-spot excimer laser, provides customized laser ablation for correction of postkeratoplasty astigmatism. DESIGN: Noncomparative consecutive interventional case series. PARTICIPANTS: Ten eyes of 10 patients with a mean age of 41.4 years (range, 26-64) had CIPTA-guided photoastigmatic refractive keratectomy (PARK) at the Clinica Oculistica of Bari (Italy). Two patients were treated for hyperopic astigmatism and eight for myopic astigmatism. All the patients had irregular astigmatism after penetrating keratoplasty. OPERATION: Topography was acquired by a corneal topograph (Orbscan II, Orbtek, Inc., Salt Lake City, UT). This, together with refractive data, was processed to obtain a customized altimetric ablation profile that was transferred to a flying-spot laser (Laserscan 2000, Lasersight, Orlando, FL). MAIN OUTCOME MEASURES: Data on uncorrected (UCVA) and best-corrected (BCVA) visual acuity, predictability, stability of refraction, and any complications were analyzed. RESULTS: Mean follow-up was 8.4 months (range, 6-12; SD 2.4). At the last postoperative examination, seven eyes (70%) had a UCVA superior to 20/40. Three eyes (30%) had a UCVA of 20/20. Five eyes (50%) were within 0.50 diopters (D) of attempted correction in the spherical equivalent, and eight eyes (80%) within 1 D. Index of success of astigmatic correction was 0.19. All the eyes (100%) gained Snellen lines of BCVA. We did not observe any decentration and/or haze after PARK treatment performed in this study. CONCLUSIONS: The combination of topographic data with computer-controlled flying-spot excimer laser ablation is a suitable solution for correcting irregular astigmatism after penetrating keratoplasty.

Topography-driven excimer laser for the retreatment of decentralized myopic photorefractive keratectomy.

OBJECTIVE: This study evaluated the efficacy, predictability, stability, and safety of a software program (Corneal Interactive Programmed Topographic Ablation, CIPTA, LIGI, Taranto, Italy), which, by transferring programmed ablation from the corneal topograph to a flying-spot excimer laser, provides customized laser ablation for correction of postmyopic photorefractive keratectomy (PRK) decentrations. DESIGN: Noncomparative consecutive case series. PARTICIPANTS: Thirty-two eyes of 32 subjects with a mean age of 35 years (range, 19-49; standard deviation [SD], 7.9) had CIPTA-guided PRK at the Clinica Oculistica of Bari University (Italy). All the subjects had irregular astigmatism after postmyopic PRK because of clinically significant, decentered treatments of more than 1 mm. OPERATION: Individual topographies were acquired by a corneal topograph (Orbscan II, Orbtek, Inc., Salt Lake City, UT). These, together with refractive data, were processed to obtain a customized altimetric ablation profile that was transferred to a flying-spot laser (Laserscan 2000, Lasersight, Orlando, FL). MAIN OUTCOME MEASURES: The topographic study of centration and data on uncorrected (UCVA) and best-corrected (BCVA) visual acuity, predictability, and stability of refraction, and any complications, were analyzed. RESULTS: Mean follow-up was 10.3 months (range, 4-18 months; SD, 5.8). At the last postoperative examination, 29 eyes (90.6%) had a UCVA superior to 20/40. Nineteen eyes (59.4%) had a UCVA of 20/20. Twenty-two eyes (68.75%) were within 0.50 diopters (D) of attempted correction in the spherical equivalent and 28 eyes (87.5%) were within 1 D. The index of success of astigmatic correction was 0.15. No eye lost Snellen lines of BCVA, whereas 18 eyes (56.25%) gained Snellen lines. Postoperative topographies revealed well-centered treatments. CONCLUSIONS: The combination of topographic data with computer controlled flying-spot excimer laser ablation is a suitable solution for correcting irregular astigmatism after postmyopic PRK decentrations.

Topography-driven photorefractive keratectomy: results of corneal interactive programmed topographic ablation software.

OBJECTIVE: This study evaluated the efficacy, predictability, stability, and safety of a software program (Corneal Interactive Programmed Topographic Ablation (CIPTA) LIGI, Taranto, Italy) which, by transferring programmed ablation from the corneal topography to a flying-spot excimer laser, provides customized laser ablation. DESIGN: Noncomparative consecutive case series. PARTICIPANTS: Forty-two eyes of 34 subjects with a mean age of 33.9 (range, 20-54) had CIPTA at the Cattedra di Ottica Fisiopatologica of Bari (Italy). Twenty-eight eyes were treated for hyperopic astigmatism and 14 for myopic astigmatism. All the subjects had irregular astigmatism. OPERATION: Topography was acquired by a corneal topography mapping system (Orbscan, Orbtek, Inc., Salt Lake City, UT). These data were processed to obtain a customized altimetric ablation profile, which was transferred to a flying-spot laser (Laserscan 2000, Lasersight, Orlando, FL). MAIN OUTCOME MEASURES: Data on uncorrected (UCVA) and best-corrected visual acuity (BCVA), predictability, and stability of refraction and any complications were analyzed. RESULTS: Mean follow-up was 13.2 months. At the last postoperative examination, 26 eyes (92.8%) in the hyperopic group and 12 eyes (85.7%) in the myopic group had an UCVA superior to 20/40. Twelve hyperopic eyes (42.8%) and five myopic eyes (35.7%) had a UCVA of 20/20. All patients fell between 1 diopter of attempted correction in the spherical equivalent. Only 1 (2.4%) of the 42 eyes, belonging to the hyperopic group, lost 1 Snellen line of BCVA. We did not observe any decentration and/or haze after photorefractive keratectomy treatment or any irregularity in the flap-stroma interface in the three laser in situ keratomileusis operations performed in this study. CONCLUSIONS: The combination of topographic data with computer-controlled flying-spot excimer laser ablation is a suitable solution for correcting irregular astigmatism due to different causes.

[Effect of scleral buckling on ocular tone]. / Influenza del cerchiaggio sul tono oculare.

Having examined in literature the intraocular pressure changings due to periocular encirclement, the Authors analyse a casenstry of 135 eyeballs in which a silicone band encirclement was performed. They conclude emphasizing the hypotonizing action of this technique, due to ciliary body ischemia, hypothesizing the use of this surgical technique in case of neovascular glaucoma.

[The cytology of subretinal fluid in retinal detachment]. / La citologia del liquido sottoretinico nel distacco di retina.

The Authors discuss the ever topical problem of subretinal liquid genesis in patients affected with retinal detachment. For this and they study its cytology and in the light of the results they have obtained, they draw the following conclusion: 1. Cells are extremely rare. 2. Such cells are partly monocytes (roundish, with a large nucleus and positive esterases), partly histiocytes and hyalocytes (elongated or polygon-shaped, with cytoplasmatic extensions and negative esterases).