Analysis of cytokines in the aqueous humor during intravitreal Ranibizumab treatment of diabetic macular edema.

This study aimed to analyze the concentrations of VEGF, b-FGF, TNF, interleukin (IL)-1, IL-6, IL-8, IL-10, and IL-12 in the aqueous humor of patients with diabetic macular edema with and without peripheral retinal ischemia and to ascertain the changes in the levels of these molecules during treatment with ranibizumab. A therapeutic, prospective, randomized interventional study was carried out. Twenty-four eyes from 24 patients were studied and divided into 3 groups. Group 1 (9 eyes) included patients with diabetic macular edema without peripheral ischemia. Group 2 (10 eyes) included patients with diabetic macular edema with peripheral ischemia. Group 3 (5 eyes), the control group, included patients without systemic and/or eye diseases. Patients in Groups 1 and 2 received 3 intravitreal injections of 2 mg/0.05 ml ranibizumab at an interval of approximately 30 days. Before administering the injections, the aqueous humor was collected. In the control group, aqueous humor was collected before facetectomy. During treatment, the median IL-6 concentration significantly increased in Group 1 but showed a slight but not significant decrease in Group 2. Interleukin 8 levels were significantly different at the end of treatment compared to the beginning in Groups 1 and 2. TNF, IL-1, IL-10, and IL-12 levels were practically unchanged in both groups. VEGF was significantly reduced at the end of the study in Groups 1 and 2. B-FGF was not detected in most of the studied patients, and in those with detectable levels, there was no significant variation. There was a significant increase in the median level of interleukin 6 in the group without ischemia and a significant decrease in VEGF in both groups. The cytokines TNF, IL-1, IL-10, and IL-12 did not show significant variation.

Association between Inflammatory Factors in the Aqueous Humor and Hyperreflective Foci in Patients with Intractable Macular Edema Treated with Antivascular Endothelial Growth Factor.

BACKGROUND: To evaluate the correlations between the inflammatory factors in the aqueous humor and hyperreflective foci (HRF) in patients with intractable macular edema treated with antivascular endothelial growth factor (anti-VEGF). METHODS: This study included 17 patients with intractable macular edema (ME) treated with anti-VEGF agents. Inflammatory factors in the aqueous humor were measured by the Cytometric Beads Array before injection, and the numbers of HRF pre- and post-anti-VEGF treatment were counted from four different directions (90 degrees, 45 degrees, 180 degrees, and 135 degrees) in the SD-OCT images, respectively, before treatment and one month after treatment. The correlations between inflammatory factors and the numbers of HRF were assessed. RESULTS: The numbers of HRF were reduced significantly after anti-VEGF treatment. The change in the HRFs at the 90-degree location was significantly positively correlated with IL-8 and VCAM-1. The change of all HRFs was significantly positively correlated with IL-8. The HRFs before the treatment also had a positive correlation with IL-8 and VCAM-1. CONCLUSION: After anti-VEGF treatment, the numbers of HRF in intractable ME declined greatly. The higher the levels of IL-8 and VCAM-1 before treatment, the more significant the reduction of HRF after anti-VEGF treatment, which indicated that HRF could be an effective noninvasive imaging indicator for evaluating the effect of anti-VEGF on intractable macular edema. The OCT images at the 90-degree location could better show the inflammatory reaction of patients and also had better clinical significance for the prognosis evaluation of ME associated with inflammation.

Early Onset of Age-Related Cataracts in Cystine/Glutamate Antiporter Knockout Mice.

Purpose: The purpose of this study was to determine the importance of the xCT is a subunit. The cystine/glutamate antiporter is actually system xc-xCT subunit of the cystine/glutamate antiporter in maintaining redox balance by investigating the effects of the loss of xCT on lens transparency and cystine/cysteine balance in the aqueous humour. Methods: C57Bl/6 wild-type and xCT knockout mice at five age groups (6 weeks to 12 months) were used. Lens transparency was examined using a slit-lamp and morphological changes visualized by immunolabelling and confocal microscopy. Quantification of glutathione in lenses and cysteine and cystine levels in the aqueous was conducted by liquid chromatography tandem mass spectrometry (LC-MS/MS). Results: Slit-lamp examinations revealed that 3-month-old wild-type mice and xCT knockout mice lenses exhibited an anterior localized cataract. The frequency of this cataract significantly increased in the knockout mice compared to the wild-type mice. Morphological studies revealed a localized swelling of the lens fiber cells at the anterior pole. Glutathione levels in whole lenses were similar between wild-type and knockout mice. However, glutathione levels were significantly decreased at 3 months in the knockout mice in the lens epithelium compared to the wild-type mice. Aqueous cysteine levels remained similar between wild-type and knockout mice at all age groups, whereas cystine levels were significantly increased in 3-, 9-, and 12-month-old knockout mice compared to wild-type mice. Conclusions: Loss of xCT resulted in the depletion of glutathione in the epithelium and an oxidative shift in the cysteine/cystine ratio of the aqueous. Together, these oxidative changes may contribute to the accelerated development of an anterior cataract in knockout mice, which appears to be a normal feature of aging in wild-type mice.

Evaluation of choroidal thickness, macular thickness, and aqueous flare after cataract surgery in patients with and without diabetes: a prospective randomized study.

BACKGROUND: In diabetic eyes, various choroidal abnormalities are noted in addition to changes in the retinal circulation, and the risk of increased aqueous flare and retinal thickening after cataract surgery is higher in diabetic eyes. Inflammation caused by surgery induces breakdown of the blood-retinal barrier and affects the retina, although the influence on the choroid is unknown. Several researchers have evaluated the choroidal thickness (CT) after cataract surgery in patients with diabetes; however, the results are inconsistent. The purpose of this study was to evaluate the influence of uneventful small-incision phacoemulsification cataract surgery on the subfoveal choroidal thickness (SCT), the central macular thickness (CMT), and aqueous flare in patients with diabetes. METHODS: This study included 59 randomly selected eyes (33 eyes of patients with diabetes and 26 eyes of control patients without diabetes) undergoing small-incision cataract surgery. Among the diabetic eyes, 26 were without diabetic retinopathy, and the remaining eyes had non-proliferative diabetic retinopathy. Aqueous flare, CMT, and SCT measurements were performed before and at 1 week, 1 month, and 3 months after surgery. RESULTS: The postoperative CMT continued to increase significantly until 3 months in both groups. Although the CMT was more in patients with diabetes than in patients without diabetes during the follow-up period, there was no significant difference between the two groups. The aqueous flare value increased until 3 months after surgery in both groups. Although the increase was significant at 3 months after surgery in patients with diabetes, the increase in controls was not significant. The aqueous flare values differed significantly between the two groups before and at 3 months after surgery. There was no significant within-group or between-group difference in pre- and postoperative SCT values. CONCLUSION: In diabetic eyes with early stage of retinopathy, even small-incision cataract surgery can induce increased aqueous flare and macular thickening until 3 months, although there is no significant change in the choroidal thickness. Further studies are essential to evaluate choroidal changes after the cataract surgery in diabetic eyes.

Correlation between anterior chamber flare changes and diabetic macular edema after intravitreal injection of ranibizumab and aflibercept.

PURPOSE: To evaluate aqueous flare change patterns following anti-vascular endothelial growth factor therapy for diabetic macular edema (DME) and investigate the relationship between changes in flare values and central macular thickness (CMT). STUDY DESIGN: Retrospective, interventional case series METHODS: A total of 84 eyes of 62 patients with DME received either intravitreal ranibizumab (IVR; n = 62) or aflibercept (IVA; n = 22). A laser flare photometer (Kowa FM500, Kowa Company, Ltd) was used to measure flare values, and CMT was assessed using optical coherence tomography. Flare values and CMT were measured prior to injection (baseline) and at, 1, 7 and 14 days after injection. RESULTS: Flare values in the IVR group decreased significantly at day 14 (P = 0.001), whereas the IVA group showed a significant increase in flare values at day 1 (P < 0.001). In the IVA group, the baseline flare values were significantly higher in the CMT reduction group than in the non-CMT reduction group (P = 0.035). There was no correlation between changes in flare values and CMT either in the IVA or IVR group. CONCLUSIONS: Flare value changes in patients treated with IVR decreased at day 14 post-injection. This may indicate when the most anti-inflammatory effect was obtained. There was no correlation between changes in flare values and CMT either in the IVA or IVR group; nevertheless, our research suggests that the baseline flare value is a predictive factor for the efficacy of IVA in DME.

Intraocular infiltration of Philadelphia chromosome-positive acute lymphoblastic leukemia diagnosed by polymerase chain reaction from the aqueous humor: A case report.

RATIONALE: Intraocular manifestation of hematopoietic tumors is rare and often difficult to distinguish from inflammation. We report a patient with acute lymphoblastic leukemia (ALL) who developed intraocular infiltration during the remission period. PATIENT CONCERNS: A 40-year-old man presented with hypopyon in his right eye. Three months later, extensive subretinal infiltration and the elevation of intraocular pressure were observed. Fourteen months prior to this, he had been diagnosed with Philadelphia chromosome-positive ALL, and had received chemotherapy and bone marrow transplantation that resulted in complete remission. DIAGNOSIS: The breakpoint cluster region-Ableson (BCR/ABL) chimera was detected by polymerase chain reaction (PCR) analysis in the patient's aqueous humor. Additionally, a high expression of WT1 (Wilms tumor gene) mRNA in the aqueous humor was discovered. A bone marrow examination yielded a high expression of BCR/ABL fusion gene, and it was determined the patient had experienced a relapse of ALL. INTERVENTIONS: The dasatinib was administered orally to the patient. OUTCOMES: The intraocular infiltration disappeared, and intraocular pressure was normalized. LESSONS: Intraocular infiltration in leukemia patients may be an indication of relapse regardless of systemic conditions. Analyzing mRNA expression of BCR/ABL and WT1 of ocular fluid in patients with hypopyon is beneficial in diagnosing topical relapses in leukemia.

Detection of small molecule concentration gradients in ocular tissues and humours.

The eye is an elegant organ consisting of a number of tissues and fluids with specialised functions that together allow it to effectively transmit and transduce light input to the brain for visual perception. One key determinant of this integrated function is the spatial relationship of ocular tissues. Biomolecular distributions within the main ocular tissues cornea, lens, and retina have been studied extensively in isolation, yet the potential for metabolic communication between ocular tissues via the ocular humours has been difficult to visualise. To address this limitation, the current study presents a method to map spatial distributions of metabolites and small molecules in whole eyes, including ocular humours. Using a tape-transfer system and freeze-drying, the spatial distribution of ocular small molecules was investigated in mouse, rat, fish (black bream), and rabbit eyes using negative ion mode MALDI imaging mass spectrometry. Full-scan imaging was used for discovery experiments, while MS/MS imaging for identification and localisation was also demonstrated. In all eyes, metabolites such as glutathione and phospholipids were localised in the main ocular tissues. In addition, in rodent eyes, major metabolites were distributed relatively uniformly in ocular humours. In contrast, both uniform and spatially defined ocular metabolite distributions were observed in the black bream eye. Tissue and ocular humour distributions were reproducible, as demonstrated by the three-dimensional analysis of a mouse eye, and able to be captured with high spatial resolution analysis. The presented method could be used to further investigate the role of inter-tissue metabolism in ocular health, and to support the development of therapeutics to treat major ocular diseases.

Alzheimer's Disease and Retinal Degeneration: A Glimpse at Essential Trace Metals in Ocular Fluids and Tissues.

BACKGROUND: Life expectancy is increasing all over the world, although neurodegenerative disorders might drastically affect the individual activity of aged people. Of those, Alzheimer's Disease (AD) is one of the most social-cost age-linked diseases of industrialized countries. To date, retinal diseases seem to be more common in the developing world and characterize principally aged people. Agerelated Macular Degeneration (AMD) is a late-onset, neurodegenerative retinal disease that shares several clinical and pathological features with AD, including stress stimuli such as oxidative stress, inflammation and amyloid formations. METHODS: In both diseases, the detrimental intra/extra-cellular deposits have many similarities. Aging, hypercholesterolemia, hypertension, obesity, arteriosclerosis and smoking are risk factors to develop both diseases. Cellular aging routes have similar organelle and signaling patterns in retina and brain. The possibility to find out new research strategies represent a step forward to disclose potential treatment for both of them. Essential trace metals play critical roles in both physiological and pathological condition of retina, optic nerve and brain, by influencing metabolic processes chiefly upon complex multifactorial pathogenesis. CONCLUSION: Hence, this review addresses current knowledge about some up-to-date investigated essential trace metals associated with AD and AMD. Changes in the levels of systemic and ocular fluid essential metals might reflect the early stages of AMD, possibly disclosing neurodegeneration pathways shared with AD, which might open to potential early detection.

Clinical factors contributing to postoperative aqueous flare intensity after 27-gauge pars plana vitrectomy for the primary rhegmatogenous retinal detachment.

PURPOSE: To investigate the perioperative clinical factors, which contribute to the postsurgical aqueous flare intensity (AFI) following 27-gauge pars plana vitrectomy (27GPPV) for primary rhegmatogenous retinal detachment (RRD). STUDY DESIGN: Retrospective clinical study. METHODS: We performed retrospective analyses of the medical records of 47 eyes of 47 patients with primary RRD who had undergone 27GPPV with a wide-angle viewing system. AFI was measured preoperatively and 1 week, 1 month, 3 months, 6 months, and 12 months after the surgery. RESULTS: AFI was significantly increased 1 week after the surgery (p<0.01) and then decreased overtime. At 6 months after surgery it was still statistically significantly higher than preoperative AFI (p=0.03). There was no statistical difference between preoperative AFI and that at 12 months following surgery. Multiple regression analyses revealed that the number of retinal photocoagulations and the performance of scleral indentation had significant positive correlation with AFI at 1 week, 1 month, 3 months, and 6 months, and at 1 month and 3 months after the surgery, respectively. CONCLUSION: Intraoperative retinal photocoagulation and scleral indentation are probable causes of increased AFI after 27G PPV for RRD.

Application of Laser Flare Photometry in the Quantification of Blood-Aqueous Barrier Breakdown after Micro-incision Vitrectomy.

Purpose: The purpose of the study is to quantify aqueous flare using laser flare photometry (LFM) in patients undergoing 25-G pars plana vitrectomy (PPV) and assess the need for postoperative topical corticosteroid administration . Methods: Prospective evaluation of 50 eyes (50 patients) was performed using LFM until day 30 postoperative. Duration of surgery, indication of PPV, and use of laser and/or cryotherapy were noted. Topical corticosteroids were used if mean LFM values were >50, or if there was anterior chamber fibrin. Results: Mean age of the subjects was 48.62 ± 10.07 years. The preoperative LFM value for 50 subjects was 17.42 ± 25.20. Topical corticosteroids were initiated in only 22 patients. The LFM values of subjects were not different from baseline at 1 month whether or not the subjects received corticosteroids (p > 0.106). Conclusions: With 25-G PPV, there is minimal breakdown of blood-aqueous barrier. LFM helps in monitoring postoperative inflammation, obviating the need for topical corticosteroids in significant number of patients.

Relationship between aqueous humor cytokine level changes and retinal vascular changes after intravitreal aflibercept for diabetic macular edema.

The aim of this work was to investigate the changes in aqueous humor cytokine levels after intravitreal injection of aflibercept in diabetic macular edema (DME) and to evaluate the relationship between cytokines modifications and central macular thickness (CMT) and retinal/choroidal vascular changes using structural and functional optical coherence tomography (OCT). Aqueous concentrations of 38 cytokines were measured via multiplex bead assay. In addition, spectral domain OCT and OCT angiography with SSADA software (XR Avanti® AngioVue) were performed at baseline and after intravitreal injections. VEGF, IL-6, IL-5, IL-1ß, Eotaxin, GRO, IL-12p40, IL-12p70, IL-1RA, Flt-3L and IP-10 showed a statistically significant decrease through the follow-up (p < 0.05; p < 0.001), while Fraktalkine and GM-CSF significantly increased (p < 0.05). Best corrected visual acuity significantly increased and CMT significantly decreased during follow-up (p < 0.001 and p = 0.013). Superficial capillary plexus and deep capillary plexus density significantly increased (p < 0.001 and p = 0.014). A positive relation was found between GRO, VEGF, Fraktalkine, IP-10, IL-12p70 aqueous humor levels and CMT (p < 0.05; p < 0.001). Aflibercept is a primary anti-VEGF treatment producing a decrease of DME due to the reduction of vascular permeability, nevertheless other inflammatory cytokines showed modification after aflibercept intravitreal injections probably related to edema modification or to an interaction of aflibercept with other inflammatory cytokines.

Pilot study assessing the structural changes in posttrabecular aqueous humor outflow pathway after trabecular meshwork surgery using swept-source optical coherence tomography.

This study evaluated the morphological change in aqueous humor outflow (AHO) pathways using swept-source optical coherence tomography (SS-OCT) volumetric scans in glaucoma patients before and after glaucoma surgery. In this prospective observational case series, 15 eyes (13 patients) with glaucoma were treated with 120-degree Trabectome or 360-degree suture trabeculotomy and followed up for 3 months. B-scan images of the posttrabecular AHO pathway were reconstructed and the pathway areas were evaluated, before and after surgery. Changes in posttrabecular AHO pathway were qualitatively classified as "increased", "non-significant change", and "decreased" on reconstructed B-scan images. Quantitative measurements of the posttrabecular AHO pathway areas were performed pre- and postoperatively. Factors associated with both qualitative and quantitative changes in AHO pathway were investigated. From 30 regions (15 nasal and 15 temporal regions) in the 15 eyes, AHO pathways were analyzable in 20 regions pre- and postoperatively. Qualitative assessments of the pathway changes were "increased" in 8 regions, "non-significant change" in 9 regions, and "decreased" in 3 regions. Quantitative assessments of the average pathway area did not change significantly (from 3155±1633 pixels preoperatively to 3212±1684 pixels postoperatively, P = 0.50). All parameters relating to intraocular pressure changes or the surgical location were not associated with postoperative AHO pathway change. The intrascleral AHO pathway could be well visualized in glaucoma patients pre- and postoperatively using swept-source optical coherence tomography. However, structural changes in the AHO pathway assessed by SS-OCT were not significant after trabecular-targeted glaucoma surgery. Functional assessments of AHO are needed in future studies.

Intraocular Lymphoma Masquerading as Recurrent Iridocyclitis: Findings Based on in vivo Confocal Microscopy.

PURPOSE: To emphasize the application prospects of in vivo confocal microscopy (IVCM) in distinguishing intraocular lesions from inflammatory and neoplastic diseases. METHODS: Retrospective case report. RESULTS: A patient with neoplastic masquerade syndrome initially underwent IVCM examination. After six separate intravitreal injections of 400 mg/0.1 ml methotrexate, IVCM revealed a complete remission of intraocular lymphoma. CONCLUSIONS: Although IVCM findings alone are not enough to diagnose intraocular neoplasm with absolute certainty, they can provide useful indication for distinguishing between intraocular inflammatory diseases and neoplasms.

Functional assessment of the aqueous humour distal outflow pathways in bovine eyes using time-of-flight magnetic resonance tomography.

The major part of the aqueous humor leaves the eye through the "conventional outflow pathway", consisting of the trabecular meshwork, Schlemm's canal, collector channels, an intrasceral plexus and the episcleral veins. While the trabecular meshwork is well characterized, little is known about anatomical and functional features of the peripheral outflow tract beyond Schlemm's canal. The emergence of minimally-invasive glaucoma surgery directly targeting the outflow resistance in the trabecular meshwork has elicited growing interest in these structures. We used time-of-flight magnetic resonance imaging in ex vivo bovine eyes to map fluid flow under physiological conditions. We were able to identify the peripheral outflow vessels solely by the signal detected from the fluid flow inside their lumina. A question of clinical relevance is, whether localized opening of the trabecular meshwork leads to only localized or to a 360° increase in intrascleral flow. To address this, a goniotomy ab interno was performed in 3 eyes and the flow signal intensity was quantified sectorially. A significant increase in fluid flow was observed in the sector distal to the goniotomy (p = 0.0005) but not in the other sectors (p = 0.1). As a proof of concept we demonstrated that TOF-MRI based detection of flow in the peripheral aqueous outflow tract is feasible. The functional link observed between trabecular meshwork sectors and their distal outflow tract sectors may be relevant for minimally-invasive glaucoma surgery in humans.

Bilateral disciform keratitis of presumed adenoviral etiology.

Adenoviral conjunctivitis may lead to subepithelial corneal infiltrates as a late complication. Herein, we aim to present a 19-year-old healthy female, who developed bilateral disciform keratitis three weeks after suffering adenoviral conjunctivitis. She presented with widespread subepithelial corneal infiltrates in addition to central corneal edema with white distinct border resembling immune stromal ring, as well as Descemet's folds and keratic precipitates in the central area. Following topical corticosteroid and ganciclovir for 10 days, her condition improved. After 1 month, she had another episode. Short-term topical corticosteroids in addition to long-term topical cyclosporine and nonpreserved artificial tears were able to prevent further recurrences.

[Imaging of the Intrascleral Aqueous Drainage System - New Insights for Glaucoma Surgery Targeting the Trabecular Meshwork]. / Bildgebung der intraskleralen Kammerwasserabflusswege ­ neue Einblicke für die Trabekelwerkschirurgie.

Numerous new techniques in glaucoma surgery target the trabecular meshwork, which is considered to be the main site of aqueous outflow resistance. These approaches rely on a functioning aqueous drainage system distal to the site of surgery. Thus, the intrascleral aqueous outflow tract comprises Schlemm's canal, collector channels and aqueous veins and has become an object of increasing research interest. The intrascleral outflow tract contributes approximately 25-50 % to the total aqueous outflow resistance, but the outflow capacity differs greatly over the segments of the eye. Morphological and functional assessment of the intrascleral outflow tract is challenging, due to its deep scleral location and the complex nature of its small diameter vessel network. In this review, we present novel insights into its morphology and function, based on advances in a variety of imaging modalities, including optical coherence tomography, fluorescence imaging and electron microscopy. Together with clinical data, they support the paradigm of significant sectorial differences in aqueous outflow, which has a direct impact on glaucoma surgery targeting sectors of the trabecular meshwork, such as trabeculectomy ab interno or trabecular meshwork bypass stents. Possible future applications of intrascleral outflow tract imaging are discussed.

Three-dimensional Laser Scanning Confocal Analysis of Conjunctival Microcysts in Glaucomatous Patients Before and After Trabeculectomy.

BACKGROUND/AIM: In glaucoma, conjunctival epithelial microcysts (CEM) have been extensively investigated by means of laser scanning confocal microscopy. In the present case series, we examined eight glaucomatous patients undergoing trabeculectomy to obtain a 3-dimensional (3-D) characterization of CEM. MATERIALS AND METHODS: Image acquisition was performed in z-scan automatic volume mode by Heidelberg Retina Tomograph III/Rostock Cornea Module and a series of 40 images of 300×300 µm (384×384 pixels) to a maximum depth of 40 µm were acquired throughout the upper bulbar conjunctiva before (at the site planned for surgery) and eight weeks after trabeculectomy. The 3-D volume tissue reconstruction with maximal size of 300×300×40 µm was obtained. RESULTS: In the enface view, CEM appeared as empty, optically clear, round or oval shaped sub-epithelial structures. The 3-D spatial reconstruction showed microcysts as oval-shaped and optically clear elements, which were close, but clearly separated from the epithelium. CEM were embedded in the extra-cellular spaces and located about 10 µm below the epithelial surface. After trabeculectomy, CEM increased density and area especially along the horizontal axis. CONCLUSION: The 3-D in vivo confocal reconstruction of CEM permits for better clarification of their microscopic anatomy and patho-physiological significance, confirming their involvement in AH flow through the bleb-wall after filtration surgery for glaucoma.