Cardiometabolic factors and risk of non-arteritic anterior ischemic optic neuropathy: a systematic review and meta-analysis.

PURPOSE: The purpose of this systematic review and meta-analysis of the literature is to evaluate the association between cardiometabolic risk factors (hypertension, diabetes mellitus, hypercholesterolemia/dyslipidemia, HDL cholesterol, LDL cholesterol, lipoprotein(a), and triglycerides) and non-arteritic anterior ischemic optic neuropathy (NAION). METHODS: Pertinent publications were identified through a systematic search in PubMed and EMBASE databases, without language restrictions. The pooled odds ratios (OR) and standardized mean differences (SMD), with their 95% confidence intervals (95% CI) were estimated using random effects (DerSimonian Laird) models, as appropriate. A set of subgroup analyses and meta-regression analysis models were performed. RESULTS: Twenty-one studies (including 1560 patients with NAION and 2292 controls), examining the association between NAION and cardiometabolic risk factors, were eligible for the systematic review and meta-analysis. Hypertension (pooled OR = 1.50; 95% CI: 1.16-1.94), diabetes mellitus (pooled OR = 1.71; 95% CI: 1.33-2.21), and hypercholesterolemia/dyslipidemia (pooled OR = 2.00; 95% CI: 1.53-2.62) were associated with NAION. Among the components of dyslipidemia, higher serum triglycerides were associated with NAION, with a medium effect size (SMD = + 0.58, 95% CI: + 0.12 to + 1.04), whereas synthesis of four studies reporting on HDL and LDL cholesterol did not reveal any significant associations. A significant association between NAION and higher serum lipoprotein(a) levels (pooled OR = 2.88; 95%CI: 1.01-8.21) was also noted. CONCLUSIONS: This systematic review and meta-analysis found that NAION was associated with cardiometabolic factors, suggesting that vascular dysfunction may be implicated in the pathogenesis of the disease. Our findings may alert health care providers to try modifying these risk factors for NAION prevention.

INTERNAL LIMITING MEMBRANE PEELING IN MACULAR HOLE SURGERY; WHY, WHEN, AND HOW?

PURPOSE: To review the current rationale for internal limiting membrane (ILM) peeling in macular hole (MH) surgery and to discuss the evidence base behind why, when, and how surgeons peel the ILM. METHODS: Review of the current literature. RESULTS: Pars plana vitrectomy is an effective treatment for idiopathic MH, and peeling of the ILM has been shown to improve closure rates and to prevent postoperative reopening. However, some authors argue against ILM peeling because it results in a number of changes in retinal structure and function and may not be necessary in all cases. Furthermore, the extent of ILM peeling optimally performed and the most favorable techniques to remove the ILM are uncertain. Several technique variations including ILM flaps, ILM scraping, and foveal sparing ILM peeling have been described as alternatives to conventional peeling in specific clinical scenarios. CONCLUSION: Internal limiting membrane peeling improves MH closure rates but can have several consequences on retinal structure and function. Adjuvants to aid peeling, instrumentation, technique, and experience may all alter the outcome. Hole size and other variables are important in assessing the requirement for peeling and potentially its extent. A variety of evolving alternatives to conventional peeling may improve outcomes and need further study.

Anti-platelet effects of vitamin supplements in age-related macular degeneration: an in vitro study.

OBJECTIVE: The purpose of this experimental study was to investigate the role of vitamin supplements (Ocuvite, Vitalux Omega, and Nutrof Total) as possible inhibitors of the onset of age-related macular degeneration (AMD). MATERIALS AND METHODS: The anti-aggregating effect of each vitamin was determined against four accumulative factors namely, platelet activating factor (PAF), adenosine diphosphate (ADP), thrombin receptor-activating peptide (TRAP), and arachidonic acid (AA) in the platelet rich plasma (PRP) of healthy volunteers. RESULTS: Ocuvite, Vitalux Omega, and Nutrof Total were more potent inhibitors against PAF and ADP compared to TRAP and AA. Among the three vitamins, Nutrof Total displayed more potent inhibitions against TRAP and AA, while against PAF and ADP all the three vitamins revealed similar IC50 values. CONCLUSIONS: The vitamins Ocuvite, Vitalux Omega, and Nutrof Total have anti-aggregating effects and therefore can be used against AMD in healthy volunteers.

Prediction of regression of retinal neovascularisation after panretinal photocoagulation for proliferative diabetic retinopathy.

PURPOSE: The purpose of this study was to evaluate the regression of neovascularization elsewhere (NVE) after panretinal photocoagulation (PRP) based on its location in relation to the internal limiting membrane (ILM). METHODS: Participants in this retrospective case series were 47 patients with active NVE within the vascular arcade. All patients were treated with PRP and followed up for at least 12 months. The time to regression of NVE based on its location relative to the ILM on spectral domain-optical coherence tomography (SD-OCT) was analyzed. RESULTS: The proportion of eyes, showing regression of NVE at the end of follow-up period was 19/25 (76 %) in the "below ILM" group and 13/22 (59 %) in the "above ILM" group. The "below ILM" group was associated with a twofold enhanced regression of NVE in comparison to the "above ILM" group (HR = 2.13, p = 0.038). CONCLUSIONS: Regression of NVE is determined by its location relative to the ILM. Patients with "below ILM" NVE were found to show a twofold increased regression rate in comparison with the "above ILM" group, while the proportion of eyes showing regression of NVE at the end of the follow-up period was significantly greater in the "below ILM" than the "above ILM" group.

HYPERREFLECTIVE FOCI AS AN INDEPENDENT VISUAL OUTCOME PREDICTOR IN MACULAR EDEMA DUE TO RETINAL VASCULAR DISEASES TREATED WITH INTRAVITREAL DEXAMETHASONE OR RANIBIZUMAB.

PURPOSE: To evaluate the potential role of hyperreflective foci (HF) in predicting visual outcome in patients undergoing treatment for macular edema due to retinal vascular diseases. METHODS: Data and images of 92 patients with macular edema due to diabetes mellitus or branch retinal vein occlusion, treated with either intravitreal dexamethasone implant or ranibizumab, were analyzed. All patients underwent best-corrected visual acuity measurement, slit-lamp examination, spectral domain optical coherence tomography at baseline and at all time points of the follow-up (Month 1, 2, 3, 6, and 9). Generalized least squares random effects linear or logistic regression analysis was used to investigate potential factors associated with the final best-corrected visual acuity and number of HF, respectively. RESULTS: Increasing age (P < 0.001), central retinal thickness (P < 0.001), number of HF (P = 0.028), presence of subretinal fluid (P < 0.001), intraretinal fluid (P < 0.001), intraretinal cysts (P < 0.001), and disruption of ellipsoid zone/external limiting membrane (P < 0.001) were significantly associated with poorer visual outcome. Factors associated with HF were increasing central retinal thickness (P = 0.003), presence of subretinal fluid (P = 0.049), intraretinal fluid (P = 0.002), cysts (P = 0.015), and disruption of ellipsoid zone (P = 0.047). No significant differences in change in best-corrected visual acuity, central retinal thickness, and HF were observed between the two treatment groups. CONCLUSION: Hyperreflective foci are associated with poorer visual outcome in patients with macular edema due to retinal vascular diseases. Similar reductions in HF are achieved by intravitreal steroid and anti-vascular endothelial growth factor agent.

PREVALENCE OF THE COMPLEMENT FACTOR H AND GSTM1 GENES POLYMORPHISMS IN PATIENTS WITH CENTRAL SEROUS CHORIORETINOPATHY.

PURPOSE: The purpose of our study was to investigate the potential association between the complement factor H (CFH) (rs3753394, rs800292, rs2284664, rs1329428, and rs1065489) and GSTM1 gene polymorphisms, and central serous chorioretinopathy (CSCR) susceptibility in a well-defined Greek cohort. METHODS: We enrolled a case-control study in a Greek population with 41 cases and 78 controls. Five milliliters of peripheral blood was collected from each participant, and DNA was extracted using the PureLink Genomic DNA kit. The CFH (rs3753394, rs800292, rs2284664, rs1329428, and rs1065489) single nucleotide polymorphisms and GSTM1 polymorphism were tested using polymerase chain reaction assays. RESULTS: Between CSCR (n = 41) cases and controls (n = 78), the TT rs3753394, GG rs1329428, and TT rs1065489 genotypes' frequencies of the CFH gene were found to be significantly associated with risk of CSCR. The genotype frequency of the CFH rs2284664, rs800292, and of the GSTM1 gene polymorphisms was not found to be significantly associated with CSCR. CONCLUSION: Our results demonstrated a significant association between CSCR and single nucleotide polymorphisms in the CFH gene (rs3753394, rs1329428, and rs1065489), suggesting that disturbances in choroidal vasculature, through intercorrelation with adrenomedullin, play a significant role in CSCR pathogenesis.

Complications of intravitreal ocriplasmin for vitreomacular traction and macular hole: a prospective spectral-domain optical coherence tomography study.

OBJECTIVE: The purpose of this study was to evaluate the safety of intravitreal ocriplasmin prospectively, reporting potential complications in patients with vitreomacular traction (VMT) alone or associated with macular hole (MH). MATERIALS AND METHODS: Participants in this prospective, multicenter study, were 24 patients with VMT (17 with VMT alone and seven with MH combined with VMT). All patients were treated with a single ocriplasmin injection and followed-up prospectively at baseline, day 7, 28 and the last examination of the follow-up for each patient (mean ± SD: 64.2 ± 24.4 d, range: 40-145 d). Best-corrected visual acuity (BCVA) was assessed, and spectral-domain optical coherence tomography was performed at each visit while the percentage of resolution of VMT and the association with various potential adverse events were recorded and analyzed. RESULTS: 66.7% of patients presented VMT release at the end of the follow-up, while 28.6% exhibited MH closure. Severe adverse events, such as enlargement of preexisting MH and formation of lamellar MH, were observed in one and four cases, respectively and remained till the end of the follow-up. Moderate adverse events, such as ellipsoid zone disruption and subretinal fluid development, became evident seven days after injection, in four cases. Formation of cystoid macular edema (CME), not evident at baseline, was noticed in three cases at day 28 after injection. Mild adverse events, like vitreous floaters, photopsias, eye pain and foreign body sensation, were noticed at day 7 and resolved till the end of the follow-up. CONCLUSIONS: Mild and moderate adverse events occurred mainly during the first week of the follow-up, while severe adverse events, such as the lamellar MH formation and CME at day 28 post injection were seen.

Electroretinographic and optical coherence tomography findings in breast cancer patients using aromatase inhibitors.

BACKGROUND: The present cross-sectional study has the purpose to investigate the impact of aromatase inhibitors (AIs) on retinal nerve fiber layer (RNFL) thickness, optic nerve and macular function in patients using AIs for breast cancer treatment. METHODS: Participants in our study were 41 hormone-receptor-positive earlystage breast cancer patients who were treated with AIs in the adjuvant setting. Moreover, 40 age- and gender-matched control subjects, having neither ocular nor systemic disorders, were included in this study. All participants underwent a complete ophthalmological examination, including best corrected visual acuity (BCVA) assessment, RNFL thickness and central foveal thickness (CFT) measurement, visual evoked potentials (VEP) recording and multifocal-electroretinogram (mf-ERG) recording. Univariate and multiple regression analyses were performed. RESULTS: At the multiple regression analyses, patients receiving AIs presented with lower average RNFL and inferior RNFL. Moreover, similarly to the univariate analysis, intake of AIs was associated with lower amplitude P100, lower retinal response density in ring 1 and ring 2, longer peak time P100 and longer P1 time in ring 1. CONCLUSION: Our study is the first in the literature investigating the potential effect of AIs on RNFL thickness, optic nerve and macular function in patients using AIs for breast cancer treatment. The principal message of our study is that patients using AIs exhibited a significant decrease in RNFL thickness (average, superior and inferior), retinal response density and visual acuity compared to healthy controls, while VEP findings (both amplitude and peak time of P100) differ significantly as well.

Evolution of vitreomacular adhesion to acute vitreofoveal separation with special emphasis on a traction-induced foveal pathology. A prospective study of spectral-domain optical coherence tomography.

PURPOSE: To investigate the evolution of vitreomacular adhesion (VMA) to acute vitreofoveal separation with particular emphasis on cases involving the underlying fovea. METHODS: In this observational case series, of 192 cases in the VMA stage, 51 progressed to acute vitreofoveal separation; this subgroup was divided into those with normal separation (Group I) and those with co-existing macular findings (Group II). All patients were examined using spectral domain-optical coherence tomography (SD-OCT) at regular three-month intervals. We recorded the best-corrected visual acuity (BCVA), the vitreomacular angle of the VMA (nasally and temporally), the horizontal diameter of the VMA, the macular thickness, the integrity of the photoreceptor layer and of the external limiting membrane. The Amsler grid test was used in the intermediate examinations in cases where patients developed symptoms. RESULTS: Out of the 51 cases in the VMA stage, 45 (88.2%) progressed to normal spontaneous vitreofoveal separation, while six (11.8%) developed findings of the fovea, such as macular thinning (two cases), an anomalous foveal contour (two cases), a macular tissue defect (one case) and vitreous separation from only the temporal side of the VMA in one case. Foveal findings were the same during the follow-up period in all but one case in which improvement was noted. Differences in BCVA between baseline measurements, those made immediately after vitreofoveal separation, and those made during final examination were not statistically significant. For the whole sample of our study (51 cases), the mean observation time at the VMA stage was 21.8 ±10.6 months, while the mean follow-up time after vitreofoveal separation was 9.7 ±4.9 months. In cases that developed incidents from the fovea, the mean observation time from the baseline to the last examination before vitreofoveal separation was 16.5 ±11.2 months and the mean follow-up time from the diagnosis of vitreofoveal separation to the final examination was 8.5 ±4.4 months. CONCLUSIONS: VMA, excepting its progression to vitreomacular traction or spontaneous release, in a subset of patients can also cause findings associated with the fovea, concomitantly with vitreofoveal separation. Vitreofoveal separation can induce unilateral anatomic distortion of the fovea accompanied by symptoms, such as metamorphopsia or micropsia.

Effect of macular ischemia on intravitreal ranibizumab treatment for diabetic macular edema.

PURPOSE: To evaluate the impact of macular ischemia on the functional and anatomical outcome after intravitreal injections of ranibizumab for the treatment of diabetic macular edema (DME). PROCEDURES: Participants were 49 patients with diabetes mellitus, divided into two groups based on the presence of ischemia on fluorescein angiography: (i) nonischemic group (n = 32) and (ii) ischemic group (n = 17). All patients were treated with intravitreal ranibizumab and were followed up for 6 months. The main outcome measures were changes in visual acuity (VA) and central foveal thickness (CFT). RESULTS: There was a statistically significant improvement in VA and CFT between baseline and the end of the follow-up in the nonischemic group, while in the ischemic group there was no significant difference in VA but CFT differed significantly at the 6-month follow-up. CONCLUSIONS: Macular ischemia may have a negative impact on functional outcomes 6 months after intravitreal ranibizumab treatment in patients with DME but has no effect on anatomical outcomes.

In vitro effects of vitamin supplements on platelet-activating factor and its metabolism in age-related macular degeneration.

OBJECTIVE: The purpose of our study was to investigate for the first time a series of vitamin supplements used for age-related macular degeneration (AMD) as potential inhibitors of platelet-activating factor (PAF). MATERIALS AND METHODS: Various vitamin supplements were tested in washed rabbit platelets (WRPs), in order to investigate the interaction between vitamin supplements (InShape, Nutrof, Ocuvite, Vitalux) and inhibition of PAF-induced platelet aggregation. Additionally, we examined their ability to affect PAF-metabolism, through their in vitro effect on PAF basic metabolic enzymes (PAF-CPT, lyso PAF-AT, and PAF-AH). RESULTS: Nutrof exhibited the strongest anti-PAF activity, while Vitalux was the most potent anti-inflammatory factor. CONCLUSION: This is the first study to bring in surface potent anti-inflammatory and anti-angiogenic activities of some vitamin supplements used against AMD, through their in vitro anti-PAF effects in WRPs and the rabbit plasma and leukocyte PAF metabolism, suggesting a promising role of vitamin supplements and especially resveratrol, concerning its potent anti-angiogenic activity in AMD.

Incomplete Gardner's syndrome with blepharoptosis as the first symptom.

Gardner's syndrome (GS) is an autosomal dominant form of polyposis characterized by the presence of multiple polyps in the colon together with osseous tumors and soft-tissue tumors, such as epidermoid cysts and lipomas. An osteoma is a benign, osteogenic tumor and may be sporadic or related to GS. Here, we present a patient with a giant sino-orbital osteoma and blepharoptosis as the only symptom of incomplete GS. A 74-year-old woman, with no previous history of trauma or ophthalmic surgery, presented with a 2 years history of right blepharoptosis without diplopia. The results of slit-lamp and fundoscopic examination were normal. Computed tomography showed a giant sino-orbital osteoma. With suspicion for GS, we thoroughly examined the patient and found no soft-tissue tumors. Fifteen years ago, the patient, who had a family history of colonic polyposis, underwent right colectomy and chemotherapy for adenocarcinoma. We report a case of incomplete GS with blepharoptosis as the first symptom.

UGH Syndrome Resolution after IOL Explantation and Concomitant Carlevale IOL Implantation.

OBJECTIVE: To examine the use of Carlevale IOL placement in patients with UGH, and to evaluate surgical outcomes. DESIGN: In this retrospective study, 28 patients with UGH syndrome that were subjected to IOL explantation and concomitant Carlevale IOL implantation were included in the study. METHODS: Information about VA, IOP, number of glaucoma medication, need for glaucoma surgery, presence of hemorrhage and inflammation were recorded up to 6 months after the procedure. RESULTS: We found a statistically significant increase in mean visual acuity and complete resolution of uveitis in all patients. Mean IOP and the mean number of glaucoma medications were significantly decreased postoperatively, while 14% of patients required additional glaucoma surgery. CONCLUSIONS: IOL explantation and concomitant Carlevale IOL implantation may provide a viable solution for UGH syndrome resolution, increases visual acuity, and decreases the need for glaucoma medication.

Risk factors for poor vision-related quality of life among cataract patients. Evaluation of baseline data.

BACKGROUND: Our study aims to investigate the possible risk factors for poor vision-related quality of life in patients scheduled to undergo phacoemulsification. METHODS: Participants in our study were 220 patients who were eligible for phacoemulsification cataract surgery. All participants underwent a routine ophthalmological examination and completed the Visual Function Questionnaire-25 (VFQ-25), which encompasses 12 subscales and the composite score. Sociodemographic and lifestyle parameters were evaluated as potential risk factors for low VFQ-25 composite score, as well as subscale scores. Multivariate regression analysis was performed. RESULTS: Composite score did not exhibit any significant associations. General Health subscale score was positively associated with higher educational level. Patients who currently worked presented with lower Vision Specific Mental Health subscale score (OR: 0.33, 95 % CI: 0.18 to 0.63). Vision Specific Role Difficulties subscale score was positively associated with exercise (OR: 1.89, 95 % CI: 1.30 to 2.75). Vision Specific Dependency subscale score was independently positively associated with marital status (married vs single/widowed/divorced, OR: 1.83, 95 % CI: 1.08 to 3.12) but inversely with current working status (OR: 0.40, 95 % CI: 0.20 to 0.79). Males exhibited lower Peripheral Vision subscale score compared with females (OR: 0.19, 95 % CI: 0.04 to 0.91). CONCLUSIONS: Baseline vision-related quality of life in cataract patients presenting for surgery seems affected by inherent sociodemographic and lifestyle parameters, such as gender, educational level, marital status, current working status and exercise. Therefore, clinicians should be aware of the discrepancies that risk factors may confer, and should thus focus on the most vulnerable subgroups.

Branch retinal vein occlusion: epidemiology, pathogenesis, risk factors, clinical features, diagnosis, and complications. An update of the literature.

BACKGROUND/PURPOSE: Retinal vein occlusion is the second most common retinal vascular disorder after diabetic retinopathy and is considered to be an important cause of visual loss. In this review, the purpose is to make an update of the literature about the classification, epidemiology, pathogenesis, risk factors, clinical features, and complications of branch retinal vein occlusion (BRVO). METHODS: Eligible articles were identified using a comprehensive literature search of MEDLINE, using the terms "branch retinal vein occlusion," "pathogenesis," "epidemiology," "risk factors," "clinical features," "diagnosis," and "complications." Additional articles were also selected from reference lists of articles identified by the electronic database search. RESULTS: Classification, epidemiology, pathogenesis, risk factors, clinical features, and complications are analyzed. CONCLUSIONS: Branch retinal vein occlusion has an incidence of 0.5% to 1.2%. Several risk factors, such as hypertension, hyperlipidemia, diabetes mellitus, thrombophilia and hypercoagulation, systemic and inflammatory diseases, medications, and ocular conditions, have found to be associated with BRVO. The symptoms depended on the site and severity of the occlusion. The average reduction in visual acuity for ischemic BRVO is 20/50 and for nonischemic BRVO is 20/60. Acute BRVO can be detected by fundoscopy, where flame hemorrhages, dot and blot hemorrhages, cotton wool spots, hard exudates, retinal edema, and dilated tortuous veins can be observed. Chronic BRVO would be more subtle and characterized by the appearance of venous collateral formation and vascular sheathing, in addition to complications previously mentioned. Areas of ischemia can be evaluated using fluorescein angiography. The extent of macular edema and the presence of retinal detachment can be detected by fundoscopic examination or fluorescein angiography, although optical coherence tomography is considered to be the best method. As far as complications, the most common is macular edema, followed by retinal neovascularization, vitreous hemorrhage, or retinal detachment.

Assessment of the macula in keratoconus: an optical coherence tomography and multifocal electroretinography study.

PURPOSE: The purpose of our study was to assess the macular thickness and the electrophysiological changes in keratoconic patients without any systemic or ocular disorders. METHODS: 64 eyes of 32 keratoconus patients as well as 60 eyes of 30 controls participated in the study. All participants underwent a complete ophthalmological examination, including best-corrected visual acuity (BCVA) assessment, color vision testing, fundus examination, intraocular pressure measurement, central foveal thickness (CFT) measurement by optical coherence tomography (OCT) scan, and multifocal-electroretinogram (mf-ERG) recording. CFT, retinal response density (RRD) and P1 latency were measured. RESULTS: There was no statistically significant difference between the two groups concerning CFT and P1 latency in mf-ERG. The RRD in mf-ERG differed significantly between keratoconus patients and controls. Of note, BCVA was positively associated with RRD in keratoconus patients. CONCLUSION: In some cases of keratoconus, a macular dysfunction not visible ophthalmoscopically may coexist and the low visual acuity could be due not only to the corneal abnormality, but also to the photoreceptor dysfunction. As a result, the preoperative electrophysiological study of patients with keratoconus is crucial to avoid a needless corneal transplantation.

Long-term results of intravitreal ranibizumab, intravitreal ranibizumab with photodynamic therapy, and intravitreal triamcinolone with photodynamic therapy for the treatment of retinal angiomatous proliferation.

PURPOSE: To compare intravitreal ranibizumab, intravitreal ranibizumab plus photodynamic therapy (PDT), and intravitreal triamcinolone plus PDT in retinal angiomatous proliferation, presenting the results of a 3-year follow-up. METHODS: Thirty-seven eyes of 37 patients with retinal angiomatous proliferation were randomized to 1 of the 3 groups. Group 1 (n = 13) received 3 monthly injections of 0.5 mg ranibizumab, Group 2 (n = 13) received 1 session of PDT and 3 monthly injections of ranibizumab, and Group 3 (n = 11) received 1 session of PDT and 1 injection of 4 mg triamcinolone. Retreatment, with the same therapeutic scheme in each group, was considered in case of persistence or recurrence of subretinal/intraretinal fluid. RESULTS: Twelve patients in Groups 1 and 2 and 9 patients in Group 3 completed the 3-year follow-up. A total of 58% of patients in Group 1, 50% in Group 2, and 88.9% in Group 3 had the same or better visual acuity at the end of the follow-up (P = 0.081). Patients in Group 3 exhibited considerable improvement in visual acuity (P = 0.032) and statistically significant decrease in central retinal thickness (P < 0.0001) than the 2 other groups at the end of the follow-up. Also, the patients in Group 3 received on average the lowest number of injections (P < 0.0001). Of note, geographic atrophy mainly at the place of previous retinal angiomatous proliferation lesion was detected in 0% in Group 1, 25% in Group 2, and 55.6% in Group 3 (P = 0.203), while 33.3% of patients in Group 1 developed retinal scar. CONCLUSION: Treatment with ranibizumab or ranibizumab plus PDT resulted in stabilization of the disease, while treatment with IVT plus PDT achieved better results in terms of functional and anatomical features compared with the other groups.