Bilateral Hypertensive Retinopathy Complicated with Retinal Neovascularization: Panretinal Photocoagulation or Intravitreal Anti-VEGF Treatment?

PURPOSE: To present the case of a patient with bilateral hypertensive retinopathy complicated with retinal neovascularization who received anti-VEGF intravitreal injection in one eye and panretinal photocoagulation (PRP) in the fellow eye. METHODS: A 33-year-old male patient presented with gradual visual loss in both eyes for the last 5 months. At that time, he was examined by an ophthalmologist and occlusive retinopathy due to malignant systematic hypertension was diagnosed. He was put on antihypertensive treatment but no ophthalmic treatment was undertaken. At presentation, 5 months later, best-corrected visual acuity (BCVA) was 0.1 in the right eye (RE) and 0.9 in the left eye (LE). Fundus examination was compatible with hypertensive retinopathy complicated with retinal neovascularization. Fluorescein angiography (FFA) revealed macular ischemia mainly in the RE and large areas of peripheral retinal ischemia and neovascularization with vascular leakage in both eyes. The patient was treated with two anti-VEGF (ranibizumab) injections with 2 months interval in the RE and PRP laser in the LE. RESULTS: Follow-up examination after 12 months showed mild improvement in BCVA, and FFA documented regression of retinal neovascularization in both eyes. CONCLUSION: Hypertensive retinopathy can be rarely complicated with retinal neovascularization. Treatment with PRP can be undertaken. In our case, the use of an intravitreal anti-VEGF agent seemed to halt its progression satisfactorily.

Glaucoma associated with the management of rhegmatogenous retinal detachment.

Transient or permanent elevation of intraocular pressure (IOP) is a common complication following vitreoretinal surgery. Usually secondary glaucoma, which develops after scleral buckling procedures, or pars plana vitrectomy for repair of rhegmatogenous retinal detachment, is of multifactorial origin. It is essential, for appropriate management, to detect the cause of outflow obstruction. An exacerbation of preexisting open-angle glaucoma or a steroid-induced elevation of IOP should also be considered. Scleral buckling may be complicated by congestion and anterior rotation of the ciliary body resulting in secondary angle closure, which can usually resolve with medical therapy. The use of intravitreal gases may also induce secondary angle-closure with or without pupillary block. Aspiration of a quantity of the intraocular gas may be indicated. Secondary glaucoma can also develop after intravitreal injection of silicone oil due to pupillary block, inflammation, synechial angle closure, or migration of emulsified silicone oil in the anterior chamber and obstruction of the aqueous outflow pathway. In most eyes medical therapy is successful in controlling IOP; however, silicone oil removal with or without concurrent glaucoma surgery may also be required. Diode laser transscleral cyclophotocoagulation and glaucoma drainage devices constitute useful treatment modalities for long-term IOP control. Cooperation between vitreoretinal and glaucoma specialists is necessary to achieve successful management.

Macular hole surgery with short-acting gas and short-duration face-down positioning.

PURPOSE: To report on the outcomes of vitrectomy and sulfur hexafluoride (SF(6)) gas tamponade for idiopathic macular holes with 2 days of face-down positioning. PATIENTS AND METHODS: This was a prospective, nonrandomized, observational sequential case-series study on 23 consecutive patients receiving macular hole surgery using 20% SF(6) and advised to stay in a face-down position for 2 days postoperatively (SF(6) group). These patients were compared to 23 consecutive patients who had previously undergone macular hole surgery, had received 14% C(3)F(8), and were advised to maintain a face-down position for 2 days (C(3)F(8) group). Patients in both groups underwent vitrectomy, internal limiting membrane peeling, and fluid gas exchange using either SF(6) or C(3)F(8.) Preoperative and postoperative data included best corrected visual acuity recorded in LogMAR units, slit-lamp biomicroscopy, and optical coherence tomography. RESULTS: At a 6-month follow-up, macular hole closure was noted in 23/23 eyes (100%) and in 22/23 eyes (96%) in the SF(6) and C(3)F(8) groups, respectively. The improvement in visual acuity (measured through Snellen acuity lines both preoperatively until 6 months postoperatively) was 4.08 ± 2.31 (95% confidence interval [CI]: 3.08-5.08) for the SF(6) group and 2.87 ± 2.30 (95% CI: 1.87-3.86) for the C(3)F(8) group; this difference was not statistically significant (P = 0.06). CONCLUSION: Vitrectomy with internal limiting membrane peeling and a short-acting gas tamponade using SF(6) with posture limitation for 2 days may give a high success rate in macular hole surgery.

Lamellar macular hole formation following vitrectomy for rhegmatogenous retinal detachment repair.

BACKGROUND: The purpose of this study was to investigate lamellar macular hole formation in six patients after rhegmatogenous retinal detachment repair. METHODS: A retrospective review of medical records of patients who underwent primary pars plana vitrectomy for rhegmatogenous retinal detachment repair was performed. Optical coherence tomography characteristics and best-corrected visual acuity were evaluated. Patients who developed lamellar macular hole after pars plana vitrectomy for rhegmatogenous retinal detachment repair were identified. RESULTS: A total of 1185 eyes underwent pars plana vitrectomy for retinal detachment between 2004 and 2009. Optical coherence tomography evaluation was available in 450 cases. Six of these cases demonstrated lamellar macular hole formation, which was diagnosed by OCT-3. The mean time from retinal detachment surgery to lamellar hole diagnosis was 4.1 months. The presence of an epiretinal membrane on the surface of the juxtafoveal retina was a common finding in all six patients. Visual acuity was improved after successful retinal reattachment and remained unchanged after lamellar hole formation. CONCLUSION: Lamellar macular holes developing after pars plana vitrectomy is a rare complication. Stability of optical coherence tomography findings and best-corrected visual acuity after lamellar macular hole formation may be observed for at least two years.

Full Thickness Macular Hole Closure after Exchanging Silicone-Oil Tamponade with C(3)F(8) without Posturing.

PURPOSE: To report a case of macular hole closure after the exchange of a silicone-oil tamponade with gas C(3)F(8) 14%. METHOD: A 64-year-old female patient with a stage IV macular hole underwent a three-port pars-plana vitrectomy and internal limiting membrane peeling. Due to the patient's chronic illness (respiratory problems), a silicone-oil tamponade was preferred. However, the macula hole was still flat opened four months postoperatively. Therefore, the patient underwent an exchange of silicone oil with gas C(3)F(8) 14%. No face-down position was advised postoperatively due to her health problems. RESULTS: Macular hole closure was confirmed with optical coherence tomography six weeks after exchanging the silicone oil with gas. CONCLUSIONS: Macular hole surgery using a silicone-oil tamponade has been proposed as treatment of choice for patients unable to posture. In our case, the use of a long-acting gas (C(3)F(8) 14%), even without posturing, proved to be more effective.

Proliferative vitreoretinopathy in a child with visceral leishmaniasis.

PURPOSE: We present a rare case of ocular leishmaniasis complicated by proliferative vitreoretinopathy in a child with active visceral leishmaniasis. METHODS: A 10-year-old boy with active visceral leishmaniasis presented with a 5- day history of redness, photophobia, and blurred vision in his left eye. Visual acuity was measured and the child had a complete ocular examination. RESULTS: Snellen best-corrected visual acuity (BCVA) was 10/10 in the right eye and 7/10 in the left eye at presentation. Ophthalmic examination of the right eye was normal but the left eye showed clinical signs of panuveitis. Laboratory investigations were negative. Treatment with systemic and local steroids was initiated and clinical improvement achieved. Eight months later, the patient had a relapse of systemic and ocular disease with severe panuveitis in both eyes. A combined tractional-rhegmatogenous retinal detachment was present in the left eye. Pars plana vitrectomy was undertaken in the left eye and the patient was started on systemic and local steroid treatment. Retinal reattachment was achieved postoperatively but visual acuity in the left eye remained poor. CONCLUSIONS: Early diagnosis, prompt systemic and ocular treatment, as well as close ophthalmic examination are essential in such cases.

Association between corneal hysteresis and central corneal thickness in glaucomatous and non-glaucomatous eyes.

PURPOSE: We aimed to determine corneal hysteresis values (CH) using the ocular response analyser (ORA) in non-glaucomatous and glaucomatous eyes and their relationship with central corneal thickness (CCT). METHODS: Corneal hysteresis, intraocular pressure (IOP) as measured by Goldmann applanation tonometry (GAT) and CCT were prospectively evaluated in 74 non-glaucoma subjects with IOP < 21 mmHg and in 108 patients with treated primary open-angle glaucoma (POAG). One eye in each subject was randomly selected for inclusion in the analysis. RESULTS: Mean (+/- standard deviation [SD]) age was 59.2 +/- 14.2 years in the non-glaucoma group and 62.4 +/- 9.8 years in the glaucoma group. Mean (+/- SD) GAT IOP was 15.7 +/- 2.65 mmHg and 16.38 +/- 2.73 mmHg in the non-glaucoma and glaucoma groups, respectively. There was no statistically significant difference between the two groups in mean age (p = 0.396) or mean GAT IOP (p = 0.098). Mean (+/- SD) CH was 10.97 +/- 1.59 mmHg in the non-glaucoma and 8.95 +/- 1.27 mmHg in the glaucoma groups, respectively. The difference in mean CH between the two groups was statistically significant (p < 0.0001). There was a strong positive correlation between CH and CCT in the non-glaucoma group (r = 0.743) and a significantly (p = 0.001) weaker correlation (r = 0.426) in the glaucoma group. CONCLUSIONS: Corneal hysteresis was significantly lower in eyes with treated POAG than in non-glaucomatous eyes. The corneal biomechanical response was strongly associated with CCT in non-glaucoma subjects, but only moderately so in glaucoma patients. It can be assumed that diverse structural factors, in addition to thickness, determine the differences in the corneal biomechanical profile between non-glaucomatous and glaucomatous eyes. Corneal hysteresis could be a useful tool in the diagnosis of glaucoma.

Variations in content and structure of glycosaminoglycans of the vitreous gel from different mammalian species.

The vitreous of all species is composed of essentially the same type of extracellular matrix macromolecules organized to a transparent gel. In this study, the composition and fi ne chemical structure of the glycosaminoglycans (GAGs) in the vitreous gel from sheep and goat were determined and compared with those of human and pig vitreous gels. The results showed that, in all examined species; hyaluronan (HA) was the predominant GAG, whereas chondroitin sulphate (CS) was the minor one. In the vitreous gel of the most relative species, i.e. sheep and goat, higher amounts of both of HA and CS were estimated as compared with pig and human tissues. The distribution of hydrodynamic sizes of HA and CS was significantly differed among different species. All HA preparations consisted of molecules with great variability in hydrodynamic sizes. The relative proportions of the large HA molecules (size >1.8 x 10(6) kDa) were significantly higher in sheep and goat as compared with human and pig vitreous gel. The length of CS chains was also of larger size in sheep and goat (50 and 58 kDa, respectively) than the respective chains in human and pig vitreous gel (38 and 28 kDa, respectively). The sulphation patterns of CS preparations were determined following enzymic treatments, HPLC and capillary electrophoretic analyses. The human vitreous-derived CS chains showed quite different sulphation profile than that of CS isolated from other species, since 4-sulphated disaccharides were identified as the dominant moiety. In conclusion, significant compositional and structural variations between the vitreous matrixes of different species at the GAG level were identified. The functional significance of these species-dependent variations is discussed.

Effect of local hypothermia on the anterior chamber and vitreous cavity temperature: in vivo study in rabbits.

BACKGROUND: This study aims to record the variations of the anterior chamber and vitreous cavity temperature after application of local hypothermia. MATERIAL AND METHODS: Local hypothermia was applied on 20 rabbits' eyes after general anesthesia using a liquid which had been placed in a special plastic container and had been frozen at -20 degrees C. In 10 rabbits (Group A) the frozen container was placed on the eyes without direct contact with the cornea, the hypothermia being applied through the eyelids, for 10 min. In the other 10 rabbits (Group B), the container was in direct contact with the cornea for 10 min. After that time, both the anterior chamber and vitreous cavity temperatures were measured in both groups using a special 20 G tip and were recorded with a digital thermometer (BAT-10, Physitemp Instruments Inc.). Reactions on the fundus were assessed by indirect ophthalmoscopy one day after hypothermia application. RESULTS: Mean reduction from the body temperature of temperature in the anterior chamber and in the vitreous was 10 +/- 1 degrees C and 4.2 +/- 0.5 degrees C respectively for Group A, and 20 +/- 0.8 degrees C and 8.5 +/- 0.5 degrees C respectively for Group B. All differences were statistically significant. CONCLUSIONS: Our study shows that local hypothermia application, even without direct contact with the cornea, reduces significantly the temperature in the center of the vitreous in rabbits. This temperature reduction could be beneficial in conditions of intraocular inflammation, where hypothermia could act synergetically with other means to decrease the anterior and/or posterior segment inflammation.

On the plausible association between environmental conditions and human eye damage.

The increase in solar ultraviolet radiation can have various direct and indirect effects on human health, like the incidence of ocular damage. Data of eye damage in residents of three suburban regions in Greece and in two groups of monks/nuns and fishermen are examined here. The statistics performed on these data provides new information about the plausible association between increased levels of solar ultraviolet radiation, air-pollution at ground level, and the development of ocular defects.

Pig vitreous gel: macromolecular composition with particular reference to hyaluronan-binding proteoglycans.

The aim of this study was to examine the macromolecular composition of pig vitreous body with particular emphasis on hyaluronan-binding proteoglycans. The whole pig vitreous gel was found to contain 76 microg of hyaluronan-derived uronic acid, 700 microg of total protein and 150 microg of collagen per ml of gel. The contents of neutral hexoses and sialic acids were 80 and 22 microg/ml of vitreous gel, but only a minor proportion of them were found to be associated with the proteoglycan fraction. As estimated by gel chromatography on Sepharose CL-2B, hyaluronan presents a polydisperse hydrodynamic behavior with a lower molecular mass (M(r)) value of 220 kDa. The existence of low amounts of a hyaluronan-binding proteoglycan population with structural and immunological characteristics similar to a member of the hyalectan family, versican, has also been demonstrated. The concentration of this versican-like proteoglycan in whole vitreous accounts for 50 microg proteoglycan protein per ml of vitreous gel and represents a minor proportion (about 7%) of the total protein content. The proteoglycan has an average M(r) of 360 kDa and is substituted by chondroitin sulphate (CS) side chains. Study of the CS sulphation pattern showed that the chains were composed of both type 4- and 6-sulphated disaccharide units.

Occurrence and structural characterization of versican-like proteoglycan in human vitreous.

Human vitreous gel is a special type of extracellular matrix, in which interpenetrating networks of collagen fibrils and hyaluronan are found. In this study, we report that apart from significant amounts of collagen, hyaluronan and sialylated glycoproteins, it was found that the human vitreous gel also contained low amounts of versican-like proteoglycan. The concentration of versican-like proteoglycan in the whole vitreous is 0.06 mg protein/ml of vitreous gel and represents a small percentage (about 5%) of the total protein content. The versican-like proteoglycan has a molecular mass of 380 kDa, as estimated by gel chromatography. Its core protein is substituted by chondroitin sulphate side chains (average molecular weight 37 kDa), in which 6-sulphated disaccharides predominated. According to the physicochemical data, the number of chondroitin sulphate chains is likely to be 5-7 per molecule. These proteoglycan monomers form large aggregates with endogenous hyaluronan. Versican, which is able to bind lectins via its C-terminal region, may bridge or interconnect various constituents of the extracellular matrix via its terminal domains in order to stabilize large supramolecular complexes at the vitreous, contributing towards the integrity and specific properties of the tissue.