UVEITIS TREATED WITH DEXAMETHASONE IMPLANT.

PURPOSE: To evaluate the real-life efficacy and safety of the intravitreal dexamethasone implant in uveitis. METHODS: This retrospective observational multicentric study included 152 eyes treated exclusively by 358 dexamethasone implant injections. The main outcome measures included change in the best-corrected visual acuity, central macular thickness, and vitreous haze score. RESULTS: Patients were treated with dexamethasone implant for macular edema (51.3%), vitritis with macular edema (40.1%), vitritis (5.3%), and other causes (3.3%). The mean duration of follow-up was 19.0 months. The mean gain in best-corrected visual acuity during follow-up was +12.1 letters. An improvement in best-corrected visual acuity ≥5, 10, and 15 letters was found in 64.5, 50.7, and 35.5% of cases, respectively. 59.7% of eyes with macular edema at baseline were found to be anatomical responders. Vitritis resolution (vitreous haze = 0+) was obtained in 81.4% of cases. Ocular hypertension (intraocular pressure ≥25 mmHg and/or gain ≥10 mmHg from baseline) occurred in 28.3% of patients. No filtering surgery/laser therapy was required. A total of 40.2% of phakic subjects underwent cataract surgery on average 11.2 months after the first injection. CONCLUSION: This study confirms the efficacy and safety of the dexamethasone implant in noninfectious uveitis. Cataract and ocular hypertension were not uncommon but easily manageable.

Transient therapeutic effect of vitrectomy in primary intraocular lymphoma.

This photo essay shows the transient therapeutic effect of pars plana vitrectomy (PPV) in a patient affected by primary intraocular lymphoma (PIOL). PPV is crucial for the diagnosis of PIOL, but it may also play a role in the therapeutic approach.

Deep inside Multifocal Choroiditis: an Optical Coherence Tomography Angiography approach.

The aim of the study was to report the clinical utility of optical coherence tomography angiography (OCT-A) in characterizing and differentiating inflammatory lesions and choroidal neovascularization (CNV) in multifocal choroiditis (MFC). A patient affected by MFC complaining central visual loss and scotoma in his left eye was fully investigated with dye-based angiographies, structural OCT and OCT-A. A reactivation of macular CNV was initially suspected, while OCT-A revealed the absence of any decorrelation signal both over the retinal pigment epithelium (RPE) and between RPE and Bruchs' membrane. OCT-A is a promising tool in detecting inflammatory CNV and in differentiating CNV from primitive inflammatory damage. Finely characterizing the aspect of a lesion allows us to choose the best therapeutic strategy for managing these potentially blinding diseases.

Full-thickness choroidal thinning as a feature of Fuchs Uveitis Syndrome: quantitative evaluation of the choroid by Enhanced Depth Imaging Optical Coherence Tomography in a cohort of consecutive patients.

PURPOSE: To perform a quantitative analysis of choroidal thickness in patients with Fuchs Uveitis Syndrome (FUS) using enhanced depth imaging optical coherence tomography (EDI-OCT). METHODS: All patients underwent comprehensive ophthalmic examination, including best-corrected visual acuity, slit-lamp biomicroscopy, applanation tonometry, axial length measurements with a swept-source biometer (IOLMaster 700, Carl Zeiss Medic AG, Jena, Germany) and macular 30° linear EDI- B-scan SD-OCT section (Spectralis HRAII+OCT, Heidelberg Engineering, Heidelberg, Germany) in both eyes. Analysis of choroidal thickness was performed at three different locations: subfoveally, 750 µm nasally, and 750 µm temporally to the fovea. Patients having received any surgery or intravitreal injections in the last 12 months and with axial length variance ≥ 1 mm between both eyes were excluded. RESULTS: Sixteen eyes of eight consecutive patients with unilateral FUS were included. Segmented analysis of the choroid, separately considering Haller's layer and Sattler's-choriocapillaris layers, showed statistically significant lower values (p < 0.05) in affected eyes (FEs) compared to fellow eyes (NFEs). In NFEs, total choroidal thickness mean values ranged from 305.62 ± 92.96 µm to 347.50 ± 91.55 µm; in FEs those values were significantly lower (p < 0.05), ranging from 232.62 ± 89.33 µm to 255.62 ± 89.33 µm. CONCLUSION: Diffuse and full-thickness choroidal thinning in FEs was observed. Considering the absence of significant axial length differences between FEs and NFEs in our patient series, these data seem to suggest that the full-thickness choroidal thinning in FEs may be due to the inflammatory process. In that way, FUS might be regarded as an inflammatory condition involving the whole uveal tunic, even the posterior part of it, definitively supplanting the early definition of "heterochromic iridociclytis".

Ocular penetration of topical antibiotics: study on the penetration of chloramphenicol, tobramycin and netilmicin into the anterior chamber after topical administration.

BACKGROUND: To compare penetration in the aqueous humour of topically applied antibiotics. DESIGN: Randomized prospective study, Department of Ophthalmology, University of Perugia, Italy PARTICIPANTS: Patients undergoing cataract surgery. METHODS: One hundred twenty-two patients were included: 14 received one drop of chloramphenicol suspension; 12 one application of chloramphenicol gel; 11 one drop of netilmicin suspension; 13 one drop of tobramycin suspension; 37 repeated instillations of chloramphenicol suspension every 10 min for a total of four drops; and 35 repeated instillations of chloramphenicol gel every 10 min for a total of four drops. Samples were taken immediately before surgery from the anterior chamber in order to determine the antibiotic by means of high-performance liquid chromatography. Samples were taken 45-190 min after the eye drops were instilled. MAIN OUTCOME MEASURES: Intraocular penetration of chloramphenicol, netilmicin and tobramicyn. RESULTS: After a single administration, netilmicin and tobramycin were undetectable, whereas the chloramphenicol suspension reached a mean concentration of 0.23 ± 0.21 µg/mL, and the chloramphenicol gel a mean concentration of 0.13 ± 0.14 µg/mL. After repeated administrations, the mean concentrations of the chloramphenicol suspension and gel were 0.60 ± 0.26 µg/mL and 0.58 ± 0.18 µg/mL, respectively. CONCLUSIONS: Tobramycin and netilmicin do not reach detectable concentrations, whereas chloramphenicol, after multiple administrations, reaches concentrations that are effective against Haemophilus influenzae and Haemophilus parainfluenzae, Legionella pneumophila, Moraxella catarrhalis, Neisseria meningitidis, Pasteurella multocida and Streptococcus pneumoniae. This means that chloramphenicol can be rationally used in the prophylaxis and treatment of infections supported by sensitive germs.

Evaluation of warm compresses and topical cyclosporine treatment in meibomian gland dysfunction by confocal scanning laser microscopy.

PURPOSE: The aim of our study is to confirm the utility of warm compresses (WC) and artificial tears (AT) in meibomian gland dysfunction (MGD) management and to understand if its association with topical cyclosporine A (CsA) improves outcomes. METHODS: Patients with diagnosis of MGD-related dry eye were evaluated. In this prospective, randomized, double-masked study, patients were randomized in two treatments: AT plus WC (group A), and AT plus WC plus CsA 0.05% ophthalmic emulsion (group B). At baseline and at 1, 3, and 6 months, Ocular Surface Disease Index (OSDI) questionnaire was completed, and tear evaluation (BUT, Schirmer and osmolarity test), ocular surface evaluation (fluorescein and lissamine green staining), clinical (Shimazaki grading) and in vivo confocal microscopy (IVCM) evaluation of rete ridges (RRs) were performed. RESULTS: A total of 40 eyes, 20 in each group, completed the study. Analysis of OSDI, tear test, ocular surface evaluation and clinical grading of MG showed significant improvement at 6 months, whereas no difference was found between the two groups at 6 months. The analysis of IVCM showed significant improvement in both groups, but significantly better results in group B were found compared to group A at 6 months. CONCLUSION: WC performed 3 times daily during the 1st month and once daily afterwards, in addition to AT, were useful to manage the obstruction of MG and related signs and symptoms. Additional effects of CsA were visible in IVCM only at 6 months. IVCM is an effective tool to monitor treatments in MGD.

Primary small gauge pars plana vitrectomy and silicone oil endotamponade for endophthalmitis after cataract surgery: Clinical and OCT findings.

BACKGROUND: Retrospective analysis of morphological and functional outcomes after pars-plana vitrectomy and Silicone-Oil (SO) endotamponade in acute postoperative endophthalmitis (APOE). METHODS: Minimum follow-up was 6 months. Every included patient received best-corrected visual acuity (BCVA) assessment, pre-operatively and at last follow-up. Spectralis OCT was used to investigate disorganization of inner (DRIL) and outer (DROL) retinal layers at 1, 3, 6 months and at last follow-up. OCT-A was performed to assess foveal avascular zone (FAZ) and vascular perfusion density (VPD) at 6 months and at last follow-up. RESULTS: Seventeen eyes were recruited. Postoperative findings: BCVA ≥ 20/40 (in 14 eyes); epiretinal membranes (13); hyperreflective epiretinal material soon after surgery in (6) SO-filled eyes; inner retinal layers atrophy (5); macular edema (2); DROL (4) with persistent EZ disruption at final visit (2); no significant difference between study and fellow eyes in central macular thickness, FAZ and VPD; VPD decreased in all cases with prominent disorganization of retinal architecture. CONCLUSION: OCT changes after APOE can be persistent or completely/partially self-resolving and seems related to the outward progression path of the infection/inflammation from the vitreous cavity to the inner and outer retina, rather than to the surgery.

Real-world outcomes of anti-VEGF therapy in treatment-naïve neovascular age-related macular degeneration diagnosed on OCT angiography: the REVEAL study.

PURPOSE: To compare the 12 months visual and anatomical outcomes of treatment-naïve neovascular age-related macular degeneration (nAMD) patients diagnosed by optical coherence tomography angiography (OCT-A) compared with fluorescein angiography (FA)/indocyanine green angiography (ICGA), after anti-VEGF treatment in a real-world setting. METHODS: Monocentric, observational, parallel-group study of nAMD patients diagnosed with either FA/ICGA or non-invasive OCT-A methods. Patients were treated with a fixed dosing regimen of intravitreal ranibizumab or aflibercept and followed up for 12 months. Primary outcomes were the 12 months functional (BCVA) and anatomical (CST reduction) gains between the two groups. The stratification of BCVA and CST gains by type of neovascular lesion and by anti-VEGF treatment was also assessed. RESULTS: Seventy-two patients received FA/ICGA for the initial diagnosis of nAMD, while 73 received OCT-A. Overall, the mean BCVA gain at 12 months was 11.5 ± 9.6 letters. There were no statistically significant differences between the invasive and non-invasive imaging groups in BCVA gain (p = 0.87) or CST reduction (p = 0.76). No statistically significant outcome differences between different lesion types and the two drugs were observed. CONCLUSION: In a real-world setting, nAMD patients diagnosed with OCT-A showed meaningful improvements in visual and anatomical parameters during 12 months of treatment, without significant differences with those diagnosed by invasive modalities.

Choroidal vasculature analysis in MEK inhibitor-associated retinopathy.

PURPOSE: To evaluate choroidal vascularity index (CVI) in patients developing mitogen-activated protein kinase kinase (MEK) inhibitor-associated retinopathy (MEKAR). METHODS: In this prospective observational study, extensive ophthalmic examination was performed, including enhanced-depth-imaging-optical coherence tomography (EDI-OCT). EDI-OCT scans of patients receiving Cobimetinib, taken at baseline and at MEKAR manifestation, were considered for choroid analysis. Choroidal thickness (CT) was measured on high-resolution b-scans passing through the fovea at three different locations. Same scans were therefore imported for binarization into a previously reported software and CVI was calculated as the ratio of luminal area (LA) to total choroid area (TCA). RESULTS: When compared to baseline, eyes with MEKAR (14 eyes) did not show significative CT variation in subfoveal region (p = 0,57), 750-µm-nasal to the fovea (p = 0,08) and 750-µm-temporal to the fovea (p = 0,07). Similarly, there were no statistically significant differences for TCA (p = 0.54), LA (p = 0.85), stromal area (SA) (p = 0.13), LA/SA (p = 0.34) and CVI (p = 0.47). Best-corrected visual acuity was significantly reduced at fluid accumulation when compared to baseline values (p = 0.03), with complete recovery after fluid resolution (p = 0.73). CONCLUSION: Multiple parameters reflecting the status of the choroid seemed not influenced by Cobimetinib administration. Retinal pigment epithelium toxic disfunction likely represents the crucial step in MEKAR pathogenesis.

Effect of preoperative topical nepafenac 0.1% on inflammatory response after uncomplicated cataract surgery in healthy subjects.

PURPOSE: To determine the effect of preoperative topical Nepafenac administration on anterior chamber flare after uneventful cataract surgery in healthy subjects. METHODS: Prospective randomized clinical trial. Seventy-three eyes of 73 healthy patients undergoing routine cataract surgery were randomized to receive (group A) topical nepafenac (1 mg/ml) or not to receive (group B) 1 drop 3 times per day for 3 days before surgery. All eyes received the same postoperative anti-inflammatory therapy. Clinical outcome parameters such as best corrected visual acuity, intraocular pressure, retinal central foveal thickness and aqueous flare were recorded preoperatively, 1, 15, 30 and 60 days after surgery. RESULTS: Three patients were excluded for poor compliance, and three patients were excluded or developing pseudophakic macular oedema during the follow-up. Both groups were comparable for age, gender, and showed similar BCVA, intraocular pressure and central macular thickness values preoperatively and during the entire follow-up (p > 0.01). Aqueous flare values showed a statistically increase in both groups respect to preoperative values through follow-up evaluations (p < 0.01), while values were significantly lower in group A than in group B 30 days after surgery (p < 0.01). CONCLUSION: Preoperative administration of topical Nepafenac reduces the inflammatory response in healthy patients undergoing uncomplicated cataract surgery one month after surgery respect to non-treated group.

OCT-Angiography as a reliable prognostic tool in laser-treated proliferative diabetic retinopathy: The RENOCTA Study.

PURPOSE: To quantitatively assess retinal neovascularizations (RNVs) in proliferative diabetic retinopathy (PDR) before and after photocoagulative laser treatment (PLT) using Optical Coherence Tomography Angiography (OCT-A). METHODS: Consecutive patients with PDR were examined with fluorescein angiography (FA) and OCT-A before and after PLT. Baseline and after-treatment FA images were quantitatively analyzed to assess both the RNVs area and leakage area. On OCT-A RNVs area, vascular perfusion density (VPD), vessel length density (VLD) and fractal dimension were computed. VPD of the full-retina OCT-A underneath the RNV was determined to evaluate potential laser-induced changes in vascular perfusion. RESULTS: Fifteen eyes of 13 patients with PDR were enrolled. The mean area of the RNVs was 0.47 ± 0.50 mm2 in the baseline OCT-A and 0.32 ± 0.40 mm2 in the post-treatment assessment (p = 0.0002). The mean RNV VPD of RNV was 2% ± 4% in pre-treatment and 1% ± 1% for the post-treatment (p = 0.0001). The mean VLD of RNV was 7.26 ± 1.53 at baseline and 6.64 ± 1.65 in the post treatment (p = 0.0002). A significant difference in terms of mean RNVs area and VPD reduction between eyes that needed additional treatment and those that did not (~40% vs ~20%; p < 0.05), was observed. Mean VPD of full-retinal thickness OCT-angiogram was 55% ± 10% for the pre-treatment and 53% ± 8% for the post treatment scan (p = 0.02). CONCLUSION: The quantitative OCT-A assessment of laser-induced changes of RNVs can be a useful non-invasive approach for determining treatment efficacy. A reduction of RNVs area or VPD ⩾ 40% might reveal those eyes that won't require additional treatment. Retinal perfusion impairment seemed to progress independently from the treatment.

Choroidal Vascular Changes in Multiple Evanescent White Dot Syndrome.

Purpose: To evaluate choroidal structural changes in patients with multiple evanescent white dot syndrome (MEWDS) during the acute and recovery stages.Methods: Enhanced-depth imaging optical coherence tomography (EDI-OCT) scans of 16 patients with unilateral MEWDS were acquired during the acute and recovery stages in both eyes. Images were binarized with the ImageJ software to measure subfoveal choroidal thickness (CT), total choroid area, luminal area and choroidal vascularity index (CVI).Results: In the acute stage, subfoveal CT, total choroidal area and CVI were significantly higher in eyes with MEWDS compared to fellow eyes (371.2 ± 101.8 vs 317.1 ± 90.3 µm, p = .001; 2.826 ± 0.686 vs 2.524 ± 0.674 mm2, p = .014; 69.49 ± 3.51 vs 68.27 ± 3.41%, p = .044, respectively). In the recovery stage, subfoveal CT, total choroidal area and CVI in eyes with MEWDS significantly decreased to respectively 333.4 ± 90.5 µm, p = .007, 2.592 ± 0.570 p = .002, and 67.31 ± 2.74%, p = .014.Conclusions: Choroidal thickness and vascularity are significantly increased during the acute stage of MEWDS.

Comparison of the Effect of Diclofenac 0.1% and Nepafenac 0.1% on Aqueous Flare in Patients Undergoing Cataract Surgery: A Prospective Randomized Study.

OBJECTIVES: To compare, using laser flare meter (LFM), the efficacy of topical nepafenac 0.1, % and diclofenac 0.1% ophthalmic solution in the control of anterior chamber inflammation after uncomplicated cataract surgery. METHODS: Patients undergoing phacoemulsification for age-related cataract were recruited. Complete evaluation with visual acuity, slit-lamp examination, endothelial cell density, intraocular pressure, retinal tomography and anterior chamber flare evaluation was performed before surgery and 1, 15, 30 and 60 days after surgery. Patients were randomly assigned to receive topical diclofenac 0.1% 4 times a day for four weeks or nepafenac 0.1% 3 times a day for three weeks in addition to topical steroids and antibiotic. RESULTS: 64 (31 males, mean age 77.3 ± 5.9) patients were enrolled. Half of them were randomly assigned to group A (diclofenac 0.1%) and half to group B (nepafenac 0.1%). There was a statistically significant visual acuity improvement postoperatively in both groups, with no statistical difference between the groups. Intraocular pressure, corneal thickness, endothelial cells count and macular thickness parameters didn't significantly vary between before and after surgery. One-day after surgery, aqueous flare was significantly higher (22,27 ± 9,25 ph/ms in group A and 22,36 ± 7,47 in group B) than before surgery (14,59 ± 7,16 ph/ms in group A and 11,84 ± 4,44 in group B) in both groups, then declining in the first month and reaching preoperative levels again by 2 months in both groups. In group B, LFM values at 15 and 30 days after surgery were significantly lower (13,59 ± 4,80 and 14,07 ± 5,01) than in group A (17,00 ± 6,97 and 16,96 ± 6,13). CONCLUSIONS: Nepafenac ensured a better inflammation control than diclofenac during the first month.

Comparison of anti-inflammatory effects of eye drops formulations after uncomplicated cataract surgery.

AIM: The aim of this study is to compare the efficacy of different dexamethasone eye drops formulations in controlling postoperative inflammation. METHODS: Cataract surgery was carried out in 72 patients (35 males) divided into two groups: group A (36 patients, mean age = 78.0 ± 5.6) received four times daily for 2 weeks a suspension containing tobramycin 0.3% mg/ml + dexamethasone 0.1% mg/ml, and group B (36 patients, mean age = 76.2 ± 6.8) a solution containing tobramycin 0.3% mg/ml + dexamethasone 0.1% mg/ml. Both groups received ofloxacin 0.5% four times daily for 7 days, and nepafenac 0.1% three times daily for 3 weeks. Best-corrected visual acuity, intraocular pressure, corneal thickness, endothelial cells count, aqueous flare and macular thickness were evaluated preoperatively and at 1 day, 15 days, 1 and 2 months. RESULTS: In group A, intraocular pressure, corneal thickness and aqueous humour flare values preoperatively and at the end of follow-up were 14.3 ± 1.8 and 13.2 ± 1.8 mmHg, 546.4 ± 34.6 and 539.6 ± 36.1 µm, 11.84 ± 4.44 and 13.52 ± 5.54 ph/ms, respectively, with no statistically significant difference. In group B, intraocular pressure, corneal thickness and aqueous humour flare values preoperatively and at the end of follow-up were 14.3 ± 1.5 and 13.1 ± 1.7 mmHg, 552.9 ± 37.4 and 548.1 ± 39.3 µm, 11.45 ± 4.06 and 13.73 ± 4.99 ph/ms, respectively, with no statistically significant difference. No difference was detected in the macular thickness values in the parafoveal area preoperatively and at 2 months follow-up in group A (332.18 ± 16.19 and 337.71 ± 16.33 µm) and group B (329.11 ± 18.28 and 334.37 ± 20.86 µm), respectively. CONCLUSION: The two different formulations of dexamethasone eye drops reached the same anti-inflammatory effects.

Functional correlation between choroidal and retinal vascularity in low-grade diabetic retinopathy.

AIMS: To perform an automated functional assessment of retinal and choroidal microvasculature in eyes with low-grade diabetic retinopathy (DR) using optical coherence tomography angiography (OCT-A) and to identify potential perfusion changes in case of early vascular damage. METHODS: This is an observational, case-control study of consecutive diabetic patients with level 20 DR severity scale score and age-matched healthy subjects. A prototypal OCT-angiography was used to obtain the OCT-angiograms of the superficial capillary plexus (SCP), deep capillary plexus (DCP) and choriocapillaris (CC) layer. A validated automated microstructural analysis provided data on SCP, DCP and CC vascular perfusion density (VPD). A comparative assessment between different vascular layers and different groups was performed. RESULTS: Twenty-nine diabetic patients (7 females, 24%) and 20 healthy controls were enrolled. VPD values were significantly lower in the DCP (25.1% vs. 26.5%; p = 0.04) and CC (71.2% vs. 86.6%; p = 0.0001) of diabetic patients compared with controls. A statistically significant negative linear correlation was reported between CC VPD and DCP VPD in diabetic patients; at the reverse, a positive linear correlation between the same parameters was noticed in controls. CONCLUSION: Retinal and choroidal vascular networks, although distinct entities, seem functionally interconnected: varying the degree of perfusion may be a mutual compensatory mechanism in response to an ischemic injury.

Intravitreal Dexamethasone Implant as a Sustained Release Drug Delivery Device for the Treatment of Ocular Diseases: A Comprehensive Review of the Literature.

Drug delivery into the vitreous chamber remains a great challenge in the pharmaceutical industry due to the complex anatomy and physiology of the eye. Intravitreal injection is the mainstream route of drug administration to the posterior segment of the eye. The purpose of this review is to assess the current literature about the widening use of the intravitreal 0.7 mg dexamethasone (Dex) implant, and to provide a comprehensive collection of all the ocular disorders that benefit from Dex administration. Although anti-vascular endothelial growth-factors (VEGFs) have been largely indicated as a first-choice level, the Dex implant represents an important treatment option, especially in selected cases, such as vitrectomized eyes or patients in whom anti-VEGF failed or are contraindicated. In this article, the safety profile as well as the list of the possible complications related to intravitreal Dex injection are also discussed.