Current concepts in vitreomacular traction syndrome.

PURPOSE OF REVIEW: As Reese first described the vitreomacular traction (VMT) syndrome in 1970, the knowledge base about the disease has been changing over time due to the advent of the high-definition optical coherence tomography (HD-OCT). The aim of this article was to present the current information on the pathophysiology, anatomic macular abnormality associations, treatments, and new concepts in VMT syndrome. RECENT FINDINGS: HD-OCT has provided unprecedented visualization of the vitreomacular interface, which has led to better comprehension of the VMT syndrome. The technologic advances also emphasized the need to review the basis of the VMT syndrome and define as yet unsettled and often confusing concepts. SUMMARY: The recognition of the role of VMT in a variety of macular conditions is imperative for proper diagnosis and appropriate management of these diseases.

REVERSIBLE BILATERAL SUBFOVEAL ELLIPSOID ZONE FOCAL THICKENING ASSOCIATED WITH OVERDOSE OF PHOSPHODIESTERASE TYPE 5 INHIBITORS INTAKE.

PURPOSE: To describe the clinical findings and outcome of an unusual case of subfoveal yellowish deposits associated with excessive doses of phosphodiesterase Type 5 inhibitors intake. METHODS: Single retrospective case report. RESULTS: A 50-year-old South American man with a personal history of multiple orally administered phosphodiesterase Type 5 inhibitors drugs to treat a chronic erectile dysfunction complained of dyschromatopsia, photophobia, and a 3-month history of blurred vision. The fundus examination revealed a symmetrical yellowish lesion in both eyes with a subfoveal hyperreflective signal on the spectral domain optical coherence tomography at the level of the ellipsoid zone. Dysregulation of the blue-yellow axis was noticed in the color vision test and the electroretinogram demonstrated a tiny decrease in the b-wave amplitude. The use of phosphodiesterase Type 5 inhibitors was discontinued and the patient was examined 3 months later. Optical coherence tomography revealed complete disappearance of the deposit in both eyes and the associated symptoms resolved rapidly with discontinuation of the drug. CONCLUSION: A bilateral ellipsoid zone subfoveal focal thickening may be related to a yellowish symmetrical spot on the fovea in patients with a history of phosphodiesterase Type 5 inhibitors overdose intake. Functional and structural findings are reversible in a short-term period after discontinuing the oral treatment.

Globe penetration during loco-regional anesthesia: prevalence and review of cases.

AIM: To describe prevalence and different clinical signs and management of cases with penetrating eye injuries during loco-regional anesthesia for ophthalmic surgery. METHODS: A retrospective review of clinical records was carried out, identifying cases of globe penetration secondary to peribulbar anesthesia injection during 5y activity in Centro de Oftalmología Barraquer. RESULTS: A total of 17 460 needle-based ocular anesthesia procedures were performed in our centre and 4 cases of globe penetration were recorded with an estimated prevalence of 0.024%. Globe penetrations were always detected in the first 24h after surgery. Vitreous haemorrhage was found in all the cases. Two eyes presented retinal detachment and two eyes choroidal detachment (CD). The initial surgical approach was performed within the first 48h. Silicone oil was used as tamponade in three eyes and the fourth case remained only with air. Detachments were solved successfully in all the cases. Functional results varied among cases, depending on ocular remarkable antecedent and globe penetration with or without retinal or CD. CONCLUSION: Prevalence of globe penetration during loco-regional anesthesia is low in our centre. Physicians should consider the possibility of globe penetration in eyes with postoperative atypical appearance after loco-regional anesthesia. Immediate B-scan ultrasonography is recommended in suspicious cases with a dense vitreous haemorrhage. An early vitrectomy surgery in conjunction with laser or cryotherapy at the penetration sites is essential for good anatomical and functional results.

[Isolated conjunctival sebaceous adenoma associated with acute endophtalmitis]. / Adenoma sebáceo conjuntival aislado asociado a endoftalmitis aguda.

Sebaceous adenoma of the conjunctiva is a very rare lesion of uncertain origin. It is usually associated with Muir-Torre syndrome in which neoplasms are also found in other parts of the body. We present the case of a 71-year-old man without a previous or family history of neoplasia, who presented with severe inflammation and an infection in his right eye associated with a tumor of the conjunctiva near the caruncle. The lesion was excised and histopathology revealed a sebaceous adenoma. Microsatellite instability was not observed immunohistochemically. He remains alive and well.

Diabetic Retinopathy Is Associated with Decreased Tyrosine Nitrosylation of Vitreous Interleukins IL-1α, IL-1ß, and IL-7.

OBJECTIVE: To simultaneously evaluate tyrosine nitrosylation and phosphorylation levels of vitreous interleukins of patients with diabetic retinopathy, in which abnormal tyrosine phosphorylation has been previously described. RESEARCH DESIGN AND METHODS: Specific immunoprecipitation of interleukins IL-1α, IL-1ß, IL-2 and IL-7 was carried out in samples obtained during vitrectomy performed for proliferative diabetic retinopathy in patients (n=12) and for macular hole in controls (n=12). Tyrosine nitrosylation and phosphorylation levels of the immunoprecipitated interleukins were analysed by Western blot with the respective specific antibodies and correlated. The results were also correlated with the total amount of immunoprecipitated interleukin protein. The mean phosphorylation/nitrosylation ratios of these proteins in vitreous humour of both the control group and diabetic patients were determined. RESULTS: Diabetes was associated with decreased tyrosine nitrosylation of IL-1α, IL-1ß and IL-7 and an increased tyrosine phosphorylation/nitrosylation ratio with respect to controls in IL-1α (1.58±0.22 vs. 2.74±0.39, respectively; p<0.05) and IL-7 (2.15±0.01 vs. 3.26±0.57, respectively; p<0.05). No significant changes were observed in nitrotyrosine or in the tyrosine phosphorylation/nitrosylation ratio of IL-2. CONCLUSIONS: Proliferative diabetic retinopathy is associated with concomitant and simultaneous changes in both tyrosine phosphorylation and tyrosine nitrosylation status of specific pro-inflammatory interleukins present in the vitreous fluid such as IL-1α, IL-1ß and IL-7. These changes could be related to the increase in pro-inflammatory activity detected in diabetes-induced retinopathy.

Takayasu's retinopathy.

We report the case of a 63-year-old woman with Takayasu's arteritis who experienced progressive visual loss in her right eye (RE) over several months. Visual acuity was 0.4 in the RE, which showed marked retinal arteriovenous dilation and highly irregular arteriolar calibre. She had no light perception in the left eye, which showed diffuse atrophy of the retinal pigment epithelium and prepapillary fibrovascular proliferation. Fluorescein angiography revealed delayed and slow retinal and choroidal circulation and areas of peripheral ischemia. A diagnosis of Takayasu's retinopathy was made and the non-perfused areas were treated with laser photocoagulation. Takayasu's disease can result in chronic ocular ischemia. Angiographic examination is particularly important in this context and may provide additional findings which affect staging and treatment of the disease. The role of the ophthalmologist includes laser photocoagulation, monitoring for complications and timely referral for vascular surgery.

A strong genetic association between the tumor necrosis factor locus and proliferative vitreoretinopathy: the retina 4 project.

OBJECTIVE: To assess the genetic contribution to proliferative vitreoretinopathy (PVR) and report the strong association observed in the tumor necrosis factor (TNF) locus. DESIGN: As a component of The Retina 4 Project, a case-controlled, candidate gene association study in the TNF locus was conducted. PARTICIPANTS AND CONTROLS: Blood from 450 patients with (138 cases) and without (312 controls) post-rhegmatogenous retinal detachment (RD) PVR was genotyped to determine polymorphisms located in the TNFα gene. METHODS: Single nucleotide polymorphisms (SNPs) with correlation coefficients of ≥ 0.8 and a minor allelic frequency of ≥ 10% were studied. Functional SNPs or SNPs previously described in association with other inflammatory diseases were also added for analysis. The SNPlex Genotyping System (Applied Biosystems, Foster City, CA) was used for genotyping. Single nucleotide polymorphism and haplotype analyses were performed. Bioinformatic tools were used to evaluate those SNPs that were significantly associated. MAIN OUTCOME MEASURES: Single and haplotypic significant associations with PVR. RESULTS: A total of 11 common tag SNPs in the following genes were analyzed: lymphotoxin alpha (LTA), TNFα, leukocyte-specific transcript 1 (LST1), and the activating natural killer receptor p30 (NCR3). After permutation, there was a significant association in the non-synonymous polymorphism rs2229094(T→C) in the LTA gene (P = 0.0283), which encodes a cysteine to arginine change in the signal peptide. This marker was also present in all significant haplotypic associations and was not observed in any nonsignificant associations. When this SNP was analyzed using bioinformatic tools, the hydropathy profile changed, as well as the transmembrane region and the splicing site predictions. CONCLUSIONS: The strong association found in the rs2229094(T→C) of the LTA gene may indicate an important role of this polymorphism in the development of PVR. If supported in extended studies, the rs2229094(T→C) may have significant implications regarding the genetic risk of the retinal repairing process.

Prospective clinical trial evaluating the efficacy of photodynamic therapy for symptomatic circumscribed choroidal hemangioma.

PURPOSE: To evaluate photodynamic therapy (PDT) for symptomatic circumscribed choroidal hemangioma (CCH). DESIGN: Prospective, multicenter, nonrandomized clinical trial. PARTICIPANTS: Thirty-one eyes of 31 patients with posterior pole CCH and symptoms caused by exudation into the macular area. INTERVENTION: Photodynamic therapy was applied by Zeiss laser. Intravenous verteporfin at 6 mg/m(2) body surface was administered before treatment, and light emitted at 689 nm for photosensitization. The treatment spot diameter was calculated on early-phase frames of pretreatment indocyanine green angiography. Fifteen minutes after starting the verteporfin infusion, the laser beam was applied to the retina at radiant exposure 50 J/cm(2) and exposure time 83 seconds. One to 4 treatments were applied at 12-week intervals over 1 year. Standardized evaluation was performed before and at 4-week intervals after each treatment, and at 3, 6, 9, and 12 months. All patients were followed for >or=12 months. MAIN OUTCOME MEASURES: The primary outcome measure was the absence of exudative retinal detachment at the 12-month follow-up visit on ophthalmoscopy, fluorescein angiography, and optical coherence tomography. Secondary measures were the visual acuity outcome, with best-corrected visual acuity determined by the Early Treatment for Diabetic Retinopathy Study chart, tumor thickness decrease on B-scan ultrasonography, and adverse events. RESULTS: Among the total, 82.8% of patients required 1, 13.8% 2, and 3.4% 3 PDTs to eliminate exudative retinal detachment. Visual acuity increased from a mean of 20/60 to 20/35 (P<0.001). Sixty-nine percent of patients demonstrated visual recovery (P<0.001). Cystoid macular edema regressed in all cases and exudative macular detachment disappeared in all but 2 cases. The CCH thickness decreased in all cases from a mean of 3.0 to 1.7 mm, with the most intense effect seen after 4 weeks of treatment (P<0.001). Visual fields showed resolution of central scotomas. There were no severe adverse events. CONCLUSIONS: Combining PDT with the standard age-related macular degeneration protocol is an effective treatment for CCH in terms of resolution of exudative subretinal fluid and recovery of VA. FINANCIAL DISCLOSURE(S): The authors have no proprietary or commercial interest in any materials discussed in this article.

A spatial analysis to evaluate the impact of deregulation policies in the pharmacy sector: Evidence from the case of Navarre.

Community pharmacies represent unusual enterprises as their main function is intrinsically related to the provision of healthcare services. Hence, market competition in this sector needs to be regulated, in order to ensure equitable accessibility, efficiency and quality of services. However, recently a general deregulation trend may be observed in Europe. In this paper, we focus on location restrictions, i.e. on demographic and geographic constraints to open new pharmacies, and we evaluate the impact of their relaxation. In particular, we analyze the case of the city of Pamplona (ES), where a striking increase in the number of pharmacies occurred, after the introduction of a new regulatory system in 2000. We evaluate, thanks to an in-depth spatial analysis, the evolution of the system to date and the effects produced on the consumers, in terms of accessibility, and on the competitors, in terms of market shares distribution. By comparing the obtained results with the ones related to the case of a second Spanish city, characterized by more strict restrictions, it emerges that the deregulation risks to produce a limited improvement in terms of accessibility and to exacerbate differences among consumers. Moreover, an increasing number of competitors does not necessarily imply a more equitable distribution of market shares, thus putting at risk the desired effects in terms of cost reduction and service quality improvement.

Clinical and OCT Findings in a Case of a Presumed Perfluorooctane Retinal Acute Toxicity.

Retinal acute toxicity may be produced by several etiologies. Iatrogenic toxicity is one of the most-feared complications related to vitreoretinal surgery. The authors report a case of retinal acute toxicity due to the use of perfluorooctane during an uneventful retinal detachment surgery done elsewhere. The aim of this report is to describe the clinical and optical coherence tomography features of this complication, which unfortunately occurred in more than 100 cases in Spain. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:460-462.].

Therapeutic efficacy of the live-attenuated Mycobacterium tuberculosis vaccine, MTBVAC, in a preclinical model of bladder cancer.

Intravesical instillation of bacillus Calmette-Guérin (BCG) has been a first-line therapy for non-muscle-invasive bladder cancer for the last 4 decades. However, this treatment causes serious adverse events in a significant number of patients and a substantial percentage of recurrence episodes. MTBVAC is a live-attenuated vaccine derived from a Mycobacterium tuberculosis clinical isolate and is currently under evaluation in clinical trials to replace BCG as a tuberculosis vaccine. Here, we describe for the first time the potential of MTBVAC as a bladder cancer therapy in vitro and in vivo in a preclinical model. MTBVAC colonized human bladder tumor cells to a much greater extent than BCG via a mechanism mediated by macropinocytosis and induced cell growth inhibition after internalization. In vivo testing in an orthotopic murine model of bladder cancer demonstrated a higher antitumor effect of MTBVAC in experimental conditions in which BCG did not work. Our data encourage further studies to support the possible application of MTBVAC as a new immunotherapeutic agent for bladder cancer.

Stereotactic radiotherapy for ocular melanoma: initial experience using closed eyes for ocular target immobilization.

To assess the reliability and target positioning reproducibility with eyes closed in uveal melanoma patients treated with a micromultileaf-based linear accelerator dedicated for stereotactic radiotherapy. Five consecutive patients treated with curative radiotherapy for uveal melanoma were monitored for positioning reproducibility with resimulation CT scans performed every two days while on treatment (23 resimulation CTs available). All patients underwent MRIs of the orbits before simulation to help to define the target and organs at risk (e.g., lenses, optic nerves, ciliary bodies, and lacrimal glands) in the simulation CT (MRI-to-CT bone registration). Patients were simulated, resimulated, and treated with eyes closed. Patient #1 was treated with 5 daily fractions while patients #2 to #5, were treated with 10 daily fractions. We chose the lens of the tumor-bearing eye as the structure to be controlled, assuming that correct repositioning of the lens should be a valid surrogate for correctness of target repositioning. Displacements (mean and standard deviations, SD) of the lens in the three axes were measured for each patient. Systematic and standard errors were calculated. Planning target volume (PTV) margins were estimated according to McKenzie et al. [Phys Med Biol 45, 3331-3342 (2000)]. For both AP-PA and left-right shifts calculated SD were always below 1 mm, except for patient #4, who was treated with a non-customized bolus that pushed the globe backwards in a random fashion. In ideal set-up conditions PTV margins around the target were estimated to be 3 mm. Asking patients to close their eyes is a simple and reliable immobilization procedure when treating ocular tumors with stereotactic radiotherapy. Margins of 3 mm around the target may be necessary to safely treat these tumors under ideal set-up conditions.

Adenoma sebáceo conjuntival aislado asociado a endoftalmitis aguda / Isolated conjunctival sebaceous adenoma associated with acute endophtalmitis

El adenoma sebáceo de la conjuntiva es una lesión muy rara y de un origen incierto. Habitualmente se asocia al síndrome de Muir-Torre en el que además hay neoplasias en otras partes del organismo. Presentamos el caso de un varón de 71 años sin afectación neoplásica ni antecedentes familiares, con un cuadro inflamatorio e infeccioso severo en el ojo derecho asociado a una tumoración a nivel conjuntival próximo a la carúncula. La lesión se extirpó y el estudio anatomopatológico reveló un adenoma sebáceo. No se observó inmunohistoquímicamente inestabilidad de microsatélites. La evolución fue satisfactoria.(AU)

Sebaceous adenoma of the conjunctiva is a very rare lesion of uncertain origin. It is usually associated with Muir-Torre syndrome in which neoplasms are also found in other parts of the body. We present the case of a 71-year-old man without a previous or family history of neoplasia, who presented with severe inflammation and an infection in his right eye associated with a tumor of the conjunctiva near the caruncle. The lesion was excised and histopathology revealed a sebaceous adenoma. Microsatellite instability was not observed immunohistochemically. He remains alive and well.(AU)

Progression of Cutaneous Vitiligo in a Patient with Large Posterior Choroidal Melanoma: A Case Report.

BACKGROUND/AIMS: The aim of our study was to report a case of progression of cutaneous vitiligo after large posterior choroidal melanoma diagnosis. METHODS: The clinical history, fundus findings and histopathological features suggest the diagnosis of cutaneous vitiligous progression after a diagnosis of large posterior choroidal melanoma. RESULTS: A 30-year-old female, with a personal history of cutaneous vitiligo for 12 years, was diagnosed with choroidal melanoma 18 months previously. The cutaneous vitiligo had progressed over her back, body and arms during the preceding 3 years. She refused treatment because she was in her 28th week of pregnancy. When she came to our clinic her visual symptoms had worsened, and the fundus examination showed a melanocytic choroidal mass. After confirming that there was no extraocular extension, she was treated with enucleation. A histopathological study confirmed the choroidal melanoma diagnosis. CONCLUSION: The association between the progression of vitiligo and the diagnosis of uveal melanoma could be considered a good prognostic factor, as has been described in cases of cutaneous melanoma. A longer follow-up of these patients will allow us to confirm this association.

Vitreomacular traction syndrome: postoperative functional and anatomic outcomes.

BACKGROUND AND OBJECTIVE: To analyze a variety of vitreomacular traction (VMT) morphologies to establish a major classification that better reflects the preoperative predictive factors of postoperative visual and anatomic outcomes. PATIENTS AND METHODS: Thirty-six eyes submitted to vitrectomy surgery were categorized with a VMT pattern (V- or J-shaped) and diameter (focal < 1,500 µm or broad > 1,500 µm) based on optical coherence tomography. RESULTS: The researchers compared different classifications of VMT. Despite similar postoperative best corrected visual acuity (BCVA) values (P = .393), cases with focal VMT had greater visual improvement (P = .027) because the preoperative BCVA was significantly lower in the focal group (P = .007). However, the BCVA improvements did not differ between the groups regarding the classic VMT morphologic patterns (P = .235). CONCLUSION: Postoperative outcomes and macular disorders are closely related to VMT size. The adhesion diameter (focal or broad VMT) and not the classic VMT morphologic pattern (V- or J-shaped) may better predict the postoperative anatomic and functional outcomes.

Traumatic endophthalmitis caused by Nocardia kruczakiae in a patient with traumatic eye injury.

BACKGROUND: We describe a case of traumatic ocular endophthalmitis caused by Nocardia kruczakiae after vegetable trauma in an immunocompetent child. FINDINGS: A 5-year-old boy suffered from a trauma with a palm tree leaflet. Two months later, he was diagnosed with traumatic infectious uveitis and intumescent cataract with anterior capsule rupture. Intensive treatment with systemic and topical vancomycin, ceftazidime and methylprednisolone began. After 1 month, he underwent phacoemulsification with intraocular lens implantation (IOL). After some episodes of reactivation, he was diagnosed with traumatic nocardial endophthalmitis from aqueous humour samples. Several operations and specific antibiotic therapy resolved the infection. CONCLUSIONS: In cases of traumatic endophthalmitis and several recurrences, it is extremely useful to make an etiologic diagnosis in order to treat the patient with specific antibiotics.

Photodynamic therapy in the management of circumscribed choroidal hemangioma.

OBJECTIVE: To evaluate the efficacy of photodynamic therapy (PDT) for symptomatic circumscribed choroidal hemangioma (CCH). DESIGN: A retrospective case series analysis through chart review of patients with CCH treated by means of PDT. PARTICIPANTS: Thirteen patients with circumscribed choroidal hemangioma. METHODS: Through retrospective charts review, the patients' demographics, clinical features, management, and follow-up data were obtained and analyzed. Outcome measures were change in visual acuity, required sessions, and adjunctive treatments. RESULTS: Median follow-up was 26 months. Seven patients (54%) underwent only 1 session, 5 patients (38%) 2 sessions, and 1 received 5 sessions and was finally treated with external beam radiotherapy (EBRT). Visual acuity improved by at least 1 line (1-5) in 11 patients and remained stable in 2. Exudative subretinal fluid was completely resolved in 92% of the cases at the last visit. No major local side effects were found. CONCLUSIONS: PDT of CCH can effectively induce tumor regression and resolution of exudative subretinal fluid, improving, or stabilizing vision.

Heavy silicone oil (densiron) and supine position in the management of massive suprachoroidal hemorrhage: use of heavy silicone for suprachoroidal hemorrhage.

PURPOSE: To describe a case of massive suprachoroidal hemorrhage after a phacoemulsification managed with pars plana vitrectomy, heavy silicone oil (Densiron), and supine position. METHODS: Report of a 69-year-old woman with systemic hypertension and under antiplatelet treatment who developed a massive suprachoroidal hemorrhage. RESULTS: The patient underwent a pars plana vitrectomy and heavy oil endotamponade combined with 3 radial sclerotomies to drain the suprachoroidal blood. Two months after this surgery, the retina remains attached and visual acuity is 3/60 with aphakia and half of the vitreous cavity filled with Densiron. CONCLUSION: Pars plana vitrectomy and Densiron endotamponade with supine position can represent a good surgical option in such a dramatic case as a suprachoroidal hemorrhage. Long-term heavy silicone oil endotamponade cannot be advised in these cases.

Vitreomacular traction syndrome.

The advent of new technologies such as high definition optical coherence tomography (OCT) has not only provided unprecedented imaging capabilities, but also raised the need to define concepts not yet settled and often confusing such as the vitreomacular traction (VMT) syndrome. While technological advances drive us into the future by clarifying the pathophysiology of many diseases and enabling novel therapeutic options, it is at the same time necessary to review basic disease concepts in addition to definitions and classifications. VMT syndrome is implicated in the pathophysiology of a number of macular disorders, translating into a variety of anatomical and functional consequences underscoring the complexity of the condition. These macular changes are closely related to the VMT configuration and have led to proposing classification of this syndrome based on OCT findings. The size and severity of the remaining vitreomacular attachment may define the specific maculopathy. Focal VMT usually leads to macular hole formation, tractional cystoid macular edema and foveal retinal detachment, while broad VMT is associated with epiretinal membranes, diffuse retinal thickening and impaired foveal depression recovery. Despite similar postoperative visual acuity (VA) in focal and broad VMT subgroups, visual improvement is greater with focal VMT because preoperative VA is frequently lower. Surgical procedures are effective to relieve VMT and improve VA in most eyes; outcomes vary with VMT morphology and the duration of symptoms.

A propensity score matching application: indications and results of adding scleral buckle to vitrectomy: The Retina 1 Project: Report 3.

PURPOSE: To identify the indications and differences in outcomes for adding a scleral buckle (SB) to pars plana vitrectomy (PPV) in a prospective series of rhegmatogenous retinal detachment (RD) by using propensity score matching (PSM) to analyze causal effects in observational studies. METHODS: Data were collected from the Retina 1 Project, a prospective, interventional, nonrandomized study of consecutive RDs. Case selection was based upon treatment with PPV or PPV+SB. Surgeons followed personal criteria for the inclusion of SB in the PPV. Propensity score matching corrected for selection biases. Outcomes were assessed by anatomic and visual criteria and the development of proliferative vitreoretinopathy. RESULTS: Of 523 patients analyzed, 251 had PPV and 272 had PPV+SB. Surgeons used PPV+SB more frequently in younger patients with RD, in those with posterior or unidentified breaks, in phakic eyes, in eyes with the posterior vitreous attached, and for more extended RDs. Overall single surgery anatomic success rate was 86.4%. Based on PSM, there were no difference in reattachment rates of the PPV group, 86.9%, and the PPV+SB group, 85.93%. The incidence of PVR was similar in both groups, with 8.5% in the PPV group and 10.5% in the PPV+SB group. CONCLUSIONS: Data from the Retina 1 Project established the indications for adding SB to PPV in treating primary RD in this series. No anatomic or visual differences between PPV and PPV+SB were found.