Bevacizumab versus triamcinolone for persistent diabetic macular edema: a randomized clinical trial.

PURPOSE: To evaluate 24-week visual acuity and anatomic outcomes of two "pro re nata" (prn) treatment strategies (intravitreal bevacizumab [IVB] prn versus intravitreal triamcinolone acetonide [IVT] prn) in patients with persistent diabetic macular edema (pDME) after 24 weeks of prn-IVB. METHODS: One hundred eyes with center-involving DME were enrolled and treated with prn-IVB for 24 weeks; at week 24, eyes with pDME (central subfield thickness [CST] on spectral domain optical coherence tomography > 300 µm) were randomized to IVB monthly prn (group I; prn-IVB) or IVT every 3 months prn (group II; prn-IVT) and eyes in which the CST was ≤ 300 µm were assigned to continue prn-IVB (group III). RESULTS: Seventy-four eyes completed a 48-week study period. At week 24, 65 (79.3%) eyes still had DME with CST > 300 µm and, therefore, were randomized to prn-IVB (group I, n = 33) or prn-IVT (group II, n = 32); the remaining 17 (20.7%) eyes had CST ≤ 300 µm and were assigned to continued treatment with prn-IVB (group III). At baseline, mean CST (µm) ± standard error of the mean (SEM) was 447.2 ± 24.4, 478.0 ± 19.7, and 386.0 ± 21.0 in groups I, II, and III, respectively (p > 0.05). At week 48, there was no significant difference in mean CST between groups I and II (369.9 ± 23.3 and 426.0 ± 26.1, respectively; p = 0.9995). A significant reduction in mean CST, compared with baseline, was noted at weeks 28 (p = 0.0002) and 44 (p = 0.0002) in group II. Group I did not show a significant reduction in mean CST compared with baseline at any study visit. There were no significant differences in mean CST between groups I and II at any study visit. At baseline, mean ± SEM best-corrected visual acuity (BCVA) (logMAR) was 0.50 ± 0.00, 0.60 ± 0.10, and 0.50 ± 0.10 in groups I, II, and III, respectively (p > 0.05). At week 48, there was no statistically significant difference in mean BCVA between groups I and II (0.50 ± 0.10 and 0.80 ± 0.10, respectively; p = 0.4473). There was no significant improvement in mean BCVA, as compared with baseline, at any study follow-up visit in any of the groups. Group II demonstrated significantly lower BCVA after 24 weeks of IVT (at week 48) compared with baseline (p = 0.0435). There was no significant difference in mean BCVA between groups I and II at any time-point. CONCLUSION: In eyes with pDME after 24 weeks of treatment with prn-IVB, there was no difference between continued treatment with prn-IVB versus a treatment switch to prn-IVT with respect to mean BCVA or mean CST at week 48. However, BCVA was stable in the prn-IVB group, while prn-IVT was associated with BCVA reduction from baseline and a higher risk of IOP elevation.

Corneal absorption of a new riboflavin-nanostructured system for transepithelial collagen cross-linking.

Corneal collagen cross-linking (CXL) has been described as a promising therapy for keratoconus. According to standard CXL protocol, epithelium should be debrided before treatment to allow penetration of riboflavin into the corneal stroma. However, removal of the epithelium can increase procedure risks. In this study we aim to evaluate stromal penetration of a biocompatible riboflavin-based nanoemulsion system (riboflavin-5-phosphate and riboflavin-base) in rabbit corneas with intact epithelium. Two riboflavin nanoemulsions were developed. Transmittance and absorption coefficient were measured on corneas with intact epithelia after 30, 60, 120, 180, and 240 minutes following exposure to either the nanoemulsions or standard 0.1% or 1% riboflavin-dextran solutions. For the nanoemulsions, the epithelium was removed after measurements to assure that the riboflavin had passed through the hydrophobic epithelium and retained within the stroma. Results were compared to de-epithelialized corneas exposed to 0.1% riboflavin solution and to the same riboflavin nanoemulsions for 30 minutes (standard protocol). Mean transmittance and absorption measured in epithelialized corneas receiving the standard 0.1% riboflavin solution did not reach the levels found on the debrided corneas using the standard technique. Neither increasing the time of exposure nor the concentration of the riboflavin solution from 0.1% to 1% improved riboflavin penetration through the epithelium. When using riboflavin-5-phosphate nanoemulsion for 240 minutes, we found no difference between the mean absorption coefficients to the standard cross-linking protocol (p = 0.54). Riboflavin nanoemulsion was able to penetrate the corneal epithelium, achieving, after 240 minutes, greater stromal concentration when compared to debrided corneas with the standard protocol (p = 0.002). The riboflavin-5-phosphate nanoemulsion diffused better into the stroma than the riboflavin-base nanoemulsion.

Restoration of retinal morphology and residual scarring after photocoagulation.

PURPOSE: To study healing of retinal laser lesions in patients undergoing PRP using SD-OCT. METHODS: Moderate, light and barely visible retinal burns were produced in patients with proliferative diabetic retinopathy scheduled for PRP using 100-, 20- and 10-ms pulses of 532-nm laser, with retinal spot sizes of 100, 200 and 400 µm. Lesions were measured with OCT at 1 hr, 1 week, 1, 2, 4, 6, 9 and 12 months. OCT imaging was correlated with histology in a separate study in rabbits. RESULTS: Lesions produced by the standard 100-ms exposures exhibited steady scarring, with the damage zone stabilized after 2 months. For 400- and 200-µm spots and 100-ms pulses, the residual scar area at 12 months was approximately 50% of the initial lesion size for moderate, light and barely visible burns. In contrast, lesions produced by shorter exposures demonstrated enhanced restoration of the photoreceptor layer, especially in smaller burns. With 20-ms pulses, the damage zone decreased to 32%, 24% and 20% for moderate, light and barely visible burns of 400 µm, respectively, and down to 12% for barely visible burns of 200 µm. In the 100-µm spots, the residual scar area of the moderate 100-ms burns was 41% of the initial lesion, while barely visible 10-ms burns contracted to 6% of the initial size. Histological observations in rabbits were useful for proper interpretation of the damage zone boundaries in OCT. CONCLUSIONS: Traditional photocoagulation parameters (400 µm, 100 ms and moderate burn) result in a stable scar similar in size to the beam diameter. Restoration of the damaged photoreceptor layer in lighter lesions produced by shorter pulses should allow reducing the common side-effects of photocoagulation such as scotomata and scarring.

Spectral-domain optical coherence tomography in patients with commotio retinae.

PURPOSE: To describe the morphologic characteristics of commotio retinae using spectral-domain optical coherence tomography and to evaluate its utility in prognosis and follow-up. METHODS: Consecutive patients with commotio retinae underwent complete ophthalmic examination, color fundus photography, spectral-domain optical coherence tomography, fundus autofluorescence, and near-infrared autofluorescence. RESULTS: There were 11 eyes of 11 patients (8 men), with a mean age of 30.8 ± 12.1 years. The follow-up ranged from 9 days to 6 months. Spectral-domain optical coherence tomography identified hyperreflectivity underneath the inner/outer segment junction in the area of commotio retinae in 9 patients (81.1%), which subsided in a few days. Five patients (45.5%) revealed areas of disruption of the inner/outer segment junction and hyperreflectivity of the overlying retina, which progressed to external retinal atrophy and visual loss (P = 0.002). The 5 patients with visual sequelae revealed pigment disorders and alterations in fundus autofluorescence and near-infrared autofluorescence during follow-up, and 3 patients (60%) presented with intraretinal hemorrhages. CONCLUSION: Spectral-domain optical coherence tomography of mild lesions with good visual outcome showed transient hyperreflectivity of the outer retina. The cases with severe trauma were related to acute disruption of the inner/outer segment junction and hyperreflectivity of the overlying retina and were regularly associated with retinal atrophy, pigment disturbance, and poor visual prognosis.

Fundus Autofluorescence and Spectral Domain OCT in Central Serous Chorioretinopathy.

Background. To describe the standard autofluorescence (FAF), the near infrared autofluorescence (NIA) and optical coherence tomography (OCT) patterns in central serous chorioretinopathy, correlating them with fluorescein angiography. Methods. Cross-sectional observational study, in which patients with at least seven months of CSC underwent ophthalmologic examination, fundus photography, FAF, NIA, fluorescein angiography (FA), and spectral-domain OCT. Results. Seventeen eyes of thirteen patients were included. The presentation features were a mottled hyperFAF in the detached area and areas with pigment mottling. NIA images showed areas of hyperNIA similar to FAF and localized areas of hypoNIA, which correlated with the points of leakage in the FA. OCT showed pigment epithelium detachment at the location of these hypoNIA spots. Discussion. FAF showed increased presence of fluorophores in the area of retinal detachment, which is believed to appear secondary to lipofuscin accumulation in the RPE or the presence of debris in the subretinal fluid. NIA has been related to the choroidal melanin content and there were areas of both increased and decreased NIA, which could be explained by damage ahead the retina, basically RPE and choroid. These findings, along with the PEDs found in the areas of hypoNIA, support the notion of a primary choroidal disease in CSC.

Endophthalmitis after pars plana vitrectomy: results of the Pan American Collaborative Retina Study Group.

PURPOSE: To determine the incidence of endophthalmitis after 20-, 23-, and 25-gauge pars plana vitrectomies (PPVs). METHODS: Retrospective comparative case series of consecutive patients who underwent 20-, 23-, or 25-gauge PPV at 11 centers from Latin America between 2005 to 2009. Pars plana vitrectomy cases were identified through a search of the billing records of each institution. Cases of PPV performed in the management of trauma, endophthalmitis, and combined PPV phacoemulsification cases were excluded. Endophthalmitis was diagnosed by clinical criteria regardless of the microbiologic results. The incidence of post-PPV endophthalmitis was compared between 20-, 23-, and 25-gauge PPVs. RESULTS: A total of 35,427 cases of PPV were identified during the study period (n = 19,865 for 20 gauge, n = 10,845 for 23 gauge, and n = 4,717 for 25 gauge). The 5-year post-PPV endophthalmitis incidence rates were 0.020% (4 of 19,865), 0.028% (3 of 10,845), and 0.021% (1 of 4,717) for 20 gauge, 23 gauge, and 25 gauge, respectively (P = 0.9685). CONCLUSION: Small-gauge transconjunctival PPV does not appear to increase the rates of post-PPV endophthalmitis.

Randomized clinical trial evaluating mETDRS versus normal or high-density micropulse photocoagulation for diabetic macular edema.

PURPOSE: To compare modified Early Treatment Diabetic Retinopathy Study (mETDRS) focal/grid laser photocoagulation with normal-density (ND-SDM) or high-density (HD-SDM) subthreshold diode-laser micropulse photocoagulation for the treatment diabetic macular edema (DME). METHODS: A prospective, randomized, controlled, double-masked clinical trial with patients with previously untreated DME and best corrected visual acuity (BCVA) worse than 20/40 and better than 20/400. Patients were randomized to receive either mETDRS focal/grid photocoagulation (42 patients), ND-SDM (39 patients), or HD-SDM (42 patients). Before treatment and 1, 3, 6, and 12 months after treatment, all patients underwent ophthalmic examinations, BCVA, color fundus photography, fluorescein angiography, and optical coherence tomography (OCT). RESULTS: At 12 months, the HD-SDM group had the best improvement in BCVA (0.25 logMAR), followed by the mETDRS group (0.08 logMAR), whereas no improvements were seen in the ND-SDM group (0.03 logMAR). All groups showed statistically significant progressive reduction of central macular thickness (CMT) throughout the study (P < 0.001). The HD-SDM group exhibited the greatest CMT reduction (154 µm), which was not significantly different from that of the mETDRS group (126 µm; P = 0.75). CONCLUSIONS: At 1 year, the clinical performance of HD-SDM was superior to that of the mETDRS photocoagulation technique, according to the anatomic and functional measures of improvement used in this investigation. A rationale for this treatment modality as a preferable approach is suggested, and the precise role of subthreshold micropulse laser treatment may become more defined as experience grows, guided by optimized treatment guidelines and more comprehensive trials. (Clinicaltrials.gov number, NCT00552435.).

Fundus autofluorescence in patients with blunt ocular trauma.

PURPOSE: To report fundus autofluorescence and optical coherence tomography (OCT) findings in patients with blunt ocular trauma. METHODS: Six eyes of six consecutive patients with blunt ocular trauma were evaluated in an observational case series using colour fundus photography, the Heidelberg Retina Angiograph 2 (HRA2) system for fundus autofluorescence (FAF) and OCT (Stratus OCT). RESULTS: Three patients presented with secondary retinal pigment epitheliopathy that was identified as a reduced FAF plaque with interposed increased FAF granular smaller lesions. These findings were not as evident in fundus examination and colour photography in two patients. Visual field in one patient showed a decreased area of sensitivity that correlated to the reduced/increased autofluorescent lesion. The other three patients had subretinal haemorrhage and choroidal rupture, which appeared with a reduced FAF with an increased FAF rim after resolution. OCT demonstrated a choriocapillaris/ retinal pigment epithelium (RPE) complex disruption and its resolution over time in all patients with choroidal rupture. CONCLUSION: Damaged RPE area was more evident and better delineated by FAF imaging compared with fundus examination and fundus photography alone. Autofluorescence imaging might be a useful exam to show the length and severity of post-traumatic retinal lesions and it may add relevant information in the global evaluation of blunt ocular trauma complications. Moreover, OCT added valuable information to the diagnosis and progression of choroidal rupture. Further studies to determine the predictive value of FAF in ocular blunt trauma are warranted.

Controlled transscleral drug delivery formulations to the eye: establishing new concepts and paradigms in ocular anti-inflammatory therapeutics and antibacterial prophylaxis.

IMPORTANCE OF THE FIELD: The use of topical agents poses unique and challenging hurdles for drug delivery. Topical steroids effectively control ocular inflammation, but are associated with the well-recognized dilemma of patient compliance. Although administration of topical antimicrobials as prophylaxis is acceptable among ophthalmologists, this common practice has no sound evidence base. Developing a new antimicrobial agent or delivery strategy with enhanced penetration by considering the anatomical and physiological constraints exerted by the barriers of the eye is not a commonly perceived strategy. Exploiting the permeability of the sclera, subconjunctival routes may offer a promising alternative for enhanced drug delivery and tissue targeting. AREA COVERED IN THIS REVIEW: Ocular drug delivery strategies were reviewed for ocular inflammation and infections clinically adopted for newer class of antimicrobials, which use a multipronged approach to limit risks of endophthalmitis. WHAT THE READER WILL GAIN: The analysis substantiates a new transscleral drug delivery therapeutic approach for cataract surgery. TAKE HOME MESSAGE: A new anti-inflammatory and anti-infective paradigm that frees the patient from the nuisance of topical therapeutics is introduced, opening a large investigative avenue for future improved therapies.

Clinical factors related to visual outcome in central serous chorioretinopathy.

PURPOSE: The purpose of this study was to describe clinical, angiographic, and tomo-graphic prognostic factors in central serous chorioretinopathy. METHODS: This is a prospective uncontrolled case series. Forty-six eyes (43 patients) with clinical and angiographic findings consistent with central serous chorioretinopathy were included. Clinical data regarding age, sex, duration of symptoms, associated conditions, and best-corrected visual acuity (BCVA) were collected at baseline. Optical coherence tomography was performed at baseline, monthly until fluid resolution occurred, and at the end of the follow-up. RESULTS: Mean follow-up was 22.8 months. Mean baseline and final logarithm of the minimum angle of resolution BCVA were 0.3 and 0.12 (P < 0.0001), respectively. Statistically significant correlations were observed between the baseline BCVA as well as duration of symptoms and final BCVA. Angiographic patterns were not significantly correlated with the visual outcome. Shorter periods of subfoveal fluid during the follow-up were correlated with better visual acuity. Mean foveal thickness after fluid resolution was 178 +/- 22 microm. Both baseline and final BCVA were strongly correlated with the foveal thickness after fluid resolution. CONCLUSION: Initial BCVA may be a reliable predictor of the visual outcome in central serous chorioretinopathy. Eyes with worse BCVA may have an increased risk of foveal atrophy. Fluid persistence on optical coherence tomography may be associated with worse visual prognosis.

Subconjunctival delivery of antibiotics in a controlled-release system: a novel anti-infective prophylaxis approach for cataract surgery.

OBJECTIVE: To compare the efficacy of subconjunctival injection of a combination of triamcinolone and ciprofloxacin hydrochloride, 2 mg/0.1 mL, in a controlled-release system (DuoCat) with that of ciprofloxacin hydrochloride, 0.3%, eyedrops for infection prophylaxis. METHODS: Rabbit eyes were injected subconjunctivally with a combination of triamcinolone and ciprofloxacin hydrochloride, 2 mg/0.1 mL, or ciprofloxacin hydrochloride, 2 mg/0.1 mL, alone. The aqueous and vitreous humor pharmacokinetic profiles were compared with those of a single drop of ciprofloxacin hydrochloride, 0.3%, 6 times daily. In 45 rabbits, Staphylococcus aureus was injected into the anterior chamber: 15 randomly received 1 drop of ciprofloxacin hydrochloride, 0.3%, every 4 hours during 24 hours; 15 received drops of balanced salt solution; and 15 received a combination of triamcinolone and ciprofloxacin hydrochloride, 2 mg/0.1 mL. After 24 hours, endophthalmitis scores were recorded, aqueous and vitreous humors underwent culture, and histologic analysis was performed. RESULTS: The combined triamcinolone and ciprofloxacin treatment allowed higher intraocular levels of ciprofloxacin. The median endophthalmitis clinical scores for the combination of triamcinolone and ciprofloxacin and ciprofloxacin-only eyedrop groups were equivalent (P = .42) and were significantly lower than those of the balanced salt solution group (P < .001). The culture was negative for S aureus in the combined triamcinolone and ciprofloxacin and ciprofloxacin eyedrop regimens. No adverse effects were observed with either route. CONCLUSIONS: Ciprofloxacin eyedrops and combined triamcinolone and ciprofloxacin were equally tolerated and efficacious. The combined triamcinolone and ciprofloxacin treatment may eliminate noncompliance issues and may prove to be a valuable clinical tool for surgical prophylaxis. CLINICAL RELEVANCE: The combined triamcinolone and ciprofloxacin treatment may be a new useful strategy for surgical prophylaxis.

A single intraoperative sub-tenon's capsule injection of triamcinolone and ciprofloxacin in a controlled-release system for cataract surgery.

PURPOSE: To compare intraoperative injection of triamcinolone and ciprofloxacin in a controlled-release system (DuoCat) with prednisolone and ciprofloxacin eye drops after cataract surgery. METHODS: In this randomized, double-masked, controlled trial, a total of 135 patients undergoing cataract surgery were randomly allocated to two groups: 67 patients treated after surgery with prednisolone 1% and ciprofloxacin 3% eye drops four times daily (week 1), three times daily (week 2), twice daily (week 3), and once daily (week 4) and 0.3% ciprofloxacin drops four times daily (weeks 1 and 2), and 68 patients treated at the end of surgery with a sub-Tenon's injection of 25 mg triamcinolone and 2 mg ciprofloxacin in biodegradable microspheres. The patients were examined on postoperative days 1, 3, 7, 14, and 28. The main outcome measures were postoperative anterior chamber cell and flare, intraocular pressure (IOP), lack of anti-inflammatory response, and presence of infection. RESULTS: No significant differences were observed between the groups in anterior chamber cell (P > 0.14) and flare (P > 0.02) at any postoperative visits. The mean (99% confidence interval) differences in IOP between the prednisolone and triamcinolone groups on days 1, 3, 7, 14, and 28 were -0.4 mm Hg (-2.1 to 1.3), 0.0 mm Hg (-1.4 to 1.3), 0.0 mm Hg (-1.1 to 1.1), -0.2 mm Hg (-1.1 to 0.8), and -0.1 mm Hg (-1.1 to 0.9), respectively. No patient had a postoperative infection. CONCLUSIONS: One injection of DuoCat had a therapeutic response and ocular tolerance that were equivalent to conventional eye drops in controlling inflammation after cataract surgery. (ClinicalTrials.gov number, NCT00431028.).

OCT findings in macular hole formation in eyes with complete vitreofoveal separation.

The current study describes the morphologic macular features in two eyes that developed full-thickness macular holes in the setting of documented vitreofoveal separation. Using third-generation optical coherence tomography, complete vitreofoveal separation associated with the disruption of the inner foveal retina was documented in both cases. Five months after presentation, decreased vision and epiretinal membrane formation associated with development of a full-thickness macular hole were observed in the first patient. In the second patient, a full-thickness macular hole was demonstrated by optical coherence tomography 6 weeks after presentation. These findings suggest that full-thickness macular holes may develop in eyes with vitreofoveal separation. Evidence of the disturbance of the inner foveal architecture on optical coherence tomography indicates the potential role of factors other than anteroposterior or oblique vitreoretinal tractional forces in the genesis of some full-thickness macular holes.

Intravitreal bevacizumab (Avastin) in combination with verteporfin photodynamic therapy for choroidal neovascularization associated with age-related macular degeneration (IBeVe Study).

BACKGROUND: A novel alternative for combined treatment using verteporfin photodynamic therapy (PDT) has emerged as preliminary safety and efficacy data of the intravitreal use of the anti-angiogenic bevacizumab became available. In the current study we investigate the feasibility of intravitreal bevacizumab combined with verteporfin PDT for the treatment of choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD). METHODS: A single-centre, prospective, open-label study of 11 patients with documented CNV progression after PDT treatment who underwent combined PDT and intravitreal injection of 1.5 mg of bevacizumab was undertaken. Standardized ophthalmic evaluation was performed at baseline and at weeks 1, 2, 12 and 24. Clinical evidence of complications and changes in logarithm of the minimum angle of resolution (logMAR) best-corrected visual acuity (BCVA) using Early Treatment Diabetic Retinopathy Study (ETDRS) charts and in fluorescein leakage from CNV were evaluated. RESULTS: The mean (+/-SD) age of the 11 patients was 74 (+/-5) years. Seven eyes had been treated with one previous PDT session and four eyes had two previous PDT sessions. The mean baseline logMAR ETDRS BCVA was 1.031 (Snellen equivalent, 20/200(-2)). At follow-up weeks 1, 2, 12 and 24, the mean logMAR ETDRS BCVA (Snellen equivalent) was 0.944 (20/160(-2)), 0.924 (20/160(-1)), 0.882 (20/160(+1)), and 0.933 (20/160(-2)), respectively. The change in BCVA from baseline was significant at each study follow-up interval (P < or = 0.001); at 12 and 24 weeks, the mean change in BCVA from baseline was an improvement of 1.49 and of 0.98 ETDRS line, respectively. Fluorescein leakage from CNV was absent in all eyes at week 12. One additional treatment session was required in seven (63.6%) eyes at week 24 due to recurrent fluorescein leakage from CNV ("minimum" [<50% of the leaking area noted at baseline], n = 4; and "moderate" [>50% of the leaking area noted at baseline], n = 3). No progression of the neovascular lesion was observed at week 24. No safety issues were identified throughout the period of the study. CONCLUSIONS: The overall changes in vision and fluorescein leakage from CNV throughout the study suggest that a possible synergistic effect may arise from the combination of intravitreal bevacizumab with verteporfin PDT for the treatment of neovascular AMD.

Intravitreal bevacizumab (avastin) for central and hemicentral retinal vein occlusions: IBeVO study.

PURPOSE: To evaluate the safety, visual acuity changes, and morphologic effects associated with intravitreal bevacizumab injections for the management of macular edema due to ischemic central or hemicentral retinal vein occlusion (RVO). METHODS: In this prospective, open-label study, 7 consecutive patients (7 eyes) with macular edema associated with ischemic central or hemicentral RVO were treated with intravitreal injections of 2.0 mg (0.08 mL) of bevacizumab at 12-week intervals. Standardized ophthalmic evaluation was performed at baseline and at weeks 1, 6, and 12 after each injection. Clinical evidence of toxicity and complications as well as changes in logarithm of minimum angle of resolution Early Treatment Diabetic Retinopathy Study best-corrected visual acuity (BCVA), central macular thickness (CMT) and total macular volume (TMV) shown by optical coherence tomography (OCT), and dye leakage shown by fluorescein angiography were evaluated. RESULTS: The median age of the 7 patients was 65 years (range, 58-74 years), and the median duration of symptoms before injection was 7 months (range, 2.5-16 months). At baseline, mean BCVA was 1.21 (Snellen equivalent, approximately 20/320) in the affected eye. Mean baseline CMT and TMV were 730.1 microm and 17.1 mm(3), respectively. Fluorescein leakage was observed in the macula and affected retinal quadrants in all seven eyes. Six patients completed the 25-week follow-up examination with reinjections performed at weeks 12 and 24. The most common adverse events were conjunctival hyperemia and subconjunctival hemorrhage at the injection site. At the last follow-up, mean BCVA in the affected eye was 0.68 (Snellen equivalent, 20/100(+1). No patient had a decrease in BCVA. Mean CMT and TMV at the 25-week follow-up were 260.3 microm and 9.0 mm(3), respectively; fluorescein leakage within the macula and affected retinal quadrants as compared with baseline was markedly reduced in all patients. Coupled with fluorescein angiographic findings, OCT data suggest a trend of macular edema recurrence between 6 weeks and 12 weeks after injection. CONCLUSIONS: Intravitreal bevacizumab injections of 2.0 mg at 12-week intervals were well tolerated and were associated with short-term BCVA stabilization or improvement and favorable macular changes in all patients with ischemic RVO and associated macular edema.

Optical coherence tomography evaluation of idiopathic macular hole treatment by gas-assisted posterior vitreous detachment.

PURPOSE: To report a series of patients with Stage II macular hole (MH) treated by gas-assisted posterior vitreous detachment (GAPVD). DESIGN: Interventional case series. METHODS: Six patients (six eyes) with Stage II MH were submitted to a 0.4 ml perfluoropropane (C(3)F(8)) intravitreal injection. Comprehensive ophthalmic examination including best-corrected visual acuity, fundus photography, and optical coherence tomography (OCT) was performed at baseline and one, three, and six months after the procedure. RESULTS: Preoperative OCT revealed Stage II MH in all cases. In five cases, improvement in visual acuity and closure of the macular hole on OCT was observed at one, three, and six months after GAPVD. In one case, although vitreofoveal traction was released, MH closure was not achieved; a full-thickness retinal defect persisted and final visual acuity was 20/100. CONCLUSION: GAPVD may be a viable alternative treatment for Stage II MH.

Intravitreal bevacizumab for choroidal neovascularization caused by AMD (IBeNA Study): results of a phase 1 dose-escalation study.

PURPOSE: To evaluate the safety of three dose regimens of intravitreal bevacizumab (Avastin; Genentech, Inc., South San Francisco, CA) for the management of choroidal neovascularization (CNV) associated with age-related macular degeneration (AMD). METHODS: This was a prospective, nonrandomized open-label study of 45 patients with AMD and subfoveal CNV. A standardized ophthalmic evaluation was performed at baseline and at weeks 1, 6, and 12 (+/-1) after a single intravitreous injection (1.0, 1.5, or 2.0 mg) of bevacizumab. Main outcomes measures include clinical evidence of toxicity and complications. Changes in best corrected visual acuity (BCVA) and lesion characteristics-macular morphology were also evaluated. RESULTS: The most common adverse events were conjunctival hyperemia and subconjunctival hemorrhage at the injection site. Mean BCVA improved from baseline throughout the study (P < 0.001; ANOVA with Geisser-Greenhouse correction). Compared with baseline, BCVA was improved at week 1 (P = 0.001), week 6 (P < 0.001), and week 12 (P = 0.001; Dunnett test). At week 12, the lesion area and CNV area were stable or decreased in 79.1% (34/43) and in 74.4% (32/43) of patients, respectively, with no deterioration of macular architecture observed in 83.7% (36/43). A dose-related change in BCVA (in Early Treatment Diabetic Retinopathy Study [ETDRS] lines) was observed at week 12 (1.0 mg [+0.3 line]; 1.5 mg [+0.6 line]; and 2.0 mg [+1.0 line]; P = 0.02; nonparametric test for ordered groups). CONCLUSIONS: A single intravitreal bevacizumab injection was well tolerated and, except for minor transient local adverse events, no other adverse events were observed. In the short-term, treatment was associated with vision stabilization or improvement and no unfavorable neovascular lesion-macular changes in most patients.

Retinal assessment using optical coherence tomography.

Over the 15 years since the original description, optical coherence tomography (OCT) has become one of the key diagnostic technologies in the ophthalmic subspecialty areas of retinal diseases and glaucoma. The reason for the widespread adoption of this technology originates from at least two properties of the OCT results: on the one hand, the results are accessible to the non-specialist where microscopic retinal abnormalities are grossly and easily noticeable; on the other hand, results are reproducible and exceedingly quantitative in the hands of the specialist. However, as in any other imaging technique in ophthalmology, some artifacts are expected to occur. Understanding of the basic principles of image acquisition and data processing as well as recognition of OCT limitations are crucial issues to using this equipment with cleverness. Herein, we took a brief look in the past of OCT and have explained the key basic physical principles of this imaging technology. In addition, each of the several steps encompassing a third generation OCT evaluation of retinal tissues has been addressed in details. A comprehensive explanation about next generation OCT systems has also been provided and, to conclude, we have commented on the future directions of this exceptional technique.

Neuroprotective effects of intramuscular ketamine in rabbit retinas after pars plana vitrectomy and silicone oil injection.

PURPOSE: To investigate potential retinal neuroprotective effects of intramuscular ketamine in rabbits after pars plana vitrectomy (PPV) and intravitreal silicone oil injection (SOI). METHODS: Twelve New Zealand rabbits (weight, 2.0-2.5 kg) underwent PPV with SOI in the right eye. Postoperatively, six rabbits received a daily intramuscular injection of ketamine for 4 weeks (ketamine-operated eyes), and six rabbits received a daily intramuscular injection of saline (saline-operated eyes). The retina from the left eye of each rabbit served as a control (ketamine-control and saline-control eyes). The animals were euthanized at 4 weeks after surgery. Qualitative and quantitative analyses were performed using the Zeiss Axiophot microscope and KS 400 software. RESULTS: Qualitative analysis using light microscopy demonstrated more extensive edema and cell disorganization in saline-operated retinas than in ketamine-operated, ketamine-control, and saline-control retinas. Quantitatively, the cell densities (cell/mm) in the outer nuclear layer (ONL), inner nuclear layer (INL), and ganglion cell layer (GCL) in saline-operated retinas were significantly (P < 0.05) lower than those in these layers in ketamine-operated, ketamine-control, and saline-control retinas. The cell density in the ONL in saline-operated retinas was 52% lower than that in ketamine-operated retinas, 55% lower than that in ketamine-control retinas, and 56% lower than that in saline-control retinas. The cell density in the INL in saline-operated retinas was 44% lower than that in ketamine-operated retinas, 48% lower than that in ketamine-control retinas, and 49% lower than that in saline-control retinas. The cell density in the GCL in saline-operated retinas was 60% lower than that in ketamine-operated retinas, 64% lower than that in ketamine-control retinas, and 64% lower than that in saline-control retinas. CONCLUSION: PPV with SOI was associated with retinal cell death and disorganization in rabbit eyes. Intramuscular ketamine administration provided protection against these effects.

Intravitreal injection versus sub-Tenon's infusion of triamcinolone acetonide for refractory diabetic macular edema: a randomized clinical trial.

PURPOSE: To compare the effectiveness of posterior sub-Tenon's infusion (STi) and intravitreal injection (IVI) of triamcinolone acetonide (TA) for treatment of refractory diffuse diabetic macular edema. METHODS: Thirty-six phakic diabetic patients with refractory diffuse diabetic macular edema were prospectively enrolled. Patients randomly received either 40 mg STi or 4 mg IVI of TA. Comprehensive ophthalmic evaluation was performed at baseline and 1, 2, 4, 8 +/- 1, 12 +/- 2 and 24 +/- 2 weeks after treatment. Macular morphologic changes detected by optical coherence tomography and visual acuity, intraocular pressure, and lens status were evaluated. RESULTS: Twenty-eight patients (28 eyes) completed the 24-week study. Central macular thickness was significantly reduced in the IVI group when compared with the STi group at 2, 4, 8, 12, and 24 weeks after treatment (P < 0.01). Mean visual acuities (in logarithm of the minimum angle of resolution [logMAR]) at week-4, -8, and -12 follow-up examinations were significantly higher in the IVI group (0.74, 0.75, and 0.82, respectively) when compared with the STi group (0.88, 0.88, and 0.90, respectively; P < 0.01). A significant change from baseline in mean intraocular pressure (mm Hg) was seen at weeks 4 (+/-3.21) and 8 (+/-3.35) in STi the group (P < 0.01), and at week 8 (+/-2.78) in the IVI group (P < 0.05). No patient had cataract progression during the study. CONCLUSIONS: Although the number of patients and length of follow-up in this preliminary study were limited, the changes in central macular thickness and visual acuity observed after treatment suggest that IVI TA may be more effective than STi for the management of refractory diffuse diabetic macular edema. Further studies are needed to confirm these preliminary findings.