Guidelines for the Management of Center-Involving Diabetic Macular Edema: Treatment Options and Patient Monitorization.

Diabetic macular edema (DME) is the main cause of visual impairment associated with diabetic retinopathy (DR) and macular laser, during approximately three decades, and was the single treatment option. More recently, intravitreous injections of anti-angiogenics and corticosteroids modified the treatment paradigm associated with significant vision improvements. Nevertheless, not all patients respond satisfactorily to anti-VEGF or corticosteroid injections, so an adequate treatment choice and a prompt switch in therapeutic class is recommended. Several algorithms and guidelines have been proposed for treating center involving DME to improve patients' vision and quality of life. However, in Portugal, such guidelines are lacking. The present review aimed to provide guidelines for the treatment options and patient monitorization in the management of center-involving DME. We recommend anti-vascular endothelial growth factor (VEGF) as first-line therapy after a clinical evaluation accompanied by a rigorous metabolic control. Depending on the response obtained after 3-6 monthly intravitreal injections we suggest switching outside the class in case of a non-responder, maintaining the anti-VEGF-therapy in responders to anti-angiogenics. The treatment regimen for Dexamethasone intravitreal implant (DEXii) should be pro-re-nata with bi-monthly or quarterly monitoring visits (with a scheduled visit at 6-8 weeks after DEXii for intraocular pressure control). If a patient does not respond to DEXii, switch again to anti-VEGF therapy, combine therapies, or re-evaluate patients diagnose. There is a resilient need to understand the disease, its treatments, regimens available, and convenience for all involved to propose an adequate algorithm for the treatment of diabetic retinopathy (DR) and DME in an individualized regimen. Further understanding of the contributing factors to the development and progression of DR should bring new drug discoveries for more effective and better-tolerated treatments.

Clinical impact of the 0.2 µg/day fluocinolone acetonide intravitreal implant: outcomes from the ILUVIEN® clinical evidence study in Portugal.

INTRODUCTION: The ILUVIEN® (fluocinolone acetonide) Clinical Evidence in Portugal (ICE-PT) study is a retrospective, multicenter, observational study evaluating the effectiveness and safety of the FAc implant in patients with diabetic macular edema. METHODS: Patients included in this study had received the 0.2 µg/day fluocinolone acetonide implant for the treatment of diabetic macular edema and had measurements of visual acuity and retinal thickness assessed by optical coherence tomography for at least 12 months pre- and post-fluocinolone acetonide implant administration, with ⩾2 follow-up visits. Outcomes measured included visual acuity, central foveal thickness, and intraocular pressure. RESULTS: There was a significant increase in mean visual acuity compared with baseline at 3, 6, 9, and 12 months post-fluocinolone acetonide in both the overall study population and the pseudophakic subgroup (p < 0.05 at all time points in both groups). A significant reduction in mean central foveal thickness compared with baseline was seen in the overall study population at 3, 6, 9, and 12 months post-fluocinolone acetonide (p < 0.05 at all time points). At 12-month post-fluocinolone acetonide, a small but significant intraocular pressure increase of 1.0 mmHg was seen in the overall study population. CONCLUSION: The results of this analysis show that switching from the current standard of care to the fluocinolone acetonide implant leads to beneficial effects in terms of vision and retinal structure in patients with diabetic macular edema and that patients benefited from FAc implant administration, regardless of lens status.

Unilateral Vogt-Koyanagi-Harada Disease: A Clinical Case Report.

PURPOSE: To report a case of a 20-year-old female with decreased visual acuity (VA) in the left eye (LE). METHODS: This is a retrospective and descriptive case report based on data from clinical records, patient observation and analysis of diagnostic tests. RESULTS: A 20-year-old female presented with decreased VA in the LE for 3 days. Best-corrected visual acuity (BCVA) was 20/20 in the right eye (RE) and 20/40 in the LE. Pupillary function, intraocular pressure, results of external segment examinations and slit-lamp biomicroscopy were normal, bilaterally. RE fundoscopy was normal, and in the LE it revealed papillitis and posterior pole exudative retinal detachment. Optical coherence tomography (OCT) confirmed the macular serous retinal detachment and showed thickening of the posterior choroid also revealed by orbital ultrasound and magnetic resonance imaging (MRI). Fluorescein angiography showed angiographic features typical of Vogt-Koyanagi-Harada (VKH) disease: disseminated spotted choroidal hyperfluorescence and choroidal multifocal hypofluorescence, multifocal profuse leakage in the retina with pooling, serous retinal detachment and optic disc hyperfluorescence. Serological testing for the diagnosis of infectious pathologies was negative, and the review of systems was normal. The patient received systemic steroids and cyclosporine. LE BCVA improved up to 20/20 at 18 months after the diagnosis, with complete reabsorption of subretinal fluid and normal retinal and choroidal thickness by OCT. CONCLUSION: Despite the unilateral involvement, the clinical and angiographic features were typical of VKH disease, and ophthalmologists should be aware to recognize this rare clinical variant of the disease.

Cutting Edge of Traumatic Maculopathy with Spectral-domain Optical Coherence Tomography - A Review.

This article reviews clinically relevant data regarding traumatic maculopathy (TM), frequently observed in clinical practice, especially due to sport or traffic accident injuries. It is characterized by transient gray-whitish retinal coloration and reduction of visual acuity (VA) with closed, blunt object globe trauma of their prior. It may be limited to the posterior pole (Berlin's edema), or peripheral areas of the retina. Spectral-domain optical coherence tomography (SD-OCT) provides detail insight using high resolution cross-sectional tomographs of the ocular tissue. It is a potent non-invasive tool for the clinician to follow-up. Clinicians are, thereby empowered with a tool that enables evaluation of the retinal status and allows for prediction of the prognosis. Spectral-domain optical coherence tomography supports the idea that the major site of injury is in the photoreceptor and layers of the retinal pigment epithelium (RPE). Depending on the severity of the trauma, SD-OCT may reveal differential optical densities of intraretinal spaces ranging from disappearance of the thin hyporeflective optical space in mild lesions, or areas of disruption of the inner segment/outer segment (IS/OS) junction and hyperreflectivity of the overlying retina, pigment disorders and retinal atrophy, in more severe cases. The prognosis for recovery of vision is generally good, and improvement occurs within 3-4 weeks.

Possible rare congenital dysinnervation disorder: congenital ptosis associated with adduction.

Ptosis is defined as an abnormally low position of the upper eyelid margin. It can be congenital or acquired, uni or bilateral, and isolated or associated with other ocular and nonocular defects. We report a case of a female child, aged 8 years, with congenital right ptosis increased on right adduction and with left ptosis on left adduction. There was no horizontal ocular movement limitation. Apparent underaction of the right inferior oblique muscle was also present. We believe that within the possible mechanisms it is more likely that it is a congenital innervation dysgenesis syndrome (CID)/congenital cranial dysinnervation disorder (CCDD).

A rare case of retinal artery occlusion in the context of mediterranean spotted Fever.

BACKGROUND: Mediterranean spotted fever is a zoonosis endemic in the Mediterranean region. The microorganism Rickettsia conorii is responsible for the disease due to its angiotropism for endothelial cells. It produces host cell necrosis, thrombosis, and organ dysfunction. Ophthalmologic manifestations are rare. FINDINGS: The authors describe the case of a 55-year-old female with Mediterranean spotted fever who developed localized retinal vasculitis with associated macular edema. Treatment with intravitreal triamcinolone allowed a significant recovery of visual acuity. CONCLUSION: Ophthalmological symptoms in these patients should be emphasized because there can be severe ocular complications with a potentially irreversible loss of visual acuity.