Retinal neurovascular alteration in type 2 diabetes with renal impairment in association with systemic arterial stiffness.

BACKGROUND: Diabetic retinopathy (DR) patients should be alert for subclinical macroangiopathy. We aimed to investigate the association between retinal neurovascular alteration and systemic arterial stiffness in type 2 diabetes mellitus (type 2 DM) patients with varying degrees of renal impairment. METHODS: The study included 170 patients with confirmed diagnosis of type 2 DM aged ≥18 years old. Renal function was assessed by estimated glomerular filtration rate (eGFR). Arterial stiffness was measured by brachial-ankle pulse wave velocity (baPWV) and ankle brachial index (ABI). Retinal neurovascular parameters were derived from Optical Coherence Tomography (OCT)/OCT-Angiography, represented by vessel density (VD Central, Inner, Outer, Full), foveal avascular zone (FAZ area and FAZ perimeter) of the superficial capillary plexus, the average of macular ganglion cell-inner plexiform layer thickness (ave mGC-IPLt) and the average of retinal nerve fiber layer thickness (aveRNFLt). The association between variables among the groups (according to renal function, diabetic retinopathy (DR) severity, and arterial stiffness categories) were analyzed by regression analysis with multiple hypothesis testing commands. RESULTS: Out of the 265 eyes, the mean DM duration and HbA1c were 6.21 ± 6.37 years and 8.44 ± 2.06% respectively. While the mean of eGFR, baPWV and ABI were 66.78 ± 32.80 ml/min/1.73m2, 15.49 ± 3.07 m/s, and 1.05 ± 0.12, respectively. Patients with more severe renal impairment demonstrated longer DM duration (p < 0.001), higher baPWV (p < 0.0001), and retinal vascular alteration. Proliverative DR group showed the lowest eGFR (p < 0.0001), highest baPWV (p < 0.0001), and retinal neurovascular changes. Significantly lower eGFR and retinal vascular alteration were found in the baPWV > 14 group. Some neurovascular parameters were significantly negatively correlated with baPWV; moreover, retinal neurovascular changes were also noted in the abnormal ABI group. CONCLUSIONS: The strong association between changes in the retinal neurovascular system, DR severity, renal impairment, and arterial stiffness in type 2 DM was confirmed. Patients with more severe renal impairment had higher levels of arterial stiffness, more severe DR and retinal neurovascular alteration. Retinal neurovascular changes seen in OCT/OCTA might mimic renal microvascular alteration and systemic arterial stiffness. Therefore, assessment of baPWV and OCT/OCTA should be integrated in DR screening to enhance cardiovascular risk stratification and prognosis as well as to provide clinically useful early identification of subclinical micro- and macrovascular alterations.

Use of Dichlorodimethylsilane to Produce Polydimethylsiloxane as a Substitute for Vitreous Humour: Characteristics and In Vitro Toxicity.

Polydimethylsiloxane (PDMS) is a substitute for vitreous humour in vitreoretinal surgery and is usually produced from octamethylcyclotetrasiloxane (D4). In Indonesia, both commercial PDMS and D4 are limited and expensive. Dichlorodimethylsilane (DCMS) can be an alternative to produce PDMS. DCMS is cheaper and easier to obtain than D4. However, more extra effort is needed in order to produce PDMS from DCMS. Therefore, this study aimed to produce PDMS from DCMS by varying the ratio of DCMS precursor to dichloromethane (DCM) solvent at ratios of 1:1 and 1:4 through the hydrolysis-condensation method under neutral conditions. The PDMS produced had medium- (2.06 Pa·s) and high viscosity (3.59 Pa·s), with densities ranging from 0.96 to 0.99 g/mL. The refractive index was 1.4034-1.4036 and surface tension was 21 × 10-3 N/m, while they were able to transmit ~100% visible light, which were similar values to the commercial PDMS characteristics. PDMS samples were characterized using IR and NMR spectroscopy, which confirmed they were of PDMS type. The most optimum DCMS:DCM ratio was 1:1 due to the medium-viscosity PDMS type that could be produced. The in vitro HET-CAM toxicity test showed that samples were non-irritant, similar to PDMS produced from D4. PDMS from DCMS was non-toxic and ready to be used as a vitreous humuor substitution.

Circulating Biomarkers to Predict Diabetic Retinopathy in Patients with Diabetic Kidney Disease.

The purpose of this review is to outline the currently available circulating biomarkers to predict diabetic retinopathy (DR) in patients with diabetic kidney disease (DKD). Studies have extensively reported the association between DR and DKD, suggesting the presence of common pathways of microangiopathy. The presence of other ocular complications including diabetic cataracts may hinder the detection of retinopathy, which may affect the visual outcome after surgery. Unlike DKD screening, the detection of DR requires complex, costly machines and trained technicians. Recognizing potential biological markers related to glycation and oxidative stress, inflammation and endothelial dysfunction, basement membrane thickening, angiogenesis, and thrombosis as well as novel molecular markers involved in the microangiopathy process may be useful as predictors of retinopathy and identify those at risk of DR progression, especially in cases where retinal visualization becomes a clinical challenge. Further investigations could assist in deciding which biomarkers possess the highest predictive power to predict retinopathy in clinical settings.

The soluble suppression of tumorigenicity 2 as a biomarker of early cardiac remodeling in bradycardia patients receiving permanent pacemaker therapy.

Aim: This study aims to evaluate: the difference of soluble suppression of tumorigenicity 2 (sST2) level, a biomarker for cardiac remodeling and echocardiography parameters value prior to and 1 month after implantation; and the association between pacemaker parameters and pacemaker mode along with delta sST2 levels. Materials & methods: This prospective cohort study enrolled all symptomatic bradycardia patients aged >18 years with preserved ejection fraction who underwent permanent pacemaker (PPM) implantation. Results: A total of 49 patients were included in this study. The sST2 level (ng/ml) were significantly different between prior and 1 month following PPM implantation (23.4 ± 28.4 vs 39.9 ± 63.7; p = 0.001). Conclusion: The early cardiac remodeling has occurred within 1 month after PPM implantation as indicated by increasing delta sST2 level.

It is widely known that pacing induced cardiomyopathy, which results from the utilization of a permanent pacemaker (PPM) within a long-term duration, will increase the risk of mortality and morbidity. Hence, early detection of the cardiac remodeling process is warranted in order to prevent this course. In this study, the soluble suppression of tumorigenicity 2 level (ng/ml), known as an indicator of cardiac remodeling, was significantly higher in 1 month following PPM implantation compared with the baseline (23.4 ± 28.4 vs 39.9 ± 63.7; p = 0.001). Thus, it denotes that early cardiac remodeling might occur earlier than expected, within 1 month following PPM implantation.

Effects of SGLT2 inhibitor administration on blood glucose level and body weight in type 1 diabetes rat model.

The prevalence of diabetes worldwide is increasing and 629 million people are projected to have diabetes by 2045, and the most significant burden of the disease being concentrated in low- and middle-income countries (LMICs). Type 2 diabetes is mainly treated with insulin adjunctive therapies such as metformin to improve insulin sensitivity and sodium-glucose co-transporter 2 (SGLT2) inhibitors to lower blood glucose levels. However, there was limited study on the application of SGLT2 inhibitors on type 1 diabetes, particularly empagliflozin. Therefore, this study aimed to determine the effect of SGLT2 inhibitors on blood glucose levels and body weights in a rat model of type 1 diabetes. To mimic type 1 diabetes, the rats were injected with streptozotocin 60 mg intra-peritoneally. Twenty-four rat models were randomly divided into four groups: normal rat group (negative control), untreated diabetic rat group (positive control), type 1 diabetic rats treated with metformin, and type 1 diabetic rats treated with empagliflozin. Blood glucose levels and body weight were recorded before and after induced with streptozotocin and on weeks 4, 6, 8 and 10 of the treatment with anti-diabetic drugs. This study found that the blood glucose levels before and after treatment significantly decreased in all groups (p<0.05), except in the negative control group. Similar results were observed in body weight of the rats, which all groups experienced weight loss, except the negative control. These results suggested that apart from being used in type 2 diabetes, SGLT2 inhibitors may also be used as a treatment for type 1 diabetes.

MitoTEMPOL modulates mitophagy and histopathology of Wistar rat liver after streptozotocin injection.

Objectives: This study aims to explore the effect of mitoTEMPOL on histopathology, lipid droplet, and mitophagy gene expression of Wistar rat's liver after injection of streptozotocin (STZ). Materials and Methods: Twenty male Wistar rats were divided into 4 groups: Control (n=5); 100 mg/kg BW/day mitoTEMPOL orally (n=5); 50 mg/kg BW STZ intraperitoneal injection (n=5); and mitoTEMPOL+STZ (n=5). STZ was given a single dose, while mitoTEMPOL was given for 5 weeks after 1 week of STZ injection. Histopathological appearance, lipid droplets, mitophagy, and autophagy gene expression were examined after the mitoTEMPOL treatment. Results: We found metabolic zone shifting that might be correlated with the liver activity of fatty acid oxidation in the STZ group, a decrease of lipid droplets in mitoTEMPOL and mitoTEMPOL + STZ compared with Control and STZ groups were found in this study. We also found significant changes in PINK1, Parkin, BNIP3, Mfn1, and LC3 gene expression, but no difference in Opa1, Fis1, Drp1, and p62 gene expression, suggesting a change of mitochondrial fusion rather than mitochondrial fission correlated with mitophagy. Conclusion: All this concluded that mitoTEMPOL could act as a modulator of mitophagy and metabolic function of the liver, thus amplifying its crucial role in preventing mitochondrial damage in the liver in the early onset of diabetes mellitus.

Revisiting exercise-induced premature ventricular complexes as a prognostic factor for mortality in asymptomatic patients: A systematic review and meta-analysis.

Background: Recent investigations suggest that premature ventricular complexes (PVCs) during an exercise test are associated with an elevated risk of mortality in asymptomatic individuals. However, given the small number of studies included, the association between these two entities in the asymptomatic population remains obscure. Our aim was to evaluate this matter. Methods: A comprehensive literature search was conducted utilizing several online databases up to April 2022. The study comprised cohort studies examining the relationship between exercise-induced premature ventricular complexes (EI-PVCs) and all-cause mortality (ACM) as well as cardiovascular mortality (CVM) in asymptomatic populations. To provide diagnostic values across the statistically significant parameters, we additionally calculated sensitivity, specificity, and area under the curve (AUC). Results: A total of 13 studies consisting of 82,161 patients with a mean age of 49.3 years were included. EI-PVCs were linked to an increased risk of ACM (risk ratio (RR) = 1.30 (95% confidence interval (CI) = 1.18-1.42); p < 0.001; I 2 = 59.6%, p-heterogeneity < 0.001) and CVM (RR = 1.67 (95% CI = 1.40-1.99); p < 0.001; I 2 = 7.5%, p-heterogeneity = 0.373). Subgroup analysis based on the frequency of PVCs revealed that frequent PVCs were similarly related to a higher risk of ACM and CVM, but not infrequent PVCs. Moreover, diagnostic test accuracy meta-analysis showed that recovery phase EI-PVCs have a higher overall specificity than exercise phase EI-PVCs regarding our outcomes of interest. Conclusion: EI-PVCs are correlated with a higher risk of ACM and CVM. When compared to the exercise phase, the specificity of PVCs generated during the recovery period in predicting interest outcomes is higher. As a result, we propose that the exercise ECG be utilized on a regular basis in middle-aged asymptomatic individuals to measure the frequency of PVCs and stratify the risk of mortality. Systematic review registration: [https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=328852], identifier [CRD42022328852].

Electrocardiographic Markers Indicating Right Ventricular Outflow Tract Conduction Delay as a Predictor of Major Arrhythmic Events in Patients With Brugada Syndrome: A Systematic Review and Meta-Analysis.

Introduction: Risk stratification in Brugada Syndrome (BrS) patients is still challenging due to the heterogeneity of clinical presentation; thus, some additional risk markers are needed. Several studies investigating the association between RVOT conduction delay sign on electrocardiography (ECG) and major arrhythmic events (MAE) in BrS patients showed inconclusive results. This meta-analysis aims to evaluate the association between RVOT conduction delay signs presented by aVR sign and large S wave in lead I, and MAE in BrS patients. Methods: The literature search was performed using several online databases from the inception to March 16th, 2022. We included studies consisting of two main components, including ECG markers of RVOT conduction delay (aVR sign and large S wave in lead I) and MAE related to BrS (syncope/VT/VF/SCD/aborted SCD/appropriate ICD shocks). Results: Meta-analysis of eleven cohort studies with a total of 2,575 participants showed RVOT conduction delay sign was significantly associated with MAE in BrS patients [RR = 1.87 (1.35, 2.58); p < 0.001; I 2= 52%, P heterogeneity = 0.02]. Subgroup analysis showed that aVR sign [RR = 2.00 (1.42, 2.83); p < 0.001; I 2= 0%, P heterogeneity = 0.40] and large S wave in lead I [RR = 1.74 (1.11, 2.71); p = 0.01; I 2= 60%, P heterogeneity = 0.01] were significantly associated with MAE. Summary receiver operating characteristics analysis revealed the aVR sign [AUC: 0.77 (0.73-0.80)] and large S wave in lead I [AUC: 0.69 (0.65-0.73)] were a good predictor of MAE in BrS patients. Conclusion: RVOT conduction delay sign, presented by aVR sign and large S wave in the lead I, is significantly associated with an increased risk of MAE in BrS patients. Hence, we propose that these parameters may be useful as an additional risk stratification tool to predict MAE in BrS patients. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/#recordDetails, identifier: CRD42022321090.

MitoTEMPOL Inhibits ROS-Induced Retinal Vascularization Pattern by Modulating Autophagy and Apoptosis in Rat-Injected Streptozotocin Model.

Diabetic retinopathy leads to retinal malfunction, blindness, and reduced quality of life in adult diabetes patients. The involvement of reactive oxygen species (ROS) regulation stimulated by high blood glucose levels opens the opportunity for ROS modulator agents such as MitoTEMPOL. This study aims to explore the effect of MitoTEMPOL on ROS balance that may be correlated with retinal vascularization pattern, autophagy, and apoptosis in a streptozotocin-induced rat model. Four groups of male Wistar rats (i.e., control, TEMPOL (100 mg/kg body weight [BW]), diabetic (streptozotocin, 50 mg/kg BW single dose), and diabetic + TEMPOL; n = 5 for each group) were used in the study. MitoTEMPOL was given for 5 weeks, followed by funduscopy, and gene and protein expression were explored from the rat's retina. Streptozotocin injection decreased bodyweight and increased food and water intake, as well as fasting blood glucose. The results showed that MitoTEMPOL reduced retinal vascularization pattern and decreased superoxide dismutase gene expression and protein carbonyl, caspase 3, and caspase 9 protein levels. A modulation of autophagy in diabetes that was reversed in the diabetic + TEMPOL group was found. In conclusion, MitoTEMPOL modulation on autophagy and apoptosis contributes to its role as a potent antioxidant to prevent diabetic retinopathy by inhibiting ROS-induced retinal vascularization patterns.

Pharmacological Treatment Options for Coronavirus Disease-19 in Renal Patients.

Patients with chronic kidney disease (CKD), including dialysis and transplant patients, are at greater risk of contracting SARS-CoV-2 due to kidney dysfunction and preexisting comorbidities. To date, a specific guideline on managing these high-risk patients infected with COVID-19 has not been established. As the current management of COVID-19 comprises mainly experimental drugs, the authors aim to provide information on dosing adjustments at different stages of kidney dysfunction and notable renal side effects. We performed a nonsystematical review of currently available COVID-19 drugs exploring several different clinical trial databases and search browsers. Several antivirals and monoclonal antibodies used in COVID-19 treatment require dosage adjustments in kidney dysfunction. In a global pandemic setting, nephrologists need to consider the appropriate dosage according to the renal function and closely monitor the side effects of different drug combinations to obtain the optimum therapeutic effect while avoiding further renal damage. Further studies are required to determine the safety and efficacy of these drugs in renal patients.

Delivering a modified continuous objective structured clinical examination for ophthalmology residents through a hybrid online method.

Since coronavirus disease 2019 was declared a global pandemic by the World Health Organization, it has become a challenging situation to continue medical education, including in Indonesia. The situation prohibited face-to-face (direct) educational activities in clinical settings, therefore also postponing examinations involving especially procedural skills. Adaptations were urgently needed to maintain the delivery of high-stake examinations to sustain the number of ophthalmology graduates and the continuation of eye health service. Objective structured clinical examination (OSCE) has been one of our widely used method to assess clinical competencies for ophthalmology residents, and is the one method that involves gatherings, close contact of examiners, examinees and patients, therefore the most difficult to adjust. Pandemic challenges brought technical changes in our delivering the OSCE to online, maximizing digital platforms of meetings, while still concerned to guarding the safety of candidates, patients and staffs. OSCE scenarios were also made as timely efficient as possible by changing continuous station models to a cascade one. The purpose of this article is to document our experience in conducting a feasible and reproducible OSCE in this pandemic era filled with limitations.

The Influence of Right Ventricular Pacing Location, Pacing Burden and Paced QRS Duration to Subclinical Left Ventricular Systolic Dysfunction as Shown by Global Longitudinal Strain Echocardiography.

BACKGROUND: Prolonged pacing of the right ventricle (RV) is associated with left ventricular (LV) systolic dysfunction. Several studies have shown that the RV pacing location, pacing burden (percentage), and paced QRS duration may affect LV systolic function. Subclinical LV dysfunction may occur early after implantation of a permanent pacemaker (PPM). Therefore, this study aims to detect early subclinical LV systolic dysfunction measured by global longitudinal strain (GLS) using speckle tracking echocardiography (STE) at one month after PPM implantation. METHODS: A single-center, prospective cohort study was conducted, and all patients indicated for PPM implantation with preserved LV systolic function were included. Data of RV pacing location (RV apical vs right ventricular outflow tract (RVOT), pacing burden (percentage) (≤40% vs >40%), and paced QRS duration (≤150 ms and >150 ms) were obtained. The change of GLS was also measured before and one month after PPM implantation (delta GLS). RESULTS: 37 patients were enrolled in this study, which demonstrated significant difference between GLS before (-20.30 SD 3.38) and after (-16.93 SD 3.47) PPM implantation (p=<0.001). There were no significant difference in delta GLS either between patients with RV pacing location on RV apical vs RVOT ((2.30 (0.00-10.50) vs 2.95(0.10-8.30), p=0.648) or between patient with paced QRS duration ≤150ms vs >150ms ((1.70 (0.30-8.30) vs 3.45 (0.0-10.5)), p=0.266). Meanwhile, there was a significant difference of delta GLS between patients with pacing burden ≤40% vs >40% (Mean 1.92 SD 1.37 vs 3.98 SD 3.04), p=0.007). Further analysis found that pacing burden only affected the delta GLS in group with apical RV pacing (≤40% (1.58 SD 0.59) vs > 40% (4.67 SD 3.47), p = 0.008) and did not affect the delta GLS in group with RVOT pacing (≤40% (2.32 SD 1.98) vs > 40% (3.29 SD 2.48), p = 0.446). CONCLUSION: The pacing parameter, particularly pacing burden > 40% may induce the subclinical LV systolic dysfunction after one month of pacemaker implantation as shown by decline of GLS,  especially when the RV pacing location was placed on apical.

The estimated healthcare cost of diabetic retinopathy in Indonesia and its projection for 2025.

PURPOSE: To estimate the total healthcare cost associated with diabetic retinopathy (DR) in type 2 diabetes in Indonesia and its projection for 2025. METHODS: A prevalence-based cost-of-illness model was constructed from previous population-based DR study. Projection for 2025 was derived from estimated diabetes population in 2025. Direct treatment costs of DR were estimated from the perspective of healthcare. Patient perspective costs were obtained from thorough interview including only transportation cost and lost of working days related to treatment. We developed four cost-of-illness models according to DR severity level, DR without necessary treatment, needing laser treatment, laser +intravitreal (IVT) injection and laser + IVT +vitrectomy. All costs were estimated in 2017 US$. RESULTS: The healthcare costs of DR in Indonesia were estimated to be $2.4 billion in 2017 and $8.9 billion in 2025. The total cost in 2017 consisted of the cost for no DR and mild-moderate non-proliferative DR (NPDR) requiring eye screening ($25.9 million), severe NPDR or proliferative DR (PDR) requiring laser treatment ($0.25 billion), severe NPDR or PDR requiring both laser and IVT injection ($1.75 billion) and advance level of PDR requiring vitrectomy ($0.44 billion). CONCLUSIONS: The estimated healthcare cost of DR in Indonesia in 2017 was considerably high, nearly 2% of the 2017 national state budget, and projected to increase significantly to more than threefold in 2025. The highest cost may incur for DR requiring both laser and IVT injection. Therefore, public health intervention to delay or prevent severe DR may substantially reduce the healthcare cost of DR in Indonesia.

Evaluation Of The Timing Of Intravitreal Bevacizumab Injection As Adjuvant Therapy To Panretinal Photocoagulation In Patients With Diabetic Macular Edema Secondary To Diabetic Retinopathy.

OBJECTIVE: To evaluate the difference in intravitreal bevacizumab (IVB) injection timing as adjuvant therapy to panretinal photocoagulation in patients with diabetic retinopathy combined with diabetic macular edema. METHODS: This was a retrospective nonrandomized study. Forty eyes with severe non-proliferative diabetic retinopathy (NPDR) or proliferative diabetic retinopathy (PDR) were divided into two groups; the IVB injection prior to, or after, panretinal photocoagulation. Changes in central macular thickness between the two groups were measured. RESULTS: There was no significant difference in change in central macular thickness between two groups after treatment (p=0.66), neither in eyes with severe NPDR groups (p=0.48) nor eyes with PDR (p=0.82). CONCLUSION: IVB injection after panretinal photocoagulation gives insignificant difference in changes in central macular thickness with injection prior to laser treatment in patients with diabetic retinopathy combined with diabetic macular edema.

The Superoxide Dismutase Mimetic TEMPOL and Its Effect on Retinal Ganglion Cells in Experimental Methanol-Intoxicated Rats.

INTRODUCTION: The incidence of blindness due to methanol intoxication is higher in males of productive age. The management of methanol-induced toxic optic neuropathy is yet to produce satisfactory results. Antioxidant therapy is now used as an alternative method of preventing methanol intoxication. The aim of this study was to observe the effect of TEMPOL (4-hydroxy-2,2,6,6-tetramethylpiperidinyl-1-oxyl), a superoxide dismutase (SOD) mimetic, on retinal ganglion cells in methanol-intoxicated rats. METHODS: This experimental study was conducted with 20 male Wistar rats that were 10-12 weeks old and weighed 300-350 g. The rats were divided into four groups that each received a different treatment: a negative control group, a positive control group, a methanol group, and a methanol + TEMPOL group. Enucleated eyes from all groups were sliced and stained using hematoxylin-eosin (HE). Retinal layer and ganglion cells were assessed based on cellular structure, cellular swelling, and vacuole formation in the ganglion cell layer as observed at × 200 magnification. The Kruskal-Wallis test and the Mann-Whitney test were used, with significance taken to correspond to p < 0.05. RESULTS: Retinal ganglion cells of the control group had fewer vacuoles and a more well-organized cellular structure compared to those of the methanol group. The histopathologic scores of the methanol-intoxicated group were lower than those of the TEMPOL therapy group; p = 0.011 (i.e., p < 0.05). CONCLUSIONS: TEMPOL had a positive impact on the cellular structure of retinal ganglion cells in methanol-intoxicated rats.

Visual Acuity Improvement in Continuous vs Divided Occlusion in Anisometropic Amblyopia.

PURPOSE: To compare visual acuity improvement between continuous and split part-time occlusion for the treatment of moderate and severe anisometropic amblyopia. METHODS: Randomised clinical trials in 6 - 13 y.o children with moderate and severe anisometropic amblyopia. Each patient was consecutively selected with continuous or split part-time occlusion. Best corrected visual acuity's improvement was followed up to six weeks and statistical data were analyzed using chi square and unpaired t-test. RESULTS: Best corrected visual acuity's improvement was comparable between continuous and split part-time occlusion (0.20±0.27 vs 0.21±0.25; p = 0.79). CONCLUSION: Split part-time occlusion may be considered as an alternative treatment for moderate and severe anisometropic amblyopia treatment.

Rapid resolution of toxoplasma chorioretinitis treatment using quadruple therapy.

PURPOSE: To compare the effectiveness of quadruple-drug therapy consisting of cotrimoxazole (trimethopin and sulfamethoxazole), clindamycin antibiotics, and oral corticosteroid versus triple therapy consisting of pyrimetamine, sulphadiazine, and oral corticosteroid in the resolution of toxoplasmic chorioretinitis. METHODS: This was a double-blind randomized controlled trial with repeated measures using parallel design to compare the effectiveness of quadruple-drug therapy and triple-drug therapy in patients with toxoplasmic chorioretinitis. The measurement of lesion was done using automated computer software, calculating the average of lesion size from three fundus photographs taken from the baseline and at each follow-up visit. The analytical statistics were obtained using Mann-Whitney test, comparing percentage of lesion remission test in each examination. RESULTS: The percentage of lesion remission in quadruple-drug therapy was higher than in triple-drug therapy from the first visit until the first follow-up visit, with a p-value of 0.001. In addition, the mean percentage of lesion remission from first visit to last visit was 57.5% and the median was 70.9% in the quadruple therapy group, while in the triple-drug therapy group the mean was 52.5% and the median was 54.0% (p=0.720). CONCLUSION: We conclude that the quadruple-drug therapy has a more rapid resolution effect on chorioretinitis lesion compared to triple therapy.

Macular ischemia after intravitreal amikacin on patient with intraocular foreign body.

Background: Although still used in third world countries, amikacin has a harmful effect to be used intravitreally. Purpose: To report macular ischemia after an intravitreal injection of amikacin Methods: A case report regarding a traumatized eye of a 26-year-old man that was injected intravitreally with amikacin due to intraocular foreign body endophthalmitis Results: Angiography and OCT show macular ischemia due to amikacin toxicity. Conclusion: The case reported here is to alert about the potential harmful effect of intravitreally injected amikacin despite its role as an accepted regimen for endohthalmitis cases.

Efficacy of single bevacizumab injection as adjuvant therapy to laser photocoagulation in macular edema secondary to branch retinal vein occlusion.

BACKGROUND: Macular grid laser photocoagulation remains the standard treatment for macular edema secondary to branch retinal vein occlusion (BRVO). One possible strategy for treating macular edema is to inhibit VEGF activity by competitive binding of VEGF with an anti-VEGF antibody, suggesting the therapy option with bevacizumab. However, multiple injections of anti-VEGF may lead to complications and high cost. PURPOSE: The aim of this study was to evaluate the improvement in visual acuity and central macular thickness after combination therapy of laser photocoagulation with single intravitreal bevacizumab injection in macular edema secondary to BRVO. METHODS: Nineteen patients with macular edema secondary to BRVO were assigned to either the group of nine patients in combination therapy of laser photocoagulation with intravitreal bevacizumab or the group of ten patients in the laser photocoagulation therapy. Complete ophthalmologic examinations were performed just before the therapy and at 1 month following the therapy. Changes in visual acuity were tested with the logarithm of minimum angle of resolution (logMAR), and central macular thickness was measured by optical coherence tomography (OCT). RESULTS: Combination therapy of laser photocoagulation and single intravitreal bevacizumab injection resulted in a significantly better visual acuity compared to laser photocoagulation therapy (0.35 versus 0.13 logMAR; P=0.041) and reduced macular thickness by 120.33 µm versus 71.50 µm (P=0.277), although this difference was not significant. CONCLUSION: Laser photocoagulation combined with a single intravitreal bevacizumab has a substantial effect on increasing visual acuity in macular edema secondary to BRVO.

Learning curve of sutureless transconjunctival 20-gauge vitrectomy.

BACKGROUND: To report the learning curve of transition from 20-gauge (20 G) conventional vitrectomy to a 20 G sutureless vitrectomy technique. MATERIALS AND METHODS: This is a retrospective descriptive case study of 32 eyes from 32 consecutive patients who underwent sutureless 20 G pars plana vitrectomy. A 20 G microvitreoretinal blade was introduced, beveled transconjunctivally, slowly, parallel with the limbus, creating a conjunctivoscleral tunnel incision. Study participants were divided into three groups, and surgical time, induced astigmatism, and complications were compared. RESULTS: Of 32 consecutive patients, there was no significant difference in induced astigmatism or maneuvering between the early learning curve and other groups. The true learning curve was the first three patients. There were three cases where suturing the sclerotomy was necessary: one port in each case, three of 32 cases (9.3%), or three of 96 ports (2.9%). CONCLUSION: There were no significant difficulties in surgical maneuvers while performing 20 g sutureless vitrectomy.