Evaluation of Retinal Vessel Density and Foveal Avascular Zone in Unilateral Exudative Choroidal Neovascularization by Optical Coherence Tomography Angiography.

Objectives: To evaluate treatment-naïve patients with neovascular-exudative age-related macular degeneration (eARMD) in one eye and early-/intermediate-stage nonexudative ARMD (neARMD) in the fellow eye by optical coherence tomography-angiography (OCTA). Methods: A total of 70 eyes of 35 patients (17 females) with first diagnosis of eARMD in one eye and early/intermediate-stage neARMD in the fellow eye were included in this study. The eARMD diagnosis was confirmed by fluorescein angiography. Each subject underwent OCTA imaging by RTVue XR Avanti OCT device. Capillary vessel density (VD) of superficial (SCP) and deep (DCP) retinal capillary plexuses and foveal avascular zone (FAZ) parameters were measured. Results: The mean age was 72.0±8.9 years (range 59-87). The mean visual acuity was 0.7±0.5 logMar for the eARMD eyes and 0.4±0.3 logMar for the fellow eyes (p=0.012). Nineteen patients (54.3%) had occult choroidal neovascularization (CNV), and 16 patients (45.7%) had classical CNV. The mean FAZ area was measured 0.30 ± 0.11 mm2 in the eARMD eyes and 0.27±0.11 mm2 in the fellow eyes (p=0.387). The FAZ circularity index measurement was 1.15±0.03 in eARMD eyes and 1.11±0.05 in the fellow eyes (p=0.014). There was no statistically significant difference in any measure of the macular SCP and DCP's VD between eARMD eyes and their fellow eyes. Conclusion: Potential retinal vascular alterations will be important in ARMD pathogenesis.

Laser photocoagulation, intravitreal anti-VEGF, and vitreous surgery for the treatment of juxtapapillary retinal capillary hemangioma.

Juxtapapillary retinal capillary hemangiomas (JRCHs) are benign vascular tumors located on or adjacent to the optic nerve head. A 19-year-old girl presented with epiretinal membrane (ERM) associated with an elevated and round vascular tumoral mass located in the juxtapapillary region of her left eye. She was subsequently diagnosed with isolated JRCH. A combined approach with laser photocoagulation and intravitreal bevacizumab injection was used to facilitate shrinkage of the tumor preoperatively and pars plana vitrectomy was used to remove the tumor and ERM. A small remnant of tumoral mass remained intact and did not show any growth for 7 years.

RETINAL METASTASIS FROM SQUAMOUS CELL CARCINOMA OF THE LUNG: A CASE PRESENTATION.

BACKGROUND/PURPOSE: To present a case with retinal metastasis from squamous cell carcinoma of the lung. METHODS: Case report. RESULTS: A 54-year-old man presented with blurry vision in his left eye. His medical history was significant for Stage IV squamous lung carcinoma. He was undergoing chemotherapy and had a known metastasis. He had a slightly elevated whitish lesion associated with retinal hemorrhages in the left posterior pole. Optical coherence tomography showed a full-thickness retinal mass. No involvement of the choroid could be detected. Further investigation demonstrated a de novo metastasis in the right frontal lobe of the brain. CONCLUSION: The lesion showed remarkable regression with subsequent systemic chemotherapy.

Efficacy of Dexamethasone Implants in Uveitic Macular Edema in Cases with Behçet Disease.

PURPOSE: Investigation of the efficacy of intravitreal dexamethasone implants (0.7 mg) in patients with Behçet disease (BD) who had cystoid macular edema (CME) despite immunomodulatory treatment. MATERIALS AND METHODS: Twenty-seven eyes of 20 patients who had intravitreal dexameth-asone implant injections and follow-up for more than 6 months were included in this study. Best corrected visual acuities (BCVA), intraocular pressures (IOP), and central macular thicknesses (CMT) were recorded. Systemic immunomodulatory treatment was noted. Injection-related complications and the need for recurrent injections were recorded. RESULTS: Statistically significant anatomical and functional success was achieved with a single injection. BCVA increased from 0.85 ± 0.72 to 0.45 ± 0.52 logMAR, while the mean CMT decreased from 406 ± 190 to 243 ± 101 µm at the sixth month. The peak of visual acuity gain was reached within the first 2 months and a substantial proportion of the patients gained 3 or more lines. There was no complication other than transient IOP elevation in 4 eyes and cataract surgery in 2 eyes. CONCLUSION: Adjuvant intravitreal dexamethasone implant injections offer promising results in cases of BD with CME. It is effective in preserving the macular anatomy and vision particularly in transition to biological agents.

Comparison of Brain Atrophy, Cognition and Optical Coherence Tomography Results Between Multiple Sclerosis Patients and Healthy Controls.

INTRODUCTION: Cognitive impairment is also an important cause of disability in MS in addition to motor, sensory, visual, and cerebellar affections. The aim of this study is to show the relation between the cognitive disability in MS with brain atrophy and retinal nerve fiber layer (RNFL). METHODS: Forty-three multiple sclerosis (MS) patients, and 15 healthy individuals as controls were included in the study. MS patients were divided into three groups as relapsing-remitting MS (RRMS), relapsing-remitting with optic neuritis (RRMS+ON), and secondary-progressive MS (SPMS). An experienced psychologist performed modified Wechsler Memory Scale Revised form (WMS-R), Lines Orientation test, Stroop Color Word Interference test (STROOP), Standard Raven Progressive Matrices (SRPM), Benton Facial Recognition Test, verbal fluency test, and Paced Auditory Serial Addition tests in all cases. Optic coherence tomographies (OCT) were done. Cranial subcortical volumes of all subjects were measured using 3-dimensonal T1A imagines obtained by the cranial subcortical 1.5 tesla MR device (fully automatic Freesurfer program). Brain parenchymal fractions were calculated by proportioning the obtained volume measurements to the total intracranial volume. RESULTS: Fifty-eight subjects (65.5% female, 34.5% male) were enrolled in the study. There were significant differences among the groups in terms of parenchymal thickness, volumes of third ventricle, and white matter. There was a significant correlation between the volumes of the deep gray matter, mesial temporal structures and lateral ventricular volumes, and the test results of the WMS-R. OCT scores of all MS patients, whether or not they experienced optic neuritis, had increased, being worse especially in the SPMS group. Correlation between RNFL and the brain parenchymal fractions of the patients were statistically significant. CONCLUSION: Manual methods instead of automatic segmentation method are being more commonly used in the studies with brain atrophy and MS in our country. A significant correlation between OCT scores and brain atrophy is shown with our present study, and this is followed as a reflection of decrease in cognitive tests that provides valuable and reliable knowledge for the literature.

Spectral domain optical coherence tomography findings of patients under treatment for pediatric acute lymphoblastic leukemia.

PURPOSE: To investigate the use of spectral domain optical coherence tomography (SD-OCT) findings in pediatric acute lymphoblastic leukemia (ALL) patients. METHODS: Children that were diagnosed with precursor B-cell ALL and classified as belonging to the medium-risk group for relapse were selected for this study. Individuals who were in continuous remission and on maintenance therapy were included in the study group. Cases that had central nervous system involvement were excluded. Age-matched, otherwise healthy children were selected for the control group. Each study participant underwent a comprehensive eye examination and SD-OCT evaluation. Thickness measurements were made within the retinal nerve fiber layer (RNFL), central macula, posterior polar, and peripapillary choroid. RESULTS: A total of 112 eyes of 56 children were included: 54 eyes in the study group and 58 in the control group. Compared to the control group, subfoveal and temporal choroidal thicknesses of the posterior pole were significantly thinner in the study group (P < 0.005). Similarly, peripapillary choroidal thicknesses were significantly thinner in most sectors of the study group (P < 0.005). There were no major differences between groups in terms of central macular thicknesses and overall RNFL thicknesses. CONCLUSIONS: Evidence of choroidal attenuation was found in this subgroup of pediatric ALL patients. Further studies are warranted to clarify the utility of SD-OCT in detecting subclinical ocular involvement and monitoring treatment response and risk of relapse in patients with pediatric leukemia.

Amino acid and vascular endothelial growth factor levels in subretinal fluid in rhegmatogenous retinal detachment.

PURPOSE: To study the concentrations of amino acids and vascular endothelial growth factor (VEGF) in subretinal fluid (SRF) of cases with rhegmatogenous retinal detachment (RRD). The relevance of the results with postoperative anatomic and functional success in RRD was investigated. METHODS: Fifty-three patients were included in this prospective study. The study group consisted of 46 patients who had scleral buckling surgery with the diagnosis of RRD, and SRF was obtained during the surgery. The control specimens consisted of vitreous samples of seven patients who were diagnosed with pars plana vitrectomy without RRD. Study cases were divided into three groups, corresponding to the duration of retinal detachment. Clinical characteristics, including best corrected visual acuity (BCVA) and anatomic status at month 6, were recorded. Concentrations of 15 selected amino acids were quantified by using high performance liquid chromatography, and VEGF levels were measured with enzyme immunoassay. RESULTS: When compared with the control group, SRF concentrations of aspartate, citrulline, glutamate, and glycine increased significantly in the study group (p<0.05). Statistical analysis showed that concentrations of alanine, isoleucine, leucine, methionine, phenylalanine, threonine, tyrosine, and valine decreased (p<0.05). SRF levels of glutamine, taurine, and serine had no significant change. SRF VEGF levels were significantly higher than the vitreous samples of the controls (p<0.001). Time-dependent changes and interactions between VEGF and amino acids were observed. There was no correlation between the concentrations of amino acids or VEGF with the parameters of BCVA and anatomical success. CONCLUSIONS: Significant changes occur in concentrations of amino acids and VEGF in SRF of cases with RRD. Our results suggest that several mechanisms contribute to the pathophysiology.

Correlation of spectral domain optical coherence tomography findings and visual acuity in central serous chorioretinopathy.

PURPOSE: To investigate the correlation between spectral domain optical coherence tomography findings and best-corrected visual acuity (BCVA) in patients with central serous chorioretinopathy (CSC) and to determine the visual prognostic factors. METHODS: We retrospectively studied 56 eyes of 49 patients who had the diagnosis of CSC. Patients were categorized into subgroups depending on symptoms and clinical findings. Together with the overall foveal integrity of inner segment/outer segment (IS/OS) and external limiting membrane, several features of CSC including hyperreflective dots and hypertrophy of retinal pigment epithelium were investigated with spectral domain optical coherence tomography. Thickness measurements within the retina and choroid were performed. RESULTS: Best-corrected visual acuity was closely associated with IS/OS line integrity (P < 0.001). The length of IS/OS disruption also had significant correlation with BCVA (r = -0.324, P = 0.016). Loss of foveal IS/OS and external limiting membrane line integrity was related to low BCVA (P < 0.001 for both). Presence of hyperreflective dots (P < 0.001) and retinal pigment epithelium hypertrophy (P = 0.011) had significant association with visual status. In cases with sequelae of CSC, BCVA was correlated with parameters of outer retinal damage. CONCLUSION: Besides the overall integrity of IS/OS line and the length of disruption, loss of foveal IS/OS and external limiting membrane integrity are also noteworthy in cases with CSC. Hyperreflective dots and retinal pigment epithelium hypertrophy are closely associated with BCVA in cases with CSC. Analysis of the subgroups has shown that morphologic changes that persist until the late phases of the disease could potentially affect the visual outcome.

S100b protein levels in subretinal fluid in rhegmatogenous retinal detachment.

PURPOSE: To investigate the relevance of the concentration of S100B in subretinal fluid (SRF) with the postoperative anatomical and functional success and proliferative vitreoretinopathy (PVR) formation parameters in rhegmatogenous retinal detachment (RRD). METHODS: Fifty-three patients (34 male, 19 female) were included in this prospective study. Study group consisted of 46 patients who had scleral buckling (SB) surgery with the diagnosis of RRD. Control group consisted of six patients who had pars plana vitrectomy (PPV) for either full-thickness macular hole or subluxated intraocular lens. SRFs were obtained during SB surgery. Study cases were divided into three groups, corresponding to the duration of retinal detachment (DRD). Clinical characteristics including best-corrected visual acuity (BCVA), anatomical status at 6 months, the presence of postoperative PVR that resulted in recurrent detachment and any possible re-operations were recorded. The concentration of S100B was quantified by using an enzyme immunoassay test kit. RESULTS: The concentration of S100B in SRF increased significantly after RRD. And, S100B levels were evidently elevated in concordance with DRD. There was no correlation between the concentration of SRF - S100B with preoperative or postoperative BCVA. Again, S100B levels were not related to the extent of RRD or postoperative PVR formation. CONCLUSION: Concentration of S100B in SRF is good marker of retinal stress and increases in concordance with DRD. However it would not help to predict the possible anatomical and functional success or postoperative PVR formation.

Herpes zoster ophthalmicus and lateral rectus palsy in an elderly patient.

Acquired palsy of the lateral rectus presents with horizontal diplopia and has a broad differential. Herpes zoster ophthalmicus- (HZO) related cranial nerve palsy is a transient and self-limiting condition. Systemic antiviral treatment is administered in order to prevent sight-threatening complications. In suspected cases, zosteriform rash should be questioned. One should keep in mind that acquired esotropia in the elderly may sometimes present following HZO.

Intravitreal versus sub-tenon posterior triamcinolone injection in bilateral diffuse diabetic macular edema.

PURPOSE: To compare the efficacy of intravitreal and sub-Tenon (ST) posterior triamcinolone injection in the treatment of bilateral diabetic diffuse macular edema (DDME). METHODS: 28 eyes of 14 diabetic patients with bilateral DDME were included in this prospective randomized study. One eye of each individual received a sub-Tenon (ST) posterior triamcinolone injection (ST group), whereas the fellow eye received an intravitreal triamcinolone injection (IV group). All eyes were treated with supplementary focal laser after the injections. Cases were evaluated 1, 2, 3 and 6 months after the initial treatment. RESULTS: Both groups had visual improvement and macular edema reduction following the injections. This temporary effect was prominent for 24 weeks in the IV group and for 8 weeks in the ST group. Edema resorption and visual improvement were more pronounced in the IV group, although this difference was not statistically significant. No major complications were observed except for moderate and reversible intraocular pressure elevation in some cases. CONCLUSION: Both intravitreal and ST injections of triamcinolone appear to yield a significant visual recovery and prompt resolution of DDME. The beneficial outcome appears to be more longstanding with intravitreal injection.

SUBCONJUNCTIVAL INTERFERON α-2A APPLICATION IN A CASE WITH SERPIGINOUS CHOROIDOPATHY.

BACKGROUND: Serpiginous choroidopathy (SC) is a chronic, inflammatory disease which progresses with recurrences leading to visual loss. Diverse immunosuppressive regimens have been used for treatment. In case of an unanticipated side effect with immunosuppressive agents, alternative modalities in SC are limited. METHODS: A 38-year-old woman presented with slight deterioration in visual acuity in her right eye. She had had a visually devastating episode of SC in the left eye 8 months previously. She received combination therapy of prednisone, cyclosporine, and intravitreal triamcinolone for the left eye. With that treatment, vision in her left eye declined to light perception due to macular involvement and renal functions were impaired. Eight months later, she was hospitalized with the diagnosis of SC in the right eye. In the quest for an alternative modality, a combination of antituberculosis medications was given initially, because of the high PPD reading. Despite 10 days of treatment, the lesion persistently progressed. Subsequently, interferon (INF) α-2a therapy was initiated solely as daily injections of 1 million unit (MIU) subconjunctivally. The frequency of injections was tapered within the course. Currently, injections are still being dispensed once a month. RESULTS: Throughout the 12 months of follow-up, the patient had no major side effects due to INF α-2a therapy. At present, SC in the right eye is inactive and the macula is safe in terms of incurring. The vision is 20/20 in the right eye, whereas it is light perception in the left eye. CONCLUSION: Interferon α-2a administration in SC can be an efficient modality and is free of immunosuppression related side effects. Subconjunctival application seems to be a promising and safe tool for treatment.

Intravitreal triamcinolone improves recovery of visual acuity in nonarteritic anterior ischemic optic neuropathy.

BACKGROUND: The visual outcome in untreated nonarteritic anterior ischemic optic neuropathy (NAION) is dismal. Because intravitreal triamcinolone (IVTA) has shown promise in improving edematous retinal disorders, a pilot trial of this therapy in NAION was considered reasonable. METHODS: Four eyes of 4 patients with severe visual loss due to NAION were treated with 4 mg IVTA (study group). The control group consisted of 6 consecutive patients with NAION who received no treatment. Patients were evaluated by the visual acuity and visual field measurements of the Early Treatment Diabetic Retinopathy Study (ETDRS) and fluorescein angiography. RESULTS: All patients completed at least 9 months of follow-up. In the study group, the mean improvement in visual acuity were 4, 5.8, and 6.2 ETDRS lines at the first and third weeks and final visit, respectively. Optic disc swelling and leakage had markedly decreased at the first postinjection week and had disappeared by the third week examination in all eyes. In the control group, the mean improvements in visual acuity were 0, 0.7, and 1.3 ETDRS lines at the first and third weeks and final visit, respectively. Control eyes showed resolution of the optic disc swelling between the fourth week and third month visits. No marked change in visual field defects was observed in either group. CONCLUSIONS: IVTA provided relatively improved recovery of visual acuity and relatively rapid resolution of optic disc swelling in a small sample of patients with acute NAION. It did not provide visual field improvement. A larger trial is merited by the results of this small pilot study.

Intravitreal triamcinolone as an adjunct in the treatment of concomitant proliferative diabetic retinopathy and diffuse diabetic macular oedema. Combined IVTA and laser treatment for PDR with CSMO.

PURPOSE: To investigate if triamcinolone acetonide (TA) can be an adjunct to laser treatment in patients with concomitant non-high-risk proliferative diabetic retinopathy (PDR) and diffuse clinically significant diabetic macular oedema (CSMO). METHODS: This prospective, interventional and comparative clinical study included 32 eyes of 16 patients with bilateral concomitant non-high-risk PDR and diffuse CSMO. Each patient received 4 mg intravitreal TA for the eye with worse visual acuity (study group) and macular focal and grid laser photocoagulation (MP) for the other eye (control group). One month later, each patient received four sessions of panretinal photocoagulation for both eyes plus MP for the eyes in the study group. The visual and angiographic results of both groups were compared. RESULTS: In the study group, the mean visual acuity (VA) improved from 0.12 +/- 2.3 lines at the baseline to 0.19 +/- 3.1 (P = 0.004), 0.20 +/- 3.2 (P = 0.004), 0.19 +/- 3.6 (P = 0.009) and 0.19 +/- 3.3 lines (P = 0.091) at the 1-, 3-, 6- and 9-month follow-up intervals, respectively. The macular oedema was found to be resolved in 11 eyes (69%) and decreased in five eyes (31%). In the control group, the mean VA deteriorated progressively from 0.41 +/- 3.1 lines at the baseline to 0.20 +/- 3.1 lines (P = 0.026) at the end of the study and the macular oedema decreased only in three eyes (19%) at the sixth follow-up month. CONCLUSIONS: During the follow-up period of the study, intravitreal TA as an adjunct in the treatment of concomitant non-high-risk PDR and diffuse CSMO led to a more-favourable clinical outcome than conventional laser treatment.

Ocular surface changes with applanation contact lens and coupling fluid use after argon laser photocoagulation in noninsulin-dependent diabetes mellitus.

PURPOSE: To describe the effect of coupling solutions used during laser photocoagulation on the ocular surface of patients with noninsulin-dependent diabetes mellitus (NIDDM). DESIGN: A prospective case-controlled study. METHODS: Ninety-two eyes of 46 NIDDM patients with clinically significant macular edema, poor metabolic control of diabetes, and peripheral neuropathy and 100 eyes of 50 normal control subjects were studied. The patients' eyes were assigned to argon green focal/grid laser photocoagulation using an applanation contact lens and one of the coupling fluids; 2% methocel, Thilo-Tears Gel, 1.4% sodium hyaluronate, or 0.9% simple saline. The control subjects received time-matched three-mirror contact lens fundus examinations. All subjects underwent corneal sensitivity measurements, Schirmer test, tear film breakup time, and corneal fluorescein staining before as well as 3 and 8 days after the laser procedures and contact lens examinations. Patients with corneal problems persisting after 8 days were followed longer. RESULTS: Diabetic eyes assigned to 2% methocel and 1.4% sodium hyaluronate had significantly lower mean corneal sensitivities and break-up time values as well as significantly higher mean fluorescein staining scores at all examination points after laser photocoagulation. All diabetic eyes with aqueous deficiency assigned to 2% methocel and 1.4% sodium hyaluronate developed delayed corneal epithelial healing. CONCLUSION: The use of viscous coupling solutions during applanation contact lens-aided laser procedures may be detrimental for the corneal epithelium in poorly controlled NIDDM patients with peripheral neuropathy and coexisting aqueous deficiency.

Pars plana vitrectomy and removal of the internal limiting membrane in the treatment of chronic macular oedema.

BACKGROUND: To evaluate the results of pars plana vitrectomy with peeling of the internal limiting membrane (ILM) in eyes with chronic macular oedema. METHODS: PPV with indocyanine green (ICG) assisted peeling of the ILM was performed in 33 eyes with diabetic (21 eyes) or non-diabetic (12 eyes) macular oedema. Postoperatively, resolution of macular oedema, improvement of visual acuity (VA) and complications were documented. The peeled membranes were submitted for light and transmission electron microscopic evaluation. RESULTS: The mean follow-up time was 12.2 months. The macular oedema decreased or was resolved in 17 (81%) eyes in the diabetic group and in 11 (92%) eyes in the non-diabetic group. VA improved by at least 2 lines in 11 (52%) eyes in the diabetic group and in 7 (58%) eyes in the non-diabetic group. The difference between visual acuity improvements of the two groups was not statistically significant (P>0.05). However, in the diabetic group the difference of visual improvement between cystoid and diffuse type of macular oedema eyes was statistically significant (14% versus 71%, P=0.02). Light and transmission electron microscopy showed the presence of ILM in all specimens. During the follow-up period no recurrence of macular oedema or epiretinal membrane formation was observed. CONCLUSION: Pars plana vitrectomy with peeling of the ILM and epiretinal membrane leads to the resolution of macular oedema in the majority of eyes. This however, is not always associated with VA improvement. In diabetic eyes, cystoid type of macular oedema appears to be a poor prognostic factor for improved VA.

Radial optic neurotomy in central retinal vein occlusion: preliminary results.

BACKGROUND: To investigate the efficacy of radial optic neurotomy (RON) on visual prognosis and clinical findings in central retinal vein occlusion (CRVO). METHODS: Prospective, non-randomised, self-controlled comparative trial. Six patients with ischemic CRVO who had visual acuity (VA) less than or equal to 0.1 and duration of CRVO at least 1 month, and 6 patients with non-ischemic CRVO who maintained their VA less than or equal to 0.1 during the minimal follow-up of 3 months underwent pars plana vitrectomy and RON. LogMAR VA measurement and fluorescein angiography were performed before and after surgery. Automated perimetry was obtained from 4 patients at the last visit. Main outcome measures were VA and clinical changes in fundus appearance of CRVO evaluated with fundus photography and fluorescein angiography. RESULTS: Radial optic neurotomy was successfully performed in all 12 patients without serious complications. All patients were of clinical improvement of fundus findings. In 11 (92%) patients, a visual improvement of at least 2 lines was observed. After mean follow-up of 9.3 months, mean improvement in VA was 5.1 +/- 3.1 lines (range, 2-14 lines). Cystoid macular oedema and degeneration were observed in 8 (67) patients. Four patients, two of whom had preoperative ocular hypertension had raised intraocular pressure controlled with topical antiglaucoma medication. In late postoperative period, one ischemic eye developed vitreous haemorrhage necessitating vitrectomy and endolaser photocoagulation. Automated perimetry revealed segmental visual field defects in all the examined eyes. CONCLUSIONS: Radial optic neurotomy in CRVO yields clinical and visual improvement in majority of the patients. Cystoid macular oedema and degeneration are the major factors responsible for restriction of VA improvement. Further randomised and controlled studies with longer follow-up are essential to establish the appropriate timing and indications of RON in CRVO.