Subthreshold laser treatment for retinal arterial macroaneurysm.

PURPOSE: To assess the effects of subthreshold laser treatment (STLT) for retinal arterial macroaneurysms (RAM) associated with foveal exudative manifestations and visual acuity deterioration. METHODS: Patients with RAM associated with foveal exudative manifestations and best-corrected visual acuity (BCVA) worse than 20/80 Snellen equivalent underwent a ophthalmological examination, including ETDRS visual acuity, optical coherence tomography (OCT) and fluorescein angiography. The patients were prospectively observed for 4 months, and in absence of spontaneous improvement, they underwent STLT using an infrared diode laser. RESULTS: Primary outcome measures were a reduction in mean central point thickness (CPT) and BCVA changes at the 12-month examination. Secondary outcomes included changes in mean total macular volume (TMV) and central subfield thickness (CST). Nine patients were enrolled and prospectively followed up. The mean baseline values of BCVA, CPT, TMV and CST were 0.8 ± 0.1 (logMAR ± SD), 340 ± 49 µm, 7.14 ± 0.05 mm(3) and 366 ± 37 µm, respectively. At the 4-month examination following STLT, the mean BCVA improved to 0.6 ± 0.2, whereas the mean CPT, TMV, and CST decreased to 274 ± 29 µm, 6.87 ± 0.11 mm(3) and 296 ± 33 µm. At the 12-month examination, the mean BCVA was 0.36 ± 0.2, the mean CPT was 195 ±11 µm, the mean TMV was 6.55 ± 0.19 mm(3), and the mean CST was 239 ± 14 µm, respectively. No side-effects were noted. In particular, no sign of retinal thinning and underlying backscattering typical of conventional laser treatment could be detected at the site of the laser application on OCT. CONCLUSION: The current pilot investigation of STLT for the treatment of symptomatic RAM revelas encouraging data. A randomised clinical trial is required to ascertain the real efficacy of this technique and the most appropriate settings to be employed.

Fundus autofluorescence in subfoveal choroidal neovascularisation secondary to Pathological Myopia.

AIM: To describe the fundus autofluorescence (FAF) characteristics of choroidal neovascularisation (CNV) associated with pathological myopia (PM), and their modification after photodynamic therapy (PDT). DESIGN: Open-label, prospective, interventional case series. METHODS: Forty-two patients affected by subfoveal CNV in PM underwent PDT with a 24-month follow-up. Each patient underwent an ophthalmological examination every 3 months, including FAF and fluorescein angiography. FAF distribution was qualitatively evaluated at the CNV site, around the CNV and outside the area affected by CNV. RESULTS: CNV at baseline showed a high FAF signal with uniform distribution, or with some spots of low FAF internally, in 64% and 36% of cases, respectively. At the 3-month control after PDT, the CNV retained the same response, but a round halo of increased signal extending beyond the site of the PDT application was detectable around the CNV. At the end of the follow-up, a high or a low FAF signal was detected in 40% and 60% of cases, respectively. CONCLUSION: CNV secondary to PM shows a specific, high signal, FAF pattern. A round halo of increased FAF signal surrounding the CNV was detectable after PDT application, whereas a FAF signal progressive reduction was visible at and around the CNV site from the sixth month. A high FAF signal at the CNV site is associated with an improved visual acuity outcome at the 2-year follow-up. Further studies to correlate the morphological and functional features are advisable, especially by means of microperimetric analyses and with a longer-term follow-up.

A new heavy internal tamponade in vitreoretinal surgery: an in vitro study.

AimTo study the solubility of perfluorohexyloctane (F6H8) in silicone oil (polydimethylsiloxane (PDMS) 1000) and to measure the viscosity and the specific gravity of the mixture obtained (heavy silicone oil or HSO tamponade) to define the ideal ratio of these components.MethodsThe solubility diagram of the mixture was obtained with the turbidimetric method, indicating the miscibility of F6H8 and silicone oil 1000 at all the useful temperatures. The viscosity was measured in steady shear conditions by using a controlled stress rheometer (Haake RS150) and a double cone/plate (DC 60/4) system, both at 25 and 37 degrees C for different volume per cent compositions of the mixture. The specific gravity was measured at 37 degrees C using a digital densimeter.ResultsA mixture of F6H8 30 v% and PDMS 70 v% was found to be transparent and stable at all the useful temperatures. By combining these proportions of the two substances, a resultant density of 1.06 g/cm(3) was obtained. The viscosity of the 30% F6H8 mixture was 203 mPa.s at 25 degrees C and 163 mPa.s at 37 degrees C respectively.ConclusionsThe ideal F6H8 and silicone oil mixture can be obtained combining 30% of F6H8 with 70% of silicone oil 1000. This mixture seems to have rheological properties useful for its use as an alternative intraocular heavy tamponade.Eye (2008) 22, 1082-1088; doi:10.1038/eye.2008.144; published online 6 June 2008.

Intravitreal triamcinolone acetonide combined with subthreshold grid laser treatment for macular oedema in branch retinal vein occlusion: a pilot study.

BACKGROUND: To compare the effectiveness of subthreshold grid laser treatment (SGLT) with infrared micropulse diode laser alone or in combination with intravitreal triamcinolone injection (SGLT-IVTJ) for the treatment of macular oedema (MO) secondary to branch retinal vein occlusion (BRVO). METHODS: Pilot randomised clinical trial including 24 patients (24 eyes) who were randomised either to the SGLT (13 eyes) or to SGLT-IVTJ (11 eyes). Complete ophthalmic examinations, including Early Treatment of Diabetic Retinopathy Study visual acuity, OCT and fluorescein angiography, were performed at the moment of the study entry and at 3-month intervals, with a planned follow-up of 12 months. Main outcome measures were the decrease in mean foveal thickness (MFT) on OCT, and the proportion of eyes that gained at least 10 letters (approximately two or more lines of visual acuity gain) at the 12-month examination. Secondary outcomes were the decrease in mean total macular volume on OCT, and the timing of MO resolution. RESULTS: The change in MFT from the initial values was statistically significant for the SGLT-IVTJ from the 3-month examination and for the SGLP from the 6-month examination (p<0.001). At the 12-month evaluation, 10 patients of the SGLT-IVTJ group (91%) and eight of the SGLT group (62%) gained at least 10 letters (two lines) in visual acuity. The mean number of lines gained was 3.4 and 1.3 in the SGLT-IVTJ and in the SGLT group, respectively. CONCLUSIONS: The combined SGLT-IVT treatment of MO secondary to BRVO allows a significant visual acuity improvement, when compared with simple grid laser treatment.

The spectrum of iris angiography abnormalities in pseudoexfoliation syndrome.

PURPOSE: To analyse the spectrum of angiographic features in patients monolaterally or bilaterally affected by pseudoexfoliation syndrome (PES), with and without glaucoma, and to evaluate the sensibility and specificity of these features in the diagnosis of glaucoma. METHODS: Sixty-eight patients affected by PES and 20 healthy subjects underwent iris fluorescein angiography (IFA) and iris indocyanine green angiography (IICGA). Angiographic features analysed were hypoperfusion, microneovascularizations, and anastomotic vessels. RESULTS: There was no statistically significant difference among unaffected, unilaterally affected, and bilaterally affected eyes. Patients affected by PES glaucoma showed a statistically significant difference with respect to the other groups for most of the variables. The results of qualitative variables revealed a gradual increase of the vascular involvement in the different groups. Peripupillary tufts, stromal tufts, and radial arterioles showed the best sensibility and specificity values on IFA, whereas radial arterioles and plexuses showed the highest sensibility and specificity values on IICGA. Considering all the parameters, the results were not associated with large effects on the post-test probability of disease. The values of likelihood ratio indicated that none of the examined variables was sufficiently able to discriminate patients affected by PSE glaucoma from the overall group. CONCLUSIONS: Patients clinically affected only monolaterally by PES show microvascular changes, which are similar in both eyes. Glaucoma PES represents a more advanced stage of the disease, with more pronounced alterations, even though no typical microvascular pattern can be identified by iris angiography.

Recurrence of hemispheric retinal vein occlusion.

The purpose of this article is to report a case in which a double hemispheric retinal vein occlusion (HSRVO) occurred in the same eye, involving firstly the superior half and later the inferior half of the retina. A 63-year-old woman with ill-controlled hypertension had been diagnosed with central retinal vein occlusion in the right eye in January 1998. The patient had a HSRVO of the superior hemiretina in November 2003, and a HSRVO of the inferior hemiretina in August 2005. The patient underwent a complete work-up, but the only detected risk factor was hypertension. Bearing in mind the absence of an effective treatment able to reduce both the incidence and the recurrence of retinal vein occlusion, detection and control of the risk factors, such as hypertension, is essential. We should make every effort to improve the compliance of our patients in controlling general diseases all their lives.

Intraocular lens decentration and posterior capsule opacification: anatomo-pathologic findings after implantation of AMOSI40 IOLS.

PURPOSE: To evaluate the incidence of intraocular lens (IOL) decentration and posterior capsule opacification (PCO) after implantation of a three-piece posterior chamber silicone IOL in a series of eyes examined postmortem. METHODS: Twenty-three pseudophakic enucleated human cadaver eyes, implanted with AMO SI40NB IOLs after phacoemulsification, were analyzed. Eyes obtained postmortem were sectioned at the equatorial plane and the anterior segment photographed from a posterior view. Location of IOL optic and haptics, type of fixation, and centration of IOL was evaluated. PCO was graded and the presence of Nd:YAG laser posterior capsulotomy was noted. RESULTS: Mean age at the time of surgery was 77.83 years, mean time since implantation was 18.26 months. In all the eyes examined, IOL haptics were positioned in the capsular bag. Mean decentration was 0.20+/-0.16 mm. No correlation was found between IOL decentration and time since implantation. The degree of peripheral PCO ranged from none (13.0%) to mild (39.1%) to moderate (26.1%) to severe (21.7%). The degree of central PCO ranged from none (52.2%) to mild (30.4%) to moderate (4.3%). Three patients (13.0%) underwent Nd:YAG laser posterior capsulotomy. CONCLUSIONS: A very good centration can be obtained when silicone AMOSI40NB IOLs are correctly implanted with the haptics inside the capsular bag. About half of the implants showed no central PCO while Nd:YAG laser posterior capsulotomy rates documented a relatively low PCO 18 months after surgery. A careful in the bag haptics placement is needed in order to reduce the IOL decentration and to prevent central PCO.

Atypical pattern of retardation on GDx-VCC and its effect on retinal nerve fibre layer evaluation in glaucomatous eyes.

PURPOSE: To assess the effect of atypical pattern of retardation (APR) on retinal nerve fibre layer (RNFL) measurements made by scanning laser polarimetry (SLP) with variable corneal compensation (GDx-VCC) in glaucomatous eyes. METHODS: One eye each of 30 glaucomatous patients (average mean deviation (MD): -6.4+/-4.8) with APR on GDx-VCC retardation map were selected. In total, 34 glaucomatous, age- and severity-matched eyes (average MD: -7.0+/-5.3) and 36 age-matched healthy subjects, both with a normal pattern of retardation (NPR) represented control groups. APR on retardation maps was characterized by alternating peripapillary circumferential bands of low and high retardation, or high retardation areas arranged in a spokelike pattern, or high retardation nasal and temporal splotchy areas. Typical scan score (TSS) was extracted for each included eye. GDx-VCC parameters (mean+/-SD) in the two groups of glaucomatous eyes were compared with healthy eyes' corresponding values (Mann-Whitney U-test). Areas under receiver operating characteristic (AUROC) curves were generated to assess the APR effect on the parameters' diagnostic ability. RESULTS: All parameters discriminated adequately between healthy and glaucomatous eyes with NPR (AUROCs > or =0.9 for nine parameters). On the contrary, considering healthy and glaucomatous eyes with APR, four thickness parameters could not separate the two groups and AUROCs > or =0.85 appeared only for Inferior and Superior Ratio, NFI, Max Modulation. CONCLUSION: APR may void the effect of custom compensation and provide spurious RNFL thickness measurements. When a printout of glaucomatous eyes with APR is evaluated, it is proper to rely on ratios, modulation parameters, and NFI, since the diagnostic ability of thickness parameters is significantly reduced.

Comparing measurements of retinal nerve fiber layer thickness obtained on scanning laser polarimetry with fixed and variable corneal compensator.

PURPOSE: To compare retinal nerve fiber layer (RNFL) thickness measurements obtained on scanning laser polarimetry (SLP) with commercially available instruments coupled with fixed (FCC) and variable corneal compensator (VCC). METHODS: Forty-two eyes of 42 patients underwent a complete ophthalmologic evaluation and achromatic automated perimetry (24-2 program, SITA standard strategy). Nineteen eyes were healthy (average mean deviation: -0.12 dB +/- 2.26) and 23 glaucomatous (average mean deviation: -4.92 dB +/- 6.49). All patients underwent SLP with both FCC and VCC. Adequate compensation of corneal birefringence on FCC-SLP was checked acquiring macular retardation map (MRM). RNFL thickness was evaluated considering superior and inferior maximum (SM, IM), average thickness and ellipse average (AT, EA), and superior and inferior average (SA, IA). Mean values (+/-SD) for each parameter measured by the two polarimeters were compared and linear regression calculated. The ability of each parameter to discriminate between normal and glaucomatous eyes was evaluated on both polarimeters calculating area under ROC curve. RESULTS: A significant linear correlation for all parameters was noted (r range: 0.65-0.78). VCC produced slightly higher thickness values than FCC, both in normal and glaucomatous eyes. On both polarimeters, area under ROC curve for all parameters discriminated adequately healthy from glaucomatous eyes (range: 0.68-0.81). CONCLUSIONS: In a highly comparable and selected group of normal and glaucomatous eyes, FCC-SLP and VCC-SLP showed considerable concordance in measuring peripapillary RNFL thickness, both for sectorial and global parameters. Proper corneal birefringence compensation provided separation of normal from glaucomatous eyes on both polarimeters.

Macular edema and visual loss after macular pucker surgery with ICG-assisted internal limiting membrane peeling.

PURPOSE: To describe the occurrence of massive macular edema and visual loss after indocyanine green-assisted (ICG) macular pucker surgery. METHODS/RESULTS: A 74 years old female presented with a macular pucker and a hypertrophy of the retinal pigment epithelium (RPE) in her left eye. The preoperative visual acuity (VA) was 20/100. Surgery consisted of cataract extraction, lens implantation and standard pars plana vitrectomy with peeling of epiretinal tissue followed by the removal of the internal limiting membrane (ILM) remnants stained using a 0.05% ICG solution. One day after surgery, VA was counting fingers. There was an extensive macular edema and retinal thickening with hyperfluorescence during fluorescein angiography and pronounced autofluorescence using ICG filters. During follow up, the macular edema resolved completely, but VA decreased to 20/800 at six months postoperatively. There was a central scotoma and unstable fixation seen during microperimetry. DISCUSSION: This case report indicates that ICG might come into contact with bare retina if injected following removal of epiretinal membranes. Whether the observed RPE hypertrophy might have contributed to the pathogenesis of the adverse effect described remains hypothetical.

Angiographic pattern of recurrent choroidal neovascularization in age-related macular degeneration.

PURPOSE: To evaluate the angiographic characteristics of recurrent choroidal neovascularization (R-CNV) in age-related macular degeneration (AMD). METHODS: A prospective investigation on 107 consecutive patients with exudative AMD and CNV not involving the fovea was conducted. Fluorescein angiography (FA) and indocyanine green angiography (ICGA) were planned before krypton laser treatment, and after 3 weeks, 2, 3, 4, 6, 9, 12, 18, and 24 months from photocoagulation. Laser treatment was FA-guided in eyes with classic CNV, and ICGA-guided in eyes with occult CNV on FA. RESULTS: At baseline on FA, 23.3% had classic CNV, whereas, 76.6% showed occult CNV. On ICGA, CNV assumed a focal and a plaque pattern in 81.3 and 18.6% of cases, respectively. Overall, post-laser CNVs occurred in 56 eyes. FA identified well-defined and ill-defined R-CNV in 25 and 75% of cases, respectively. ICGA identified three different R-CNV patterns: focal, annular, and plaque. Focal R-CNV was defined as a single dot-like hyperfluorescence, which was detected in 69.6% of cases, with subfoveal location in half of them. Annular R-CNV was identified by a hyperfluorescent lesion, partially or completely encircling treated area, which was visible in 19.6% of cases, all with subfoveal involvement. Plaque R-CNV was defined as a hyperfluorescent lesion larger than 1 disc diameter in size, and was seen in 10.7% of cases, all with subfoveal location. CONCLUSIONS: ICGA is able to improve R-CNV visualization identifying three different R-CNV patterns. Focal R-CNV is the most frequent pattern and can be re-treated in half of the cases.

Angiographic features after photodynamic therapy for choroidal neovascularisation in age related macular degeneration and pathological myopia.

AIM: To describe the angiographic features after photodynamic therapy (PDT) with verteporfin in choroidal neovascularisation (CNV) associated both with age related macular degeneration (AMD) and pathological myopia (PM). METHODS: 36 patients affected by subfoveal CNV in AMD and 25 patients with subfoveal CNV in PM underwent an ophthalmological examination including fluorescein angiography (FA) and indocyanine green angiography (ICGA) using the IMAGEnet System. Post-PDT examinations were performed 7, 30, and 90 days later. RESULTS: The typical angiographic aspect after PDT for AMD related CNV was a round hypofluorescence visible both on FA and on ICGA, which included both CNV and the surrounding tissues and corresponded to the area exposed to laser light. In PM the CNV appeared hypofluorescent during the early phases and gradually became hyperfluorescent during the late phases on FA, whereas on ICGA it was detectable in its whole extension as a hyperfluorescent lesion since the early phases. Differently from AMD, there was no round hypofluorescence surrounding the CNV on FA or on ICGA. Moreover, five patients in the AMD group showed hot spots on ICGA, which spontaneously disappeared during the follow up. Classic and occult components of the AMD related CNV revealed a different angiographic response to PDT, showing with the latter only a partial closure 1 week after PDT followed by a complete reopening at the first month in 100% of cases. CONCLUSION: The post-PDT hypofluorescence typical of AMD related CNV, especially visible on FA, might be secondary to a combination of choriocapillary occlusion and masking effect due to swelling of retinal pigment epithelium cells. Hot spots in the AMD affected patients could be interpreted as the expression of a non-thermal choroidal vasculitis secondary to PDT.

Electro-oculographic abnormality in eyes with uveal melanoma.

PURPOSE: To seek out correlations between preoperative electro-oculogram (EOG) recordings with different types of uveal melanomas, after surgery. METHODS: We analysed the EOG recordings of 120 patients with uveal melanomas, histologically verified, 100 in the choroid and 20 in the iris and ciliary body. The EOG data were correlated with the site, size and histological type of the tumor. RESULTS: In 100 eyes with choroidal melanoma the Arden Index (AI) was less than in fellow eyes (mean 126.6, SD +/- 23.8 and 202.9, SD +/- 47.0; p=0.01). The EOG values were not different with respect to the histological type, site and size of tumor. In cases with iris and ciliary body melanomas the AI were not significantly different from the fellow eyes (mean 180.6, SD +/- 23.6 and 203.2, SD +/- 38.7; p=0.07). CONCLUSIONS: Since the EOG is abnormal in eyes with choroidal melanoma, it can be considered a powerful auxiliary for diagnosing these tumors.

Genetic heterogeneity in Malattia Leventinese.

Malattia Leventinese (ML) is a dominant macular dystrophy characterized by drusen at the posterior pole. ML has been associated with a single mutation (R345W) in the EGF-containing fibulin-like extracellular matrix protein 1 (EFEMP-1) gene, but also the EFEMP-2 gene, known to share genetic homology with EFEMP-1, is considered a candidate gene for this genetic disorder. We have characterized clinically and genetically seven members of a three-generation family affected by ML. Results showed that five family members were clinically affected but the DNA sequencing failed to reveal the typical R345W mutation. Furthermore, the linkage analysis to EFEMP-1 (using polymorphic markers D2S337 and D2S2368) and to EFEMP-2 (using D11S987 and D11S1314 markers) gave negative results. Therefore, our results suggest EFEMP-1 or EFEMP-2 genes cannot be excluded as being responsible for ML but other genes have to be considered in the pathogenesis of the disease.

Occult choroidal neovascularization in adult-onset foveomacular vitelliform dystrophy.

AIMS: To report 6 cases in which indocyanine green angiography (ICGA) failed to convert occult choroidal neovascularization (CNV) into well-defined CNV in adult-onset foveomacular vitelliform dystrophy (AOFVD). METHODS: Patients with AOFVD observed from 1993 to 1999 were prospectively followed up. Whenever the development of CNV was suspected, ICGA was performed to detect the precise location and extension of CNV by means of the IMAGEnet System. RESULTS: Six out of 51 patients (11.7%) developed CNV during the follow-up. The CNV was of the occult type, with an associated detachment of the pigment epithelium in 1 eye. On ICGA, a large hyperfluorescent lesion appeared after about 10 min, irregularly increasing with time, without a clear visualization of site and extension of CNV. CONCLUSIONS: In AOFVD, ICGA may fail to convert occult CNV into well-defined CNV, which is amenable to laser treatment, since hyperfluorescence caused by the probably vitelliform material binding to the ICG molecule and the CNV-induced hyperfluorescence cannot be angiographically distinguished from each other.

Iris alteration using mechanical iris retractors.

A 74-year-old woman had a 3-port pars plana vitrectomy for a dropped nucleus after complicated phacoemulsification. Flexible nylon iris retractors were positioned to dilate the small pupil. The patient died of a pulmonary embolus 1 day after surgery. The eyeball was removed at autopsy, and pathology of the iris was investigated. Localized damage to the iris where the retractor hooks were positioned was noted, but no other alterations to the iris were observed. These findings may explain the recovery of pupil function that is common after surgery with mechanical iris retractors.

Comparative evaluation of corneal epithelial permeability after the use of diclofenac 0.1% and flurbiprofen 0.03% after phacoemulsification.

PURPOSE: To assess the corneal epithelial function after prolonged topical administration of diclofenac 0.1% and flurbiprofen 0.03% single-dose eyedrops. SETTING: University Eye Clinic of Trieste, Trieste, Italy. METHODS: This randomized prospective study comprised 24 patients scheduled for phacoemulsification. The patients were randomly assigned to receive diclofenac or flurbiprofen eyedrops for 2 months after surgery. Corneal epithelial permeability was determined by fluorophotometry 7, 37, and 67 days after surgery. RESULTS: An increase in corneal epithelial permeability was observed in the diclofenac group 37 and 67 days after surgery. No epithelial function alterations occurred in the flurbiprofen group. CONCLUSIONS: Subclinical impairment of the epithelial function was observed during topical treatment with diclofenac 0.1% single-dose eyedrops after phacoemulsification. The mechanism responsible for this effect remains unknown.

Subretinal fluid ferning test in rhegmatogenous retinal detachment.

PURPOSE: The ferning test involves a process of crystallization achieved simply by removing water and is feasible for all ocular fluids. The ferning test of subretinal fluid (SRF) from patients with rhegmatogenous retinal detachment (RRD) reveals three different patterns: type 1 showing thin crystals, type 2 with larger crystals and type 3 with small, curvilinear structures with no tree-like appearance. The present study was designed to determine whether the SRF ferning test is correlated with the clinical features and the surgical outcome of RRD. METHODS: A series of 65 consecutive patients with RRD at the first onset were considered. Particular attention was paid to duration, extension, and surgical outcome of RRD. SRF samples were collected during scleral buckling surgery. The fluid was dropped onto the slide of a light microscope, left to dry, and examined under the microscope. RESULTS: There was a significant difference between SRF ferning types 1 and 2 as regards, duration and extension (both p < 0.001). There was also a significant difference between SRF ferning types 2 and 3 as regards duration (p<0.001), extension (p<0.001), and surgical outcome (p<0.05). CONCLUSIONS: The ferning test of SRF is quick and simple and can be regarded as a useful tool for obtaining information about clinical features, such as duration or extension of first, onset in uncomplicated cases of RRD especially for purposes of forensic medicine.