Choroidal excavation in choroidal osteoma complicated by choroidal neovascularization.

PurposeTo describe multimodal imaging features of choroidal osteoma (CO) complicated by choroidal neovascularization (CNV) and focal choroidal excavation (FCE).MethodsPatients presenting with CO and CNV between January and October 2016 were considered for this study. Diagnosis of CO was confirmed by ultrasound examination. All patients underwent multimodal imaging including optical coherence tomography (OCT), swept-source OCT angiography (DRI OCT Triton, Topcon, Inc., Tokyo, Japan) and fluorescein angiography (Spectralis HRA+OCT; Heidelberg Engineering, Heidelberg, Germany).ResultsTwo patients (one with bilateral CO) were included in the study. OCT showed a FCE in two eyes of two patients (one in correspondence of the CNV and the other adjacent to the CNV). OCT-A demonstrated presence of microvascular flow within neovascular network of the CNVs. Decalcification of the tumor was noted in correspondence of one eye with FCE.ConclusionsFCE may be found in eyes with choroidal osteoma and CNV. OCT-A was a valuable tool for detection of CNV complicating choroidal osteoma. Decalcification of choroidal osteoma may represent a common pathogenic pathway for development of FCE and CNV in choroidal osteoma.

Optical coherence tomography analysis of evolution of Bruch's membrane features in angioid streaks.

PurposeTo describe optical coherence tomography (OCT) features in the Bruch's membrane (BM) of eyes with angioid streaks (AS) and evaluate their evolution over the follow-up.Patients and methodsPatients with AS presenting between March 2016 and September 2016 at two tertiary referral centers were consecutively recruited in this study. Eligibility criteria included prior spectral domain (SD)-OCT images, taken at least 3 months before at the same referral center, with automated eye tracking and image alignment modules. Alterations of BM were described and compared to previous scans over the follow-up. Multimodal imaging was used to identify alteration of retinal pigment epithelium (RPE) and choroid.ResultsThirty-two eyes of 16 consecutive patients with AS were included. BM undulations, mostly observed around the optic nerve head, were found in 19 (59.4%) of 32 eyes. BM breaks were found in 31 (96.9%) out of 32 eyes. Evolution of BM undulations into BM breaks was observed in 5 eyes (15.6%). Choroidal neovascularization (CNV) was observed in 12 eyes (37.5%) during follow-up, typically in areas of BM interruption.ConclusionsBM undulations, probably caused by high stretching forces exerted on the BM around the optic nerve head, seem to precede some BM breaks. BM interruptions may be a preferred way for the growth of CNV, which was identified in one-third of our cases.

Pharmacological approach to diabetic macular edema.

Diabetic macular edema (DME) is a highly prevalent cause of vision loss and has a remarkable impact on public health, and on the quality of life of diabetic patients. Even though laser photocoagulation has been the standard of care for decades, a substantial group of patients are unresponsive and fail to improve after laser treatment. Recently, new pharmacological approaches based on the use of intravitreal drugs, such as corticosteroids and anti-vascular endothelial growth factor, have revolutionized the treatment of DME. The use of intravitreal drugs is supported by the improvement in visual acuity reported by several clinical trials and can limit the potentially destructive effects of the laser treatment. Encouraging results also emerged from studies evaluating the use of a combination therapy, or the association of intravitreal drugs and laser treatment. This review aims at providing a brief synopsis of the main investigations regarding the current pharmacological approach to DME.

Evidence for anti-VEGF treatment of diabetic macular edema.

Diabetic macular edema (DME) is the most important cause of vision loss in patients with diabetes mellitus. Diabetic retinopathy has a remarkable impact on public health and on the quality of life of diabetic patients and thus requires special consideration. The first line of treatment remains the management of systemic risk factors but is often insufficient in controlling DME and currently, laser retinal photocoagulation is considered the standard of care. However, laser treatment reduces the risk of moderate visual loss by approximately 50% without guaranteeing remarkable effects on visual improvement. For these reasons, new strategies in the treatment of DME have been studied, in particular the use of anti-vascular endothelial growth factor (anti-VEGF) drugs. VEGF is a pluripotent growth factor that acts as a vasopermeability factor and an endothelial cell mitogen. For this reason, it represents an interesting candidate as a therapeutic target for the treatment of DME. The aim of this article is to review the evidence behind the use of anti-VEGF drugs in the treatment of DME.

Steroids as part of combination treatment: the future for the management of macular edema?

Diabetic macular edema (DME), defined as a retinal thickening involving or approaching the center of the macula, plays a major role in vision loss related to diabetic retinopathy. This article presents an in-depth analysis of therapeutic perspectives on DME by means of an approach based on combination therapy with steroids. Corticosteroid drugs have been demonstrated to both inhibit the expression of vascular endothelial growth factor (VEGF) and the VEGF gene, and to have antiinflammatory properties. A treatment algorithm is provided regarding the management of DME. While grid laser photocoagulation remains the first-line therapy for focal vasogenic DME, diffuse DME can be effectively treated by means of intravitreal injections of corticosteroids. Recalcitrant DME can also be managed beneficially with intravitreal steroids. The management of DME is complex, and often multiple treatment approaches are needed. Each form of DME should be properly classified and specifically treated. The combination treatment has still an important role in the combined treatment options for DME.

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.

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.

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.

Early angiographic changes after laser treatment of choroidal neovascularisation in age-related macular degeneration.

PURPOSE: To describe angiographic features detectable on fluorescein angiography (FA) and indocyanine green angiography (ICGA) early after laser photocoagulation of choroidal neovascularisation (CNV) in age-related macular degeneration (AMD). METHODS: Thirty-five eyes of patients with AMD and juxtafoveal or extrafoveal CNV referred to the angiographic centre of the Eye Clinic of Trieste were considered. Ophthalmological assessment included FA and ICGA performed 2 days before and 30 min after laser treatment, and then 1, 2, 7, 14, 21 and 28 days after photocoagulation. Further clinical angiographic examinations were carried out 2, 3, 4 and 6 months after treatment. Photocoagulation was performed for classic CNV on FA and occult CNV on FA, appearing as well-defined focal spot on ICGA. RESULTS: Our results show that interpretation of early post-treatment angiographic examinations may be awkward because diffuse leakage on FA and hot spots on ICGA are normally detectable soon after laser treatment and thereafter during the first 2 weeks. Later, at the 3-week control, leakage on FA and hot spots on ICGA are visible in 62.8% and in 37% of cases respectively; they disappear completely by the 4-week control. CONCLUSION: Difficulty in analysing FA and ICGA in the early post-photocoagulation period underlines the importance of the decision regarding when to perform the first reliable post-laser control and how to improve its interpretation. We suggest that the first angiographic control be performed 3 weeks after treatment, strictly monitoring those eyes showing leakage or marginal hot spots over the following weeks. Overlapping the post-laser hypofluorescent area on the pre-laser lesion can ensure the complete coverage of CNV, and analysis of the retinal and choroidal vascular pattern inside and near the photocoagulated area during the different angiographic phases, albeit difficult, is essential for the interpretation of the angiographic lesions.

Vascularized pigment epithelial detachment in adult-onset foveomacular vitelliform dystrophy.

PURPOSE: To report a case showing adult-onset foveomacular vitelliform dystrophy (AOFVD), associated with vascularized pigment epithelial detachment. CASE REPORT: A 72-year-old female affected by AOFVD complained with blurred vision and metamorphopsia in her right eye, seven months after a routinary clinical examination. Visual acuity in right eye dropped from 0.6 to 0.3, and biomicroscopic fundus examination revealed a serous pigment epithelial detachment arising from the temporal margin of the pseudovitelliform lesion. Fluorescein angiography showed an uneven filling of the pigment epithelial detachment, suggesting the presence of a subfoveal choroidal neovascularisation, which was confirmed by indocyanine green angiography. DISCUSSION: The association between AOFVD and vascularized pigment epithelial detachment, supports the hypothesis that AOFVD may be a different subgroup of age-related macular degeneration with specific genetic predisposition.

Visual representation of space in congenital and acquired strabismus.

The aim of the present work was to readdress the problem of altered spatial localization in strabismic subjects and to assess whether and how spatial representation is affected by the degree of plasticity of the brain. We therefore compared targeting performance in adult subjects affected by acquired strabismus versus children affected by congenital strabismus. Our data confirm the correlation between deviation of the eye and targeting errors, but they also show that this correlation is not present when strabismus occurs early in life. We suggest that the neuronal machinery involved in the building of an internal representation of space reaches its full maturity several years after birth and that this might explain the limited differences observed in targeting errors between normal and strabismic children.

Grid laser treatment in macular branch retinal vein occlusion.

BACKGROUND: Macular branch retinal vein occlusion (MBRVO) is a subgroup of branch retinal vein occlusion in which the occlusion is limited to a small venous vessel draining a sector of the macular region. The present study aimed to evaluate prospectively whether grid laser treatment is useful in improving the visual acuity of eyes affected by MBRVO with significant macular edema. METHODS: Ninety-nine patients affected by MBRVO of recent onset were prospectively studied during a 24-month period; eyes were randomly assigned to the control group, the early grid laser treatment group or the delayed grid laser treatment group. Clinical and angiographic features were recorded during the whole follow-up; parameters such as visual acuity and macular edema were carefully evaluated, the latter even by means of stereophotography. RESULTS: With respect to the baseline mean visual acuity values, a statistically significant improvement was noted at the 3-month follow-up and at the 1-year follow-up. No additional improvement was noted at the 2-year follow-up. No statistically significant difference was found between the treated groups and the control group. CONCLUSIONS: We hypothesize that the abrupt ischemic damage subsequent to MBRVO is the main factor causing the central function impairment. Grid laser treatment is not able to reduce the macular edema more than the natural evolution, and does not improve visual acuity.

Grid laser treatment of macular edema in macular branch retinal vein occlusion.

AIM: Macular branch retinal vein occlusion (MBRVO) is a subgroup of branch retinal vein occlusion in which the occlusion is limited to a small venous vessel draining a sector of the macular region. The present study aims to evaluate the efficacy of grid laser treatment for macular edema in MBRVO. METHODS: 77 Patients with MBRVO of recent onset were prospectively studied during a 24 month period. Eyes were randomly assigned to a grid laser treatment group and to a control group. Clinical parameters such as visual acuity, presence of macular edema and angiographic features were recorded during the follow-up period. RESULTS: Visual acuity increased significantly in both groups after 3 months of follow-up (p<0.001) and after 1 year of follow-up (p<0.005). No additional improvement was noted at the two year control. There was no statistical difference between the two groups. CONCLUSIONS: The visual prognosis of MBRVO is not improved after grid laser treatment of macular edema. This suggests that sudden ischemic damage to central photoreceptors rather than macular edema is the main factor for permanent visual acuity reduction.

Fluorescein angiography and indocyanine green videoangiography in the iris of pseudoexfoliation syndrome.

The precise evaluation of iris vascular pattern in pseudoexfoliation syndrome (PXS) may be difficult on iris fluorescein angiography (IFA) because of the frequent presence of a heavily pigmented iris and late conspicuous leakage. Thanks to its special characteristics, iris indocyanine green videoangiography (IICGV) is able precisely to visualize details of the iris vascular pattern. The aim of the study is to analyze the feasibility of IICGV in detecting microvascular changes in PXS and compare these findings with those of IFA. Twenty-eight patients affected in both eyes by PXS underwent an ophthalmologic examination including IFA and IICGV. IICGV was performed using IMAGEnet system H1024. A better visualization of iris hypoperfusion and anastomotic vessels was obtained on IICGV, whereas iris microneovascularization was far more clearly visible on IFA. Moreover, iris pigment epithelium defects were detectable on IICGV. IICGV may be considered a useful tool in the evaluation of the iris vascular pattern in PXS. Iris hypoperfusion could not play a contributory role in the development of iris microvascular changes.

Adult-onset foveomacular vitelliform dystrophy and indocyanine green videoangiography.

BACKGROUND: Adult-onset foveomacular vitelliform dystrophy (AOFVD) represents a heterogeneous group of disorders with different clinical, angiographic, and histopathological features. The most common form is characterized by a yellow, round to oval subretinal macular lesion with or without central pigmented spot. METHODS: Eight patients affected by typical AOFVD underwent fluorescein angiography and indocyanine green videoangiography (ICGV). RESULTS: Fluorescein angiography showed a central hypofluorescent spot surrounded by an irregular hyperfluorescent ring. ICGV demonstrated a foveal nonfluorescent spot, visible during the entire examination, and a hyperfluorescent area surrounding the central spot, which became evident soon after the beginning of the examination. CONCLUSIONS: In light of previous histopathological studies, the central nonfluorescent spot may be interpreted as a masking effect of a pigment clump, whereas the hyper-fluorescent area may represent dye pooling or staining of the subretinal pigment epithelial material.