Endothelial analysis in patients having corneal intrastromal surgery with Cornealring for correction of Keratoconus.

PURPOSE: Evaluate corneal endothelium by means of specular microscopy exam in patients with Keratoconus, before and after Cornealring® corneal intrastromal ring surgery. METHODS: One hundred and two eyes of 67 patients, aged between 12 and 45, with the average age of 27.31 ± 8.15 years, 30 females and 37 males, were selected to be submitted to the implant of Cornealring® corneal ring segments in pre- and post-surgery (six months after the procedure) in the External Diseases and Cornea Ward of the Instituto Panamericano da Visão. RESULTS: Of the 102 eyes treated, only those that received two rings of equal thickness up to 250 µ showed statistical significance between the initial and final mean number of endothelial cells (P = 0.008), a decrease of 10.1% in the mean coefficient of variation (P = 0.003), and a 9.75% decrease in initial and final hexagonal cell counts. The other eyes receiving rings of other thicknesses showed no statistically significant differences between the mean initial and final SM examinations. CONCLUSION: A longer segment is necessary for the confirmation or not of the alterations found in this study, particularly regarding the thickness of the ring used, because with the new technologies and the improvement in the result of deep lamellar transplantation, the decrease in the cell count might represent a problem in the indication of this procedure following thick corneal ring implants.

Evaluation of the impact of intracorneal ring segments implantation on the quality of life of patients with keratoconus using the NEI-RQL (National Eye Institute Refractive Error Quality of life) instrument.

BACKGROUND/AIMS: A prospective study evaluating the impact of intracorneal ring segment (ICRS) implantation on the quality of life of patients with keratoconus using the NEI-RQL (National Eye Institute Refractive Error Quality of Life) instrument. METHODS: Sixty-nine eyes of 42 keratoconus patients were implanted with the Keraring. All patients self-administered the NEI-RQL before and 4(1/2) to 8 months after surgery. The results were evaluated and analysed, along with best-corrected visual acuity (BCVA), refraction, contrast sensitivity, corneal topography and aberrometry preoperatively and 3 months postoperatively. RESULTS: There was a significant improvement in all NEI-RQL scales and the overall scale. "Clarity of vision," "far vision," "near vision," "activity limitations," "appearance" and "satisfaction with correction" had the greatest improvement, ranging from 25 to 50 preoperatively to 80 to 90 after surgery. Best spectacle-corrected visual acuity and binocular BCVA improved significantly, and there was a significant decrease in keratometric values, from 50.22 dioptres preoperatively to 46.27 dioptres postoperatively. Contrast sensitivity function improved postoperatively, especially at the frequency of 6 cpd. Low-order root mean square (RMS) improved after surgery, but high-order RMS did not. CONCLUSION: ICRS implantation not only improves the quantitative metrics such as visual acuity and refraction, but also has a positive impact on patients' quality of life.

Twelve-month short-term safety and visual-acuity results from a multicentre prospective study of epiretinal strontium-90 brachytherapy with bevacizumab for the treatment of subfoveal choroidal neovascularisation secondary to age-related macular degeneration.

BACKGROUND/AIMS: This study evaluated the short-term safety and feasibility of epiretinal strontium-90 brachytherapy delivered concomitantly with intravitreal bevacizumab for the treatment of subfoveal CNV due to AMD for 12 months. A 3-year follow-up is planned. METHODS: In this prospective, non-randomised, multicentre study, 34 treatment-naïve patients with predominantly classic, minimally classic and occult subfoveal CNV lesions received a single treatment with 24 Gy beta radiation (strontium-90) and two injections of the anti-VEGF antibody bevacizumab. Adverse events were observed. BCVA was measured using standard ETDRS vision charts. RESULTS: Twelve months after treatment, no radiation-associated adverse events were observed. In the intent-to-treat (ITT) population, 91% of patients lost <3 lines (15 ETDRS letters) of vision at 12 months, 68% improved or maintained their BCVA at 12 months, and 38% gained >/=3 lines. The mean change in BCVA observed at month 12 was a gain of 8.9 letters. CONCLUSION: The safety and efficacy of intraocular, epiretinal brachytherapy delivered concomitantly with anti-VEGF therapy for the treatment of subfoveal CNV secondary to AMD were promising in this small study population. Long-term safety will be assessed for 3 years. This regimen is being evaluated in a large, multicentre, phase III study.

Schilbach-Rott syndrome in a third family: further delineation of an autosomal dominant trait.

We describe a father-son Mexican pair with typical features of Schilbach-Rott syndrome (SRS): ocular hypotelorism, cleft palate, hypospadias (only in the child), and microcephaly. This observation documents for the first time a male to male transmission and therefore confirms that the SRS is inherited as an autosomal dominant trait with variable expressivity.

Central visual field in patients with retinal branch vein occlusion.

We studied the central visual fields in 11 eyes with retinal branch vein occlusion that presented extensive areas of capillary nonperfusion by fluorescein angiography. Relative scotomata corresponding to the areas of capillary nonperfusion were seen in seven eyes where the venous occlusion was of recent onset (average, 11 months). In the remaining four eyes with long-standing venous occlusion (average, 24 months), capillary occlusion was associated with absolute scotomata.

Biomicroscopic study of the vitreous in eyes with macular pucker after retinal detachment surgery.

The posterior vitreous condition of 43 eyes with macular pucker following retinal detachment surgery was studied using the El Bayadi-Kajiura preset lens mounted on a slit lamp. The posterior vitreous was found to be attached in one eye (2%), completely detached in 29 eyes (68%), and partially detached with residual vitreoretinal adhesion to the macular area in 13 eyes (30%). Macular pucker with partial posterior vitreous detachment was significantly more frequent (P less than .05) in eyes with refractive errors of -4 diopters or less. That condition was also accompanied by a higher incidence of dye leakage in the macular area by fluorescein angiography, a shorter time lapse between retinal detachment surgery and development of macular pucker, and a worse visual outcome than was found in eyes with complete posterior vitreous detachment.

Photofield mapping in the evaluation and management of subretinal neovascularization.

Photofield mapping is a useful method for classifying subretinal neovascularization based on its area and location. Careful central field mapping is performed to delineate scotomata during evaluation of patients with subretinal new vessels. A photofield map is then constructed by projecting 35 mm fundus photographs and angiograms onto an appropriately-oriented central visual field map. The composite map (photofield) documents the location and relationship of scotomata, subretinal neovascularization, foveal avascular zone, and retinal blood vessels. The areas of subretinal neovascularization and scotomata are measured in square millimeters with a planimeter. The distance between their closest edge and the center of the foveal avascular zone is measured in millimeters. This method permits quantitative comparison of results with different photocoagulation protocols and instrumentation. Such comparative analysis may help improve the technique and instrumentation used in laser photocoagulation of subretinal neovascularization.

Retinal pigment epithelium decompensation. I. Clinical features and natural course.

We studied 97 eyes (73 patients) that showed a sharp contrast between the grossly normal appearance of the posterior pole by funduscopy and the fluorescein angiography findings of multiple patches of retinal pigment epithelium (RPE) transmission defect in the early transit, associated with focal areas of RPE staining in the late transit. The staining was located primarily at the superior edge of the RPE defect (63 eyes). The average age of the patients was 52.2 years at the time of diagnosis, and the ratio of men to women was 3.5 to 1. Ocular histories were unremarkable, except for 27 eyes with documented central serous retinopathy. Thirty-two consecutive eyes have been followed for an average of 3.9 years, and 30 of those eyes have shown visual deterioration.

Retinal pigment epithelium decompensation. II. Laser treatment.

Forty-one of 97 eyes with retinal pigment epithelium decompensation (RPED) were treated with monochromatic green argon laser photocoagulation to the focal area of RPE staining detected in the late fluorescein transit. Nineteen eyes were treated because of progressive visual deterioration. The other 22 eyes already had visual acuities of 20/50 or worse. Vision stabilized or improved in 34 eyes (82.9%) after an average of 1.6 years following treatment, compared with improvement in only 5 of 56 untreated eyes after an average follow-up period of 2.1 years. After an average follow-up of 7.1 years, 12 of 97 eyes with RPED developed choroidal neovascularization (9 spontaneously and 3 after photocoagulation) in the area where late RPE staining had been observed.

Natural history of choroidal neovascularization in degenerative myopia.

We studied 354 eyes with myopic chorioretinal degeneration by means of standard clinical evaluation and fluorescein angiography. The eyes were classified on the basis of the degree of chorioretinal degeneration found in the posterior pole. Lacquer cracks (breaks in Bruch's membrane) were noted in 82% of the 149 eyes with choroidal neovascular membranes (CNM) and in 96% of the 58 eyes with isolated subretinal hemorrhages. These hemorrhages were reabsorbed without adverse visual sequelae in 32 eyes that were followed; in 14 of these eyes that were followed closely, the average time of reabsorption was 6.4 weeks. Seventy eyes with CNM were followed for an average of 40.9 months. In 96% of these eyes the CNM remained stable or regressed, leaving an atrophic, nonexudative scar. This study indicates that CNM in degenerative myopia is usually self-limited.

A- and B-scan characteristics of shifting fluid level.

A shifting fluid level (SFL) was detected by A- and B-scans in 155 eyes. All eyes had a hemorrhage into the vitreous. In 129 of the 155 eyes (83%) the vitreous hemorrhage resulted from proliferative diabetic retinopathy. In 11 (7%) and seven eyes (5%), respectively, the hemorrhage was a complication of closed vitrectomy and scleral buckling procedures. In eight eyes (5%), the hemorrhage resulted from severe penetrating ocular trauma. The SFL was characterized by a high-amplitude echo on A-scan, and straight horizontal or vertical linear echo on horizontal or vertical B-scan, respectively. It showed a typical shift toward the most posterior portion of the globe when the eye was moved in the different positions of gaze. The SFL was overlying the retina in 150 eyes (97%) and was suspected to be subretinal in five eyes (3%). SFL represented a layer of sedimented red blood cells on the surface of the retina or choroid.

Surgical treatments of proliferative vitreoretinopathy.

Four hundred ten eyes with retinal detachment and proliferative vitreoretinopathy underwent closed vitrectomy with membrane peeling, scleral buckling, and intraocular air injection. The retina was reattached in 243 eyes (59.3%). Useful vision was attained in 223 eyes. The preoperative proliferative vitreoretinopathy was clinically graded in six groups of increasing severity (C-1, C-2, C-3, D-1, D-2, D-3). From grades C-2 to D-3, a significant trend related a decreased rate of retinal reattachment with increased severity. However, grade C-1 showed a significantly lower success rate than did grade C-2. Scleral buckling alone may be the treatment of choice in grade C-1 eyes. Grade D-3 eyes had the worst anatomic and functional results. Preoperatively, there was a significant relationship between increasing severity of proliferative vitreoretinopathy and frequency of aphakia, and aphakic eyes showed a significantly lower rate of retinal reattachment than did phakic eyes.

Negative-lens field expander for patients with concentric field constriction.

An oversized, negative-power spectacle lens may be used as a field expander to improve mobility and general orientation ability of patients with peripheral field loss but intact central vision. The device is inexpensive and simple to use for brief spotting periods.

Chronic macular edema in retinal branch vein occlusion: role of laser photocoagulation.

We used the monochromatic green argon laser to treat 41 eyes with retinal branch vein occlusion (RBVO) and decreased vision because of chronic macular edema of at least six months duration after the onset of RBVO. The average follow-up period after treatment was 19 months. Cystoid macular edema (CME) occurred in 34 eyes and noncystoid macular edema in seven eyes. In eyes with chronic CME we decreased intracapillary pressure in the portion of the macula drained by the occluded vein by segmental retinal arteriolar narrowing using photocoagulation to the retinal arterioles that perfused the involved portion of the macula. Partial or complete resolution of macular edema occurred in 27 eyes. Vision improved in 19 eyes and was stabilized in seven eyes. In eyes with chronic noncystoid macular edema treatment consisted of focal closure of leaking microaneurysms and retinal telangiectasias with photocoagulation. Closure of these leaking vessels associated with partial or complete resorption of hard exudates that had accumulated in the macula secondary to the leakage occurred in six of the seven photocoagulated eyes. Vision improved in four eyes and was stabilized in two eyes.

Immersion A- and B-scan ultrasonography. Its use in preoperative evaluation of diabetic vitreous hemorrhage.

Immersion A- and B-scan ultrasonography was performed before vitreous surgery in 256 eyes with diabetic vitreous hemorrhage. Of 32 eyes with vitreous hemorrhage without vitreous traction (group 1), 28 (88%) showed useful postoperative vision. Of 87 eyes with vitreous traction without tractional retinal detachment (group 2), 69 (79%) had useful postoperative vision. Eyes with tractional retinal detachments were classified as follows: X-shaped detachment with narrow vitreoretinal adhesions (group 3, 75 eyes), and H-shaped detachment with broad vitreoretinal adhesions (group 4, 62 eyes). Useful postoperative vision returned in 43 eyes in group 3 (57%) and in only 14 eyes in group 4 (23%), a statistically significant difference. Visual improvement was greater in groups 1 and 2 than in groups 3 and 4. Postoperative functional results were worse when the macular area was the site of vitreoretinal adhesion and traction.

Role of the vitreous in cystoid macular edema.

Eyes suffering from various conditions, such as aphakia, diabetic retinopathy, peripheral uveitis, branch vein occlusion, or retinitis pigmentosa, are predisposed to vitreous detachment. When vitreous detachment occurs, the vitreous can remain attached to the macula due to a firm vitreomacular adhesion. This partial posterior vitreous detachment associated with continuous vitreous traction to the macular area can lead to the development of cystoid macular edema. Two types of vitreous traction have been observed: traction with narrow vitreous strand and traction with broad vitreoretinal adhesion. It has been postulated that the posterior vitreous can cause cystoid macular edema by vitreous contraction without vitreous detachment, producing tractional forces at sites of firm vitreoretinal adhesions that are located at the optic disc and macula. Cystoid macular edema is often accompanied by leakage from dilated retinal capillaries at the optic disc.

Bilateral choroidal osteoma with subretinal neovascularization.

Choroidal osteoma is a rare entity, reported previously mainly in females. We report a case of bilateral choroidal osteoma in a 15-year-old boy. Ultrasonography and computerized tomography findings were key to establishing the diagnosis. During two years' follow-up, there was observable growth in the tumor size. Leakage from subretinal neovascular tufts covering the tumor caused visual deterioration. Photocoagulation of the subretinal new vessels was performed twice, with limited success, but the value of this treatment in choroidal osteomas needs further study.

Manifestations of Whipple's disease in the posterior segment of the eye.

Ocular manifestations of Whipple's disease result from CNS involvement, direct intraocular involvement, or both. Ocular signs caused by CNS involvement occurred in 30 of the 34 patients with ocular manifestations described in the literature. In only four of the 34 cases were ocular manifestations due solely to intraocular involvement. Two cases reported herein had unique intraocular involvement, manifested as diffuse chorioretinal inflammation. Fluorescein angiography showed diffuse vasculitis, with hemorrhages, exudates, retinal capillary occlusion in the perifoveal and midperipheral areas, capillary dilation at the optic disc, and choroidal folds. Proper antibiotic treatment resulted in ocular and systemic recovery. Follow-up is mandatory because of possible recurrences, which may start with intraocular signs, followed by systemic manifestations. Some cases progress to fetal CNS involvement. Therefore, when intraocular signs recur in treated patients, antibiotic therapy should be restarted or dose should be increased.