Prethreshold retinopathy of prematurity: VEGF inhibition without VEGF inhibitors.

The risk of developing treatment-warranted Type 1 retinopathy of prematurity (ROP) might be reduced in preterm infants by modifying certain systemic factors. There are steps that can be taken both early and late in the course of retinal vascular maturation that may potentially reduce an infant's risk of developing Type 1 ROP. In prethreshold stage 2-3 ROP without plus disease, a combination of supplemental oxygen, correction of severe anemia, and light adaptation to reduce rod photoreceptor oxygen consumption helped us to reduce ROP severity, and encouraged a return to a more physiologic retinal vascular maturation pattern. Thus, it may be possible to reduce the risk of developing Type 1 ROP by making adjustments in certain systemic parameters aimed at reducing retinal hypoxia, thereby gently lowering pathologically elevated levels of vascular endothelial growth factor (VEGF) within the eye.

Effect of oral niacin on central retinal vein occlusion.

PURPOSE: Niacin, a treatment for dyslipidemia, is known to induce vasodilation as a secondary effect. Previous instances of patients with chronic central retinal vein occlusion (CRVO) and cystoid macular edema (CME) have been observed to spontaneously improve when placed on systemic niacin for hypercholesterolemia. The purpose of this study was to evaluate the effects of niacin on CRVO and associated ocular complications. METHODS: A prospective, single-center, non-randomized, interventional case series of niacin for CRVO was conducted. Best-correct visual acuity (BCVA), central macular thickness (CMT), and ocular complications were analyzed in 50 patients over 1 year. Eight patients were controls. RESULTS: The mean initial logMAR BCVA was 0.915, and improved with niacin to 0.745 (P = 0.12), 0.665 (P = 0.02) and 0.658 (P = 0.03) after 3, 6, and 12 months of follow-up, respectively. At baseline, mean CMT was 678.9 µm, and improved to 478.1 µm (P = 0.001), 388.6 µm (P < 0.001), and 317.4 µm (P < 0.001) for the same time points. The control group had a mean initial logMAR BCVA of 1.023, which gradually deteriorated to 1.162 (P = 0.36) after 12 months, and baseline CMT of 700.0 µm at baseline, which gradually improved to 490.9 µm (P = 0.06) after 12 months. Panretinal photocoagulation for neovascularization was required in 5 patients (13.2%) receiving niacin and 3 (37.5%) controls. CONCLUSIONS: These data suggest that niacin may be associated with functional and anatomic improvements in eyes with CRVO. Future investigations will help ascertain whether there is a role for niacin as an adjunct therapy to intravitreal injections in the management of CRVO.

Complete visual recovery after incipient crao due to ocular hypoperfusion in a patient with moyamoya disease.

PURPOSE: The purpose of this study was to report a case of an impending central retinal artery occlusion with hypoperfusion in a moyamoya patient. METHODS: A young, surgically revascularized moyamoya patient experienced severe unilateral vision loss from 20/25 to hand motions because of impending central retinal artery occlusion. The patient was treated with a combination of intermittent ocular massage, intraocular pressure-lowering medications, and aspirin. PATIENTS: A case of a moyamoya patient at Stanford University Medical Center. RESULTS: Visual acuity was restored to baseline by improving the ocular arterial-venous gradient after prompt administration of ocular massage, intraocular pressure-lowering drops, and aspirin. CONCLUSION: This dramatic result suggests that, if performed in a timely manner, augmentation of ocular perfusion can result in complete restoration of vision in some cases of incipient central retinal artery occlusion.

Pseudoduplication of the optic disk.

PURPOSE: The purpose of this study was to report a case of a chorioretinal coloboma mimicking a second optic disk in an asymptomatic 12-year-old boy. METHODS: This is a case report. RESULTS: An asymptomatic 12-year-old boy presented with a chorioretinal coloboma of the right eye giving the impression of a second optic disk. The patient also had a superior visual field defect. CONCLUSION: True optic nerve duplication is a rare entity that can be mimicked by other etiologies, including choroidal colobomas and postinflammatory lesions, requiring careful examination by clinicians.

Rethinking STOP-ROP: is it worthwhile trying to modulate excessive VEGF levels in prethreshold ROP eyes by systemic intervention? A review of the role of oxygen, light adaptation state, and anemia in prethreshold ROP.

PURPOSE: To review systemic modifiable factors that might downregulate pathologic levels of vascular endothelial growth factor (VEGF) in prethreshold retinopathy of prematurity (ROP), and thereby reduce the risk of blindness in affected infants. METHODS: Review of the author's clinical experience as compared to the STOP-ROP study, and discussion and literature review of the potential effects of oxygen supplementation, light adaptation state, and correction of severe anemia on the course of prethreshold retinopathy of prematurity (ROP). RESULTS: Moderate oxygen supplementation, combined with light adaptation to reduce retinal oxygen consumption and correction of severe anemia, were associated, in the author's experience, with improvement in the clinical course of prethreshold ROP. Withdrawal of these measures was often associated with deterioration of ROP. CONCLUSION: Systemic measures can be taken that may reduce the risk of blindness in infants with prethreshold ROP. For those infants who require laser treatment for threshold ROP, prior efforts to moderate excessive levels of VEGF may improve the chances of a successful surgical result, by slowing the momentum of the disease.