Quantitative Parameters Relevant for Diabetic Macular Edema Evaluation by Optical Coherence Tomography Angiography.

Diabetic macular edema (DME) is one of the main ocular complications of diabetes mellitus (DM) that can lead to important vision loss in diabetic patients. In clinical practice, there are cases of DME with unsatisfying treatment responses, despite adequate therapeutic management. Diabetic macular ischemia (DMI) is one of the causes suggested to be associated with the persistence of fluid accumulation. Optical coherence tomography angiography (OCTA) is a non-invasive imaging modality, able to give in-depth information about retinal vascularization in a 3-dimensional manner. The OCTA devices currently available can provide various OCTA metrics that quantitatively assess the retinal microvasculature. In this paper, we reviewed the results of multiple studies that investigated the changes in OCTA metrics in the setting of DME and their possible contribution to the diagnosis, therapeutic management, follow-up and prognosis of patients with DME. We analyzed and compared relevant studies that investigated OCTA parameters related to changes in macular perfusion in the setting of DME and we evaluated the correlations between DME and several quantitative parameters, such as vessel density (VD), perfusion density (PD), foveal avascular zone (FAZ)-related parameters, as well as complexity indices of retinal vasculature. The results of our research showed that OCTA metrics, evaluated especially at the level of the deep vascular plexus (DVP), are useful instruments that can contribute to the assessment of patients with DME.

Retromode Imaging in Age-Related Macular Degeneration.

Background and Objectives: Retromode is a relatively new retinal-imaging technique that is based on the transillumination principle and is obtained with a scanning laser ophthalmoscope that uses light in the infrared spectrum. The laser light penetrates into the deep retinal layers and the choroid. Retromode images are captured with a laterally displaced aperture, and the detector captures only the scattered light. The result is a high-contrast pseudo-three-dimensional image. Age-related macular degeneration (AMD) is a disabling retinal disease. AMD is characterized in its early stage by small and intermediate drusen formation, while the signs of intermediate AMD are large drusen and/or pigmentary abnormalities. Late AMD has two forms, geographic atrophy, which is the advanced form of dry AMD, and wet AMD. Most of the lesions of AMD are located in the outer layers of the retina. This new imaging method can provide a glimpse of the deep retinal layers' topographic changes in a non-invasive, fast, and effective way that can match the other imaging tools available. Materials and Methods: The literature review was performed by searching the PubMed database using the following combination of keywords: retromode imaging and age-related macular degeneration. Relevant images similar to the ones in the literature were identified and used as models. Results: The purpose of this article is to highlight the utility of incorporating retromode imaging into the multimodal evaluation of the retina in patients with AMD and to gather and integrate these findings into a brief but comprehensive paper. Conclusions: Retromode imaging is a good screening, diagnosis, and monitoring tool for patients with AMD.

Difficulties in choosing the right intraocular lens in a previously vitrectomized patient - the role of the tear film.

We present the difficulties in choosing the right IOL, when facing a great variability of the keratometric measurements, in the case of a patient operated for epiretinal membrane and lamellar macular hole, who developed complicated cataract in the operated eye. Upon commencing the biometric measurements, inconsistency in keratometric values led to further investigations. Repeated placido disc topography initially showed corneal ectasia, which posed a problem on selecting the right type of intra-ocular lens. Ocular surface pathology was suspected, and after treatment, the topography was repeated with a Scheimpflug topographer, that showed an improved keratometric profile. The surgical solution was to implant an aspheric monofocal IOL, in the bag, with extended depth of focus that enhances intermediate vision, disregarding the previous keratometric measurements. Refractive and functional outcomes were good. In cases of biometric measurements that show inconsistency in keratometric values, ocular surface disease as well as corneal ectasia should be taken into consideration. The right implant should not be chosen based on a single measurement, but rather several measurements should be made and compared and the choice should not be made before treating the ocular surface.

Further advances in the diagnosis and treatment of Leber's Hereditary Optic Neuropathy - a review.

Leber's Hereditary Optic Neuropathy (LHON), is one of the most frequent mitochondrial diseases characterized by Retinal Ganglion Cells degeneration. Pathogenic gene mutations in LHON induces mitochondrial impairment, which in turn leads to insufficient mitochondrial ATP production. The pathologic hallmark of the disease is primary degeneration of retinal ganglion cells, which results in optic nerve atrophy. The paper reviews some of the recent advances in the understanding of LHON: new genetics discoveries and novel therapeutic approaches.

Femtosecond-LASIK outcomes using the VisuMax®-MEL® 80 platform for hyperopia and hyperopic astigmatism refractive surgery.

The present study evaluated the efficacy, the safety and the predictability of the Femtosecond laser-assisted in situ keratomileusis (Femto-LASIK) procedure for hyperopia and hyperopic astigmatism. We retrospectively analyzed the postoperative 12-month evolution of 593 eyes with hyperopia and hyperopic astigmatism that underwent Femto-LASIK treatment. The procedure was predictable and effective. No eye lost 2 lines of corrected distance visual acuity (CDVA), demonstrating a safety profile of the procedure. Nine percent of the eyes gained at least one line of CDVA. The accuracy of the spherical equivalent after 12 months was 74% within ±1.0 diopter (D) of emmetropia. The refractive outcomes were stable during the follow-up period. There were no significant complications during the procedure. Femto-LASIK using the VisuMax®-MEL® 80 platform was demonstrated to be a suitable option to correct selected cases of hyperopia and hyperopic astigmatism. A longer follow-up period is required to better assess the refractive results and to detect any further regression.

Lens-induced uveitis in a patient with hypermature cataract.

Objective: Our paper aims to report an unusual case of phacogenic uveitis with secondary glaucoma occurring after spontaneous rupture of the lens capsule in a patient with hypermature age-related cataract, to describe its particularities and to review the classification of the lens-induced uveitis. Methods: We described the case of an 83-year-old male with a history of hypermature cataract, who presented to our clinic for right eye pain. Examination revealed circumciliary congestion, diffuse corneal edema, lens debris floating in the anterior chamber, pseudohypopyon and the opacification of the whole lens. An elevated intraocular pressure was also associated. We did not observe any history of previous intraocular surgery or trauma. Results: We diagnosed the case as a phacogenic uveitis with secondary glaucoma and we planned to remove the inflammation trigger, namely the lens and its fragments by the most adequate technique, in order to control the inflammation and the IOP spikes, to alleviate the pain and to improve the patient's visual function and the quality of life. Conclusions: Phacogenic uveitis may present a cloudy cornea and a turbid anterior chamber that mimics endophthalmitis. Careful examination, medical history and ancillary investigations are helpful in establishing an accurate diagnosis and the appropriate treatment can reduce or eliminate the inflammation completely, decrease the intraocular pressure, being able to allow, depending on the particularities of the case, the visual gain.

Corneal topography in preoperative evaluation for laser keratorefractive surgery - a review.

Corneal topography is a mandatory investigation in the preoperative evaluation of the patient candidate for laser keratorefractive surgery, in order to assess the corneal shape, to determine the radii of curvature and the corneal thickness. Abnormal corneal topography is the most important identifiable risk factor for corneal ectasia. This paper reviews the principles of successive generations of topographers and illustrates several normal and abnormal corneal topographies.

Toric intraocular lens implantation - atypical cases.

Objective: To describe the results of toric intraocular lens (IOL) implantation in three atypical cases (four eyes) with cataract and corneal astigmatism: one with bilateral keratoconus, one with pellucid marginal degeneration and one with buphthalmos due to congenital glaucoma. Methods: Three patients (four eyes) with corneal astigmatism (one with bilateral keratoconus, one with pellucid marginal degeneration and one with buphthalmos due to congenital glaucoma) underwent cataract surgery by standard phacoemulsification and the implantation of toric IOLs in the capsular bag. The presence of corneal astigmatism was identified by automated keratometry and confirmed by Scheimpflug-based corneal tomography. The toric IOL implanted in all cases was a single-piece AcrySof Toric IOL (Alcon Laboratories, Inc.). Postoperative visual acuity, the reduction in the refractive astigmatism, the spherical equivalent (SE) and the rotational stability of the toric IOL were recorded for all the patients. Results: Visual acuity increased and the refractive astigmatism decreased in all cases. In Case 1, the right eye achieved a postoperative uncorrected visual acuity (UCVA) of 20/ 20, a decrease in the refractive astigmatism from -3 DCyl to -0.75 DCyl and a spherical equivalent (SE) of -0.25. The left eye presented with a best-corrected visual acuity (BCVA) of 20/ 20, a decrease in the refractive astigmatism from -1.50 DCyl to -1.25 DCyl and a SE of -0.25. In Case 2, the postoperative UCVA was 20/ 20, with a decrease in the refractive astigmatism from -5.5 DCyl to -1 DCyl and a SE for the right eye of 0.00 D. In Case 3, the postoperative BCVA was 20/ 20, with a decrease in the refractive astigmatism from -4.75 DCyl to -1.50 DCyl and a SE of +1.25. No misalignment of the axis of the toric IOL was observed in any patient at subsequent follow-ups. The postoperative visual acuity was satisfactory for all the patients. Conclusions: Toric intraocular lenses can be an effective option for implantation in patients with cataract and corneal astigmatism in atypical situations such as mild to moderate keratoconus, pellucid marginal degeneration and buphthalmos due to congenital glaucoma. Predicting the refractive outcome is difficult in atypical cases and the surgeon should have accuracy and consistency in the preoperative measurements, for achieving satisfactory postoperative results.

Cumulative visual impact of two coagulability disorders: A case report.

Cumulative visual impact of two coagulability disorders were reviewed by presenting a case of a young female patient with a spontaneous abortion and two thromboembolic events in 8 years, whose visual function was severely affected. The particularities of her genetic constellation regarding the retinal circulation are also discussed. The patient developed a central retinal artery occlusion in the right eye during pregnancy in 2010, which led to an extended hematological workup that revealed presence of MTHFR C677T and MTHFR A1298C heterozygote mutations. The screening for myeloproliferative disorders showed JAK2 V617F gene mutation. Test results confirmed the diagnosis of thrombophilia and essential thrombocythemia and she was recommended permanent treatment with low molecular weight heparin, platelet antiaggregant, peripheral vasodilator and neuroprotectors. Despite the treatment, the patient developed central retinal vein occlusion in the fellow eye 8 years after the first thromboembolic event. The visual acuity for the right eye (0.9 logMAR) remained poor and the visual acuity for the left eye recovered completely (from 0.3 logMAR to 0 logMAR). However, new retinal artery or vein occlusions could occur in the future and there is also a risk of thrombosis in other areas, such as cerebral, pulmonary or renal, due to the general coagulability imbalance.

Intraoperative flap-related complications in FemtoLASIK surgeries performed with Visumax® femtosecond laser: A ten-year Romanian experience.

Incidence and clinical results of intraoperative flap and interface-related complications were investigated after Femtosecond-LASIK surgery, where flap creation was performed with VisuMax® femtosecond laser. A retrospective 10-year cohort study was conducted including all eyes treated for all refractive errors by Femtosecond-LASIK technique. All the flaps were made by the same refractive surgeon with the VisuMax® (Carl Zeiss Meditec) femtosecond laser. We report the intraoperative flap and interface-related complications in these eyes, also describing their management. The study included 4,032 eyes. Flap and interface-related complications were: opaque bubble layer (OBL) 21.18%, suction loss 1.29%, difficult docking 0.69%, difficult dissection of the flap 0.59%, bleeding from limbal blood vessels 0.35%, de-epithelialization of the flap 0.12%, and interface debris 0.025%. These situations were appropriately addressed, with favorable outcomes. Flap creation is an important step in LASIK surgery. The predictability and safety have improved since the flap incision is assisted by a femtosecond laser, but complications of the flap and interface can still occur during the flap creation. Refractive surgeons should be aware and properly manage any unusual situation.

Accuracy of five intraocular lens formulas in eyes with trifocal lens implant.

Accuracy of intraocular lens (IOL) calculation formulas SRK/T, Hoffer Q, Holladay 1, Haigis and Barrett Universal II were compared in prediction of postoperative refraction for multifocal and implants using a single optical biometry device. The authors included 88 refractive lens exchange and cataract surgeries, with AcrySof IQ PanOptix implant (Alcon Laboratories, Inc.). All eyes were divided into three groups based on axial length (AL), group 1: <22 mm (14 eyes), group 2: 22-24.5 mm (68 eyes) and group 3: >24.5 mm (6 eyes). The refractive prediction error (RPE) and mean absolute error (MAE) were calculated for 5 different formulas: SRK/T, Hoffer Q, Holladay 1, Haigis and Barrett Universal II. For eyes with the AL between 22 mm and 24.5 mm the greatest percentage of eyes with RPEs within ±0.25 D was 32.4% for Haigis formula, followed by Barrett Universal II, Hoffer Q and Holladay 1 with 29.4%. The percentage of eyes with RPEs within ±0.50 D was 100% only for Barrett Universal II and Holladay 1, 94.1% for SRK/T and 91.2% for Haigis and Hoffer Q. The first and third group with AL <22 and >24.5 mm were too small to have statistical significance due to the reluctancy to use multifocal IOLs on extreme ALs. ANOVA test showed no statistical difference (P=0.166) between the RPEs measured for each formula in this cohort. This study showed no statistical difference between formulas for this trifocal lens implant. There was a tendency for the RPE to be within ±0.25 D for most of the eyes with the Haigis formula, and within ±0.50 D for all the eyes with the Barrett Universal II formula in the group with the AL between 22 and 24.5 mm.

Bevacizumab in Wet AMD treatment: A tribute to the thirteen years of experience from the beginning of the anti-VEGF era in Romania.

This study aimed to identify and describe anatomical and functional changes on short (1-3 months) and medium (6-12 months) term after intravitreal injections of bevacizumab (Avastin, Genentech) in patients with choroidal neovascularization (CNV) in the context of exudative form of age-related macular degeneration (AMD). We performed a retrospective, analytical, interventional study, based on a series of cases with exudative form of AMD, which also comprised a prospective component related to the inclusion and treatment of the patients with a very new interventional method for that time (2006) and the follow-up of the effects of intravitreal injection of bevacizumab (1.25 mg) therapy in three monthly doses for short (1-3 months) and medium (6-18 months) periods of time. The follow-up of these patients was made by determining visual acuity (VA) as best corrected visual acuity (BCVA) at baseline and at every visit, slit lamp examination with contact or noncontact lenses each time, and optical coherence tomography and/or angiofluorography, applied only for certain patients, at various times of the study. In total, 376 intravitreal injections were administered to 117 eyes of 96 patients. The VA improved in the assessment of 3 months in 77 eyes (66%), either subjective (by the patient) or objectively quantified (by the physician). In 40 eyes (34%), there was no change in VA. In patients for whom optical coherence tomography could be performed, a significant reduction of the macula's thickness was found. The use of bevacizumab in subretinal neovascular membrane treatment is effective and safe on short and medium term, with the improvement of BCVA and reduction of macular edema in a significant number of cases.

Bilateral Central Retinal Vein Occlusion, multiple dental implants and severe glomerulonephtitis - Any connection?

We present a case of Bilateral Central Retinal Vein Occlusion in a patient who received 11 dental implants and later developed idiopathic glomerulonephritis with renal failure.

Leber's Hereditary Optic Neuropathy - Case Discussion.

Purpose. To report a case of a young patient with a clinical condition suggestive of Leber's hereditary optic neuropathy (LHON) confirmed by genetic testing. Material and methods. We present a case of a 21-year-old Caucasian male with bilateral visual loss. The patient complained of visual loss, initially in the right eye and two weeks thereafter in the left eye. Ophthalmological examination revealed visual acuity of 20/ 400 in both eyes, anterior segment of normal appearance, normal direct and consensual pupillary light reflexes, and absence of a relative afferent pupillary defect. Fundus examination demonstrated bilateral protruding, hyperemic, with blurred margins in the nasal quadrant papilla and reduced excavation, tortuous vessels, peripapillary telangiectasias. The optical coherence tomography (OCT) revealed bilateral increase of the retinal nerve fiber layer (RNFL) thickness and ganglion cell layer - inner plexiform layer complex (GCL-IPL complex) severely thinned. Results. The clinical suspicion of Leber's hereditary optic neuropathy was confirmed by the 3460 mutation, which was identified on blood mitochondrial analysis. Meantime, the visual acuity decreased to CF in both eyes. We initiated treatment with idebenone (300 mg T.I.D.). After three months of follow-up, visual acuity was CF in both eyes, bilateral pupillary light reflexes within normal limits and optic disc pallor was noticed in both eyes. Conclusion. No visual recovery was noticed after one year. We recommended that the idebenone treatment was continued and the patient was followed-up further.

Non-arteritic anterior ischemic optic neuropathy - Case report.

We present a case of Non-Arteritic Anterior Ischemic Optic Neuropathy (NA-AION) with uncertain etiology but a good recovery with a total gain of central visual acuity.

New perspectives in the use of laser diode transscleral cyclophotocoagulation. A prospective single center observational cohort study.

PURPOSE: The paper intends to present the results of using new methods of a new generation diode laser transscleral cyclophotocoagulation (TSCPC) in patients with different types of glaucoma. PATIENTS, MATERIALS AND METHODS: There have been treated 53 eyes from 59 patients with glaucoma refractory to medical, laser or surgical treatment. We have used the newest generation of 810 nm wavelength diode laser. There have been used two protocols of continuous-wave diode laser emitting radiation for cyclophotocoagulation. The first technique - the standard cyclophotocoagulation (high power and low exposure duration) - has been used for the eyes with limited visual function [visual acuity (VA) extremely low or eyes disorganized]. The second technique - slow coagulation, also named "slow burn" (lower power and greater exposure duration) - has been used for the eyes with apparently better visual prognosis (VA≥20∕400). For evaluation, we followed both subjective parameters (eye pain decrease) and objective parameters [intraocular pressure (IOP) lowering and VA evolution]. Patients have been evaluated before laser intervention and postoperative at one, three and six months. RESULTS: IOP has significantly decreased in both patient groups. In the eyes with better visual function (VA≥1∕20), where we have used the "slow coagulation" technique, we found no decrease of VA. Eye pain has disappeared in almost all treated cases. CONCLUSIONS: The diode laser TSCPC is an efficient method of lowering IOP and decreasing eye pain. The "slow burn" technique has been shown its efficiency for extending the indications of cyclophotocoagulation also in glaucomatous eyes with better functional prognosis.

Bilateral papillary oedema - case report.

OBJECTIVE: We report one case of malignant high blood pressure with no systemic signs but with ocular complaints. METHODS: The paper presents the case of a 31-year-old male who complained of sudden loss of visual acuity in both eyes. The ophthalmological examination revealed bilateral papillary oedema. General and cardiological examinations revealed he was suffering from malignant high blood pressure. RESULTS: The pathogenic treatment resulted in resolution of signs and symptoms with favourable ophthalmological evolution and almost entirely functional recovery. Clinical, paraclinical and imagistic data suggested the diagnosis of pheochromocytoma. CONCLUSION: This case highlighted ocular complications of high blood pressure. The paper summarizes the differential diagnosis and management of high blood pressure and reviews the most common causes of secondary hypertension in young patients.

Femtosecond-LASIK outcomes using the VisuMax®-MEL® 80 platform for mixed astigmatism refractive surgery.

AIM: To evaluate the predictability, efficacy and safety of Femtosecond-laser-assisted in situ keratomileusis (LASIK) procedure for mixed astigmatism. PATIENTS, MATERIALS AND METHODS: We prospectively evaluated for 12 months 74 eyes (52 patients) with mixed astigmatism that underwent Femtosecond-LASIK treatment. The preoperative mean refractive sphere value was +1.879±1.313 diopters (D) and the mean refractive cylinder value was -4.169±1.091 D. The anterior corneal flap was cut using the VisuMax® femtosecond laser and then the stromal ablation was done using the MEL® 80 excimer laser. RESULTS: Mean age was 30.22±6.421 years with 61.53% female patients. Postoperative spherical equivalent at 12 months was within ±0.5D of emmetropia in 75.8% of eyes and within ±1D in 97.3% of eyes. Postoperative uncorrected distance visual acuity was equivalent to or better than the preoperative corrected distance visual acuity in 91.9% of eyes. Compared to the preoperative corrected distance visual acuity (CDVA), 8.1% of eyes gained one line, 2.7% gained two lines and 2.7% gained three lines of visual acuity. CONCLUSIONS: Femtosecond-LASIK using the VisuMax®-MEL® 80 platform appears to have safe, effective and predictable results in mixed astigmatic eyes. The results are impressive for high refractive error treatment and for improvement of both uncorrected and corrected distance visual acuity.

One year refractive outcomes of Femtosecond-LASIK in mild, moderate and high myopia.

Purpose: To evaluate the safety, efficacy, predictability and stability for a cohort of myopic eyes treated by Femtosecond-LASIK procedure. Methods: 60 eyes (36 patients) with different degrees of myopia that underwent refractive surgery by using the Femtosecond-LASIK technique were prospectively evaluated for 12 months. The mean preoperative spherical equivalent value was -3.827 ± 1.410 diopters (D) (range: -8.125 to -1.375 D). VisuMax® femtosecond laser was used for cutting the corneal flap and then the Mel80® excimer laser for the stromal ablation. Results: Mean age was 30.80 ± 5.745 years (range: 21 to 46 years) with 75% female patients. Postoperative spherical equivalent at 12 months was within ±0.25 D of emmetropia in 90% of the eyes and within ±0.50 D of emmetropia in 100% of the eyes. All the eyes achieved an uncorrected distance visual acuity (UDVA) of 1.0 (decimal scale). No eye lost lines of preoperative corrected distance visual acuity (CDVA). No major intraoperative or postoperative complications were encountered. Conclusions: Femtosecond-LASIK seems to be a suitable option for the correction of mild, moderate, and high myopia, as the procedure showed to be safe, effective, and predictable for the treatment of myopic refractive errors.