Gabapentin and Memantine for Treatment of Acquired Pendular Nystagmus: Effects on Visual Outcomes.

BACKGROUND: The most common causes of acquired pendular nystagmus (APN) are multiple sclerosis (MS) and oculopalatal tremor (OPT), both of which result in poor visual quality of life. The objective of our study was to evaluate the effects of memantine and gabapentin treatments on visual function. We also sought to correlate visual outcomes with ocular motor measures and to describe the side effects of our treatments. METHODS: This study was single-center cross-over trial. A total of 16 patients with chronic pendular nystagmus, 10 with MS and 6 with OPT were enrolled. Visual acuity (in logarithm of the minimum angle of resolution [LogMAR]), oscillopsia amplitude and direction, eye movement recordings, and visual function questionnaires (25-Item National Eye Institute Visual Functioning Questionnaire [NEI-VFQ-25]) were performed before and during the treatments (gabapentin: 300 mg 4 times a day and memantine: 10 mg 4 times a day). RESULTS: A total of 29 eyes with nystagmus were evaluated. Median near monocular visual acuity improved in both treatment arms, by 0.18 LogMAR on memantine and 0.12 LogMAR on gabapentin. Distance oscillopsia improved on memantine and on gabapentin. Median near oscillopsia did not significantly change on memantine or gabapentin. Significant improvement in ocular motor parameters was observed on both treatments. Because of side effects, 18.8% of patients discontinued memantine treatment-one of them for a serious adverse event. Only 6.7% of patients discontinued gabapentin. Baseline near oscillopsia was greater among those with higher nystagmus amplitude and velocity. CONCLUSIONS: This study demonstrated that both memantine and gabapentin reduce APN, improving functional visual outcomes. Gabapentin showed a better tolerability, suggesting that this agent should be used as a first-line agent for APN. Data from our investigation emphasize the importance of visual functional outcome evaluations in clinical trials for APN.

Minimal-Access Endoscopic Endonasal Management of Dysthyroid Optic Neuropathy: The Dysthone Study.

BACKGROUND: Dysthyroid optic neuropathy (DON) is a devastating complication of thyroid eye disease. Corticosteroids are the primary medical treatment for DON, but some refractory patients may require surgical management. OBJECTIVE: To evaluate the efficacy of endoscopic endonasal decompression of the orbital apex in refractory DON. METHODS: This study included patients with refractory DON who underwent endoscopic endonasal decompression of the orbital apex from February 2015 to October 2016. A total of 23 orbital apices were decompressed across 17 patients. Visual acuity, ophthalmometry, tonometry, and visual field were evaluated at the preoperative, early and delayed postoperative stages. Statistical analyses were performed using RStudio software. A Wilcoxon test for matched data was performed to determine if there was a statistically significant difference between pre- and postsurgical treatment for the following items: visual acuity, proptosis, visual field, and intraocular pressure. RESULTS: Visual acuity improved in 69.5% of the cases with a mean gain of 2.5 points ± 1.6 (P < .05). Additionally, there was an 18.3% reduction in mean proptosis across all cases (P < .05) and a 13.7% decrease in intraocular pressure (P < .05) for all patients. Finally, visual field improved in 82.6% (P < .05) of the cases. The mean time for follow-up was of 6.28 ± 3.7 mo. There were 3 cases of transient postoperative rhinitis and 2 cases of transient diplopia. Two patients experienced recurrence at 4 and 8 mo, respectively. CONCLUSION: Endoscopic endonasal decompression of the orbital apex significantly improves visual parameters. As a result, multidisciplinary screening for patients is crucial to ensure prompt surgical decompression.

Modern neuro-ophthalmological evaluation of patients with pituitary disorders.

Pituitary adenomas can manifest as ophthalmological symptoms, such as decreased vision, impaired visual field or diplopia. It is important to recognize these neuro-ophthalmological syndromes to achieve early diagnosis and treatment and to improve prognosis. Currently, ophthalmological examination includes precise measuring instruments, such as optical coherence tomography (OCT), which allows the evaluation of optic atrophy related to compression of the anterior optic tract. These measurements are reproducible and are useful for diagnostic and prognostic evaluation. In this review, we describe the ophthalmological syndromes associated with pituitary tumours: anterior optic pathway compression, followed by oculomotor disorders and pituitary apoplexy.

EVALUATION OF OBSTRUCTIVE SLEEP APNEA SYNDROME AS A RISK FACTOR FOR DIABETIC MACULAR EDEMA IN PATIENTS WITH TYPE II DIABETES.

PURPOSE: To evaluate the association between obstructive sleep apnea and diabetic macular edema (DME) in patients with Type II diabetes, using the apnea-hypopnea index and other nocturnal hypoxemia parameters. METHODS: This cross-sectional, case-control study included 99 patients with Type II diabetes: the first group included patients with DME (DME+ group) and the second patients without DME (DME- group). Polysomnography was performed in all patients. The two groups were compared, and the risk factors were studied using logistic regression. RESULTS: The DME+ group comprised 38 patients, and the DME- group comprised 61 patients, aged a mean 68.8 years and 66.3 years (P = 0.27), respectively; mean body mass index was 29.7 and 30.9 (P = 0.16), respectively. The mean apnea-hypopnea index was significantly higher in the DME+ group (43.95 [13.5-87.3]) than in the DME- group (35.18 [3.55-90.7]) (P = 0.034). Patients with DME had more severe obstructive sleep apnea (apnea-hypopnea index >30) than the others: 71% versus 50.8% (P = 0.049). Cumulative time of SPO2 below 90% (CT90%) was independently associated with DME after adjusting for confounding factors, whereas there was no difference between the oxygen desaturation index and minimum O2 saturation. CONCLUSION: Severe obstructive sleep apnea (apnea-hypopnea index >30) and parameters of nocturnal hypoxemia (cumulative time of SPO2 below 90%) are associated with DME.

Retinal vein occlusion and obstructive sleep apnea: a series of 114 patients.

PURPOSE: Evaluate the prevalence of obstructive sleep apnea (OSA) in patients with retinal vein occlusion (RVO). METHODS: A prospective and controlled study including 114 patients from January to September 2016, who were divided into two groups: 69 patients with RVO (RVO+) and 45 controls (RVO-), matched for age, sex and disease. All the patients completed a simple questionnaire and the Epworth Sleepiness Scale and underwent a RUSleeping® (portable monitoring device and then continuously monitored the subject's respiration to detect respiratory events). In addition, all patients with RVO were administered OSA screening with a polysomnography (PSG) during an overnight stay in the hospital, which was analysed by a single sleep apnea specialist. RESULTS: Sleep apnea was suspected in 73.9% in the RVO group and 63% in the control group based on the simple questionnaire; 22% in the RVO group and 4.3% in the control group according to the Epworth Sleepiness Scale; 82.6% in the RVO group and 55.6% in the control group (p = 0.005) according to RUSleeping® . Multivariate logistic regression analysis (based on RUsleeping® ) confirmed that RVO was associated with OSA (adjusted odds ratio, 5.65, [1.60-19.92], p = 0.007). All patients in the RVO group were confirmed by PSG, and finally, 91.5% were diagnosed with moderate-to-severe OSA. Among the RVO+ patients, the mean apnea-hypopnoea index (AHI) was 42.2 events per hour (7.7-96.5). OSA was moderate in 22% patients and severe in 69.5% patients. There was no significant relationship between RVO severity and the PSG data variables. CONCLUSION: The systematic screening of OSA with the gold standard PSG found a high prevalence of OSA in patients with RVO. The OSA is probably a risk factor associated with RVO. Polysomnography remains the gold standard method; nevertheless, the RUsleeping® RTS portable monitoring device can assess the presence and severity of sleep apnea with a low failure rate and a single use, prior to PSG, which is less available in clinical practice. Further studies with larger samples are needed to clarify the association.

Evaluation of Efficacy and Safety of Dexamethasone Intravitreal Implants of Vitrectomized and Nonvitrectomized Eyes in a Real-World Study.

PURPOSE: To compare the efficacy and safety of the dexamethasone (DEX) intravitreal implant of vitrectomized and nonvitrectomized eyes in real-world conditions. METHODS: This was a retrospective, multicenter, observational study. All consecutive patients presenting with at least one 0.7-mg intravitreal injection of DEX implant were included in this study. A total of 186 eyes in 170 patients were analyzed. Fifty-nine eyes were vitrectomized at baseline and 127 eyes had no vitrectomy at the last visit. Among the baseline-vitrectomized eyes analyzed, 72.9% were treatment naive eyes, and 44.1% of nonvitrectomized eyes had no prior treatment. RESULTS: There was no statistically significant difference in the variation in best-corrected visual acuity (BCVA) between the 2 groups (P = 0.343). Variations of BCVA and central macular thickness were not significantly different between nonvitrectomized eyes and baseline-vitrectomized eyes. The intraocular pressure profile was the same in both nonvitrectomized eyes and baseline-vitrectomized eyes. The mean interval between injections was 6.9 months (2; 27.7) for nonvitrectomized eyes and 5.2 months (4; 22.1) for baseline-vitrectomized eyes (P = 0.001). The mean number of IVIs was 2 (1; 6) for nonvitrectomized eyes and 2.3 (1; 10) for baseline-vitrectomized eyes (P = 0.188) during the total follow-up period. CONCLUSION: This large cohort shows that vitrectomy does not seem to influence the efficacy and safety profile of dexamethasone intravitreal implant for DME.

REAL-LIFE STUDY IN DIABETIC MACULAR EDEMA TREATED WITH DEXAMETHASONE IMPLANT: The Reldex Study.

PURPOSE: To evaluate the efficacy and safety of intravitreal implant of dexamethasone (Ozurdex) in diabetic macular edema in real-life practice. METHODS: In this bicentric retrospective study, the authors reviewed 128 eyes of 89 patients. Main outcome measures included changes in best-corrected visual acuity, central macular thickness, time to retreatment, and incidence of adverse effects. Linear mixed-effects models were used to study changes in best-corrected visual acuity and central macular thickness over the 3-year follow-up. RESULTS: Best-corrected visual acuity increased by a mean of 3.6 letters at Month 2 (P = 0.005), 4.2 letters at Month 12 (P = 0.006), 5.3 at Month 24 (P = 0.007), and 9.5 letters at Month 36 (P = 0.023). The proportion of eyes achieving at least a 15-letter improvement from baseline was 25.4% at Month 36. Central macular thickness decreased from 451 µm to 289 µm at Month 2 (P < 0.001), 370 µm at Month 12 (P < 0.001), 377 µm at Month 24 (P = 0.004), and 280 µm at Month 36 (P = 0.001). A mean of 3.6 injections were administered over the 3-year follow-up. Ten percent of eyes developed a transient increase in intraocular pressure (IOP ≥ 25 mmHg), and cataract was removed from 47% of phakic eyes. CONCLUSION: This large case series study showed favorable 3-year outcomes when using Ozurdex to treat diabetic macular edema. Intravitreal Ozurdex provides substantial long-term benefits in the treatment of diabetic macular edema in real-life.

TOLERANCE OF INTRAVITREAL DEXAMETHASONE IMPLANTS IN PATIENTS WITH OCULAR HYPERTENSION OR OPEN-ANGLE GLAUCOMA.

PURPOSE: Evaluate the pressure tolerance of dexamethasone implants in open-angle glaucoma (OAG+) patients and ocular hypertension (OHT+) patients compared with nonglaucomatous and nonhypertensive patients. METHODS: Retrospective observational 2-center, controlled study including 100 patients treated with intravitreal injections of dexamethasone, divided into 2 groups: Group 1, OAG+/OHT+ (n = 50), and Group 2, OAG-/OHT- (n = 50), matched for age and disease. Intraocular pressure (IOP) and hypotensive treatment were evaluated initially, at 8 days, and every month for 6 months after intravitreal treatment. The primary endpoint was IOP increase greater than 10 mmHg. RESULTS: Thirty-four percent of glaucomatous patients experienced a transient IOP increase greater than 10 mmHg versus 16% in the OAG-/OHT- group (P = 0.06). Intraocular pressure greater than 25 mmHg was recorded early on Day 8 in 6% of the OAG+ patients versus 2% of the OAG- patients. Fifty-four percent of the glaucoma patients increased their treatment, and hypotensive treatment was initiated in 38% of the OAG- patients (P = 0.1). Filtering surgery was only required in the OAG+/OHT+ group (6% versus 0%), particularly in dual-therapy and triple-therapy patients, who had a higher risk of filtering surgery (P = 0.008). CONCLUSION: Half of the OAG+ and OHT+ patients needed an add-on treatment, with early onset beginning on Day 8 in 6%. This emphasizes the need for IOP monitoring during treatment, especially for OAG+/OHT+ patients.

SAFETY OF INTRAVITREAL DEXAMETHASONE IMPLANT (OZURDEX): The SAFODEX study. Incidence and Risk Factors of Ocular Hypertension.

PURPOSE: To analyze the incidence, risk factors, and time course of intraocular pressure elevation after intravitreal dexamethasone implant (Ozurdex). METHODS: The medical charts of 421 consecutive eyes (361 patients) receiving one or more Ozurdex implant between October 2010 and February 2015 were reviewed retrospectively. Ocular hypertension was defined as intraocular pressure of at least 25 mmHg or an increase of at least 10 mmHg from baseline. The main indications for treatment were retinal vein occlusion (34%), diabetic macular edema (30%), postsurgical macular edema (17%), uveitis (14%), and other etiologies (5%). RESULTS: Among 1,000 intravitreal injections, ocular hypertension was recorded for 28.5% of injected eyes over a mean follow-up period of 16.8 months (3-55). Intraocular pressure-lowering medication was required for 31% of eyes. Only three eyes with preexisting glaucoma required filtering surgery to manage postinjection intraocular pressure elevation. Early retreatment between the third and fourth month does not increase the risk of intraocular pressure elevation. Younger age, male sex, Type 1 diabetes, preexisting glaucoma treated with dual or triple therapy, and a history of retinal vein occlusion or uveitis were significant risk factors for ocular hypertension after dexamethasone implant injection (P < 0.05 for all the above). CONCLUSION: Episodes of ocular hypertension after Ozurdex implant were generally transient and successfully managed with topical treatment. An analysis of the risk factors may help to determine the risk-benefit ratio for individual patients treated with dexamethasone implants.