[Present state of diagnostic and screening of the diabetic retinopathy and diabetic macular oedema]. / Soucasný stav diagnostiky a screeningu diabetické retinopatie a diabetického makulárního edému.

Diabetic retinopathy (DR) and its complications are worldwide one ofthe main causes ofthe visual impairment and blindness. An incidence of DR is substantially raised due to increasing amount of diabetic patients in population. Systematic screening of diabetic eye complications makes possible a timely incorporation of patients with diabetes mellitus to a lifelong preventive ophthalmological treatment. According to an extent of progress of the DR, these patients are treated by retinal laser coagulation or inhibitors of growth factors and/or surgical treatment of retinal complications by the pars plana vitrectomy. Essential aspects of the effective prevention of the origin and development of diabetic eye complications are cooperation of diabetologist and ophthalmologist, education of patients and their active approach to the treatment.

[Problematic issues related to screening for diabetic retinopathy]. / Problemy pri sledování pacientu s diabetickou retinopatií.

The aim of this paper is to highlight the importance of screening for diabetic retinopathy and the education of diabetic patients. The key prerequisite of an effective screening is close collaboration between health care professionals. Successful screening detects DR at early stages and helps to prevent severe visual loss. Two cases of proliferative DR exhibiting the most serious complications (vitreous haemorrhage, traction retinal detachment and combined traction and rhegmatogenous retinal detachment, neovascular glaucoma) are reported. The first comorbid patient lost her vision despite the adequate treatment. The second patient was successfully managed with pars plana vitrectomy with final visual acuity better to the preoperative value.

TREATMENT OPTIONS FOR PREMACULAR AND SUB-INTERNAL LIMITING MEMBRANE HEMORRHAGE.

INTRODUCTION: Premacular hemorrhage (PH) and sub-internal limiting membrane hemorrhage (sub-ILM-H) are among the causes of sudden deterioration of central visual acuity. Anatomical and functional outcomes of different therapeutic options were evaluated retrospectively. METHODS: The study included three eyes of three patients (2 females and 1 male). Location of the hemorrhage was determined by spectral domain optical coherence tomography. Subhyaloid premacular location of the hemorrhage was proven in one eye of each woman and sub-ILM location of the hemorrhage in one eye of the male. The baseline best corrected visual acuity (BCVA) was 0.63 in the eyes of the females and 0.16 in the eye of the male. Conservative treatment option was chosen in case of juxtafoveolar PH in the eye of the female patient on anticoagulant warfarin therapy. The female patient with PH secondary to proliferative diabetic retinopathy (PDR) underwent Nd: YAG laser hyaloidotomy. The male patient with unexplained cause of the sub- ILM-H underwent 25-Gauge vitrectomy with ILM peeling and subsequent ultrastructural morphometric and histopathological examination of the ILM. RESULTS: Both BCVA and retinal finding improvement were achieved in all patients. Final BCVA was 0.8 in the eye of the female patient with PDR and 1.0 in rest of the eyes of the other patients. No complications were recorded at follow-up visits. Histopathological and morphometric examination demonstrated variable ILM thickness (2.70 ±1.58 μm) and proved presence of fibroblasts and macrophages with hemosiderin deposits on the retinal side of ILM. CONCLUSION: The choice of the treatment option of PH and sub-ILM-H depends on input parameters such as the initial BCVA, the extent and the location of the hemorrhage, as well as the overall health of the patient. Nd: YAG laser hyaloidotomy is an effective method for rapid recovery of visual functions. Surgical ILM peeling and aspiration of the underlying hemorrhage result in the removal of breakdown products of hemoglobin and minimization of the risk of secondary epiretinal membranes development.

OCT Findings and Long-term Follow-up Results of Vitrectomy in Patients with Optic Disc Pit and Associated Maculopathy.

PURPOSE: To evaluate OCT findings and long-term follow-up results in patient with optic disc pit (ODP) and associated maculopathy treated with pars plana vitrectomy (PPV). METHODS: Six eyes of 6 patients (3 females, 3 males) were included in a retrospective study. We excluded patients with ODP without maculopathy. Patients were followed in years 2008-2017. Mean age at the first examination was 40,3 years (15-70 years). Duration of worsening of the best corrected visual acuity (BCVA) ranged from 2 days to few years. In all patients we performed BCVA test at Early Treatment of Diabetic Retinopathy Study (ETDRS) optotype, examination of anterior and posterior segment and photo documentation of fundus. Optic disc, parapapillary region and macula were examined by optic coherence tomography (OCT). Four patients underwent 23-Ga PPV with active detachment of posterior hyaloid membrane and tamponade with perfluoropropan (16% C3F8). In 2 patients a sample of tissue from ODP was taken during PPV to histological examination. RESULTS: Mean BCVA at the first examination was 0,10 (ranging from 0,05 to 0,16). OCT findings proved macular schisis in outer retinal layers (RSE) in 2 eyes, in 1 of these eyes with additional presence of subretinal fluid. In 4 patients macular schisis in outer as well as inner retinal layers (RSI) was present, in 2 of them with additional subretinal fluid. In 5 eyes glial tissue and/or vitreous condensation was present in ODP. Four eyes with RSE and RSI improved both anatomically as well as functionally after vitrectomy. In 1 patient with previous communication between ODP and RSE this was closed after vitrectomy. Mean pre-operative BCVA was 0,11 (ranging from 0,05 to 0,16), mean final BVCA was 0,5 (ranging from 0,25 to 0,63), mean visual gain was +30 letters (ranging from +10 to +45). Mean follow-up after PPV was 59 months (36-96). CONCLUSION: Spectral OCT shows variability of morphological findings in patient with ODP associated with maculopathy. Traction of glial tissue and/or condensed vitreous in ODP together with adherent posterior vitreous membrane could be one of the factors causing macular retinoschisis and/or secondary serous macular detachment. Complete separation of vitreous from optic nerve head during the vitrectomy is an efficient treatment resulting in macular reattachment and improvement in visual functions. Key words: optic disc pit, intrapapillary proliferation, macular retinoschisis, optical coherence tomography, pars plana vitrectomy, posterior vitreous detachment.

[Two-Year Follow-up Results of Patients with Macular Oedema Due to Retinal Vein Occlusion Treated with Ranibizumab]. / Dvouleté zkusenosti s intravitreální lécbou makulárního edému ranibizumabem u pacientu s okluzí retinální vény.

PURPOSE: To evaluate 2-year follow-up results of patients with macular oedema (ME) caused by central (CRVO) and branch (BRVO) retinal vein occlusion treated with intravitreal ranibizumab at the Department of Ophthalmology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic. METHODS: Retrospective study. RESULTS: The 2-year follow-up was completed by 18 patients with ME caused by CRVO and 16 patients with ME caused by BRVO. In CRVO group mean age at diagnosis was 63 years, mean interval from diagnosis to the beginning of treatment was 3,6 months. During the first year of treatment the mean improvement of best corrected visual acuity (BCVA) was 17,4 letters of Early Treatment Diabetic Retinopathy Study (ETDRS) optotype, during the second year +2,4 letters. Mean number of injections was 6,8 in the first and 3,6 in the second year of treatment, mean total of 10,2 injections. In BRVO group the mean age at diagnosis was 68 years, mean interval from diagnosis to the beginning of treatment 6 month, mean gain in BCVA was +18,7 letters in the first and +1 letters in the second year of treatment, mean number of injections was 7 and 3,2 respectively, mean total of 9,6 injections. In both groups neither ocular nor systemic serious adverse effects were noted. CONCLUSION: According to our results intravitreal ranibizumab is a safe and effective treatment for ME caused by retinal vein occlusion. Our results in BRVO group were in accordance with published international studies - BRAVO (BRVO) +18,3 letters, HORIZON -0,7 and even slightly better in CRVO group - CRUISE (CRVO) +13,9 letters, HORIZON study -4,1 lettersKey words: macular oedema, ranibizumab, retinal vein occlusion, central retinal vein occlusion, branch retinal vein occlusion, 2-year follow-up.

Comparison of laser-Doppler flowmetry with biochemical indicators of endothelial dysfunction related to early microangiopathy in Type 1 diabetic patients.

The aim of this study was to compare biochemical markers of endothelial activation with microcirculation measured by laser-Doppler flowmetry in Type 1 diabetic patients with or without microangiopathy. A total of 44 Type 1 diabetic patients were subdivided into those with (n=24) and without (n=20) microangiopathy according to ophthalmological findings and the presence or absence of microalbuminuria. The control group consisted of 25 healthy people of comparable age, sex, and body mass index. Postocclusive reactive hyperemia (PORH) and thermal hyperemia (TH, at 44 degrees C) were measured at the forearm. Serum N-acetyl-beta-glucosaminidase (NAG) activity, serum E-selectin, and ICAM-1 concentrations were used as biochemical markers of endothelial dysfunction. A significantly lower velocity of perfusion increase during postocclusive hyperemia (PORH(max) x t(1)(-1)) and during thermal hyperemia (TH(max) x t(2)(-1)) (P<.01) were accompanied by higher serum NAG activity (20.9+/-4.6 vs. 16.3+/-2.5 U l(-1), P<.01) in diabetic patients with microangiopathy as compared to healthy persons. An inverse relationship was found between PORH(max) x t(1)(-1) and NAG (r=-.33) results in diabetic patients. In addition, higher mean values of serum NAG activity, E-selectin, and ICAM-1 concentrations were associated with significantly lower values of microcirculation parameters (PORH(max) x t(2)(-1) and TH(max) x t(2)(-1)) in six patients without microangiopathy who had at least one of the above biochemical markers higher than mean+2 S.D. range. We suggest that serum NAG activity, E-selectin, and ICAM-1 concentrations may be used together with laser-Doppler flowmetry in Type 1 diabetic patients as early indicators of vascular changes in very early stage of diabetic microangiopathy.

Long-term results of pars plana vitrectomy and silicone oil for complications of diabetic retinopathy.

Pars plana vitrectomy (PPV) with silicone oil implantation (SOI) was performed for advanced proliferative diabetic retinopathy (PDR) in 110 eyes of 98 diabetic patients. In 77 eyes (70%) it was a primary SOI as part of the initial operation; in 33 eyes (30%) it was a secondary SOI in reoperations. Indications for SOI were traction retinal detachment of the posterior pole, combined traction and rhegmatogenous detachment, vitreous haemorrhage with florid vascularised fibrous proliferations, and recurrent vitreous haemorrhage after PPV. The patients were followed up for 24 to 72 months, with a mean of 53 months. At the end of follow-up, anatomical success was achieved in 63 eyes (57%), and functional success with visual acuity 0.01 and better in 35 eyes (32%). Functional failures were caused by retinal redetachment in 47 eyes (43%), by secondary glaucoma in 10 eyes (9%), retinal ischemia in 15 eyes (13%) and keratopathy in three eyes (3%). The functional success rate decreased with follow-up from 67% after six months to 50% by 60 months after SOI. Silicone oil bubble in the anterior chamber, rubeosis iridis, cataract, and glaucoma were the most frequent postoperative complications. PPV with SOI was highly effective in many serious complications of advanced PDR. Functional success was mostly lasting and markedly improved the quality of life of these patients.

[Changes in microcirculation and selected laboratory parameters in the early stages of diabetic microangiopathy]. / Zmeny mikrocirkulace a vybraných laboratorních parametru v casných stadiích diabetické mikroangiopatie.

BACKGROUND: Early stages of diabetic microangiopathy are accompanied with dysfunction, manifested by changes of some biochemical parameters. Parallel changes were observed in microcirculation. The aim of this study was to compare microcirculation in the skin of a forearm evaluated by laser Doppler with selected laboratory markers of endothelial dysfunction in Type 1 diabetes mellitus without microangiopathy or with incipient microangiopathy. METHODS AND RESULTS: Group of 43 Type 1 diabetic patients was examined in this study. 20 of them had no signs of microangiopathy and in 23 patients a simple diabetic retinopathy (background retinopathy) was diagnosed. Control group consisted of 25 healthy persons of comparable age, sex, and body mass index. All persons involved in this study were examined by laser Doppler and by biochemical examination and the results were compared. In comparison with control group, in diabetic patients the arm occlusion significantly lowered the increase of perfusion (29 +/- 12 vs. 41 +/- 18 perfusion units (PU) p < 0.01). Similarly the perfusion velocity increase was significantly lower in diabetic patients than in healthy controls (p < 0.01). Also the velocity of the perfusion increase after the warming up was lower in the diabetic than in non-diabetic persons (p < 0.01). Such changes of perfusion or those of velocity of perfusion increase were significantly lower in diabetic patients with microangiopathy than in those without this complication. Perfusion increases after both stimuli highly correlated (r = 0.86, p < 0.001). In diabetic patients with microangiopathy significantly higher N-acetyl-beta-glucosaminidase (NAG) activities in serum and E-selection or ICAM-1 concentrations were found as compared with patients without microangiopathy, whereas plasma concentrations of tissue plasminogen activator (tPA) or inhibitor (PAI-1) were comparable with those in the control group. NAG activity inversely correlated with velocity of the perfusion increase after both the occlusion (r = -0.41, p < 0.01) and the warming (r = -0.38, p < 0.05). Similar relationship was found between tPA or E-selectin and the velocity of the perfusion increase after the occlusion (r = -0.48, p < 0.01). CONCLUSIONS: Our results confirm that biochemical parameters and microcirculation are impaired in the early stage of microangiopathy in Type 1 diabetic patients. Detailed analysis showed that both types of examination offer slightly different information on the vascular status. A long prospective study in diabetic patients without incipient vascular changes will be necessary to evaluate if biochemical or microcirculatory changes can bring an earlier information on the developing angiopathy.

[Relation of diabetic polyneuropathy to vascular and organ complications in type I diabetes mellitus]. / Vztah diabetické polyneuropatie k cévním a orgánovým komplikacím u diabetu mellitu I. typu.

The authors investigated in 194 type I diabetics the incidence and severity of diabetic polyneuropathy in relation to other organ and vascular complications, incl. autonomous neuropathy. It was revealed that the increasing severity of polyneuropathy was significantly v séru (Cr equal to or less than 130-200 mumol/l); 4--Cr greater than 200 mumol/l; associated with severe stages of nephropathy and proliferative retinopathy with amaurosis. The concurrent presence of hypertension and polyneuropathy was surprising and striking--even in patients with the mildest grade 1 polyneuropathy hypertension was present in 10% and the incidence increased significantly with the increasing severity of polyneuropathy. Ischaemic heart disease and ischaemia of the lower extremities was significantly more frequent only in patients with grade 5 polyneuropathy. In patients with grade 4 and 5 neuropathy there was a 100% incidence of autonomous neuropathy in the cardiovascular sphere. The authors did not reveal significant differences between men and women as regards the relationship between the incidence of polyneuropathy and organ and vascular complications.

[Efficiency of vitrectomy in diabetic macular edema and morphometry of surgically removed of the internal limiting membrane]. / Význam vitrektomie u diabetického makulárního edému a morfometrie chirurgicky odstranené vnitrní limitující membrány.

AIM: To evaluate the efficiency of vitrectomy with peeling of the internal limiting membrane (ILM) in eyes with diffuse and/or cystoid nontractional diabetic macular edema (ME) refractory to macular laser photocoagulation. Histopathologic and morphometric analysis of the ILM in diabetic eyes was performed. Thickness of the ILM was correlated with the level of glykosylated hemoglobin (HbA1c) and other clinical factors. MATERIAL AND METHODS: The prospective study involved 56 eyes of 52 diabetic patients with a mean age of 63 +/- 7.6 years. Vitrectomy with trypan blue-assisted ILM peeling was performed in standard way. Mean follow-up period was 8.7 months (range 3 - 19 months). The ILM was fixed immediately after peeling in 2.5% glutaraldehyde and submitted for electron microscopic evaluation. The ILM was photographed in standard magnification (x 5000) with the scale of 1 microm in the shot. RESULTS: Statistical analysis of the postoperative visual acuity (VA) in the study group of 56 eyes proved a general improvement with prevalence of the resulted VA in intervals 0.1-0.2 and 0.5-1.0 related to ETDRS chart. The VA was improved by at least 2 lines in 29 eyes of 56 eyes (51.8%), one line in 6 eyes (10.7%) and remained unchanged in 11 eyes (19.6%). The postoperative VA deteriorated by one line in 2 eyes (3.6%) and at least 2 lines in 8 eyes (14.3%). Morphometric analysis demonstrated a significant thickening of the ILM in all eyes with a mean thickness of the ILM 3.61 +/- 1.22 micro m. It was found that a higher thickness of the ILM is related to elevated HbA1c by both types of diabetes mellitus (DM) (p = 0.040). We also found significant dependence of ILM thickness in relation to duration of DM by comparison of men and women (p = 0.026) and significant correlation between ILM thickness and the age of diabetic patients related to their gender (p = 0.029). CONCLUSIONS: Vitrectomy with peeling of the ILM in eyes with chronic diffuse and/or cystoid nontractional diabetic ME mildly improves the VA and extends a hope for its stabilization. We confirmed increased thickness of the surgically peeled ILM and statistically significant correlations to elevated HbA1c by both types of DM and to further clinical characteristics of case series. Morphometric and histopathologic analyses of the ILM contribute to more objective evaluation of ultrastructure of the vitreomacular interface.

[Sympathetic ophthalmia]. / Sympatická oftalmie.

PURPOSE: To evaluate the efficacy of treatment on prevention of disease development and protection of visual outcomes in patients suffering from sympathetic ophthalmia. METHODS: Retrospective case. RESULTS: Four patients with sympathetic ophthalmia were treated in our department from 1999 to 2004. All patients were men with the mean age 27.5 years (15-49 years). In two patients, there was a history of penetrating eye injury prior to the onset of sympathetic ophthalmia, in other two patients sympathetic ophthalmia occurred after eye surgery (pars plana vitrectomy), with no previous ocular trauma. Two patients were treated with monotherapy of corticosteroids; other two patients were commenced on combined immunosuppression. In all these cases, the therapy was effective. CONCLUSION: Sympathetic ophthalmia is a rare, sight-threatening eye disease. Among the triggering factors dominates penetrating eye injury, however, there is currently an increase in the number of cases with sympathetic ophthalmia following eye surgery, mainly pars plana vitrectomy. Early introduction of immunosuppressive treatment can get the disease under control, prevent the development of intraocular inflammation and improve visual outcomes.

[Vitrectomy for diabetic cystoid macular edema -- results of 72 cases]. / Vitrektomie beim diabetischen zystoiden Makulaödem -- Ergebnisse von 72 Fällen.

BACKGROUND: We evaluated visual outcomes after vitrectomy for diabetic cystoid macular edema and factors possibly influencing final visual acuity. MATERIALS AND METHODS: Studied prospectively, pars plana vitrectomy was performed on 72 consecutive eyes of 61 patients with diabetic cystoid macular edema not responsive to laser photocoagulation therapy. Vitreomacular traction was observed on biomicroscopy, B-scan ultrasonography, and optical coherence tomography in 21 eyes, 15 eyes had a complete posterior vitreous detachment (PVD) and 36 eyes had partial peripheral PVD. Vitrectomy with releasing vitreomacular tangential and axial tractional forces was performed. All patients were followed up for at least 6 months. RESULTS: The anatomical results were satisfactory in 69 of 72 eyes (96 %), the final visual acuity improved by 2 or more lines in 45 of 72 eyes (63 %), remained unchanged in 22 of 72 eyes (31 %), and deteriorated after surgery in 5 of 72 eyes (7 %), due to residual cystoid macular edema and massive macular hard exudates. The best results were obtained in edema with tractional predominance and in eyes with a duration of cystoid macular edema shorter than 6 months. CONCLUSIONS: Vitrectomy for diabetic cystoid macular edema is an effective procedure for reducing the edema and improving visual acuity. Surgery was beneficial not only in eyes with vitreomacular traction but also in eyes with complete PVD. Visual improvement after vitrectomy is related to duration of edema, therefore the timing of the surgery is an important prognostic factor.

[Screening for diabetic retinopathy in the Czech Republic--guideline]. / Screening diabetické retinopatie v CR--guideline.

Diabetic retinopathy (DR) and diabetic maculopathy (DMP) are the most frequent and most serious complications of diabetes mellitus (DM). At present the adverse development of these microvascular complications of DM can be very successfully delayed by available therapeutic methods. The success of the therapeutic procedure depends in particular on early treatment of DR and DMP by laser coagulation and/or pars plana vitrectomy, which presumes detection of early stages of the disease. The authors evaluate the priorities of DR screening, the final effect of which is a decline of blindness caused by DM. Conditions for screening of diabetic eye disease are the diagnosis of DR by simple and safe procedures, classification of DR on the basis of the dynamics of retinal changes and standards of treatment. An integral part of the ophthalmological screening programme is professional collaboration of ophthalmologists, diabetologists, general practitioners and specialists in internist medicine. Successful screening of DR makes it possible to involve the subject in preventive and therapeutic care, education of the patient, regular lifelong follow up and early treatment of DR and DMP. By the method of screening of DR we reduce the risk of a decline of visual acuity and prevent severe functional losses as a result of diabetic ophthalmological complications.

[Results of vitrectomy in cystoid diabetic macular edema detected by optical coherence tomography]. / Výsledky vitrektomie u cystoidního diabetického makulárního edému zjistené optickou koherentní tomografií.

PURPOSE: To evaluate the surgical results of the pars plana vitrectomy (PPV) with separation of the posterior hyaloid (PH) with the cystoid diabetic macular edema (DME) using optical coherence tomography (OCT). METHODS: PPV with removing of the PH was performed in 10 eyes of 10 patients with cystoid DME. The macular structure, the vitreoretinal interface and the foveal thickness before and after PPV was evaluated using OCT and was correlated with a slit lamp biomicroscope. All 10 eyes had undergone panretinal and macular photocoagulation. RESULTS: OCT demonstrated postoperatively in all 10 eyes the regression of cystoid DME and the presence of foveal depression. Visual acuity (VA) has improved by 2 and more Snellen lines in 6 eyes with preoperative decrease of VA not longer than 5 months. CONCLUSIONS: PPV with separation of PH is efficient method in treatment of cystoid DME. Duration of cystoid DME is a significant factor for determination of functional prognosis. OCT facilitates the follow-up of the dynamics of regression of the structure and thickness of the fovea.

[Screening for diabetic maculopathy]. / Screening diabetické makulopatie.

Diabetic maculopathy (DMP) is an important but curable of eyesight losses in diabetic with type 1 and 2 diabetic mellitus (DM). In the submitted work the author investigates the pathogenesis of diabetic macular oedema (DME). Classification, diagnosis and standard of treatment of DMP, incl. the different therapeutic procedure used in concurrent DMP and proliferative diabetic retinopathy in DM type 1 and 2.

[Pars plana vitrectomy in proliferative diabetic retinopathy. Long-term results and prognostic parameters in diabetics with surgery 1983-1989]. / Pars plana vitrektomie u proliferativní diabetické retinopatie. Dlouhodobé výsledky a prognostické parametry u diabetiku operovaných v letech 1983-1989.

The authors evaluated the long-term results and prognostic parameters of pars plana vitrectomy (PPV) in complications of proliferative diabetic retinopathy in 235 eyes of 187 diabetics operated between Jan. 1 1983 and June 30 1989. In 117 eyes PPV was combined with implantation of silicon oil. During an average observation period of 27 months PPV improved markedly the visual acuity of 125 eyes (53.2%), however a visual acuity of 0.1 or better acuity was recorded only in 53 eyes (22.6%). The number of successfully operated eyes declined with the length of the observation period from 67.7% after three months to 50% after 60 months. Active vascular proliferation, iatrogenic fissures of the retina, implantation of silicone oil and postoperative development of rubeosis were statistically significant adverse factors from the prognostic aspect. With the development of new surgical procedures the importance of different prognostic factors changes partly.