Ali Erginay

OPTICAL COHERENCE TOMOGRAPHY FOR EVALUATING DIABETIC MACULAR EDEMA BEFORE AND AFTER VITRECTOMY

PURPOSEnTo report the use of optical coherence tomography (OCT) for evaluation of diffuse diabetic macular edema (DME) before and after vitrectomy.nnnDESIGNnInterventional case series.nnnMETHODSnA retrospective study was made of 15 consecutive eyes of 13 patients that had vitrectomy for diffuse DME and OCT preoperatively and postoperatively. In seven eyes of six patients (group 1), vitrectomy was performed because of vitreomacular traction observed on biomicroscopy or OCT. In the other eight eyes of seven patients (group 2), vitrectomy was performed for DME not responsive to laser photocoagulation, with no vitreomacular traction on biomicroscopy or OCT.nnnRESULTSnMean +/- standard deviation (SD) follow-up after vitrectomy was 18 +/- 10 months (range, 6 to 33 months). In group 1, mean +/- SD retinal thickness decreased significantly from 661 +/- 181 microm preoperatively to 210 +/- 32 microm at the end of follow-up (P =.018). Median best-corrected visual acuity (BCVA) improved from 20/100 before surgery (range, 20/250 to 20/50) to 20/80 at the end of follow-up (range, 20/250 to 20/25; P =.046). In one eye in group 1, vitreomacular traction was only observed on OCT and not on biomicroscopy. In group 2, mean +/- SD retinal thickness decreased from 522 +/- 103 microm preoperatively to 428 +/- 121 microm at the end of follow-up (P =.2). Median BCVA was 20/100 before vitrectomy (range, 20/320 to 20/63) and 20/200 at the end of follow-up (range, 20/250 to 20/63; P =.78).nnnCONCLUSIONSnVitrectomy was beneficial in eyes with diffuse DME combined with vitreomacular traction but not in eyes without traction. Optical coherence tomography allowed diagnosis of subtle vitreomacular traction and provided precise preoperative and postoperative assessments of macular thickness.

Macular retinoschisis in highly myopic eyes

PURPOSEnTo describe the characteristics and evolution of macular retinoschisis in high myopia observed by optical coherence tomography (OCT).nnnDESIGNnA consecutive, retrospective, observational case series.nnnMETHODSnTwenty-one highly myopic eyes (mean refractive error, -15.2, range -6 to -25) of 17 patients presenting with the unusual feature of macular thickening without a macular hole and associated with a posterior staphyloma were examined by biomicroscopy and OCT. Ten patients (13 eyes) were followed up for 12 months or more.nnnRESULTSnOn biomicroscopy, the macula of all 21 eyes had a microcystic appearance without macular hole. In all eyes, OCT showed that retinal thickening was mainly due to an extensive hyporeflective space splitting the neuroretina into a thick inner layer and a thin outer layer. We called this condition outer retinoschisis. In six cases, inner splitting, termed inner retinoschisis, was also present. The macular profile exhibited a foveal cyst in 10 eyes, a lamellar hole in six, and a foveal detachment in six. In four of the 21 eyes, a hyperreflective preretinal structure resembling the posterior hyaloid was stretched over the retinoschisis, causing foveal traction. Two of these four eyes subsequently evolved into a full-thickness macular hole.nnnCONCLUSIONnMacular retinoschisis is not uncommon in highly myopic eyes with staphyloma and is better characterized by OCT than by biomicroscopy. Intraretinal splitting occurs in both the outer and inner layers of the retina, leading to the formation of cystoid spaces. In most cases, the condition is fairly stable in terms of visual acuity and retinal thickness and change occurs slowly over time. However, a macular hole may occur when the retinoschisis is associated with tangential traction of the posterior hyaloid.

Dome-Shaped Macula in Eyes with Myopic Posterior Staphyloma

PURPOSEnTo describe an unusual feature in myopic eyes responsible for visual loss, which we call a dome-shaped macula.nnnDESIGNnRetrospective, observational case series.nnnMETHODSnAfter observing isolated cases of dome-shaped macula, we analyzed optical coherence tomography (OCT) scans of 140 highly myopic eyes present in our OCT database to find similar cases. Fifteen eyes of 10 patients had a dome-shaped macula. These patients all had undergone fluorescein angiography (FA), indocyanine green angiography (ICGA), and B-scan ultrasonography examinations.nnnRESULTSnThe mean refractive error of the affected eyes was -8.25 diopters (D; range, -2 to -15 D). Median visual acuity was 20/50. Recent visual impairment was noted in 11 of the 15 eyes studied, and metamorphopsia was noted in eight eyes. Four eyes were asymptomatic. FA showed atrophic changes in the macular retinal pigment epithelium (RPE) in all eyes, combined with focal points of leakage in seven of the 15 eyes. The dome-shaped appearance of the macula was visible on both B-scan ultrasonography and OCT: a characteristic bulge of the macular retina, RPE, and choroid within the concavity of the moderate posterior staphyloma was present in all eyes. In 10 eyes, OCT also showed a shallow foveal detachment at the top of the dome-shaped macula.nnnCONCLUSIONSnA dome-shaped macula within a myopic staphyloma is an unreported type of myopic posterior staphyloma. The dome-shaped macula often is associated with RPE atrophic changes and foveal retinal detachment, which may explain the visual impairment in these eyes.

Treatment of von Hippel-Lindau retinal hemangioblastoma by the vascular endothelial growth factor receptor inhibitor SU5416 is more effective for associated macular edema than for hemangioblastomas.

PURPOSEnTo test the efficacy of the novel vascular endothelial growth factor (VEGF) receptor inhibitor SU5416, in a case of refractory von Hippel-Lindau (VHL) retinal hemangioblastoma (RHB).nnnDESIGNnInterventional case report.nnnMETHODSnPatient included in a multicenter phase II trial. A 30-year-old woman presenting with VHL disease and multiple RHB on her only eye, refractory to conventional treatments, had decreased visual acuity due to cystoid macular edema (CME). SU5416 was administered intravenously for 7 months. Best-corrected visual acuity (BCVA) and macular thickness were measured by optical coherence tomography.nnnRESULTSnUnder treatment, the size of the RHB did not change, but CME improved significantly. Best-corrected visual acuity rose from 20/40 to 20/25. However, CME recurred after the end of the treatment.nnnCONCLUSIONnThe VEGF receptor inhibitor SU5416 failed to reduce the size of RHB but was very effective for the associated CME.

Visual outcome of surgery for epiretinal membranes with macular pseudoholes

OBJECTIVEnTo evaluate the effect of macular pseudohole on visual results after epiretinal membrane (ERM) surgery.nnnDESIGNnRetrospective case-control study.nnnPARTICIPANTSnThe postoperative results for 50 eyes with ERMs combined with pseudohole were compared with the results for a paired series of idiopathic ERMs without pseudohole operated on during the same period.nnnINTERVENTIONnAll patients underwent standard three-port pars plana vitrectomy, including core vitrectomy, and removal of the membrane.nnnMAIN OUTCOME MEASURESnAnatomic and functional evaluations were performed before and after surgery. Main outcome measures were postoperative visual acuity and the persistence or disappearance of the pseudohole.nnnRESULTSnFor the patients with pseudohole, median preoperative visual acuity was 20/63 (range, 20/32-20/860) and median postoperative visual acuity was 20/40 (range, 20/20-20/860). Vision improved by 2 or more lines in 31 (62%) of 50 eyes. Forty eyes (80%) reached visual acuity of 20/50 or more. Pseudohole persisted in 22 eyes (44%) 3 months after surgery and in 15 eyes (30%) at 6 months. There was no difference in visual acuity, whether or not the pseudohole persisted. For the patients without pseudohole, median preoperative visual acuity was 20/63 (range, 20/32-20/860). Median postoperative visual acuity was 20/40 (range, 20/20-20/860). Vision improved by 2 or more lines in 37 eyes (74%). In 36 eyes (72%), it was 20/50 or more. Neither preoperative nor postoperative visual acuity differed significantly in the groups with and without pseudohole.nnnCONCLUSIONnAfter surgery for idiopathic ERMs combined with pseudohole, visual outcome is good, and pseudohole has no adverse prognostic value. Pseudohole disappears inconstantly after surgery, but its persistence does not preclude good postoperative visual recovery.

Acute transient myopia induced by indapamide

PURPOSEnTo report on a case of acute transient myopia associated with ciliochoroidal detachment induced by indapamide.nnnMETHODnCase report. Clinical examination, ultrasonography, and fluorescein angiography were performed during the acute phase of disease and convalescence.nnnRESULTSnAfter indapamide was discontinued, acute bilateral myopia, which was associated with anterior chamber shallowing and diffuse choroidal thickening, resolved spontaneously 8 days after onset. The initial angiography showed scattered islands of delayed fluorescein filling that disappeared without any permanent change by day 30.nnnCONCLUSIONnIndapamide can induce spontaneously resolving transient myopia associated with diffuse choroidal thickening.

Subfoveal Deposits Secondary to Idiopathic Epiretinal Membranes

PURPOSEnTo describe the subfoveal deposits secondary to idiopathic epiretinal membranes (ERMs) and to assess their effect on the preoperative and postoperative course.nnnDESIGNnRetrospective, observational case series.nnnPARTICIPANTSnOne hundred patients operated on consecutively for idiopathic ERMs in a single center.nnnMETHODSnThe files of 100 consecutive patients operated on for idiopathic ERMs were reviewed by 2 independent investigators. Fellow eyes were used as matched controls. Patients with an ERM in the contralateral eye were excluded, as well as those with no available fundus photographs or optical coherence tomography (OCT) scans. In all, 87 eyes were included in the study.nnnMAIN OUTCOME MEASURESnComparison of subfoveal deposit frequency in eyes with an ERM and their fellow eyes, as shown by Stratus OCT scans and fundus photographs, and preoperative and postoperative best-corrected visual acuity (VA) in eyes with an ERM.nnnRESULTSnA subfoveal deposit was found on both preoperative fundus photographs and OCT scans in 15 eyes with an ERM (17.2%) versus 5 (5.7%) in control fellow eyes (P = 0.0303). The group of patients with a subfoveal deposit was 5.3 years older, on average, than the group without (P = 0.0206). Time of onset of ERMs and macular thickness were not different between the 2 groups (P = 0.5663 and P = 0.7488, respectively). There was no significant difference regarding gender ratio or mean preoperative and postoperative VA (P = 0.9498 and P = 0.9902, respectively).nnnCONCLUSIONSnIn this series, subfoveal deposits seemed to be associated with the presence of ERMs. Interestingly, they did not preclude good postoperative VA.nnnFINANCIAL DISCLOSURE(S)nThe author(s) have no proprietary or commercial interest in any materials discussed in this article.

Association Between Vessel Density and Visual Acuity in Patients With Diabetic Retinopathy and Poorly Controlled Type 1 Diabetes

Importance Capillary dropout is a hallmark of diabetic retinopathy, but its role in visual loss remains unclear. Objective To examine how macular vessel density is correlated with visual acuity (VA) in patients younger than 40 years who have type 1 diabetes without macular edema but who have diabetic retinopathy requiring panretinal photocoagulation. Design, Settings, and Participants Retrospective cohort study of VA and optical coherence tomography angiography data collected from consecutive patients during a single visit to Lariboisière Hospital, a tertiary referral center in Paris, France. The cohort included 22 eyes of 22 patients with type 1 diabetes without macular edema but with bilateral rapidly progressive diabetic retinopathy that was treated with panretinal photocoagulation between August 15, 2015, and December 30, 2016. Eyes were classified into 2 groups by VA: normal (logMAR, 0; Snellen equivalent, 20/20) and decreased (logMAR, >0; Snellen equivalent, <20/20). The control group included 12 eyes from age-matched healthy participants with normal vision. Main Outcomes and Measures Visual acuity and mean vessel density in 4 retinal vascular plexuses: the superficial vascular plexus and the deep capillary complex, which comprises the intermediate capillary plexus and the deep capillary plexus. Results Of the 22 participants, 11 (50%) were men, mean (SD) age was 30 (6) years, and mean (SD) hemoglobin A1c level was 8.9% (1.6%). Of the 22 eyes with diabetic retinopathy, 13 (59%) had normal VA and 9 (41%) had decreased VA (mean [SD]: logMAR, 0.12 [0.04]; Snellen equivalent, 20/25). Mean [SE] vessel density was lower for eyes with diabetic retinopathy and normal VA compared with the control group in the superficial vascular plexus (44.1% [0.9%] vs 49.1% [0.9%]; difference, −5.0% [1.3%]; 95% CI, −7.5% to −2.4%; Pu2009<u2009.001), in the deep capillary complex (44.3% [1.2%] vs 50.6% [1.3%]; difference, −6.3% [1.8%]; 95% CI, −9.9% to −2.7%; Pu2009=u2009.001), in the intermediate capillary plexus (43.8% [1.2%] vs 49.3% [1.2%]; difference, −5.5% [1.7%]; 95% CI, −9.0% to −2.0%; Pu2009=u2009.003), and in the deep capillary plexus (24.5% [1.0%] vs 30.5% [1.0%]; difference, −6.1% [1.4%]; 95% CI, −8.9% to −3.2%; Pu2009<u2009.001). Mean vessel density was lower in eyes with diabetic retinopathy and decreased VA compared with eyes with diabetic retinopathy and normal VA; the mean (SE) loss was more pronounced in the deep capillary complex (34.6% [1.5%] vs 44.3% [1.2%]; difference, −9.6% [1.9%]; 95% CI, −13.6% to −5.7%; Pu2009<u2009.001), especially in the deep capillary plexus (15.2% [1.2%] vs 24.5% [1.0%]; difference, −9.3% [1.5%]; 95% CI, −12.4% to −6.1%; Pu2009<u2009.001), than in the superficial vascular plexus (39.6% [1.1%] vs 44.1% [0.9%]; difference, −4.5% [1.4%]; 95% CI, −7.3% to −1.7%; Pu2009=u2009.002). Conclusions and Relevance These data suggest that in patients with type 1 diabetes without macular edema but with severe nonproliferative or proliferative diabetic retinopathy, decreased VA may be associated with the degree of capillary loss in the deep capillary complex.

Relevance of Retinal Thickness Changes in the OCT Inner and Outer Rings to Predict Progression to Clinical Macular Edema: An Attempt of Composite Grading of Macular Edema

Purpose: To characterize the relevance of macular thickness changes in the inner and outer rings in the progression of macular edema in eyes/patients with diabetes type 2. Methods: A total of 374 type 2 diabetic patients with mild nonproliferative diabetic retinopathy (ETDRS levels 20-35) were included in a 12-month prospective observational study to identify retinopathy progression. Retinal thickness analyses were performed in 194 eyes/patients using Cirrus SD- OCT and 166 eyes/patients using Spectralis SD-OCT. The DRCR.net classification of subclinical and clinical macular edema was used. A composite grading of macular edema is proposed in this study. Results: A total of 317 eyes/patients completed the study. SD-OCT identified clinical macular edema in 24 eyes/patients (6.7%) and subclinical macular edema in 104 eyes/patients (28.9%) at baseline. Increased thickness of the central subfield is the best predictor for the development of clinical macular edema, with 85.7% sensitivity and 71.9% specificity (OR: 2.57, 95% CI: 0.82-7.99). However, the involvement of the inner and outer rings is a cumulative predictor of progression to clinical macular edema (OR: 8.69, 95% CI: 2.85-26.52). Conclusions: A composite OCT grading of macular edema taking into account the retinal thickness changes in the inner and outer macular rings offers a simple way to characterize macular edema, with added clinical value.

La télémédecine pour le dépistage de la rétinopathie diabétique

Malgre l’amelioration de la prise en charge des diabetes et l’efficacite de la photocoagulation, la retinopathie diabetique (RD) reste une cause frequente de malvoyance en France. La principale raison en est sa prise en charge souvent trop tardive. Les societes savantes et les Recommandations de bonne pratique clinique preconisent une surveillance annuelle du fond d’œil de tout patient diabetique. Cet objectif est loin d’etre atteint en France, puisqu’une enquete recente de l’Assurance-maladie (Cnamts) a montre que seulement environ 50xa0% des patients diabetiques avaient beneficie d’un examen du fond d’œil durant l’annee precedente. La photographie du fond d’œil est une methode au moins aussi sensible que l’ophtalmoscopie pour depister la RD. Realisee par des techniciens non-medecin et couplee a la telemedecine, elle permet une organisation en reseau de sites de depistage autour d’un centre de lecture ophtalmologique. Un tel reseau, le reseau OPHDIAT, a ete deploye en Ile-de-France, il comprend 28xa0sites de depistage, et a permis d’effectuer plus de 51xa0000 examens de depistage depuis 2004xa0; il est encadre par des procedures d’assurance qualite. Des logiciels de detection automatique de la RD sont en cours de developpement, susceptibles d’ameliorer encore l’efficacite de ce systeme de depistage.