André Marcelo Vieira Gomes

INTRAOCULAR PRESSURE IN PATIENTS WITH DIABETIC MACULAR EDEMA TREATED WITH DEXAMETHASONE INTRAVITREAL IMPLANT IN THE 3-YEAR MEAD STUDY.

Purpose: To evaluate the occurrence, management, and clinical significance of increases in intraocular pressure (IOP) in patients with diabetic macular edema treated with dexamethasone intravitreal implant (DEX implant). Methods: Randomized, multicenter, 3-year, Phase III study. Patients (N = 1,048) with diabetic macular edema were randomized to DEX implant 0.7-mg, DEX implant 0.35-mg, or sham procedure with retreatment allowed at ≥6-month intervals (seven injections maximum). Results: In the DEX implant 0.7-mg, DEX implant 0.35-mg, and sham groups, respectively, ≥10-mmHg IOP increases from baseline occurred in 27.7%, 24.8%, and 3.7% of patients, and their frequency did not increase with repeat injections. IOP-lowering medication was used by 41.5%, 37.6%, and 9.1% of patients. Only one patient (0.3%) in each DEX implant group had filtering surgery to manage a steroid-induced IOP increase. Among DEX implant 0.7-mg–treated patients with and without a ≥10-mmHg IOP increase, 21.9% (21 of 96) and 22.4% (57 of 255), respectively, achieved ≥15-letter best-corrected visual acuity gain at the end of the study, and mean average change in central retinal thickness from baseline was −127 &mgr;m and −106 &mgr;m, respectively. Conclusion: DEX implant demonstrated clear benefit of treatment despite increases in IOP. Sequential implants had no cumulative effect on IOP.

Retinal thickness assessed by optical coherence tomography (OCT) in pseudophakic macular edema

PURPOSE To evaluate the usefulness of the optical coherence tomography (OCT) retinal map in angiographic pseudophakic macular edema (ACME). METHODS This is a prospective analysis of a group of 36 pseudophakic eyes at the fifth postoperative week, submitted to optical coherence tomography 2 macular map and fluorescein angiography on the same day and, a control group of twenty-two 20/20 vision eyes with a minimum 6-month postoperative period, submitted to optical coherence tomography 2 macular map only. Exclusion criteria were diabetes, any macular pathology and unreadable optical coherence tomography or angiogram. The angiograms were divided into three groups according to the edema intensity: Group I: level 0 (absence of angiographic pseudophakic macular edema); group II: levels 1 and 2 (incomplete and complete perifoveal angiographic pseudophakic macular edema respectively) and group III: levels 3 and 4 (up to one disc diameter and greater than one disc diameter angiographic pseudophakic macular edema area respectively). The nine zones of the optical coherence tomography macular map were compared between the control and the three subgroups of the study group and, between group I and groups II and III. RESULTS Among the 36 eyes, 23 (64%) were classified as group I, 10 (28%) as group II and three (8%) as group III. The mean thickness of the fovea zone was 185+/-15 microm for the control group, 189+/-24 microm for group I, 213+/-33 microm for group II and 455+/-38 microm for group III. Significant differences: between group III and the control or group I for all zones (p<0.01) and, between group II and control or group I for the fovea and temporal inner zones (p<0.05). CONCLUSION The optical coherence tomography retinal map is useful in angiographic pseudophakic macular edema diagnosis.

Emprego das medidas anatômicas do buraco macular idiopático obtidas pela tomografia de coerência óptica como fator preditivo nos resultados visuais: um estudo piloto

PURPOSE: To evaluate the anatomy of idiopathic macular hole (IMH) using Optical Coherence Tomography (OCT) and to construct a prognostic index that can be correlated with the visual outcomes and the anatomical closing. METHODS: Prospective study, in which 22 eyes with IMH had been evaluated through OCT in the daily postoperative period of IMH surgery. The Prognostic of Macular Hole Index (PMHI) was created which was correlated with the anatomical result and the postoperative visual acuity (VA) six months after surgery. RESULTS: Sixteen eyes (72.7%) got anatomical closing at the end of six months of follow-up. On analysis of PMHI, there was significant difference between group 1 (open MH) and group 2 (closed MH) (p=0.0018). The risk for failure of anatomical closing is 11 times greater when the diameter of the internal base is over 600 µm or IPBM is less than 0.6 (p=0.0495). Regarding final VA, it was observed that the IPBM had a significant negative correlation with AV (p=0.001). CONCLUSIONS: IPBM showed to be the best predictor of anatomical closing and postoperative visual acuity among the studied variables. It predicted 41% of the postoperative final visual acuity, leading us to believe that other factors, such as the time of history and the degeneration of photoreceptors in these older BM, can be involved in the visual outcomes.

Survey: technique of performing intravitreal injection among members of the Brazilian Retina and Vitreous Society (SBRV)

PURPOSE To evaluate and describe the precautions involved in the technique of intravitreal injection of antiangiogenic drugs adopted by the ophthalmologists who are members of the Brazilian Society of Retina and Vitreous (SBRV). METHODS A questionnaire containing 22 questions related to precautions taken before, during, and after intravitreal injection was sent electronically to 920 members of SBRV between November 15, 2013 and April 31, 2014. RESULTS 352 responses (38%) were obtained. There was a predominance of men (76%) from the southwest region of Brazil (51%). The professional experience varied between 6 and 15 years after medical specialization (50%). Most professionals (76%) performed an average of 1 to 10 intravitreal injections a week, and 88% of the procedures were performed in the operating room using povidone iodine (99%), sterile gloves, and blepharostat (94%). For inducing topical anesthesia, usage of anesthetic eye drops was the most used technique (65%). Ranibizumab (Lucentis®) was the most common drug (55%), and age-related macular degeneration (AMD) was the most treated disease (57%). Regarding the complications treated, 6% of the ophthalmologists had treated at least one case of retinal detachment, 20% had treated cases of endophthalmitis, 9% had treated cases of vitreous hemorrhage, and 12% had encountered cases of crystalline lens touch. CONCLUSION Intravitreal injection is a procedure routinely performed by retina specialists and has a low incidence of complications. Performing the procedure in the operating room using an aseptic technique was preferred by most of the respondents. Ranibizumab was the most used drug, and AMD was the most treated disease.

Estudo da morfologia macular após a remoção da membrana epirretiniana idiopática utilizando a tomografia de coerência óptica (OCT): um estudo piloto

PURPOSE To describe the relation between visual results and macular morphology through optical coherence tomography (OCT) in patients submitted to removal of the idiopathic epiretinal membranes. METHODS Ten eyes of ten patients with diagnosis of idiopathic epiretinal membranes underwent standard 20-G pars plana vitrectomy. Posterior hyaloid attachments were identified and dealt with. Idiopathic epiretinal membranes were removed in all cases. Corrected visual acuity, retinography, fluorescein angiography, fundus biomicroscopy and the optical coherence tomography in the pre- and postoperative periods were performed in all patients. In OCT, three characteristics were considered in each image: presence of foveal depression, presence of cystoid macular edema and mean central macular thickness. RESULTS Pre-operative visual acuity varied from 20/80 to counting fingers. The mean age was 63 years, ranging from 57 to 78 years. Five patients were male and five female. Preoperative visual acuity (VA) varied from 20/80 to CD to 1 meter. An improvement in VA of at least two lines was noted in all cases and metamorphopsia in eight eyes (80%). Four patients did not present metamorphopsia according to Amsler grid test, and the remaining presented partial improvement. On optical coherence tomography all eyes maintained increased central thickness, ranging from 232 to 605 micro (mean of 351.9 micro). Three eyes maintained cystoid macular edema. Four eyes presented final VA better or equal to 20/30. In this group the mean central thickness was of 277 micro. Foveal contour was recovered in two of these eyes. Four patients had no residual cystoid macular edema. CONCLUSIONS Optical coherence tomography is a tool that evaluates the structural changes before and after surgery to remove idiopathic epiretinal membranes. Although the foveal area architecture stays irregular six months after surgery, the visual outcomes are very promising. Other prognostics factors may be involved in the final visual results of this pathology.

Estrias angióides: análise fundoscópica de 317 casos

PURPOSE To evaluate the presence of choroidal neovascularization (CN) and their sequels in patient bearing angioid streaks (AE). METHODS Case records of patients assisted from 1976 to 2006 at the Instituto Suel Abujamra located in the city of São Paulo, Brazil, were analyzed retrospectively. Age, skin color; patient complaints at the first evaluation, visual acuity, fundoscopic aspects with special attention to disciform lesions to active or scarred subretinal CN were considered. RESULTS Among the 317 studied patients, 163 (51.5%) were men. The average age was 57, with standard deviation of 12.4 years, minimum 11 and maximum 91 years. Regarding skin color, 209 (66.2%) were white, 91 (29.0%) were yellow, 11 (3.7%) were black, and 3 (1.1%) were mulatto. AE were bilateral in all patients; of 631 researched eyes, 348 (55.1%) had brown color AE, in 153 (24.2%) they were gray and in 124 (19.6%) reddish brown. Upon diagnosis, visual acuities measured with the Snellen chart were worse than 20/200 in 40.4% of the eyes. CN absence was proven in 103 (32.5%) patients. The unilateral lesions were present in 112 (35.3%) and bilateral lesions were present in 99 (31.2%). Regarding location, 242 (74.3%) were macular, 45 (13.8%) were extramacular and 38 (11.7%) were both macular and extramacular. CONCLUSION AE are an important cause of legal blindness and can be easily bypassed in an ophthalmic routine examination in the absence of active or disciform neovascular lesions. The expressive number of these cases brings us to the importance of this study. It highlights the need for a meticulous fundoscopic examination in order to improve diagnoses of the disease and early treatment of CN.

Green light assisted internal limiting membrane peeling in macular hole surgery.

Green Light Assisted Internal Limiting Membrane Peeling in Macular Hole Surgery Macular hole surgery has evolved dramatically over the past decade. Increased anatomic and visual outcomes have made the procedure a natural choice for both surgeon and patient in selected cases. Retinal internal limiting membrane (ILM) peeling during pars plana vitrectomy (PPV) has been stated to improve anatomic closure rates and enhance visual outcome in operated eyes.1 However, ILM removal is not an easy part of the surgery to perform, mainly due to its poor visualization. Even though ILM can be directly peeled without any staining, intraocular dyes, such as indocyanine green (ICG), have been used as an enhancer in this challenging maneuver.2 Nevertheless, the enthusiasm for intraocular ICG use has recently decreased due to growing concerns regarding its possible toxic and phototoxic effects. ICG tends to accumulate in the optic nerve and retinal pigment epithelium (RPE) and may cause atrophic retinal epithelium changes.3 Low concentration infracyanine green (IFCG) has recently been reported as a safe adjuvant to ILM peeling.4 Jackson et al,5 however, suggested that IFCG is less likely to produce RPE and retinal photo toxicity but may generate damage to glial cells in culture. Gale at al6 compared the toxicity of trypan blue (TB) and ICG. The exposure to TB revealed no toxicity at any concentration or exposure time. Intravitreal triamcinolone acetonide (TA) has been described as a marker for ILM. Improved visualization has been noted, and proper ILM removal was confirmed by electron microscopy.7 The objective of this study is to describe the use of green light as an enhancer for visualization of ILM during macular hole surgery.

Aneurisma miliar de Leber associado à síndrome de tração vítreomacular: relato de caso

Retinal telangiectasias are idiopathic vascular abnormalities of the retina characterized by irregular dilatation of the retinal vessels, intraretinal and subretinal exudation. The aim of this article is to describe the uncommon association of Lebers miliary aneurysms and vitreomacular traction syndrome in a female patient. The diagnosis was established with angiofluoresceinography and optic coherence tomography. The patient was treated with focal photocoagulation with argon green laser directed to the perimacular aneurysms and pars plana posterior vitrectomy. The visual acuity showed great improvement after a four-month follow-up. The present report supports the importance of optic coherence tomography in cases where the vitreoretinal interface must be evaluated, including vascular pathologies, which allowed us to offer a better treatment to this patient.