Antonio Polito

“Light” versus “classic” laser treatment for clinically significant diabetic macular oedema

Aim: To compare the effectiveness of “light” versus “classic” laser photocoagulation in diabetic patients with clinically significant macular oedema (CSMO). Methods: A prospective randomised pilot clinical trial in which 29 eyes of 24 diabetic patients with mild to moderate non-proliferative diabetic retinopathy (NPDR) and CSMO were randomised to either “classic” or “light” Nd:YAG 532 nm (frequency doubled) green laser. “Light” laser treatment differed from conventional (“classic”) photocoagulation in that the energy employed was the lowest capable to produce barely visible burns at the level of the retinal pigment epithelium. Primary outcome measure was the change in foveal retinal thickness as measured by optical coherence tomography (OCT); secondary outcomes were the reduction/elimination of macular oedema on contact lens biomicroscopy and fluorescein angiography, change in visual acuity, contrast sensitivity, and mean deviation in the central 10° visual field. Examiners were masked to patients’ treatment. Results: 14 eyes were assigned to “classic” and 15 were assigned to “light” laser treatment. At 12 months, seven (50%) of 14 eyes treated with “classic” and six (43%) of 14 eyes treated with “light” laser had a decrease of foveal retinal thickness on OCT (p = 0.79). A comparison of reduction/elimination of oedema, visual improvement, visual loss, change in contrast sensitivity, and mean deviation in the central 10° showed no statistical difference between the groups at 12 months (p>0.05 for all groups). Conclusions: This study suggests that “light” photocoagulation for CSMO may be as effective as “classic” laser treatment, thus supporting the rationale for a larger equivalence trial.

Spontaneous resolution of a shallow detachment of the macula in a highly myopic eye

PURPOSE To report a case of pathologic myopia with shallow detachment of the macula and anatomic reattachment after spontaneous posterior vitreous separation. DESIGN Observational case report. METHODS A 66-year-old woman with pathologic myopia presented with decreased vision of 20/400 in her left eye. Biomicroscopy showed myopic chorioretinal changes, posterior staphyloma, and a shallow macular elevation. Optical coherence tomography was performed at the initial and follow-up examinations. RESULTS Initial optical coherence tomography revealed a retinal detachment, retinoschisis, and incomplete posterior vitreous detachment. One and one-half years after the initial visit the patients best-corrected visual acuity improved to 20/200, and optical coherence tomography disclosed macular reattachment, release of vitreous adhesions, and restoration of normal retinal tomographic appearance. CONCLUSIONS Spontaneous resolution of chronic shallow detachment of the macula in highly myopic eyes may occur and can be attributed to spontaneous posterior vitreous detachment.

Idiopathic macular hole surgery with low-concentration infracyanine green-assisted peeling of the internal limiting membrane.

PURPOSE To evaluate the efficacy of pars plana vitrectomy with infracyanine green (IFCG)-assisted internal limiting membrane peeling for the treatment of idiopathic macular hole. DESIGN Prospective, noncomparative interventional case series. METHODS Thirty-eight consecutive eyes of 35 patients with idiopathic macular hole were included in the study. Patients underwent early treatment diabetic retinopathy (ETDRS) visual acuity examination, dilated ophthalmoscopy, and optical coherence tomography before treatment and during follow-up. Fluorescein angiography was done in selected cases. Patients underwent a three-port pars plana vitrectomy with complete posterior hyaloid and epiretinal membrane removal. The internal limiting membrane (ILM) was stained with 0.5 cc of IFCG (0.5 mg/ml, 308 mOsm) and peeled up to the vascular arcades. Perfluoropropane gas (C(3)F(8)) 10% was used as tamponade. RESULTS Mean follow-up duration was 10 +/- 5 months (range, 3 to 24 months). Six eyes had stage 2 macular hole, 15 eyes stage 3, and 16 eyes stage 4. Overall, 37 of 38 macular holes closed after a single surgery. Median visual acuity was 20/100 (range, 20/400 to 20/50) before surgery and 20/50 (range, 20/640 to 20/25) after surgery. Visual acuity after surgery was 20/50 or better in 24 of 38 (63.1%) eyes. Twenty-five (65.8%) eyes improved by 2 or more lines, nine (23.7%) eyes were stable, and four (10.5%) eyes worsened by 2 or more lines. CONCLUSIONS This study suggests that IFCG (0.05%) effectively stains the ILM with apparent safety, and that IFCG-assisted peeling of the ILM may be useful in the treatment of idiopathic macular hole.

Intravitreal triamcinolone acetonide for florid proliferative diabetic retinopathy

BackgroundThe spectrum of ocular indications in which intravitreal injections of triamcinolone acetonide may be therapeutically useful has recently been expanding.MethodsProspective clinical interventional case study in a young adult male with florid proliferative diabetic retinopathy (FPDR).ResultsA greater reduction of retinal thickening and fluorescein leakage from retinal new vessels was observed in the right eye after intravitreal injection of triamcinolone followed by scatter panretinal photocoagulation (PKP) than in the left eye treated only by laser.ConclusionIntravitreal injection of triamcinolone acetonide may be a useful adjunct to scatter panretinal photocoagulation for FPDR.

Intravitreal Dexamethasone Implant for Macular Edema Secondary to Retinal Vein Occlusion: 12-month Follow-Up and Prognostic Factors

Purpose: To evaluate anatomical and visual outcomes following intravitreal dexamethasone implantation (Ozurdex) in eyes with visual loss due to macular edema (ME) secondary to retinal vein occlusion (RVO) and to identify predictive factors for improvement in best-corrected visual acuity (BCVA). Methods: We retrospectively analyzed medical records of 43 consecutive eyes with treatment-naïve ME secondary to recent onset RVO treated with repeated Ozurdex injections on a pro re nata basis. Results: The mean follow-up (FU) duration was 14 months (min. 12, max. 22). Both mean BCVA and central macular thickness improved significantly at the end of the FU period (p = 0.0001), and more than 30% of the eyes gained ≥3 lines within 3 months of repeated injections. Presence of foveal serous retinal detachment and macular ischemia were negatively associated with visual outcomes. Improvements were significantly associated with baseline BCVA and the integrity of the ellipsoid zone. No serious adverse events were recorded. Conclusions: In our study population, Ozurdex was a safe and effective therapeutic option for the treatment of ME associated with RVO. The results suggest that a comprehensive approach in the examination of RVO eyes may help to predict which patients are most likely to benefit from the treatment.

Long-Term Results of Full Macular Translocation for Choroidal Neovascularization in Age-Related Macular Degeneration

PURPOSE To investigate the long-term outcome of full macular translocation (FMT) for neovascular age-related macular degeneration (AMD) and to identify predictive factors. DESIGN Retrospective, uncontrolled case series. PARTICIPANTS Patients were considered for FMT if they had low vision in the fellow eye and choroidal neovascularization (CNV) along with (1) no response to vascular endothelial growth factor (VEGF) inhibitors, (2) retinal pigment epithelium (RPE) tear, (3) subretinal hemorrhage, (4) foveal scar tissue of recent onset, or (5) CNV before the availability of VEGF inhibitors. From 2004 through 2012, a total of 255 patients underwent FMT. Exclusion criteria were patients younger than 60 years, FMT for disease other than AMD, and a follow-up of less than 12 months. METHODS Preoperative, annual, and last distance best-corrected visual acuity (BCVA) were obtained retrospectively from patient files. Complications were recorded using funduscopy, optical coherence tomography, autofluorescence, and angiography. MAIN OUTCOME MEASURES Distance BCVA at 1 year and 5 years after surgery and at last visit compared with preoperative BCVA. RESULTS One hundred fifty-eight patients (mean follow-up, 45 months) were included. Median BCVA improved from 0.90 logarithm of the minimum angle of resolution (logMAR) before surgery to 0.70 logMAR 1 year after FMT (2 lines gained; P = 0.000). In a subgroup of 56 patients followed up for 5 years or more, median BCVA improved from 0.95 logMAR before surgery to 0.70 logMAR 1 year after surgery, and remained improved 5 years after FMT with a median BCVA of 0.80 logMAR (1.5 lines gained compared with preoperative BCVA; P = 0.000). The main complications were foveal RPE atrophy (n = 73; 47%) and CNV recurrence (n = 47; 30%). Foveal RPE atrophy (odds ratio [OR], 7.0), CNV recurrence (OR, 2.6), and proliferative vitreoretinopathy (PVR; OR, 17.6) were statistically significant predictors (P < 0.05) for losing 1 line or more at last visit. CONCLUSIONS In this study, BCVA was improved up to 5 years after FMT. Foveal RPE atrophy, CNV recurrence, and PVR carried a worse prognosis. In patients who are unlikely to benefit from VEGF inhibitors, FMT can be considered for second eyes with neovascular AMD.

Inverted Internal Limiting Membrane Flap Technique Versus Complete Internal Limiting Membrane Removal In Myopic Macular Hole Surgery: A Comparative Study

Purpose: To compare the results of vitrectomy with complete internal limiting membrane (ILM) removal and inverted ILM flap in the treatment of myopic macular hole (MMH). Methods: Seventy eyes of 68 patients with MMH undergone pars-plana vitrectomy (PPV) with either complete ILM removal (n = 36, Group 1) or inverted ILM flap technique (n = 34, Group 2) were included in the study. Outcomes measured were the rate of MMH closure assessed by optical coherence tomography (OCT) and visual acuity (BCVA) at six months. Results: Closure of MMH was achieved in 22 cases of Group 1 (61%) and in 32 cases of Group 2 (94%). Surgical failure was reported in 14 cases of Group 1 (39%) and in one case of Group 2 (3%). Average best-corrected visual acuity (BCVA) changed from 0.60 to 0.58 in Group 1 (P = 0.329) and from 0.70 to 0.39 in Group 2 (P < 0.01). Logistic regression analysis showed that inverted ILM flap technique was associated with 22 times higher probability of anatomic success, regardless of the MMH diameter. Conclusion: Inverted ILM flap should be preferred to complete ILM removal for the treatment of MMH. The outcomes reported with this technique were better than any other technique described until now.

New Insights Into the Development and Progression of Geographic Atrophy After Full Thickness Autologous Choroidal Graft

Purpose To investigate if the contiguity between native and transplanted retinal pigment epithelium (RPE) represents a protective factor against the progression of atrophy after autologous choroidal graft. In addition, the changes in fundus autofluorescence (FAF) in the contiguous and noncontiguous RPE areas were explored. Methods The first postoperative reliable FAF image was selected and divided into sectors based on the characteristics of the RPE at the edge of the graft. The sectors were categorized into three groups: contiguous RPE, noncontiguous RPE, and not classifiable. The area of RPE atrophy, inside and outside the graft, was measured for each sector at baseline, one, three, and five years of follow-up. The FAF pattern outside the graft was evaluated for every sector at baseline and during the follow-up. Results Nineteen patients met the inclusion criteria and were included in this study. Trend analysis showed that the atrophy progression outside the graft was statistically significant in areas where native and transplanted RPE were noncontiguous (P < 0.0001) yet not so in contiguous areas (P < 0.058). Inside the graft, both groups showed an increase in atrophy over time. In addition, the noncontiguous group developed more severe increased FAF patterns compared with the contiguous group. Conclusions RPE contiguity after autologous choroidal graft seems to be a protective factor against atrophy progression, whereas any area of damaged or absent RPE tends to enlarge over time. This may suggest that the transplantation of an RPE sheet is more likely to be effective than an RPE cell suspension.

Choroidal perfusion abnormalities associated with Acute Posterior Multifocal Placoid Pigment Epitheliopathy: a case report

BackgroundIndocyanine Green Angiography (ICG-A) and Enhanced Depth Imaging Spectral-Domain Optical Coherence Tomography (EDI-OCT) are essential imaging techniques for diagnosis, management and understanding of the pathophysiology of many chorioretinal diseases. Herein, we report the ICG-A and EDI-OCT findings from a case of Acute Posterior Multifocal Placoid Pigment Epitheliopathy (APMPPE), in which these imaging techniques enable the visualization of more diagnostic details than those observable with other widely used diagnostic tools.Case presentationA 60-year-old white female presented with bilateral blurred vision for few days. Fundus examination showed multiple, yellow-white placoid lesions at the posterior pole of both eyes. The placoid lesions were also evident on Spectral-Domain Optical Coherence Tomography (SD-OCT), Fluorescein Angiography (FA), Fundus Autofluorescence (AF), and ICG-A. A complete ophthalmologic examination was performed and the diagnosis of APMPPE was made based on imaging and clinical features. Notably, all the lesions detected by FA, AF and OCT corresponded to focal areas of hypofluorescence seen on ICG-A, whereas several additional hypofluorescent areas that were not associated with FA, AF or OCT abnormalities, were also detected with ICG-A. On follow-up, the regression of outer retinal abnormalities detected on OCT preceded the restoration of choroidal perfusion abnormalities in the corresponding locations on ICG-A. This long-standing choroidal perfusion defect could not be detected with OCT. EDI-OCT scans revealed characteristic choriocapillaris changes beneath the placoid lesions and an increase in choroidal thickness during the acute phase, with subsequent decrease in the inactive stage of the disease.ConclusionOur findings show that ICG-A and EDI-OCT provide detailed morphologic information of choroidal abnormalities in APMPPE and allow accurate evaluation of definitive resolution of the lesions. Moreover, they support the acute choroidal hypoperfusion as the primary mechanism overlying the pathogenesis of the disease, and suggest that the non-perfused areas may extend beyond the damage of the outer retina.

Morphological changes in the diseased retina on a healthy choroid-retinal pigment epithelial complex after full macular translocation for exudative age-related macular degeneration

To describe the change in the retinal morphology after full macular translocation (FMT) for exudative age‐related macular degeneration (AMD) and identify predictive factors for the visual outcome.