B. Heimes

Determinants of Macular Pigment Optical Density and Its Relation to Age-Related Maculopathy: Results from the Muenster Aging and Retina Study (MARS)

PURPOSE The controversial protective effect of macular pigment (MP), consisting of lutein (L) and zeaxantin (Z), in age-related maculopathy (ARM) and its late-stage, age-related macular degeneration (AMD) is discussed. Determinants of MP optical density (MPOD) and its relation to ARM were investigated. METHODS MPOD was accessed at eccentricities of 0.5° and 2.0° from the fovea in 369 participants in the 2.6-year follow-up examination of the prospective Muenster Aging and Retina Study using dual-wavelength analysis of autofluorescence images. ARM was graded from standardized fundus photographs according to the International Classification System. RESULTS MPOD at 0.5° and 2.0° between pairs and within single eyes was strongly correlated (P < 0.001). Smoking and body mass index showed moderately inverse associations with MPOD at 2.0°, and age was positively related to MPOD at both eccentricities. Serum L, measured at the baseline examination, was significantly associated with MPOD measured at follow-up. Likewise, use of L/Z-containing supplements raised MPOD. Crude mean MPOD increased with ascending stage of ARM. However, adjustment for influential factors and exclusion of L supplement users removed differences of mean MPOD between ARM stages. Considering further the accompanying eye, study eyes with ARM had significantly higher MPOD when the contralateral eye had AMD. CONCLUSIONS MPOD levels showed a high degree of intraindividual concordance and interindividual variability. Long-standing serum L levels, and in particular L supplementation, were the strongest determinants of MPOD. The hypothetical inverse association between MPOD and ARM stage was not confirmed.

Idiopathic macular telangiectasia type 2: distribution of macular pigment and functional investigations.

Purpose: Analysis and categorization of macular pigment (MP) distribution in type 2 idiopathic macular telangiectasia (IMT2) with regard to a possible grading scale for the severity of the disease. Methods: Nineteen IMT2 patients were examined including visual acuity (VA), fundus biomicroscopy, fluorescein angiography (FLA), microperimetry and optical coherence tomography (OCT). Distribution of MP was analyzed and categorized in MP density maps calculated from autofluorescence images obtained at 488 and 514 nm excitation wavelengths. Results: Typical features in MP density maps are in class I (n=8), a triangular segment of reduced MP in the temporal fovea and central accumulation of MP, class II (n=12), further expansion of the segment and vanishing of central accumulation, and class III (n=18), oval effacement of MP centrally, surrounding halo of MP at 5-7° eccentricity. These classes were associated with the stages of the disease and increasing restrictions in visual function. Conclusion: Association between changes in MP distribution, stages of IMT2 and restrictions in visual functions suggests that the classification of MP patterns reflects a severity scale for IMT2. Degenerative processes causing impairments in transport and storage of lutein (L) and zeaxanthin (Z) leading to secondary vascular changes may play a causative role in the disease.

Intravitreal and Orbital Floor Triamcinolone Acetonide Injections in Noninfectious Uveitis: A Comparative Study

Purpose: To compare the effect of orbital floor (OFTA) or intravitreal (IVTA) administration of triamcinolone acetonide on visual acuity and chronic cystoid macular edema (CME) in patients with uveitis. Methods: Retrospective study of patients suffering from chronic noninfectious uveitis in whom CME (n = 97) did not respond to systemic corticosteroids and/or immunosuppression combined with acetazolamide. Patients received a single injection of either IVTA (n = 48, group 1) or OFTA (n = 49, group 2). Best-corrected visual acuity, macular edema (fluorescein angiography), uveitis activity, ocular hypertension, and cataract formation were analyzed over the course of 1 year. Results: Improvement in visual acuity (≥2 lines, LogMAR) was noted in 50% (IVTA) and 34% (OFTA) after 3 months (p = 0.23), and in 18% (IVTA) and 20% (OFTA) after 12 months. CME improved in 100% (IVTA) and 76% (OFTA) of the eyes within the first month postoperatively (p = 0.36). Macular edema was reduced in 100% (group 1) and 20% (group 2) after 3 months (p < 0.01). At 1 year, cataract progression was noted in 68% (IVTA) and 27% (OFTA) (p < 0.01). Increased intraocular pressure (>21 mm Hg) was detected in 21% (IVTA) and 0% (OFTA) at 4 weeks (p < 0.01) after injection. Conclusion: Uveitic CME and visual acuity not responding to systemic immunosuppression and acetazolamide may improve after an IVTA and OFTA injection. The effect is mostly transient. While the IVTA injections were more effective for improving CME, ocular hypertension and cataracts developed more often.

Comparison of retinal thickness and fundus-related microperimetry with visual acuity in uveitic macular oedema

Purpose:  Macular oedema is a common complication and vision‐limiting factor in uveitis. The aim of this study was to compare retinal thickness as measured by optical coherence tomography and photoreceptor function as measured by fundus‐related microperimetry with respect to their correlation with visual acuity.

ASSOCIATION BETWEEN CHANGES IN MACULAR VASCULATURE IN OPTICAL COHERENCE TOMOGRAPHY- AND FLUORESCEIN- ANGIOGRAPHY AND DISTRIBUTION OF MACULAR PIGMENT IN TYPE 2 IDIOPATHIC MACULAR TELANGIECTASIA.

Purpose: We investigate the association between morphologic findings in optical coherence tomography angiography (OCTA) as a new method offering the visualization of deeper layers of retinal vasculature and fluorescein angiography (FA) and macular pigment imaging and in Type 2 macular telangiectasia. Methods: Fourty-two eyes of 21 patients with macular telangiectasia (38–68 years, 14 female) were examined by FA and OCTA and 24 eyes additionally with dual-wavelength autofluorescence. Early and late FA, macular pigment density images, and (after segmentation of retinal vasculature into superficial and deep capillary network and outer) OCTA images were graded into standardized categories. Agreement between the methods was evaluated statistically. Results: In OCTA, a reduction of density of superficial capillaries, dilated vessels in the deep capillary network, anastomoses toward the superficial capillary network, and “new” vessels in the outer retina layers can be detected. The described anatomical features, especially in the deep capillary plexus and outer retina corresponded well with changes in FA. Classes of macular pigment distribution correlated most with classes of changes in OCTA superficial capillary plexus. Conclusion: Progressive changes in macular telangiectasia apparent in FA and macular pigment imaging are most obvious in the deep capillary network and outer retina in OCTA. Optical coherence tomography angiography offers a noninvasive technology to analyze vascular changes in the retina and choroid of patients with macular telangiectasia.

[The macular pigment: short- and intermediate-term changes of macular pigment optical density following supplementation with lutein and zeaxanthin and co-antioxidants. The LUNA Study].

BACKGROUND How long do the elevated concentrations of macular pigment persist after stopping supplementation with lutein and zeaxanthin? METHODS One hundred eight (108) probands with and without age-related macular degeneration (68 female, 40 male, age 51-87 years) received a supplement containing 12 mg lutein and 1 mg zeaxanthin once per day (Ocuvite lutein) for 6 months. Analysis of macular pigment optical density (MPOD) was performed during the period of supplementation and again 3, 6, and 9 months following discontinuation of the supplement. A control group of 28 subjects received no dietary supplement. RESULTS At baseline, the mean MPOD at 0.5 degrees was 0.50 in the supplemented group. Following supplementation, values rose, and 3 months after discontinuation of supplementation the highest levels of MPOD0.5 degrees (0.59 ODU) were detected (increase of +0.1 ODU, (p<0.001). Six months after supplement discontinuation, a slight decrease of mean MPOD0.5 degrees appeared (to 0.54 ODU), followed again by a slight increase 3 months later (to 0.57 ODU). An increment of MPOD0.5 degrees in the control group was not significant (0.03 ODU, p=0.15). DISCUSSION Supplementation of lutein and zeaxanthin leads to an increase of MPOD0.5 degrees . This effect outlasts the duration of intake, and 9 months after supplementation was stopped, the mean MPOD0.5 degrees was still elevated compared with baseline levels. A longer follow-up subsequent to stopping supplementation might clarify whether the values decrease over time or whether a plateau of elevated MPOD levels is reached. High doses of lutein and zeaxanthin seem to be necessary to increase macular pigment density in the retina; afterwards, the amount of carotenoids needed to maintain high concentrations seems to be covered by daily food.

[Long-term results after pars plana vitrectomy with 25 gauge technique].

BACKGROUND The 25-gauge technique of pars plana vitrectomy appears to be a very suitable method, especially for patients with pathological epiretinal alterations of the macula. However, the procedure has been criticized for insufficient impermeability with an increased risk of endophthalmitis and that the flexibility of instruments is too high. METHOD Between 2002 and 2006, 625 eyes from 620 patients were operated on using the 25-gauge technique. Epiretinal membranes in different stages had been diagnosed in all patients. The operations were performed by only one surgeon. RESULTS The epiretinal membranes were successfully removed in all patients and 329 eyes were analyzed with long-term follow up over 3.1 years. The mean improvement in visual acuity before and after surgery was -0.41 in LogMAR. One week postoperatively normal IOP was observed in all cases. The mean preoperative IOP was 17 mmHg and 8 mmHg 1 day after surgery. In nine patients with postoperative hypotony and choroidal detachment an additional suture was required and seven patients developed a retinal detachment. Endophthalmitis was not observed in any of the patients during the follow-up period. CONCLUSIONS The 25-gauge PPV technique appears to be effective and safe for the treatment of epiretinal membranes. The operation has low complication rates with respect to endophthalmitis or retinal detachment. The procedure has recently been further improved by using more stable instruments and better lighting.

Kurz- und mittelfristige Änderungen der makulären Pigmentdichte infolge der Supplementation mit Lutein und Zeaxanthin sowie Koantioxidanzien

BACKGROUND How long do the elevated concentrations of macular pigment persist after stopping supplementation with lutein and zeaxanthin? METHODS One hundred eight (108) probands with and without age-related macular degeneration (68 female, 40 male, age 51-87 years) received a supplement containing 12 mg lutein and 1 mg zeaxanthin once per day (Ocuvite lutein) for 6 months. Analysis of macular pigment optical density (MPOD) was performed during the period of supplementation and again 3, 6, and 9 months following discontinuation of the supplement. A control group of 28 subjects received no dietary supplement. RESULTS At baseline, the mean MPOD at 0.5 degrees was 0.50 in the supplemented group. Following supplementation, values rose, and 3 months after discontinuation of supplementation the highest levels of MPOD0.5 degrees (0.59 ODU) were detected (increase of +0.1 ODU, (p<0.001). Six months after supplement discontinuation, a slight decrease of mean MPOD0.5 degrees appeared (to 0.54 ODU), followed again by a slight increase 3 months later (to 0.57 ODU). An increment of MPOD0.5 degrees in the control group was not significant (0.03 ODU, p=0.15). DISCUSSION Supplementation of lutein and zeaxanthin leads to an increase of MPOD0.5 degrees . This effect outlasts the duration of intake, and 9 months after supplementation was stopped, the mean MPOD0.5 degrees was still elevated compared with baseline levels. A longer follow-up subsequent to stopping supplementation might clarify whether the values decrease over time or whether a plateau of elevated MPOD levels is reached. High doses of lutein and zeaxanthin seem to be necessary to increase macular pigment density in the retina; afterwards, the amount of carotenoids needed to maintain high concentrations seems to be covered by daily food.

[Retinal angiomatous proliferation with associated pigment epithelium detachment: anti-VEGF therapy].

BACKGROUND Vascularized pigment epithelial detachment (PED) in retinal angiomatous proliferation (RAP) represents a special morphological form of exudative age-related macular degeneration (ARMD) in the natural course and in the frequency of complications, such as tears in the pigment epithelium. In this study the results of inhibition of vascular endothelial growth factor (VEGF) for exudative ARMD with associated PED and RAP were examined. MATERIALS AND METHODS Functional and morphological data were retrospectively collected for 61 consecutive eyes with RAP in stages 2 and 3 over an average observation period of 108 weeks. Patients were treated with bevacizumab (n=15), ranibizumab (n=29) and pegabtanib (n=17) according to the recommendations of the German Society of Ophthalmology (DOG) and the German Retina Society (RG). After an initial treatment cycle of 3 injections every 4 weeks (6 weeks for pegabtanib), best corrected visual acuity (BCVA), fluorescence angiography (FAG), indocyanine green angiography (ICG-A) and optical coherence tomography (OCT) were evaluated every 12 weeks. RESULTS The mean visual acuity was 0.8 logMAR before therapy and 0.77 logMAR after therapy so that the average difference to the original acuity was -0.03 logMAR after 12 weeks and 0.00 logMAR after 48 weeks. The central retinal thickness measured by OCT decreased on average by 81.2 µm after the first cycle of injections and by -68.4 µm after 1 year. The maximum depth of PED could be reduced on average by 1 unit and after 1 year by 1.55 units. Better functional and morphological results were obtained by therapy with ranibizumab and avastin compared to pegabtanib (p=0.03). An RIP occurred in 9.8% of the patients (n=6) on average after 16 weeks. CONCLUSIONS The morphological functional results can be improved in the early months using the therapy strategy presently recommended in Germany. However, in later stages there was a significant worsening of the functional results. Modification of the treatment strategy with respect to close surveillance and possibly early stage repeat treatment would seem advisable.

Serous vascularized pigment epithelial detachment in exudative AMD. Morphological typing and risk of tears in the RPE

PURPOSE Are there any morphological parameters in pigment epithelial detachment (PED) in eyes with age-related macular degeneration (AMD), which could identify the development of tears (RIP) in the retinal pigment epithelium (RPE) before initiation of anti-vascular endothelial growth factor (VEGF) therapy? METHODS Retrospectively, the spectral domain optical coherence tomography (SD-OCT), FLA and near infrared (NIR) images of 98 eyes with PED in exudative AMD before treatment (ranibizumab or bevacizumab) were analyzed. Eyes in which a tear in the RPE (RIP group) could be observed during treatment were compared to eyes without the development of RIP (PED group) in the following morphological parameters of PED: height, number of peaks, presence of hyporeflective fissures at the base of the PED, structure of the RPE, presence of floating structures in the PED with maximum hyperreflectivity, amount and localization of hyperreflectivity in the PED and hyperreflectivity in the NIR images. RESULTS In the 80 eyes of the PED group the mean PED height was 373.7± 197 µm and in the 18 eyes of the RIP group the mean PED height was higher (694.2± 284.3 µm, p < 0.0001). A difference was also seen in the number of peaks per PED (PED group 43%, RIP group 72%, p = 0.039) and in the hyperreflectivity in NIR images (PED group 68%, RIP group 94%, p = 0.033). There were no significant differences in the other morphological parameters. A classification into four types of PED was found by the parameters height and number of peaks. The PED type with a height > 350 µm and one peak (RIP 43%) developed tears more often (p = 0.001) than the PED type < 350 µm with one peak (RIP 0%, p = 0.001). A trend in the visual acuity over 156 weeks was seen: in PED types with heights > 350 µm there was a lower increase in the visual acuity than in PED types < 350 µm (rm ANOVA p = 0.18; ɛ HH = 0.88). Furthermore, in PED types > 350 µm with multiple peaks the total number of injections necessary was higher than in the other PED types (p = 0.032). CONCLUSION Morphological parameters, such as PED height, number of peaks per PED in OCT images and hyperreflectivity in NIR images are prognostic factors for RPE tears in exudative AMD. The PED height and number of peaks per PED are useful for classification of PED in the daily routine.