Baha’ N. Noureddin

Panretinal Photocoagulation And Intravitreal Triamcinolone Acetonide For The Management Of Proliferative Diabetic Retinopathy With Macular Edema

Purpose: To investigate intravitreal triamcinolone acetonide (IVTA) as an adjunctive therapy to panretinal photocoagulation (PRP) in patients with both high-risk proliferative diabetic retinopathy (PDR) and clinically significant macular edema (CSME). Methods: Thirty-five eyes diagnosed with both high-risk PDR and CSME underwent PRP and a single injection of 4 mg of IVTA (IVTA group). Visual, anatomic, and fluorescein angiographic changes were documented. Any complications resulting from the combined procedure were noted. These data were compared retrospectively to 35 eyes that underwent grid laser treatment to the macula followed 2 weeks later by PRP (laser group). Main outcome measures included change in best-corrected visual acuity, improvement in macular edema (clinical or angiographic), and control of the neovascular disease. Results: Mean follow-up was 9.6 months for the IVTA group and 11.9 months for the laser group. Mean pretreatment best-corrected visual acuity was 20/286 in the IVTA group and 20/282 in the laser group (P = 0.80). After 9 months of follow-up, visual acuity was 20/80 in the IVTA group versus 20/156 in the laser group (P = 0.007). Thirty-four percent of eyes in the IVTA group had final vision of 20/40 or better versus 11% in the laser group (P = 0.044). At 9 months follow-up, 84% of IVTA eyes had complete resolution of macular edema versus 46% of laser eyes (P = 0.002). Three eyes in the IVTA group had recurrence of macular edema after 6 months and required reinjection of IVTA. Elevation in intraocular pressure occurred in eight eyes in the IVTA group and responded to topical therapy. Cataract progression was observed in nine eyes in the IVTA group. Conclusions: The addition of intravitreal triamcinolone acetonide to PRP in the management of patients with both PDR and CSME seems promising. Further study is needed to assess the effect of this combined treatment.

Diode laser transcleral cyclophotocoagulation for refractory glaucoma: a 1 year follow-up of patients treated using an aggressive protocol.

PurposeTo prospectively evaluate the intraocular pressure (IOP) lowering ability, retreatment rate, and complications of transcleral Diode laser cyclophotocoagulation using a higher power setting than what is generally recommended.Patients and methodsA total of 36 eyes of thirty six patients with refractory glaucoma, and who fitted our inclusion criteria underwent Diode cyclophotocoagulation. The laser power was set at 2250 mW, with a duration of 2000 ms, and a total number of 28 shots for the first treatment and 20 shots for any consequent one. The patients were followed up for 1 year with the following outcomes being analysed: IOP, visual acuity, change in the number of medications, and complications.ResultsThe mean IOP decrease was 53% (P<0.05), and 72.2% of the patients maintained an IOP ≤21 mmHg for the whole duration of the study The number of medications necessary to control the pressure, significantly dropped from 2.8 to 0.89 (P<0.05), and 25% of the patients needed the treatment to be repeated only once.In all, 33% of the patients improved their visual acuity after the treatment, while 22% worsened, and the rest stayed the same. The most common treatment complications were conjunctival injection and corneal oedema, and these were both transient and reversible.ConclusionThe use of the higher power setting of 2250 mW, resulted in a sustained lower IOP, less use of medications, less need for retreatment, relative preservation of visual acuity, and only reversible complications.

Viscocanalostomy versus trabeculotomy ab externo in primary congenital glaucoma: 1‐year follow‐up of a prospective controlled pilot study

Aim: To study the effectiveness of viscocanalostomy in patients with primary congenital glaucoma of the isolated trabecular dysgenesis category and compare it with trabeculotomy ab externo. Methods: Eight patients with bilateral primary congenital glaucoma were enrolled in the study. After establishing the diagnosis, the more severely affected eye was randomly selected to undergo either trabeculotomy ab externo or viscocanalostomy, whereas the second eye underwent the other surgery 2 weeks after the first. The patients were examined on day 1, week 1, week 4 and thereafter every 4 weeks. Intraocular pressure (IOP) and corneal diameter measurements were obtained at week 1, month 6 and at the last reported follow-up. The paired-sample’s Student’s t test was applied for statistical analysis. Results: The mean (standard deviation (SD)) follow-up period was 12.5 (1.86) months. Preoperative IOP of eyes undergoing trabeculotomy (34.0 (2.6) mm Hg) and that of eyes undergoing viscocanalostomy (32.3 (4.1) mm Hg) showed no significant difference (p>0.1). A drop in IOP was noted in both groups at week 1, month 6 and at the last follow-up visit (p<0.001). Similarly, a decrease in the postoperative vertical and horizontal corneal diameters was noted in the two study groups. Conclusion: Viscocanalostomy proved to be as effective as trabeculotomy ab externo in lowering IOP. Moreover, it is likely to be a good surgical alternative with a higher long-term success rate in eyes with more aggressive disease.

Anticardiolipin antibodies in patients with retinal vein occlusion and no risk factors: a prospective study.

Background Several reports have described the association between antiphospholipid antibodies (APAs) and retinal venous occlusive (RVO) disease. The purpose of this study was to look at the prevalence of these antibodies in patients with RVO disease and no conventional risk factors. We specifically examined how APAs may affect the course of this disease. Methods Twenty-four patients with the diagnosis of RVO disease were screened prospectively for APAs. All were free from risk factors for retinal vein thrombosis and other immunologic conditions. Patients were observed for a period of 3 to 12 months. Results Lupus anticoagulant was negative in all 24 patients. Ten (43%) of 24 patients had anticardiolipin antibodies (ACAs). All patients with ACAs were younger than 45 years of age, with an average age of 33 years. The average age of patients with no ACAs was 66 years. Comparison of the average age of the two groups showed a statistically significant difference. There was no statistical significance between the two groups for development of neovascular disease. Seropositive patients who developed neovascularization had elevated titers for an average of 11.8 weeks versus 3.3 weeks for those who did not have neovascularization. Neovascular complications generally began several weeks after the titers became negative. Conclusion There was a significant prevalence of ACAs in young patients with RVO disease and no associated systemic risk factors. Seropositive patients who developed neovascular disease had elevated titers for more than 6 weeks. However, the role of these transient ACAs in retinal vein occlusion is still not clear and merits further study.

Interocular symmetry in retinal and optic nerve parameters in children as measured by spectral domain optical coherence tomography

Background/aims To report interocular differences in retinal nerve fibre layer (RNFL), optic nerve head and macular parameters in children using spectral domain optical coherence tomography (SD-OCT). Methods This was an observational cross-sectional study including 108 healthy children aged 6–17 years with no ocular abnormality except refractive error. After a comprehensive eye exam and axial length measurement, RNFL, optic nerve and macular thickness measurements were performed using the Cirrus OCT machine. Right and left eyes were compared and interocular differences were computed. Subjects were also divided into two groups based on age (under or over 10 years of age). Main outcome measures were interocular differences and their correlations with age and gender. Results The study included 108 children, mean age 10.7±3.1 years; significant interocular differences were observed in both macular and RNFL parameters. The macular thickness analysis revealed interocular differences in the outer nasal and outer inferior quadrants, with left eyes displaying larger values. With respect to RNFL parameters, right eyes displayed thicker nasal and temporal quadrants, and inferior clock hours; left eyes had a thicker superior quadrant. The older age group (>10 years) had more pronounced variation in interocular differences compared with the younger group with less mature visual systems. Conclusions Normal variation in interocular symmetry exists. Our results can contribute to establishing a standard reference for interocular differences in OCT parameters in children aged 6–17 years using the Cirrus device.

A family with a syndrome of ectopia lentis, spontaneous filtering blebs, and craniofacial dysmorphism

Six members of a family presented with a syndrome of mild facial dysmorphism, subluxation of the crystalline lenses, variable degrees of angle closure by iridocorneal adhesions, and patchy areas of iris atrophy. Three nonoperated eyes of two patients had spontaneous filtering blebs that presented as avascular cystic elevations of the superior conjunctiva. Systemic workup of all patients was negative for evidence of diseases known to be associated with dislocated lenses. The pedigree is most compatible with autosomal recessive inheritance with pseudodominance.

A Comparison between Tube Surgery, ND:YAG Laser and Diode Laser Cyclophotocoagulation in the Management of Refractory Glaucoma

Purpose. To compare the results of intraocular pressure (IOP) reduction by 3 treatment modalities, (a) glaucoma tube implants, (b) noncontact YAG laser cyclophotocoagulation (cycloYAG), and (c) contact transscleral diode laser cyclophotocoagulation (cyclodiode), in cases of advanced glaucoma refractory to alternative treatments. Methods. A consecutive group of 45 eyes that received cycloYAG were matched against two control groups of patients who had received tube surgery or cyclodiode, each control group having been derived from a database of patients. Results. Mean pretreatment IOP improved from 41.3, 38.6, and 32.0 mmHg for the tube, cycloYAG, and cyclodiode groups, respectively, to 16.4, 22.1, and 19.3 mmHg, respectively. Treatment success was achieved in 78%, 69%, and 71% of the tube, cycloYAG, and cyclodiode groups, respectively. Visual acuity deteriorated 2 or more Snellen lines in 16%, 7%, and 9% of the patients in the tube, cycloYAG, and cyclodiode groups, respectively. Complications included retinal detachment, hypotony, and phthisis. Conclusions. All 3 methods provided acceptable IOP lowering in the short and medium term. Control of IOP was best in patients receiving tube surgery. Cyclodiode and cycloYAG treatments were similarly effective in lowering IOP. Tube surgery was associated with a greater incidence of sight threatening complications.

Intravitreal triamcinolone acetonide: Pattern of secondary intraocular pressure rise and possible risk factors

Purpose To determine the pattern of increase in intraocular pressure (IOP) following intravitreal triamcinolone acetonide (IVTA) and identify possible risk factors associated with this rise in IOP. Methods We carried out a retrospective review of records for 185 patients (226 eyes) who received 4 mg of IVTA at the American University of Beirut Medical Center and Hotel Dieu de France eye clinics between 2003 and 2005 Results Mean follow-up was 8.17 months (range 6 to 24 months). The mean number of IVTA injections per eye was 1.31 ± 0.69. The mean IOP increased after the first IVTA injection from 15.04 ± 3.18 mmHg at baseline to a mean maximum of 17.20 ± 5.75 mmHg (p < 0.0001, paired t-test) at month 3 of follow-up with a return to mean baseline IOP (15.49 ± 4.79 mmHg) at month 12. Fifty nine of 226 eyes showed IOP higher than 21 mmHg during follow-up. Nine eyes started to have IOP greater than 21 mmHg, 6 to 12 months after a single injection. Intraocular pressure lowering medications were started when IOP exceeded 25 mmHg in 15 of the 226 eyes studied. No risk factors have been found to predict this IOP rise Conclusions IOP elevation can occur in a significant number of eyes receiving 4 mg of IVTA. This phenomenon seems to be transient and a small number of eyes required treatment during this period. Eyes that received IVTA need to be monitored for IOP changes especially during the first 3 months, but the IOP may still rise 6 months and even 12 months after a single injection. This study did not show any risk factor that may predict this IOP rise

Modified Phototherapeutic Keratectomy Technique for the Treatment of Elevated Corneal Opacities

A simple modification to the existing phototherapeutic keratectomy techniques to treat elevated corneal opacities is described for a case of severe bilateral macular dystrophy. After epithelial removal, a single drop of carboxymethylcellulose sodium 1.0% was applied centrally on the cornea. A spatula drawn smoothly stretched the drop in all directions without breaking its surface tension until the tip of the highest corneal elevation was seen. Large-diameter phototherapeutic keratectomy for 30-micron ablation was applied. This process was repeated several times, with decreasing amounts of tissue ablation as needed. Postoperative slit-lamp biomicroscopy revealed a smooth corneal surface with no elevated corneal opacities. The patient reported significant improvement with tearing and photophobia. This simple modification from painting to stretching the masking agent, thus transforming it to an ablatable mask, allowed for an effective and practical treatment of elevated corneal opacities. Carboxymethylcellulose sodium 1.0% is nontoxic, biocompatible, and requires no incubation or solidification time.

Plasma thymulin and nerve growth factor levels in patients with primary open angle glaucoma and elevated intraocular pressure

BackgroundThe objective was to measure the plasma concentrations of thymulin and nerve growth factor (NGF) in a group of patients with primary open angle glaucoma (POAG) and compare them with age- and sex-matched normal controls.MethodsTwenty-eight patients newly diagnosed with POAG who were not undergoing treatment were compared with the same number of age- and sex-matched healthy controls. Blood samples were drawn into heparinized tubes and plasma samples were collected for the determination of the concentrations of thymulin and NGF, using specific enzyme-linked immunosorbent assay (ELISA). The Student’s t test was used to perform the necessary statistical analysis of the results.ResultsSeventeen women and 11 men were enrolled in each of the two groups (study and control), with a mean age of 63.7 (SD 10.3) years in the former and 63.3 (SD 9.6) years in the latter. There was a highly significant (p<0.001) elevation in the thymulin levels in POAG patients compared with the control group. However, no significant difference was observed when comparing the plasma NGF levels.ConclusionThis is the first report to measure plasma thymulin levels in glaucoma patients. The significant results point the possible role of this immunomodulator in the pathogenesis of primary open angle glaucoma. The potential role of NGF seems to be less likely. These findings warrant further investigation.