Dimitris Papaconstantinou

Angioid streaks, clinical course, complications, and current therapeutic management.

Angioid streaks are visible irregular crack-like dehiscences in Bruch’s membrane that are associated with atrophic degeneration of the overlying retinal pigmented epithelium. Angioid streaks may be associated with pseudoxanthoma elasticum, Paget’s disease, sickle-cell anemia, acromegaly, Ehlers–Danlos syndrome, and diabetes mellitus, but also appear in patients without any systemic disease. Patients with angioid streaks are generally asymptomatic, unless the lesions extend towards the foveola or develop complications such as traumatic Bruch’s membrane rupture or macular choroidal neovascularization (CNV). The visual prognosis in patients with CNV secondary to angioid streaks if untreated, is poor and most treatment modalities, until recently, have failed to limit the devastating impact of CNV in central vision. However, it is likely that treatment with antivascular endothelial growth factor, especially in treatment-naive eyes to yield favorable results in the future and this has to be investigated in future studies.

Trabeculectomy with OloGen versus trabeculectomy for the treatment of glaucoma: a pilot study.

Purpose:  To present the preliminary results of our study comparing the outcomes of trabeculectomy with or without OloGen implant in patients requiring glaucoma surgery for uncontrolled intraocular pressure (IOP).

Acquired color vision and visual field defects in patients with ocular hypertension and early glaucoma

Purpose: To study acquired color vision and visual field defects in patients with ocular hypertension (OH) and early glaucoma. Methods: In a prospective study we evaluated 99 eyes of 56 patients with OH without visual field defects and no hereditary color deficiencies, followed up for 4 to 6 years (mean = 4.7 ± 0.6 years). Color vision defects were studied using a special computer program for Farnsworth–Munsell 100 hue test and visual field tests were performed with Humphrey analyzer using program 30–2. Both tests were repeated every six months. Results: In fifty-six eyes, glaucomatous defects were observed during the follow-up period. There was a statistically significant difference in total error score (TES) between eyes that eventually developed glaucoma (157.89 ± 31.79) and OH eyes (75.51 ± 31.57) at the first examination (t value 12.816, p < 0.001). At the same time visual field indices were within normal limits in both groups. In the glaucomatous eyes the earliest statistical significant change in TES was identified at the first year of follow-up and was −20.62 ± 2.75 (t value 9.08, p < 0.001) while in OH eyes was −2.11 ± 4.36 (t value 1.1, p = 0.276). Pearson’s coefficient was high in all examinations and showed a direct correlation between TES and mean deviation and corrected pattern standard deviation in both groups. Conclusion: Quantitative analysis of color vision defects provides the possibility of follow-up and can prove a useful means for detecting early glaucomatous changes in patients with normal visual fields.

Renal Injury Following Intravitreal Anti-VEGF Administration in Diabetic Patients with Proliferative Diabetic Retinopathy and Chronic Kidney Disease - A Possible Side Effect?

The use of intravitreal injections of anti-Vascular Endothelial Growth Factor (anti-VEGF) has been used for a broad spectrum of ocular pathologic entities. Although the dose of anti-VEGF agents used for treating eye disease is minute compared with that used intravenously, intraocular administration can lead to systemic absorption and reduce serum VEGF levels. Several systemic side effects, such as hypertension and cardiovascular complications have been rarely reported in the literature. Renal complications of intravenous administration of anti-VEGF, are well known and include a variety of renal pathological damage which can induce proteinuria and hypertension. We describe herein, 2 cases of diabetic patients with preexisting kidney disease who presented severe reduction of their renal function after intraocular administration of anti-VEGF. Although a cause -effect correlation cannot be established unless further studies are performed, we believe that pretreatment counseling should include a discussion outlining the possible risk of aggravating of the renal function in patients with kidney disease. Close cooperation with the patients nephrologist and close monitoring of the patient may be required, in such cases, in order to monitor the renal function before and after the intravitreal administration of anti-VEGF.

Optic disc pit maculopathy: the value of small-gauge vitrectomy, peeling, laser treatment, and gas tamponade.

Purpose To report the outcome of 10 patients with optic pit maculopathy (OPM) and evaluate the role of small-gauge vitrectomy, gas endotamponade, and additional laser photocoagulation treatment. Methods We retrospectively investigated 10 patients who underwent small-gauge, sutureless vitrectomy for OPM, detachment of the posterior hyaloid, internal limiting membrane (ILM) peeling, endolaser photocoagulation on the temporal margin of the optic disc, and gas tamponade. Preoperative and postoperative best-corrected visual acuity (BCVA) was recorded and optical coherence tomography (OCT) imaging was performed. Results Seven out of 10 patients gained at least 2 lines of vision; 2 patients gained 1 line of vision. Visual improvement occurred more than 3 months after surgery. One myopic patient developed a macular hole postoperatively, resulting in a poor functional result even though complete retinal attachment was achieved. The functional outcome did not always correlate well with the OCT imaging, in which complete retinal reattachment was observed in 5 out of 10 eyes. Conclusions The therapeutic approach should include both small-gauge vitrectomy and ILM peeling to relieve vitreoretinal traction, as well as laser photocoagulation of the temporal margin of the optic disc in order to prevent vitreous fluid from entering the subretinal/intraretinal space. In addition, the patients should be told that visual recovery can take a long time.

Clinical evaluation of the effect of mitomycin-C in re-operation for primary open angle glaucoma.

The aim of the study was to evaluate the effect of mitomycin-C (MMC) in a second antiglaucoma operation after failure of the first operation. We assessed 46 patients (26 male, 20 female, mean age 64.2 years) with high intraocular pressure (IOP) (mean 32.4 ± 5.2 mmHg) despite previous trabeculectomy (Tr-Ec) one to three years earlier and topical or systemic medical treatment. All patients underwent a second Tr-Ec and were randomly divided into two groups: group A, 24 patients, underwent a second Tr-Ec with MMC and group B, 22 patients, also underwent a second Tr-Ec but without MMC. Postoperative complications included: shallow anterior chamber (duration >1 week), group A 29.2%, group B 13.6%; chroidal effusion, group A 8.3%, group B 0%; cystic degeneration of conjunctiva, group A 16.6%, group B 4.5%; transient maculopathy, group A 12.5%, group B 0%. IOP control (≤ 20 mmHg after 18 months) was: group A 20 patients (83.3%) with mean 12.5 ± 3.2 mmHg and group B 13 patients (63.6%) with mean 19.6 ± 6.1 mmHg. In conclusion, the use of MMC in re-operation for primary open-angle glaucoma is associated with a higher rate of and more severe postoperative complications than Tr-Ec alone. However, it achieves significantly lower IOP in a larger number of patients.

Adherence with brimonidine in patients with glaucoma aware and not aware of electronic monitoring.

Purpose:  To assess the impact of open versus masked adherence monitoring on adherence with topical brimonidine using two different dosing schedules.

Comparative studies of RNFL thickness measured by OCT with global index of visual fields in patients with ocular hypertension and early open angle glaucoma

Purpose: To compare the functional changes in visual fields with optical coherence tomography (OCT) findings in patients with ocular hypertension, open angle glaucoma, and suspected glaucoma. In addition, our purpose is to evaluate the correlation of global indices with the structural glaucomatous defect, to assess their statistical importance in all the groups of our study, and to estimate their validity to the clinical practice. Methods: One hundred sixty nine eyes (140 patients) were enrolled. The patients were classified in three groups. Group 1 consisted of 54 eyes with ocular hypertension, group 2 of 42 eyes with preperimetric glaucoma, and group 3 of 73 eyes with chronic open angle glaucoma. All of them underwent ophthalmic examination according to a prefixed protocol, OCT exam (Stratus 3000) for retinal nerve fiber layer (RNFL) thickness measurement with fast RNFL thickness protocol and visual fields (VF) examination with Octopus perimeter (G2 program, central 30–2 threshold strategy). Pearson correlation was calculated between RNFL thickness and global index of VF. Results: A moderate correlation between RNFL thickness and indices mean sensitivity (MS), mean defect (MD) and loss variance (LV) of VF (0.547, −0.582, −0.527, respectively; P <0.001) was observed for all patients. Correlations of the ocular hypertension and preperimetric groups are weak. Correlation of RNFL thickness with global indices becomes stronger as the structural alterations become deeper in OCT exam. Correlation of RNFL thickness with the global index of VF, in respective segments around optic disk was also calculated and was found significant in the nasal, inferior, superior, and temporal segments. Conclusion: RNFL average thickness is not a reliable index for early diagnosis of glaucoma and for the follow-up of patients with ocular hypertension. Segmental RNFL thickness seems to be a more reliable index. Deep structural alterations with OCT examination constitute an important indication of early functional changes, even if they are not still detected with achromatic perimetry. The MD index of VF seems to be more sensitive for the follow-up of patients with ocular hypertension.

Severe hypotony and filtering bleb leak after intravitreal injection of ranibizumab.

We report a case of a patient with age-related macular degeneration, who had undergone trabeculectomy nine years earlier, and developed severe hypotony and bleb leak after treatment with intravitreal injections of ranibizumab. Although the incident is rare, in patients with longstanding filtering blebs, who need treatment with antivascular endothelial growth factors, close follow-up may be advocated, since the occurrence of bleb rupture could lead to permanent vision loss.

Contemporary aspects in the prognosis of traumatic hyphemas

Purpose: The present study concerns traumatic hyphemas and their prognostic factors and signs. The aim of this study is to determine the prognostic factors and signs of traumatic hyphemas. Methods: During the last five years, 72 young individuals were hospitalized with the diagnosis of suffering a traumatic hyphema and were divided in three groups according to the extent of their hyphema. The first group concerns 38 patients with a small hyphema 3–4 mm, the second group concerns 22 patients with moderate hyphema reaching the pupillary border, and the third group concerns 12 patients with a total hyphema. Results: The hyphema was absorbed in 63 patients and the IOP was controlled with medical treatment after 3–24 days. However, surgical management was necessary for two patients. Finally, antiglaucomatous treatment was administered in seven patients with persistent high intraocular pressure. Conclusions: The important clinical signs that determine the prognosis of such hyphemas are the size of hyphema, the blood color, recurrent hemorrhage, the absorption time, the increase of intraocular pressure, and blood staining of the cornea.