Elona Dhrami-Gavazi

A Comparison Between Optical Coherence Tomography Angiography and Fluorescein Angiography for the Imaging of Type 1 Neovascularization

PURPOSE To determine the sensitivity of the combination of optical coherence tomography angiography (OCTA) and structural optical coherence tomography (OCT) for detecting type 1 neovascularization (NV) and to determine significant factors that preclude visualization of type 1 NV using OCTA. METHODS Multicenter, retrospective cohort study of 115 eyes from 100 patients with type 1 NV. A retrospective review of fluorescein (FA), OCT, and OCTA imaging was performed on a consecutive series of eyes with type 1 NV from five institutions. Unmasked graders utilized FA and structural OCT data to determine the diagnosis of type 1 NV. Masked graders evaluated FA data alone, en face OCTA data alone and combined en face OCTA and structural OCT data to determine the presence of type 1 NV. Sensitivity analyses were performed using combined FA and OCT data as the reference standard. RESULTS A total of 105 eyes were diagnosed with type 1 NV using the reference. Of these, 90 (85.7%) could be detected using en face OCTA and structural OCT. The sensitivities of FA data alone and en face OCTA data alone for visualizing type 1 NV were the same (66.7%). Significant factors that precluded visualization of NV using en face OCTA included the height of pigment epithelial detachment, low signal strength, and treatment-naïve disease (P < 0.05, respectively). CONCLUSIONS En face OCTA and structural OCT showed better detection of type 1 NV than either FA alone or en face OCTA alone. Combining en face OCTA and structural OCT information may therefore be a useful way to noninvasively diagnose and monitor the treatment of type 1 NV.

Aflibercept: a review of its use in the treatment of choroidal neovascularization due to age-related macular degeneration.

Choroidal neovascularization (CNV) due to age-related macular degeneration (AMD) is an important cause of visual morbidity globally. Modern treatment strategies for neovascular AMD achieve regression of CNV by suppressing the activity of key growth factors that mediate angiogenesis. Vascular endothelial growth factor (VEGF) has been the major target of neovascular AMD therapy for almost two decades, and there have been several intravitreally-administered agents that have enabled anatomical restitution and improvement in visual function with continual dosing. Aflibercept (EYLEA®), initially named VEGF Trap-eye, is the most recent anti-VEGF agent to be granted US Food and Drug Administration approval for the treatment of neovascular AMD. Biologic advantages of aflibercept include its greater binding affinity for VEGF, a longer intravitreal half-life relative to other anti-VEGF agents, and the capacity to antagonize growth factors other than VEGF. This paper provides an up-to-date summary of the molecular mechanisms mediating CNV. The structural, pharmacodynamic, and pharmacokinetic advantages of aflibercept are also reviewed to rationalize the utility of this agent for treating CNV. Results of landmark clinical investigations, including VIEW 1 and 2 trials, and other important studies are then summarized and used to illustrate the efficacy of aflibercept for managing treatment-naïve CNV, recalcitrant CNV, and CNV due to polypoidal choroidal vasculopathy. Safety profile, patient tolerability, and quality of life measures related to aflibercept are also provided. The evidence provided in this paper suggests aflibercept to be a promising agent that can be used to reduce the treatment burden of neovascular AMD.

Influence of postoperative lens status on intraocular pressure in proliferative vitreoretinopathy.

PURPOSE To determine the influence of lens status on postoperative intraocular pressure (IOP) in eyes undergoing vitrectomy for repair of recurrent retinal detachment (RD) resulting from proliferative vitreoretinopathy (PVR). DESIGN Retrospective, consecutive, nonrandomized, single-center series. METHODS One hundred and forty-five eyes with recurrent RD resulting from PVR were reviewed retrospectively. In all, 99 eyes underwent relaxing retinotomy at the time of surgery (68.4%). Perfluorocarbon gas (n = 60) or silicone oil (n = 85) were used as postoperative tamponades. For analysis, eyes were subdivided first based on tamponade and retinotomy status. The resultant groups then were divided further by lens status into 2 groups: aphakic eyes (aphakic group) and phakic and pseudophakic eyes (nonaphakic group). RESULTS Surgical reattachment was achieved in all eyes except one. Eyes receiving both silicone oil and relaxing retinotomy had the worst baseline characteristics compared with those receiving other interventions. In this subset of eyes, a significantly lower proportion of hypotony was found in those eyes that were aphakic after surgery when compared with those eyes that were nonaphakic (P = .037). CONCLUSIONS Surgical management of PVR often results in ultimate retinal reattachment. In eyes receiving both relaxing retinotomy and silicone oil, higher IOPs and a lower proportion of hypotony are found where a native lens or intraocular implant is absent. Removal of the lens or intraocular implant may be considered for those eyes at greatest risk of hypotony.

Nanophthalmos and acquired retinoschisis.

PURPOSE To report three cases of nanophthalmos associated with acquired (senile) retinoschisis. DESIGN Observational case series. METHODS Complete ophthalmologic evaluation (including funduscopy with scleral indentation, total axial length measurement with A-scan, optical coherence tomography [Stratus 3 OCT; Carl Zeiss Meditec Inc, Dublin, California, USA], and fundus photography) of three consecutive patients presenting with nanophthalmos and acquired retinoschisis. RESULTS Three patients with nanophthalmos presented with bilateral acquired retinoschisis. One patient underwent a course of systemic steroids to treat concurrent and bilateral uveal effusion with macular edema. In this patient, one eye responded to this course of therapy without recurrence, while the fellow eye required vortex vein decompression with scleral windows, with subsequent, successful resolution. The average follow-up period was 40 months (range, eight to 95 months). Retinoschisis cavities remained stationary in each case. CONCLUSIONS Bilateral acquired retinoschisis may occur in patients with nanophthalmos, suggesting that there may be correlation in the mechanisms underlying these ocular disorders.

PURTSCHER RETINOPATHY AS A MANIFESTATION OF HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS.

Purpose: The authors describe a woman diagnosed with hemophagocytic lymphohistiocytosis and found to have retinal examination findings consistent with Purtscher retinopathy. Methods: A 52-year-old woman underwent multimodal imaging, including color fundus photography and spectral-domain optical coherence tomography, to confirm the diagnosis. Results: The ophthalmic examination and imaging confirmed the findings of Purtscher retinopathy with significant inner retinal thickening on spectral-domain optical coherence tomography. Throughout a hospital course complicated by multi-organ failure, she continued to have profoundly limited visual acuity, likely resulting from inner retinal ischemia affecting the posterior pole of both eyes. Conclusion: The authors describe a patient with hemophagocytic lymphohistiocytosis, a disease characterized by disruption of normal natural killer cell activity with subsequent uncontrolled cytokine release, who presented with Purtscher retinopathy confirmed with spectral-domain optical coherence tomography.

LONG-TERM RETROSPECTIVE ANALYSIS OF VISUAL ACUITY AND OPTICAL COHERENCE TOPOGRAPHIC CHANGES AFTER SINGLE VERSUS DOUBLE PEELING DURING VITRECTOMY FOR MACULAR EPIRETINAL MEMBRANES.

Purpose: To determine the long-term effect of internal limiting membrane with associated epiretinal membrane (ERM) peeling versus single peeling alone in terms of best-corrected visual acuity and anatomical outcomes on spectral-domain optical coherence tomography. Methods: This retrospective comparative cohort study of patients who had follow-up of >1 year and underwent surgery for ERM by a single surgeon (S.C.) from January 1, 2008 to December 31, 2012 compared cases in which the internal limiting membrane was stained with brilliant blue G to facilitate double peeling (n = 42) and single peeling (n = 43) of the ERM alone for up to 3 years of follow-up. For continuous variables, an independent two-tailed t-test was performed. For binary variables, the Fishers exact test was performed. Statistical significance was defined as P < 0.05. Results: Eighty-five of 142 patients fit the inclusion criteria. At the last follow-up, the single-peeling group were more likely to have ERM remaining in the central fovea postoperatively (P = 0.0020, becoming significant by postoperative Year 1, P = 0.022) and less likely to develop inner retinal dimpling (P = 0.000, becoming significant by postoperative Month 3, P = 0.015). At 3 years, central foveal thickness had decreased in the single-peeling group by −136.9 µm and by −84.1 &mgr;m in the double-peeling group, which was not significantly different (P = 0.08). Mean best-corrected visual acuity improved in both the groups at all time points. There was no statistically significant difference between the 2 groups at 3 years (P = 0.44; single-peeling group, 0.32 ± 0.42, Snellen 20/42; double-peeling group, 0.23 ± 0.27, Snellen 20/34). Conclusion: Brilliant blue G–assisted internal limiting membrane peeling for ERM results in a more thorough removal of residual ERM around the paracentral fovea. However, there is no difference in long-term best-corrected visual acuity at 3 years and a greater likelihood of inner retinal dimpling.

Bilateral Orbital Abscesses After Strabismus Surgery.

Infectious orbital complications after strabismus surgery are rare. Their incidence is estimated to be 1 case per 1,100 surgeries and include preseptal cellulitis, orbital cellulitis, subconjunctival and sub-Tenons abscesses, myositis, and endophthalmitis. This report describes the case of an otherwise healthy 3-year-old boy who underwent bilateral medial rectus recession and disinsertion of the inferior obliques. A few days after surgery, the patient presented with bilateral periorbital edema and inferotemporal chemosis. A series of CT scans with contrast revealed inferotemporal orbital collections OU. The patient immediately underwent transconjunctival drainage of fibrinous and seropurulent collections in the sub-Tenons space and experienced rapid improvement a few days later. The patient is reported to be in stable condition in a follow-up examination performed more than a year after the reported events.

Optic Nerve Head and Retinal Nerve Fiber Layer Differences Between Caribbean Black and African American Patients as Measured by Spectral Domain OCT.

Purpose:There are well-established differences in optic nerve morphology between patients of African and European descent. Spectral domain optical coherence tomography (OCT) scanning has demonstrated these differences with respect to optic disc area (DA), average cup-disc ratio, cup volume, and nerve fiber layer thickness. However, the term “African descent” describes a heterogenous group with considerable variability. This study evaluates differences in optic nerve and retinal nerve fiber layer (RNFL) parameters as measured by Cirrus HD-OCT between Caribbean black and African American patients. Design and Methods:A total of 25 African American subjects and 25 Caribbean black subjects with normal ocular examinations were consecutively recruited to this study. All patients received imaging of the optic nerve and nerve fiber layer with Cirrus HD-OCT. Optic nerve and RNFL parameters were evaluated for statistically significant differences using a t test. A mixed effect model for correlated data was then created to adjust outcome variables for (1) repeated measures and (2) optic nerve size. Two one-sided t tests were then utilized to determine equivalence. Results:After adjustment for DA, RNFL thickness, cup volume, DA, inferior nerve fiber layer, and vertical cup-disc ratio demonstrated statistically significant equivalence between the 2 groups (P value <0.05). The superior nerve fiber layer quadrant was significantly different between the 2 groups and may merit further investigation. Conclusions:Findings of this study suggest that optic nerve and RNFL morphology is markedly similar between Caribbean blacks and African Americans once adjusted for optic nerve size but cannot be considered equivalent in all measures, particularly in the superior nerve fiber layer.

Gestational choriocarcinoma metastasis to the extraocular muscle: a case report.

This case report describes a biopsy-proven metastasis of gestational choriocarcinoma to the medial rectus muscle. Patient evaluation and follow up included comprehensive ophthalmologic history and examination, external and fundus photography, immunohistochemistry preparations of the medial rectus muscle specimen, MRI, ultrasound of the abdomen and pelvis, comprehensive blood tests, and CT scans of the chest, abdomen, and pelvis. The tissue specimen was obtained via a medial perilimbal conjunctival peritomy. MRI revealed a mass intrinsic to the right medial rectus muscle. Immunohistochemical staining confirmed gestational choriocarcinoma metastasis in medial rectus muscle biopsy. The patient showed general and orbital improvement following 7 subsequent cycles of chemotherapy. In conclusion, gestational choriocarcinoma may metastasize to the orbit in addition to the previously reported ocular site, the choroid. A chemotherapy regimen of etoposide, methotrexate, actinomycin-D, cyclophosphamide, and vincristine can effectively treat the intraorbital component of the disease.

Exudative retinal detachment in castleman disease.

PURPOSE To describe the course of a case of Castleman disease (CD) that presented with visual symptoms and retinal disease. METHODS Clinical examination, fundus photography, and fluorescein and indocyanine green angiography were used to characterize the presence of bilateral exudative retinal detachments in a patient who was subsequently identified as having systemic lymphadenopathy. RESULTS After an extensive medical workup including CT scans, blood testing, and a lymph node and renal biopsy, the patient was diagnosed with CD. Steroids were administered to treat CD. During the course of treatment, the patient developed renal failure, which was successfully treated with plasmapheresis. Four weeks later, the bilateral retinal detachments had resolved without local treatment. CONCLUSION Exudative retinal detachments as manifestations of CD may be observed under systemic treatment for resolution before considering local therapy.