Ilias Georgalas

Photodynamic therapy with verteporfin of choroidal neovascularization in angioid streaks: Conventional versus early retreatment

Purpose To evaluate the effectiveness of conventional photodynamic therapy with verteporfin (PDT) in a series of patients with macular choroidal neovascularization (CNV) due to angioid streaks and to compare it to the effectiveness of early PDT retreatment. Methods This is a retrospective study of 24 eyes (22 consecutive patients) with subfoveal or juxtafoveal CNV secondary to angioid streaks treated with PDT from September 2000 through February 2003 and that completed at least the first year of follow-up. Until August 2001, retreatments were performed according to the conventional protocol for PDT every 3 months (Group 1, consisting of 11 eyes of 9 patients). After August 2001 (13 more eyes of 13 new patients), retreatments were performed earlier (every 8 weeks) when indicated (Group 2). The follow-up time ranged from 30 to 42 months and from 12 to 30 months in Groups 1 and 2. Results At the end of the follow-up, final best-corrected visual acuity decreased in 21 (87.5%), stabilized in 2 (8.3%), and improved in 1 (4.2%) of the total 24 eyes. In all, 19 of the 24 eyes (79.2%) had a final best-corrected visual acuity equal to or less than 20/400. There were not any statistically significant differences in final visual acuity between the two groups. Conclusions In this large series of patients with macular CNV secondary to angioid streaks, the functional and the anatomic results of PDT were not satisfactory, even when retreatments were performed earlier than the conventional time of 3 months.

Retinal hemorrhage after photodynamic therapy in patients with subfoveal choroidal neovascularization caused by age-related macular degeneration

AbstractnPurpose. To report the frequency and the evolution of the extensive retinal hemorrhages that can appear within 48xa0h after the application of photodynamic therapy.nMethods. Two hundred and fifteen individual eyes of 194 consecutive patients with subfoveal choroidal neovascularization (CNV) due to age-related macular degeneration who underwent photodynamic treatment were included in the study. The visual acuity was measured before and after treatment. Color and red-free photographs were taken. Fluorescein angiography and optical coherence tomography (OCT) were also performed in order to describe the macular hemorrhages.nResults. Four out of 215 eyes developed macular hemorrhage within 48xa0h after the photodynamic therapy. Before treatment one of the four patients had classic CNV, one predominantly classic and two patients occult CNV without any classic component. In all four cases, the hemorrhage after photodynamic therapy (PDT) was extensive, it extended beyond the arcades and it was not absorbed during the follow-up period, which ranged from 11 to 21 months. The greatest linear dimension of the hemorrhage was extremely high (>12,000xa0µm).nConclusion. Extensive macular hemorrhage was observed in 1.86% of the studied cases. The hemorrhage was not related to the type of the CNV lesion before treatment. The size and the appearance of hemorrhage within 48xa0h after treatment support the view that the hemorrhage is a direct consequence of the photodynamic therapy and not related to the natural course of the disease.

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.

β-Thalassemia and ocular implications: a systematic review

BackgroundBeta-thalassemia is a severe genetic blood disorder caused by a mutation in the gene encoding for the beta chains of hemoglobin. Individuals with beta-thalassemia major require regular lifelong Red Blood Cell transfusions to survive. Ocular involvement is quite common and may have serious implications.MethodsExtensive review of observational studies on beta-thalassemia, to determine the prevalence and spectrum of ocular abnormalities, by clinical examination and multimodal imaging, and to investigate risk factors for their development.ResultsFrequency of ocular involvement differs among various studies (41.3–85xa0%, three studies). Ocular findings in beta-thalassemia may correlate to the disease itself, iron overload or the chelating agents used. Beta-thalassemia ocular manifestations include ocular surface disease, as demonstrated by tear function parameters (two studies). Lens opacities are present in 9.3–44xa0% (five studies). Lenticular opacities and RPE degeneration correlated positively with use of desferrioxamine and deferriprone respectively (two studies). Ocular fundus abnormalities characteristic of pseudoxanthoma elasticum (PXE), including peau d’orange, angioid streaks, pattern dystrophy-like changes, and optic disc drusen are a consistent finding in seven studies. Patients with PXE-like fundus changes were older than patients without these fundus changes (two studies). Age (two studies) and splenectomy (one study) had the strongest association with presence of PXE-like fundus changes. Increased retinal vascular tortuosity independently of the PXE-like fundus changes was found in 11–17.9xa0% (three studies), which was associated with aspartate amino transferase, hemoglobin and ferritin levels (two studies). Fundus autofluorescence and electrophysiological testing (ERG and EOG) may indicate initial stages or more widespread injury than is suggested by fundus examination (two studies).ConclusionsBeta-thalassemia may present with various signs, both structural and functional. Pseudoxanthoma elasticum like fundus changes are a frequent finding in patients with b-thalassemia. These changes increase with duration or severity of the disease. Retinal vascular tortuosity may be an additional disease manifestation related to the severity and duration of anemia and independent of the PXE-like syndrome. Patients with long-standing disease need regular ophthalmic checkups because they are at risk of developing PXE-like fundus changes and potentially of subsequent choroidal neovascularization.

Diffuse retinal pigment epitheliopathy: Treatment with laser photocoagulation

Purpose To evaluate the effectiveness of laser treatment in eyes with diffuse retinal pigment epitheliopathy (DRPE). Methods The authors retrospectively reviewed the medical records of 56 consecutive patients (78 eyes) with DRPE. All eyes were treated with digital fluorescein angiography guided argon green laser photocoagulation, direct on the focal retinal pigment epithelium (RPE) leaks and in a grid pattern to the RPE decompensation areas. A processed digital red-free fundus image including all the important traces on it was used as a guide to the laser treatment. The follow-up period ranged from 6 months to 7 years. Results At the end of the follow-up time, 70 (89.7%) eyes showed anatomic improvement with complete or partial resolution of the macular exudative lesions. Visual acuity of less than 20/40 was noted in 60 eyes (76.9%) preoperatively compared with 46 eyes (59.0%) finally (p=0.0252). The visual acuity was improved in 19 eyes (24.4%), stabilized in 51 (65.4%), and reduced in only 8 eyes (10.2%). Conclusions In this series of patients with DRPE, the results of laser treatment were uniformly satisfactory producing a gradual resolution of the macular exudative lesions and an improvement or stabilization of the visual acuity.

Polypoidal choroidal vasculopathy associated with Doyne's familial choroiditis: treatment with thermal laser.

PURPOSEnTo report the unusual occurrence of polypoidal choroidal vasculopathy (PCV) in a patient with Doynes familial honeycomb choroiditis (DFHC) and its course after laser treatment.nnnDESIGNnInterventional case report.nnnMETHODSnIndocyanine green (ICG) angiography guided laser was performed on active polypoidal lesions.nnnRESULTSnA 45-year-old man with a 15-year history of bilateral DFCH and a scarred macular choroidal neovascularization in the right eye (RE) was referred to us with exudative maculopathy in the left eye (LE). His best-corrected visual acuity (BCVA) was 20/800 in the RE and 20/40 in the LE. ICG angiography revealed a picture that was characteristic for PCV in both eyes. ICG guided argon green laser was performed on the active parapapillary and perifoveal polypoidal lesions of the LE. Eight months after the laser photocoagulation treatment, the macular exudative lesions had subsided and the BCVA improved to 20/20. The favorable anatomic and functional results have remained stable over 3 years.nnnCONCLUSIONSnThis is, to our knowledge, the first case of a PCV that occurred secondary to DFHC. (Eur J Ophthalmol 2004; 14: 264-8).

Correlation Between Optic Nerve Head Parameters, RNFL, and CCT in Patients with Bilateral Pseudoexfoliation Using HRT-III

Abstract Background: It is well-established that eyes with pseudoexfoliation syndrome (PXS) have higher intraocular pressure (IOP). Early diagnosis of preperimetric glaucoma will assist with better management of these patients. The aim of this study is to evaluate the optic nerve head (ONH) parameters and retinal nerve fiber layer (RNFL) thickness in subjects with bilateral PXS, bilateral pseudoexfoliative glaucoma (PXG) and normal, correlating these results with central corneal thickness (CCT). Design: This is a cross-sectional, case control study. All participants were from the Department of Ophthalmology, Athens University Medical School. Participants: A total of 55 eyes from 55 patients with PXS (27 eyes from 27 patients with PXG and 28 eyes from 28 normal subjects) were studied. Methods: Topographic measurements of the ONH and peripapillary RNFL thickness were performed using a confocal scanning laser ophthalmoscope (the Heidelberg Retina Tomograph-III). The outcomes were correlated with the CCT of the subjects. Main Outcome Measures: PXS subjects and age-matched normal subjects did not differ significantly in ONH parameters. RNFL thickness was significantly lower in the PXS group compared with the normal group, but there was not a statistically significant difference with the PXG patients. Regarding the correlation with CCT, the PXG group showed negative correlation with mean (pu2009=u20090.027) and max cup depth (pu2009=u20090.031), while PXS subjects revealed a positive correlation with RNFL thickness (pu2009=u20090.032). Conclusions: Our study showed that PXS subjects may be at greater risk of RNFL thinning, presenting a statistically significant positive association of the latter parameter with the CCT.

Evaluation of Direct Immunofluorescence Assay and Cytological Examination in Comparison to Polymerase Chain Reaction of Conjunctival Swabs in Patients with Adult Inclusion Conjunctivitis

Abstract Purpose: To evaluate PCR, direct immunofluorescence assay (DIA) and cytological test of conjunctival swabs for the diagnosis of adult follicular conjunctivitis (AFC). Methods: Eighty-three adult patients with chronic conjunctivitis and sixteen healthy individuals were included. Conjunctival scrapings underwent PCR, DIA and cytological analysis. Exams were repeated two weeks after treatment application. Sensitivity, specificity and agreement rate with PCR of DIA and Cytology were evaluated and correlated with clinical symptoms/signs. Results: Cytology test was more sensitive than DIA and presented an acceptable agreement with PCR (Ku2009=u20090.44) in treatment-naued65 patients, concerning especially the combination of both conventional exams (Ku2009=u20090.77). Inferior diagnostic performance of was detected post-treatment, considering the combination as well (Ku2009=u20090.40). Negative post-treatment PCR correlated well with significant relief of symptoms/signs. Conclusion: Combination of Cytology and DIA seems to be a useful diagnostic option for treatment naued65 AFC patients. However, PCR remains the most reliable test for post-treatment evaluation.

Human pericardium graft in the management of bleb's complication performed in childhood: a case report

BackgroundTo report a case with hypotony due to late leakage of the filtering bleb performed during childhood and treated surgically using human pericardium graft.Case PresentationA man with hypotony related to blebs leakage in his right eye was presented. During his childhood trabeculectomy was performed to manage ocular hypertension due to pediatric glaucoma. Biomicroscopy revealed choroidal tissue incarcerated in the sclerectomy under the conjunctiva. Bleb revision was performed. Human pericardium graft was used to cover the sclerectomy and a new bleb with controlled outflow was created. The intraocular pressure (IOP) and Seidel test represent the main outcomes. Intraoperative and postoperative complications were recorded. Fifteen days postoperatively the IOP was of 7 mmHg and the bleb seemed to filter properly. Five months later the IOP was 9 mmHg and no complications were noticed. During the follow up time, the Seidel test was negative.ConclusionWe used human pericardium graft with no complications in a case of bleb leakage performed for pediatric glaucoma.

The effect of different doses of intracameral bevacizumab on surgical outcomes of trabeculectomy for neovascular glaucoma.

We read with interest the article by Gupta et al (1): “The effect of different doses of intracameral bevacizumab on surgical outcomes of trabeculectomy for neovascular glaucoma”. The authors have performed an important prospective study evaluating the efficacy of 1.25 mg and 2.5 mg of intracameral bevacizumab as an adjunct for trabeculectomy with mitomycin C (MMC) in patients with neovascular glaucoma. The authors concluded that intracameral bevacizumab prior to trabeculectomy results in good surgical outcomes and reported that the rates of complications of trabeculectomy were comparable to those of their control group where trabeculectomy alone with MMC was preformed. MMC has been traditionally used as an adjunct to trabeculectomy so as to modulate the wound-healing process and augment the results of trabeculectomy (2); however, MMC has been associated with cystic avascular blebs, bleb leakage, hypotonic maculopathy, and endophthalmitis. The potential role of anti-VEGF as an adjunct to trabeculectomy is currently under evaluation since angiogenesis plays a key role in wound healing; new blood vessels are necessary for a variety of mediators and regulators to reach the center of the healing process (2, 3). Published results are promising; however, the safety of this off-label treatment has yet to be proven (2). Additionally, there are reports in the literature where subconjunctival or intravitreal injection of anti-VEGFs resulted in a dramatic reduction in bleb vascularity (4) or even bleb leak and severe hypotony (5). In the study of Gupta et al (1), patients received intracameral injections of bevacizumab prior to trabeculectomy augmented with MMC (1) and some of their patients had previously undergone transconjunctival retinal ablation with cryotherapy a few days earlier. In our opinion, an aggressive treatment like this may have an additive negative effect in the wound-healing process and angiogenesis; subsequently, complications such as bleb leakage, avascularity, and endophthalmitis might be expected to be higher either soon or late after trabeculectomy. We agree with the authors that neovascular glaucoma is difficult to treat, sometimes requiring many therapeutic procedures and having poor results. However, we believe that the conclusion «intracameral bevacizumab should be considered as a therapeutic alternative in eyes with neovascular glaucoma prior to filtering surgery with MMC for a better therapeutic effect with reduced complications» for an off-label therapeutic application should be further examined and confirmed by prospective randomized studies.