Inés Contreras

Surgical and anatomical outcomes of pars plana vitrectomy for diffuse nontractional diabetic macular edema.

Purpose: To prospectively determine the efficacy of vitrectomy combined with intravitreal triamcinolone acetonide (IVTA) injection, internal limiting membrane (ILM) peeling, or both in treating diffuse nontractional diabetic macular edema (ME). Methods: Patients with diffuse ME of <6 months who had no evidence of macular traction or macular ischemia were included in the study. Patients previously diagnosed with glaucoma underwent vitrectomy with ILM peeling. All other patients were randomly assigned to vitrectomy or vitrectomy with ILM peeling followed by IVTA injection. Results: Forty-two eyes of 38 patients were included in the study. Mean follow-up was 12 months. A statistically significant reduction in macular thickness was found at 1 month to 6 months, disappearing at 12 months. No differences in visual acuity between treatment groups were found during follow-up. Visual acuity improved in 5 (12%) of 42 eyes, remained unchanged in 32 (76%) of 42 eyes, and worsened in 5 (12%) of 42 eyes. Complications included increase in intraocular pressure in 8 (26%) of 31 eyes, mild vitreous hemorrhage in 6 (14%) of 42 eyes, central retinal pigment epithelium changes in 5 (12%) of 42 eyes, and cataract progression in 11 (38%) of 29 phakic eyes. Conclusion: In diffuse diabetic ME with no retinal traction, vitrectomy with either ILM peeling or IVTA injection at the end of surgery produces a short-term improvement in retinal thickness but no long-term anatomical or functional improvements.

Results of bevacizumab as the primary treatment for retinal vein occlusions

Background The purpose of this study is to evaluate the efficacy of intravitreal bevacizumab as the primary treatment of macular oedema due to retinal vein occlusions. Methods Patients diagnosed as having central retinal vein occlusion (CRVO) or branch retinal vein occlusion (BRVO) with visual acuity of less than 20/40 and macular oedema with more than 300u2005μm central retinal thickness were recruited. Patients that had received any prior treatment were excluded. After an initial intravitreal injection of bevacizumab, re-treatment was performed if intraretinal or subretinal fluid with distortion of the foveal depression was found in optical coherence tomography. Results 18 eyes with CRVO and 28 eyes with BRVO were included. During a 6-month period, the mean number of injections per patient was 3.7 (BRVO group) and 4.6 (CRVO group). In the BRVO group, mean baseline logMAR visual acuity was 0.80 (SD 0.38) and macular thickness was 486.9u2005μm (SD 138.5u2005μm). After 6u2005months, mean logMAR visual acuity improved significantly to 0.44 (SD 0.34), p<0.001. Mean macular thickness decreased significantly to 268.2u2005μm (SD 62.5u2005μm), p<0.001. In the CRVO group, mean baseline logMAR visual acuity was 1.13 (SD 0.21) and macular thickness was 536.4u2005μm (SD 107.1u2005μm). Mean final logMAR visual acuity improved significantly to 0.83 (SD 0.45), p<0.001. Mean macular thickness decreased significantly to 326.17u2005μm (SD 96.70u2005μm), p<0.001. Conclusions Intravitreal bevacizumab seems to be an effective primary treatment option for macular oedema due to retinal occlusions. Its main drawback is that multiple injections are necessary to maintain visual and anatomic improvements.

Visual and anatomical outcomes of non-arteritic anterior ischemic optic neuropathy with high-dose systemic corticosteroids

BackgroundTo evaluate the visual and anatomic outcomes after systemic steroid treatment in non-arteritic anterior ischemic optic neuropathy (NAION).MethodsTen eyes from ten patients diagnosed with NAION and treated during the acute phase with 80xa0mg daily, tapering-down dose of corticosteroids were compared with a non-contemporary cohort of 27 patients that received no treatment. The visual outcomes of treated and untreated group were compared. Patients underwent complete ophthalmic examination including determination of Snellen visual acuity (VA), visual fields (VFs) (standard automated perimetry, Swedish Interactive Testing Algorithm 24–2 strategy), and optical coherence tomography (OCT) scanning of the optic nerve head at diagnosis, 6–8xa0weeks and 6xa0months after presentation.ResultsNo statistical differences were found between steroid-treated and untreated NAION for the median change in VA (Mann–Whitney Pu2009=u20090.28), median change in VF mean deviation (MD) and median change in VF pattern standard deviation (PSD) (Mann–Whitney Pu2009=u20090.213 and Pu2009=u20090.07 respectively). Statistical analysis showed no differences when comparing average RNFL loss (Pu2009=u20090.871) and RNFL loss for superior, nasal, inferior and temporal optic disc quadrants between both groups. Complications occurred in three of the ten treated patients (30%); in one of them, steroid therapy had to be discontinued. Another two patients developed a NAION in their fellow eye after 2 and 3xa0months while on low-dose prednisone. No complications developed in the control group. The study was interrupted early due to a significantly higher rate of complications observed in the treated group (Pu2009=u20090.002)ConclusionHigh-dose systemic steroid treatment did not show any beneficial effect in visual and anatomic outcomes when given during the acute phase of NAION. Furthermore, it caused serious complications in a third of the patients treated.

Optical Coherence Tomography in Multiple Sclerosis and Neuromyelitis Optica: An Update

Optical coherence tomography (OCT) uses light interference patterns to produce a cross-sectional image of the retina. It is capable of measuring the unmyelinated axons of the retinal ganglionar cells as they converge on the optic disc. In a disease like multiple sclerosis (MS), in which axonal loss has been identified as an important cause of sustained disability, it may prove an invaluable tool. OCT has demonstrated that axonal loss occurs after each episode of optic neuritis and that the degree of axonal loss is correlated to visual outcomes. Furthermore, axonal loss occurs in MS even in the absence of inflammatory episodes, and the degree of this loss is correlated with the duration of the disease process, with more thinning as the disease advances and in progressive forms. Thus, OCT retinal nerve fiber layer measurements may represent an objective outcome measure with which to evaluate the effect of treatment.

Papillomacular Bundle and Inner Retinal Thicknesses Correlate With Visual Acuity in Nonarteritic Anterior Ischemic Optic Neuropathy

PURPOSEnTo evaluate the ability of the papillomacular bundle (PMB) retinal nerve fiber layer and macular inner retinal layer thickness measurements with Spectralis optical coherence tomography (OCT) to differentiate eyes with nonarteritic anterior ischemic optic neuropathy (NAION) from uninvolved eyes and to evaluate whether their thicknesses correlate with visual acuity.nnnMETHODSnAn observational, cross-sectional study was performed, including 29 eyes with NAION and 29 uninvolved eyes from 29 patients. Eyes underwent scanning with Cirrus OCT (peripapillary and macular scanning) and Spectralis OCT (N-site axonal peripapillary scan and a new automated segmentation macular scan to measure individual retinal layers) in both eyes.nnnRESULTSnThe NAION eyes showed significant thinning versus uninvolved eyes in the macular retinal nerve fiber (P < 0.05), ganglion cell layer (GCL; P < 0.001), and inner plexiform layer (IPL; P < 0.01) by Spectralis and in the GCL-IPL by Cirrus (P < 0.02). Average and sectors of peripapillary retinal nerve fiber layer (pRNFL) and total macular thickness (TMT) were significantly reduced in NAION eyes, with both Spectralis and Cirrus OCT (P < 0.05). Spectralis temporal (ρSpearman = -0.768; P < 0.001) and PMB pRNFL thicknesses (ρSpearman = -0.675; P < 0.001), as well as central macular IPL thickness (ρSpearman = -0.735; P < 0.001), correlated strongly with best corrected visual acuity (BCVA). Quadratic regression using outer nasal TMT by Cirrus OCT and temporal pRNFL thickness by Spectralis were the best models to predict BCVA.nnnCONCLUSIONSnMacular segmentation by Spectralis and Cirrus OCT revealed inner retinal layer atrophy in NAION eyes. The temporal and PMB pRNFL thicknesses and central macular IPL thickness by Spectralis-OCT and outer nasal TMT by Cirrus were strongly correlated with BCVA in NAION eyes.

Measurement of retinal nerve fiber layer and macular ganglion cell–inner plexiform layer with spectral-domain optical coherence tomography in patients with optic nerve head drusen

PurposeTo evaluate the effect of optic nerve head drusen (ONHD) on the retinal nerve fiber layer (RNFL) and macular ganglion cell–inner plexiform layer (GCIPL) using Cirrus optical coherence tomography (OCT).MethodsFifty-seven eyes of thirty patients with ONHD and thirty-eight eyes of twenty age-matched and sex-matched control subjects underwent circumpapillary and macular scanning using Cirrus OCT. The percentages of eyes with abnormal GCIPL and RNFL values according to the Cirrus normative data were analysed and compared.ResultsOverall, eyes with ONHD showed abnormally reduced values for average and minimum GCIPL thicknesses in 35xa0% and 45xa0% of cases compared to 2xa0% for both values in control eyes (Pu2009<u20090.001). Average RNFL thickness comparison between eyes with ONHD and normal eyes revealed abnormal thinning in 33xa0% vs. 0xa0%, respectively (pu2009=u20090.002). The percentage of abnormal thinning increased with higher grades of ONHD for all the parameters evaluated, so that in grade III drusen, values were abnormally reduced in 80xa0% of eyes in all three analyses. Regarding buried ONHD, 30xa0% and 4xa0% of eyes had an abnormally reduced minimum GCIPL and average RNFL thickness, respectively. Furthermore, 26xa0% of these eyes had abnormal GCIPL exams with a normal or increased RNFL thickness.ConclusionsBoth RNFL and GCIPL analysis reveal significant thinning in eyes with ONHD directly correlated with drusen severity. In buried ONHD, the abnormality rate was significantly higher with GCIPL compared to RNFL evaluation, suggesting that GCIPL analysis might be an early structural indicator of neuronal loss in the setting of thickened RNFL.

Visual field defects due to optic disk drusen in children

BackgroundOptic nerve head drusen (ONHD) are deposits due to abnormalities in axonal metabolism and degeneration. Studies so far have focused on adults. Our aim was to study the effect of ONHD on visual function as well as optic nerve head structure using optical coherence tomography (OCT) in children.MethodsSubjects younger than 18xa0years of age with ONHD and who had a reliable visual field defect in at least one eye due to ONHD were considered for inclusion. All subjects underwent an extensive ophthalmic examination including best-corrected visual acuity (BCVA), funduscopy, and SITA 24–2 standard automated perimetry. OCT scanning was performed using Cirrus-HD Model 4000. Retinal nerve fiber layer (RNFL) thickness data were compared with a group of age-matched healthy children.ResultsFifteen children were included, with a mean age of 13xa0years (range 7 to 17xa0years). BCVA was 1.0 in all eyes, except in a child with concomitant esotropia. ONHD were bilateral in 13 children. Among the 28 eyes with ONHD, 12 (43xa0%) were classified as type 1 (buried), eight (29xa0%) as type 2 (ringed) and eight (29xa0%) as type 3 (superficial). All children had a visual field defect in at least one eye, according to the inclusion criteria; however, two eyes (7xa0%) had no defect in spite of the presence of ONHD. Five eyes showed an isolated enlarged blind spot (18xa0%), 15 cases showed a nasal defect (54xa0%), and six eyes showed a constricted visual field (21xa0%). RNFL thickness was higher in type 1 and 2 ONHD than in the control group, although these differences were only significant for the average, superior, and inferior quadrant thicknesses in type 1 and the inferior quadrant in type 2. RNFL thickness was lower in type 3 ONHD than in the control group, although these differences were only significant for the average, superior, and nasal quadrant thicknesses.ConclusionsONHD may lead to the development of visual field defects, even in children. In initial stages, ONHD produce an increase in RNFL thickness as measured with OCT. As drusen develop and become superficial, the RNFL thickness decreases. The temporal quadrant is often undamaged, probably reflecting the preservation of central visual acuity.

Optic disc cupping after optic neuritis evaluated with optic coherence tomography

PurposeTo determine whether the optic disc experiences cupping after an episode of optic neuritis as assessed by optical coherence tomography (OCT).MethodsA total of 50 patients with unilateral optic neuritis and 50 age- and sex-matched controls were studied. A complete examination, including visual acuity (VA), visual fields, and OCT scanning of the optic nerve head was performed. Mean cup-to-disc (C/D) ratios in the affected eyes were compared with fellow and control eyes.ResultsMean C/D area ratio (CDAR), C/D vertical ratio (CDVR), and C/D horizontal ratio (CDHR) were significantly larger in the affected eyes compared to fellow (P<0.001) and control eyes (P<0.05). The asymmetry in CDAR, CDVR, and CDHR between both eyes in the patients with optic neuritis was equal to or greater than 0.2 in 24, 28, and 30% respectively. A significant inverse correlation was found between the C/D ratios asymmetry and retinal nerve fibre layer (RNFL) thickness (P<0.05).ConclusionA significant increase in C/D ratio can be detected by OCT after unilateral optic neuritis, inversely correlated with RNFL thickness, and VA.

Ophthalmic features of spinocerebellar ataxia type 7.

Background: Patients with spinocerebellar ataxia 7 (SCA7) are known to develop ocular abnormalities. The purpose of this study was to characterize these abnormalities in greater detail and with the aid of newer quantitative technologies. Methods: Seven patients with SCA7 diagnosed by genetic analysis at La Paz Hospital (Madrid, Spain), a country-wide referral center for ataxias, were included in the study. Demographic data and ocular features were recorded from a complete ophthalmologic examination, specular microscopy, corneal topography (Pentacam), and optical coherence tomography (OCT). Results: All 7 patients had decreased visual acuity associated with varying degrees of macular pigmentary changes on ophthalmoscopy. All 7 had lower corneal endothelial cell densities than expected for their age, and 5 had increased corneal volume, although none had corneal edema. Patients with mild disease showed retinal thinning at the fovea. In patients with more advanced disease, retinal thinning was present also in the outer zone of the macula. Mean peripapillary retinal nerve fiber layer thickness was decreased in all patients; however, the temporal quadrant was spared except in advanced disease. Conclusions: This study of 7 patients with SCA7 amplifies previous reports of ophthalmic abnormalities in this condition by providing data from specular microscopy, corneal topography, and OCT. Abnormalities were present in the anterior and posterior ocular segments, as well as in eye movements and pupillary reactions. Visual dysfunction, present in all patients, was associated with retinal thinning. Decreased endothelial cell density and increased corneal thickness were common.

Ophthalmic features of Friedreich ataxia

PurposeTo describe ocular abnormalities in patients with Friedreich ataxia (FRDA).MethodsPatients diagnosed with FRDA by genetic analysis were invited to participate in a prospective cohort. The patients included underwent an extensive ophthalmologic examination, including low-contrast Sloan letter charts test and retinal nerve fiber layer (RNFL) thickness analysis by optical coherence tomography (OCT).ResultsTwenty-three patients agreed to participate. In all, 19 patients (83%) had a visual acuity of at least 0.8 in both eyes. Fundus examination showed diffuse optic nerve pallor in four patients. However, OCT showed a decreased mean peripapillary RNFL thickness in all but three adult cases and one teenager. The RNFL thickness was found to have a positive correlation with visual acuity (P=0.001) and contrast sensitivity (P=0.001) and a negative correlation with time elapsed from diagnosis (P=0.001).ConclusionsOCT and low contrast test sensitivity show that the visual pathway is affected in FRDA. However, in most patients there is no significant visual impairment. In a small proportion of patients visual acuity declines with disease progression. This study provides a better understanding of the ophthalmic features of FRDA.