Jose M. Caminal

A study comparing two protocols of treatment with intravitreal bevacizumab (Avastin) for neovascular age-related macular degeneration

Aims: The aim of this study was to compare two treatment options for choroidal neovascularisation (CNV) secondary to age-related macular degeneration (AMD): (1) bevacizumab administered once a month for 3 months and thereafter as needed (loading dose (LD)); and (2) bevacizumab administered as needed, after the first injection (pro re nata (as needed) (PRN)). Methods: Fifty consecutive patients were enrolled in this prospective study. The first 25 patients were included in the LD group and the last 25 patients in the PRN group. In both groups, the need for re-treatment was based on the presence of persistent or recurrent macular oedema, subretinal fluid or pigment epithelial detachment on optical coherence tomography scans. Results: At the 6-month follow-up, mean visual acuity improved by 13.7 letters (p<0.001) in the LD group and 4.6 in the PRN group (p<0.001). Thirty-six per cent of patients in the LD group compared with 12% in the PRN group gained 15 or more letters (p = 0.04). Mean foveal thickness decreased by 91.3 µm (p<0.001) in the LD group and 48.2 µm in the PRN group (p<0.001). No ocular or systemic side effects were observed. Conclusion: Patients with CNV secondary to AMD treated with a LD protocol had better results than patients treated with a PRN protocol with intravitreal bevacizumab.

Intravitreal infliximab in patients with macular degeneration who are nonresponders to antivascular endothelial growth factor therapy.

Purpose: The purpose of this study was to determine the efficacy and safety of intravitreal infliximab in the treatment of choroidal neovascularization secondary to age-related macular degeneration in patients who are nonresponders to antivascular endothelial growth factor therapy. Methods: Prospective, noncomparative, interventional case series. The primary inclusion criteria for patients consisted of previous treatment with five or more intravitreal injections of bevacizumab and/or ranibizumab, visual loss, angiographic leakage, and intraretinal and/or subretinal fluid on spectral domain optical coherence tomography. At Day 0, a single intravitreal injection of infliximab (2 mg/0.05 mL) was administered. Best-corrected visual acuity testing measured with Early Treatment Diabetic Retinopathy Study charts and spectral domain optical coherence tomography scans were performed on Days 0, 3, 7, 30, 60, and 90. Fluorescein angiography was performed at days 0 and 90. The development of systemic antibodies against infliximab (human antichimeric antibodies) was not sought. Main outcome measures were changes in best-corrected visual acuity, foveal thickness, and lesion size. Results: We included four patients. At Day 90, the best-corrected visual acuity change was −18, +3, +4, and −4 letters, respectively. Intraretinal and/or subretinal fluid on spectral domain optical coherence tomography scans was not significantly reduced in any case. Lesion size was not reduced in any case. Two patients developed intraocular inflammation with high intraocular pressure 3 and 5 weeks after the infliximab injection, respectively. One case was controlled with topical medication, and one case required posterior vitrectomy. Conclusion: Intravitreal infliximab showed no significant visual or anatomical benefit for the treatment of choroidal neovascularization secondary to age-related macular degeneration in patients who were nonresponders to antivascular endothelial growth factor therapy. In addition, half of the cases developed intraocular inflammation.

Preoperative study of the inner segment/outer segment junction of photoreceptors by spectral-domain optical coherence tomography as a prognostic factor in patients with epiretinal membranes

Objective To demonstrate whether the preoperative integrity of the inner segment/outer segment (IS/OS) junction of photoreceptors studied by spectral-domain optical coherence tomography (SD-OCT) is a prognostic factor in epiretinal membrane surgery. Methods We retrospectively studied patients with an idiopathic epiretinal membrane who underwent a 23-gauge vitrectomy to remove this membrane. Best-corrected visual acuity (BCVA) and SD-OCT scans were examined before and 6 months after the surgery. We studied the retinal microstructure, especially the IS/OS junction of the photoreceptors, and evaluated the intergroup differences between patients with an intact layer and those with an irregular or disrupted layer. We applied both the Wilcoxon and Mann–Whitney tests for statistical analysis. Results In total, 51 eyes from 51 enrolled patients were examined in this study. The postoperative BCVA was significantly better for eyes that had an intact IS/OS junction than for eyes that had an irregular or disrupted IS/OS junction, as preoperatively observed with SD-OCT scans (P < 0.001). We also observed an important association between disrupted IS/OS junctions and the presence of cystic macular edema (P < 0.01). Conclusion The presence of an intact IS/OS junction on the preoperative SD-OCT scan was an important predictor of better visual recovery after epiretinal membrane surgery.

Autofluorescence and axial length as prognostic factors for outcomes of macular hole retinal detachment surgery in high myopia.

Purpose: To evaluate the results of fundus autofluorescence and axial length as prognostic factors for surgical outcome of macular hole retinal detachment in high myopic patients. Methods: This is a retrospective, interventional, nonrandomized study. Patients were treated with posterior vitrectomy, internal limiting membrane peeling, and silicone oil tamponade. Best-corrected visual acuity, axial length, fundus autofluorescence, and spectral domain optical coherence tomography images were obtained. Results: Fifteen eyes from 15 patients (mean age, 69.4 years) were evaluated. The mean refractive error was −19 diopters, and the mean axial length was 29.9 mm. The mean best-corrected visual acuity (logMAR) improved from 2.17 to 1.42 (P = 0.02) after a mean follow-up of 19.3 months. Spectral domain optical coherence tomography scans showed retinal detachment resolution in 13 eyes (86.6%) and macular hole closure in 9 eyes (60%). Fundus autofluorescence showed macular hypoautofluorescence with foveal involvement (mean area of 9.7 mm2) in 10 eyes (66.6%). Postoperative best-corrected visual acuity was significantly worse in these eyes (P = 0.009). Axial length >30 mm was found in the 2 cases with recurrent retinal detachment and in 4 of the 6 cases without macular hole closure (66.6%). Conclusion: Macular hole retinal detachment in high myopic patients can be successfully treated with vitrectomy, internal limiting membrane peeling, and silicone oil. Axial length >30 mm and macular hypoautofluorescence with foveal involvement seem to be prognostic factors for a worse anatomical and visual outcome.

INTRAVITREAL DEXAMETHASONE IMPLANT FOR RADIATION MACULOPATHY SECONDARY TO PLAQUE BRACHYTHERAPY IN CHOROIDAL MELANOMA.

Purpose: To evaluate the efficacy of intravitreal dexamethasone implant 0.7 mg (Ozurdex) in radiation maculopathy secondary to plaque brachytherapy in choroidal melanoma. Methods: Twelve eyes diagnosed of radiation maculopathy secondary to plaque brachytherapy and treated with intravitreal dexamethasone implant were included. Visual acuity, foveal thickness using spectral domain optical coherence tomography, and grade of macular edema, using Horgan classification, were evaluated. Results: Mean age was 65.5 ± 28 years (range, 40–82 years). Mean follow-up was 8.2 ± 7.8 months (range, 2–28 months). Mean visual acuity before treatment was, in logarithm of the minimum angle of resolution scale, 1 ± 0.58 (range, 0.4–2) and mean final visual acuity 0.8 ± 0.58 (range, 0.2–2), showing a nonsignificant trend to improvement (P = 0.091; Wilcoxons test). Foveal thickness before treatment was 416 ± 263 &mgr;m (range, 222–725 &mgr;m) and final foveal thickness 254 ± 170 &mgr;m (range, 145–750), showing a significant decrease (P = 0.016; Wilcoxons test). Referring to Horgan classification, a significant reduction in grades before and after treatment was demonstrated (P = 0.007; Wilcoxons test). Conclusion: Ozurdex is a useful treatment for radiation maculopathy associated to plaque brachytherapy for uveal melanoma, with a significant decrease in foveal thickness and a significant improvement in Horgan classification. This anatomical improvement was correlated with a moderate improvement in visual acuity.

Retinal Hemangioblastoma Regression After Single Session of Photodynamic Therapy

41. Pasquale LR, Wiggs JL, Willett WC, Kang JH. The relationship between caffeine and coffee consumption and exfoliation glaucoma or glaucoma suspect: a prospective study in two cohorts. Invest Ophthalmol Vis Sci. 2012;53(10):6427-6433. Medline:22918628 42. Urgert R, van Vliet T, Zock PL, Katan MB. Heavy coffee consumption and plasma homocysteine: a randomized controlled trial in healthy volunteers. Am J Clin Nutr. 2000;72(5):1107-1110.

Acute onset of retinal detachment after posterior chamber phakic intraocular lens implantation

Case report A 34-year-old man with severe myopia, presented with acute visual loss in his right eye. This occurred 3 hours after a posterior chamber phakic (PCP) intraocular lens (IOL) implantation, and was associated with a rhegmatogenous retinal detachment. Retinal retachment surgery was performed without complications, with the outcome showing good anatomical and functional results during a 2-year follow-up period. Discussion Despite the fact that several authors have described retinal detachments following PCP IOL implantation in highly myopic patients, there is no evidence that this procedure increases the risk of retinal detachment in these patients. The occurrence of the retinal detachment immediately after the phakic IOL implantation supports the hypothesis that the surgical procedure could induce iatrogenic changes in patients with high myopia, which could increase the incidence of retinal detachment. In contrast to other reports, the interval between the PCP IOL implantation and the retinal detachment was only 3 hours in our patient. We believe this demonstrates the importance of performing a complete preoperative vitreoretinal examination in patients with severe myopia.

INCIDENCE AND RELATION WITH ANATOMICAL AND FUNCTIONAL VARIABLES OF POSTOPERATIVE MACULAR DISPLACEMENT IN RHEGMATOGENOUS RETINAL DETACHMENT.

Purpose: To investigate the incidence of postsurgical retinal displacement in patients treated with pars plana vitrectomy for rhegmatogenous retinal detachment and to assess the influence of displacement on macular function. Methods: Observational prospective study of 20 consecutive cases of rhegmatogenous retinal detachment who underwent 23-G pars plana vitrectomy with gas (C3F8 or SF6) tamponade, and prone resting. Three months after surgery, retinal displacement was evaluated by fundus autofluorescence. Macular function was evaluated with optical coherence tomography, multifocal electroretinogram, best-corrected visual acuity, and stereopsis. Results: Postoperative retinal displacement was observed in 60% of cases. No correlation between the type of tamponade used and retinal displacement was observed. Similarly, no association between retinal displacement and postoperative stereopsis or visual acuity was found. A lower amplitude in P1 wave on the multifocal electroretinogram was observed in eyes with rhegmatogenous retinal detachment compared with the contralateral eye. However, no statistically significant differences between groups with or without retinal displacement were found. Conclusion: Retinal displacement in patients who undergo pars plana vitrectomy to treat rhegmatogenous retinal detachment is common. However, this displacement does not seem to affect macular function.

Two cases of accidental dislocation of the silicone sleeve of an extrusion cannula into the vitreous cavity.

Background: Fluid-air exchange during vitreoretinal surgery is often used as a tool for subretinal fluid endodrainage. Soft-tipped flexible extrusion cannulas are commonly used to aspirate the posterior subretinal fluid. Methods: This is an observational two-case series describing two patients who underwent 20-G pars plana vitrectomy complicated by the accidental fall of the silicone sleeve of a soft-tipped extrusion cannula into the vitreous cavity. In the first case, the cannula had inadvertently been subjected to sterilization process. Results: While withdrawing the soft-tipped extrusion cannula from the eye, following internal drainage of transvitreal and subretinal fluid, the loose silicone sleeve probably got entangled at the inner lip of the sclerotomy and finally fell on the retinal surface. In both cases, the silicone sleeve was held and removed with an intraocular forceps. Conclusions: This rare complication has been reported in the literature only once previously. Sterilization of disposable subretinal fluid cannulas is not advisable because of the risk of dislocation of the silicone sleeve into the eye. Besides this, it is important to check the integrity of the silicone sleeve before and after surgery.

Spontaneous Regression of Small Melanocytic Choroidal Tumor

ondary lysosomes. It is unknown exactly how the impaired lysosomal function results in the clinical features, but it is likely that retained storage material in the retina along with other, yet-to-be– elucidated mechanisms results in widespread RPE dysfunction and photoreceptor death. In conclusion, the 2 patients presented herein and those described by Springer et al demonstrate that, in addition to corneal and lenticular opacity, retinal dystrophy may develop in patients with -mannosidosis. Consideration of retinal function, either through ERG or detailed fundus examination, is warranted prior to planning any surgical correction of corneal or lenticular opacity. Further study is required to determine the frequency with which it occurs and the rate of progression.