Josep Callizo

Efficacy and safety of intravitreal therapy in macular edema due to branch and central retinal vein occlusion: a systematic review.

Background Intravitreal agents have replaced observation in macular edema in central (CRVO) and grid laser photocoagulation in branch retinal vein occlusion (BRVO). We conducted a systematic review to evaluate efficacy and safety outcomes of intravitreal therapies for macular edema in CRVO and BRVO. Methods And Findings: MEDLINE, Embase, and the Cochrane Library were systematically searched for RCTs with no limitations of language and year of publication. 11 RCTs investigating anti-VEGF agents (ranibizumab, bevacizumab, aflibercept) and steroids (triamcinolone, dexamethasone implant) with a minimum follow-up of 1 year were evaluated. Efficacy: CRVO Greatest gain in visual acuity after 12 months was observed both under aflibercept 2 mg: +16.2 letters (8.5 injections), and under bevacizumab 1.25 mg: +16.1 letters (8 injections). Ranibizumab 0.5 mg improved vision by +13.9 letters (8.8 injections). Triamcinolone 1 mg and 4 mg stabilized visual acuity at a lower injection frequency (-1.2 letters, 2 injections). BRVO Ranibizumab 0.5 mg resulted in a visual acuity gain of +18.3 letters (8.4 injections). The effect of dexamethasone implant was transient after 1.9 implants in both indications. Safety Serious ocular adverse events were rare, e.g., endophthalmitis occurred in 0.0-0.9%. Major differences were found in an indirect comparison between steroids and anti-VEGF agents for cataract progression (19.8-35.0% vs. 0.9-7.0%) and in required treatment of increased intraocular pressure (7.0-41.0% vs. none). No major differences were identified in systemic adverse events. Conclusions Anti-VEGF agents result in a promising gain of visual acuity, but require a high injection frequency. Dexamethasone implant might be an alternative, but comparison is impaired as the effect is temporary and it has not yet been tested in PRN regimen. The ocular risk profile seems to be favorable for anti-VEGF agents in comparison to steroids. Because comparative data from head-to-head trials are missing currently, clinicians and patients should carefully weigh the benefit-harm ratio.

Combined intravitreal anti‐vascular endothelial growth factor (Avastin®) and photodynamic therapy to treat retinal juxtapapillary capillary haemangioma

Objective:  Retinal capillary haemangioma complications are characterized by progressive exudation with consecutive intraretinal and subretinal leakage. A successful therapy without side‐effects has not been found. We report a case of retinal juxtapapillary capillary haemangioma causing consecutive leakage with macular involvement. The tumour was treated with a combination of anti‐vascular endothelial growth factor (VEGF) and photodynamic therapy (PDT) and was followed for 1 year.

Atrial fibrillation in retinal vascular occlusion disease and non-arteritic anterior ischemic optic neuropathy.

Background Patients with retinal vascular occlusion disease have an increased risk for ischemic stroke and share some risk factors with cerebrovascular disease. The purpose of this study was to analyze the prevalence of atrial fibrillation (AF) in subjects with retinal vascular occlusive disease and anterior ischemic optic neuropathy and to compare these data to an ischemic stroke group. Methods Prospective, observational single-center trial. Subjects with retinal artery occlusion (RAO), retinal vein occlusion (RVO) and anterior ischemic optic neuropathy (AION) were included. Patients with ischemic stroke (IS) from a previous observational trial were used as control. Investigation included 7-day Holter ECG, echocardiography, duplex ultrasonography of the carotid arteries, and 24-hour blood pressure monitoring. Further vascular risk factors were documented. Results During the 1-year study period, 101 patients were recruited. The control group with ischemic stroke consisted of 272 subjects. At inclusion, the prevalence of AF was 12% (RAO), 10.2% (RVO), 11.1% (NAION) and 15.8% (IS). The final prevalence after Holter ECG rose to 16% (RAO), 18.4% (RVO), 14.8% (NAION) and 26.5% (IS). No significant difference was measured between groups. Conclusions We detected a similar prevalence of AF in all groups. RVO patients tended to exhibit a higher AF detection rate and lower number needed to screen than RAO and NAION. The detection of AF rose considerably via Holter ECG. As a consequence, we recommend prolonged ECG monitoring in patients with acute ophthalmic vascular diseases.

Closantel Poisoning Treated With Plasma Exchange

Report of a Case | A man in his late 50s fearing helminthiasis took 4 mL of the antihelminthic Flukiver Combi 3 times per day for 3 days (cumulative dose, 2700 mg of mebendazol and 1800 mg of closantel). Four days after the last ingestion, he arrived at a peripheral hospital with visual impairment and tongue dysesthesia. Visual acuity (VA) was 20/63 OD and 20/50 OS. The neurological and physical examination results, cranial magnetic resonance imaging findings, and laboratory values were unremarkable. We examined him 3 days later. His VA had worsened to hand movements OU. Visual fields were markedly constricted at the outer margins and relative scotoma was present around the macula (Figure, A). Electrophysiology revealed reduced visual evoked potential amplitudes with delayed peak latencies. Electrophysiological assessment was performed in conformity with the standard protocols recommended by the International Society for Clinical Electrophysiology of Vision.1,2 Full-field electroretinography (ERG) demonstrated decreased photoreceptor signal amplitudes with normal latency (eFigure 1 in the Supplement); multifocal ERG revealed reduced foveal peaks. Aware of closantel’s pharmacokinetics (high plasma protein binding, a small volume of distribution, and a long biological half-life), we attempted therapeutic PE. Membrane PE was performed in 5 sessions on alternate days via the Octo Nova system (Diamed Medizintechnik GmbH) with a Plasmaflo OP-08W(L) filter (Asahi Kasei Kuraray Medical Co, Ltd). A 1.5–plasma volume exchange was performed using human albumin (20 g/100 mL) and crystalloids in a 20% to 80% distribution, respectively, as replacement. One day after the second session, VA improved to 20/400 OU and visual fields recovered partially. Two weeks after PE, VA increased to 20/50 OU and the visual fields had marked improvement (Figure, B). Three months later, VA was 20/25 OU and visual fields had recovered almost completely (Figure, C). Furthermore, ERG showed a significant increase in photoreceptor signal amplitudes (eFigure 2 in the Supplement), and multifocal ERG showed residual central amplitude impairment.

Scleral buckling in rhegmatogenous retinal detachment with concomitant full-thickness macular hole

of progressive decrease of visual acuity within a period of several months accompanied by a visual field defect on the right eye since 3 days. Visual acuity was hand movement OD and 20 ⁄ 40 OS. Ophthalmic examination disclosed incipient cataract formation on both eyes and a rhegmatogenous retinal detachment (RD) on the right eye from 5 to 1 o‘clock with macular involvement (Fig. 1A). Peripheral retinal breaks were found at 7, 9 and 10 o¢clock, and a macular hole (MH) was assumed. Optical coherence tomography (OCT) confirmed a fullthickness hole (Fig. 1E). Additionally, proliferative vitreoretinopathy (PVR) became evident because of a full-thickness retinal involvement with retinal star fold formation at 12 o‘clock, classified as PVR Cp1. After discussing with the patient the surgical alternatives of a vitrectomy and a scleral buckling procedure, a selective buckling of the peripheral breaks was performed with a circumferential buckle and additional mild cryopexy of the retinal breaks. A sponge of 4 mm diameter was applied from 6:30 to 10:30 to cover the retinal breaks at 7, 9 and 10 o‘clock. The retina attached completely after 2 days (Fig. 1B). Visual acuity improved to 20 ⁄ 100 and no complications developed during a follow-up of 6 months. The star fold at 12 o‘clock resolved over a period of 3 months (Fig 1C). Postoperatively, the MH was followed by OCT and fundusphotography. The closure of the MH could be demonstrated 2 months after surgery (Fig. 1G). It is widely accepted that MH do not cause rhegmatogenous RD. Thus, if a MH is seen in the presence of a rhegmatogenous RD, the treatment should focus on the retinal breaks. The MH is interpreted as a lamellar hole [correction added after online publication 2 June 2011: ‘pseudohole’ was corrected to lamellar hole] and not as full-thickness hole [Harvey Lincoff, personal communication]. In this case, the presence of a full-thickness MH was verified by OCT. Nevertheless, we could demonstrate that selective treatment of the peripheral breaks is sufficient to reattach the retina. Additionally, the closure of the MH was seen during the follow-up. Pars plana vitrectomy is an alternative treatment to reattach the retina and to perform surgery to treat the MH by removing the inner limiting membrane (ILM). However, we should take into account that PVR may occur after surgery in 10–40% depending on the original disease (Kirchhof 2004). On the other hand, the extraocular surgical approach to treat RD has been demonstrated to reduce PVR formation (Kreissig et al. 1994; Sivkova & Kreissig 2002). In our case, PVR formation was already present. This is why buckling surgery was chosen. Today, pars plana vitrectomy allows the treatment of the RD and also the repair of the MH. However, ppV is an intraocular procedure which includes the risk of inducing MH (Benzerroug et al. 2008; Rahman et al. 2010). Even with ppV, a lamellar MH (pseudohole) may progress to a full-thickness MH because of the surgical trauma or when drainage is performed at the lamellar MH. As the patient complained of visual decrease for several months, we assumed that this was caused by early stage MH. Vitreous detachment without ILM peeling has been shown to be sufficient to treat MH. As a rhegmatogenous RD is caused by a retinal break that is typically followed by a posterior vitreous detachment, we decided to follow this case by short-term visits performing OCT. We could demonstrate that the MH closed within 8 weeks. In case of MH persistence, a vitrectomy with ILM peeling would have been recommended, because it has been shown to be beneficial especially in MH stage 4 (Meyer et al. 2008). Diagnosis ⁄ Therapy in Ophthalmology

Intravitreal Sustained-Release Steroid Implants for the Treatment of Macular Edema following Surgical Removal of Epiretinal Membranes

Purpose: To evaluate the efficacy of intravitreal dexamethasone implant for the treatment of postoperative persistent cystoid macular edema (CME) following macular pucker surgery. Methods: In this multicenter study, we retrospectively reviewed the data of 37 patients (39 eyes) who had been treated with intravitreal dexamethasone implant (Ozurdex®) for persistent CME following macular pucker surgery. Main outcome measures were change in best-corrected visual acuity (BCVA) and central retinal thickness (CRT). Results: All eyes underwent spectral domain optical coherence tomography examination within 130 days after implantation. We observed a significant decrease in mean CRT from 519.9 to 392.9 µm (p < 0.0001). By this time, mean BCVA had improved from 0.60 to 0.43 logMAR (p = 0.003). Seventeen eyes (43.6%) required at least 1 repeat injection of dexamethasone. Of these, 8 (47%) eyes received a total number of 3 or more dexamethasone injections. Conclusion: Intravitreal dexamethasone implant injection is an effective treatment option for persistent CME following macular pucker surgery.

Progressive scotoma with perception of photopsia

ZusammenfassungDie akute anuläre äußere Retinopathie (AAOR) ist eine sehr seltene Variante der akuten zonalen okkulten äußeren Retinopathie (AZOOR). Beide Formen sind durch die Wahrnehmung eines progredienten Gesichtsfelddefektes gekennzeichnet und können mit Photopsien einhergehen. Im Gegensatz zur okkulten Form findet sich bei der anulären Form typischerweise eine weißliche ringförmige Begrenzung des betroffenen Netzhautareals, die sich im Verlauf weiter ausdehnt. In der optischen Kohärenztomographie zeigt sich, dass dabei vorwiegend die äußere Netzhautschicht morphologisch verändert ist. Obwohl bisher keine effektive Therapie nachgewiesen wurde, konnte bei dem vorliegenden Patienten die weitere Ausdehnung des betroffenen Areals unter einer antiviralen und immunsuppressiven Kombinationstherapie gestoppt werden.AbstractAcute annular outer retinopathy (AAOR) is a very rare variant of acute zonal occult outer retinopathy (AZOOR). Both variants are characterized by the perception of a progressive visual field defect and can be accompanied by photopsia. In contrast to AZOOR, a progressive whitish and annular demarcation of the involved retina is observed in AAOR using ophthalmoscopy. Optical coherence tomography (OCT) reveals morphological changes predominantly in the outer retinal layers. Although there is no proof of an effective therapy, in the case presented here further progression could be stopped by a combination of antiviral and immunosuppressive therapy.Acute annular outer retinopathy (AAOR) is a very rare variant of acute zonal occult outer retinopathy (AZOOR). Both variants are characterized by the perception of a progressive visual field defect and can be accompanied by photopsia. In contrast to AZOOR, a progressive whitish and annular demarcation of the involved retina is observed in AAOR using ophthalmoscopy. Optical coherence tomography (OCT) reveals morphological changes predominantly in the outer retinal layers. Although there is no proof of an effective therapy, in the case presented here further progression could be stopped by a combination of antiviral and immunosuppressive therapy.

Progredientes Skotom mit Photopsiewahrnehmung

ZusammenfassungDie akute anuläre äußere Retinopathie (AAOR) ist eine sehr seltene Variante der akuten zonalen okkulten äußeren Retinopathie (AZOOR). Beide Formen sind durch die Wahrnehmung eines progredienten Gesichtsfelddefektes gekennzeichnet und können mit Photopsien einhergehen. Im Gegensatz zur okkulten Form findet sich bei der anulären Form typischerweise eine weißliche ringförmige Begrenzung des betroffenen Netzhautareals, die sich im Verlauf weiter ausdehnt. In der optischen Kohärenztomographie zeigt sich, dass dabei vorwiegend die äußere Netzhautschicht morphologisch verändert ist. Obwohl bisher keine effektive Therapie nachgewiesen wurde, konnte bei dem vorliegenden Patienten die weitere Ausdehnung des betroffenen Areals unter einer antiviralen und immunsuppressiven Kombinationstherapie gestoppt werden.AbstractAcute annular outer retinopathy (AAOR) is a very rare variant of acute zonal occult outer retinopathy (AZOOR). Both variants are characterized by the perception of a progressive visual field defect and can be accompanied by photopsia. In contrast to AZOOR, a progressive whitish and annular demarcation of the involved retina is observed in AAOR using ophthalmoscopy. Optical coherence tomography (OCT) reveals morphological changes predominantly in the outer retinal layers. Although there is no proof of an effective therapy, in the case presented here further progression could be stopped by a combination of antiviral and immunosuppressive therapy.Acute annular outer retinopathy (AAOR) is a very rare variant of acute zonal occult outer retinopathy (AZOOR). Both variants are characterized by the perception of a progressive visual field defect and can be accompanied by photopsia. In contrast to AZOOR, a progressive whitish and annular demarcation of the involved retina is observed in AAOR using ophthalmoscopy. Optical coherence tomography (OCT) reveals morphological changes predominantly in the outer retinal layers. Although there is no proof of an effective therapy, in the case presented here further progression could be stopped by a combination of antiviral and immunosuppressive therapy.

Comparison of ranibizumab versus dexamethasone for macular oedema following retinal vein occlusion: 1-year results of the COMRADE extension study

The COMRADE studies are the first randomized controlled head‐to‐head trials comparing the efficacy and safety of intravitreal ranibizumab versus dexamethasone (DEX) in patients with macular oedema secondary to retinal vein occlusion (RVO). The COMRADE extension trial was designed to provide additional 6‐month data of patients who completed the core studies.

Progredientes Skotom mit Photopsiewahrnehmung@@@Progressive scotoma with perception of photopsia

ZusammenfassungDie akute anuläre äußere Retinopathie (AAOR) ist eine sehr seltene Variante der akuten zonalen okkulten äußeren Retinopathie (AZOOR). Beide Formen sind durch die Wahrnehmung eines progredienten Gesichtsfelddefektes gekennzeichnet und können mit Photopsien einhergehen. Im Gegensatz zur okkulten Form findet sich bei der anulären Form typischerweise eine weißliche ringförmige Begrenzung des betroffenen Netzhautareals, die sich im Verlauf weiter ausdehnt. In der optischen Kohärenztomographie zeigt sich, dass dabei vorwiegend die äußere Netzhautschicht morphologisch verändert ist. Obwohl bisher keine effektive Therapie nachgewiesen wurde, konnte bei dem vorliegenden Patienten die weitere Ausdehnung des betroffenen Areals unter einer antiviralen und immunsuppressiven Kombinationstherapie gestoppt werden.AbstractAcute annular outer retinopathy (AAOR) is a very rare variant of acute zonal occult outer retinopathy (AZOOR). Both variants are characterized by the perception of a progressive visual field defect and can be accompanied by photopsia. In contrast to AZOOR, a progressive whitish and annular demarcation of the involved retina is observed in AAOR using ophthalmoscopy. Optical coherence tomography (OCT) reveals morphological changes predominantly in the outer retinal layers. Although there is no proof of an effective therapy, in the case presented here further progression could be stopped by a combination of antiviral and immunosuppressive therapy.Acute annular outer retinopathy (AAOR) is a very rare variant of acute zonal occult outer retinopathy (AZOOR). Both variants are characterized by the perception of a progressive visual field defect and can be accompanied by photopsia. In contrast to AZOOR, a progressive whitish and annular demarcation of the involved retina is observed in AAOR using ophthalmoscopy. Optical coherence tomography (OCT) reveals morphological changes predominantly in the outer retinal layers. Although there is no proof of an effective therapy, in the case presented here further progression could be stopped by a combination of antiviral and immunosuppressive therapy.