Ludovico Iannetti

Visual and anatomical outcomes of intravitreal aflibercept for treatment-resistant neovascular age-related macular degeneration.

A retrospective chart review of patients with persistent subretinal and/or intraretinal fluid, despite previous treatment with intravitreal ranibizumab (0.5 mg), who were switched to aflibercept injections, was performed. Treatment was three monthly aflibercept (2 mg) injections followed by dosing on pro re nata basis. Main outcome measures included changes in best corrected visual acuity (BCVA), 1 mm central subfield (CSF) retinal thickness, the height of the pigment epithelial detachment (PED), and subfoveal choroidal thickness on optical coherence tomography at 6 months. Thirty-one eyes of 30 patients were analyzed. The mean number of injections before aflibercept conversion was 34.4 ± 11.9. After an average of 4.5 aflibercept injections (range 3 to 6) over 6 months, no significant change in BCVA was observed (P > 0.05). Compared with baseline, there was a significant reduction of the CSF retinal thickness (449 ± 179 versus 269 ± 145 μm, P < 0.001), maximum PED height (262 ± 134 versus 183 ± 100 μm, P < 0.001), and choroidal thickness (192 ± 67 versus 167 ± 51 μm, P < 0.01). Stable visual acuity and anatomical improvement were obtained for up to 6 months after aflibercept conversion. However, choroidal thinning related to treatment was observed.

Optical Coherence Tomography for Classification and Clinical Evaluation of Macular Edema in Patients with Uveitis

Purpose: To study use of optical coherence tomography (OCT) for macular edema in uveitis. Methods: In total, 44 patients with uveitis and macular edema underwent OCT. Data obtained were correlated with anatomic type, duration of uveitis, and visual acuity (VA). Results: Both cystoid macular edema (CME) and diffuse macular edema (DME) correlate negatively with VA, although statistically CME showed stronger correlation (p = .02). Also CME had higher mean foveal thickness than DME (p < .01). Negative correlation between foveal thickness and VA (p < .05) was observed. CME correlates with uveitis duration (p < .01). Conclusions: CME and macular thickening correlate with VA reduction and uveitis duration.

Clinical Features and Prognosis of HLA B27-associated Acute Anterior Uveitis in an Italian Patient Population

Purpose: To report clinical features and prognosis of HLA B27 acute anterior uveitis. Methods: 165 patients with recurrent acute anterior uveitis were divided into two groups: HLA B27-positive (group 1, 60 patients) and HLA B27-negative (group 2, 105 patients). A comparison between the two groups was performed. Results: Unilateral involvement was higher in group 1 (p = .046), and more simultaneous bilateral cases occurred in group 2 (p = .004). Group 1 was more correlated to systemic diseases than group 2 (50 versus 17.1%, p < .001), particularly to ankylosing spondylitis (35 versus 3.8%, p < .001). Uveitis was diagnosed before spondylitis in 57% of patients. In groups 1 and 2 an immunosuppressive therapy was administered to 20 and 9.5% of patients but was exclusively given to control uveitis in 1.6 and in 2.8% of cases, respectively. Conclusions: A strong association between HLA B27 uveitis and ankylosing spondylitis was confirmed and usually uveitis preceded rheumatological involvement.

Spectral-Domain Optical Coherence Tomography in Uveitic Macular Edema: Morphological Features and Prognostic Factors

Aim: To assess the morphological characteristics of uveitic macular edema studied with Spectralis optical coherence tomography (OCT) and to investigate the correlation between the tomographic features and visual acuity. Methods: 71 eyes of 55 patients underwent examination with Spectralis OCT (Heidelberg Engineering, Germany). Data was correlated with logMAR best-corrected visual acuity (BCVA). Results: Two morphological patterns were observed: cystoid macular edema (CME) in 69% and diffuse macular edema in 31% of eyes. BCVA was 0.2 in CME, 0.1 in diffuse edema (p = 0.008). Foveal thickness was 413.4 ± 212 µm in CME, 311.27 ± 53 µm in diffuse edema (p = 0.03). BVCA was 0.3 in eyes with serous retinal detachment (SRD), 0.2 in eyes without SRD (p = 0.02). BCVA was 0.4 in eyes with inner segment/outer segment (IS/OS) disruption, 0.1 in eyes with integrity of the IS/OS junction (p = 0.01). Conclusions: BCVA is negatively correlated with cystoid pattern, foveal thickening and SRD. Disruption of the IS/OS junction is associated with poor vision in uveitic macular edema.

Recent Understanding on Diagnosis and Management of Central Nervous System Vasculitis in Children

Central nervous system vasculitides in children may develop as a primary condition or secondary to an underlying systemic disease. Many vasculitides affect both adults and children, while some others occur almost exclusively in childhood. Patients usually present with systemic symptoms with single or multiorgan dysfunction. The involvement of central nervous system in childhood is not frequent and it occurs more often as a feature of subtypes like childhood polyarteritis nodosa, Kawasaki disease, Henoch Schönlein purpura, and Bechet disease. Primary angiitis of the central nervous system of childhood is a reversible cause of severe neurological impairment, including acute ischemic stroke, intractable seizures, and cognitive decline. The first line therapy of CNS vasculitides is mainly based on corticosteroids and immunosuppressor drugs. Other strategies include plasmapheresis, immunoglobulins, and biologic drugs. This paper discusses on current understanding of most frequent primary and secondary central nervous system vasculitides in children including a tailored-diagnostic approach and new evidence regarding treatment.

Role of the intravitreal growth factors in the pathogenesis of idiopathic epiretinal membrane

PURPOSE The aim of the present study is to evaluate the roles of TGFs β1 and β2, glial cell line-derived neurotrophic factor (GDNF), and nerve growth factor (NGF) in the pathogenesis of idiopathic epiretinal membrane (ERM). METHODS Eight patients, six males and two females, with an average age of 60.25 ± 17.16 years (range, 33-75 years) who were affected by idiopathic ERM were enrolled in the study. All patients underwent standard pars plana vitrectomy surgery with membrane removal and specific ELISA was performed to evaluate TGFβ1, TGFβ2, GDNF, and NGF in the vitreous samples. This was repeated after acidification of the samples with hydrochloric acid. RESULTS Before acidification, ELISA analysis revealed a significant increase of TGFβ2 in the samples with idiopathic ERM (327.98 ± 99.58 pg/mL; range, 206.864-466.235 pg/mL) compared to the control group (187.17 ± 58.20 pg/mL; range, 132.758-271.707 pg/mL; t = 3.4; P < 0.05). A statistically significant difference was also obtained after acidification of the samples (618.15 ± 201.43 pg/mL; range, 409.795-866.215 pg/mL compared to 265.04 ± 98.15 pg/mL; range, 152.478-352.101 pg/mL; t = 4.5; P < 0.05). Notably, before acidification the differences in NGF between the two groups were not statistically significant (t = 0.79; P = 0.46), while after acidification a significant increase of the NGF levels in ERM samples was found in comparison with the control group (723.41 ± 235.4 vs. 242.84 ± 104.61; t = 3; P < 0.05). CONCLUSIONS The present study reveals that TGFβ2 and NGF are associated with idiopathic ERMs, suggesting a novel compensatory mechanism so far never proposed.

Management of Uveitis-Related Choroidal Neovascularization: From the Pathogenesis to the Therapy

Inflammatory choroidal neovascularization is a severe but uncommon complication of uveitis, more frequent in posterior uveitis such as punctate inner choroidopathy, multifocal choroiditis, serpiginous choroiditis, and Vogt-Koyanagi-Harada syndrome. Its pathogenesis is supposed to be similar to the wet age related macular degeneration: hypoxia, release of vascular endothelial growth factor, stromal cell derived factor 1-alpha, and other mediators seem to be involved in the uveitis-related choroidal neovascularization. A review on the factors implicated so far in the pathogenesis of inflammatory choroidal neovascularization was performed. Also we reported the success rate of single studies concerning the therapies of choroidal neovascularization secondary to uveitis during the last decade: photodynamic therapy, intravitreal bevacizumab, and intravitreal ranibizumab, besides steroidal and immunosuppressive therapy. Hereby a standardization of the therapeutic approach is proposed.

Central serous chorioretinopathy as a presenting symptom of endogenous Cushing syndrome: a case report

Purpose To report a case of Cushing syndrome due to adrenocortical adenoma revealed by central serous chorioretinopathy. Methods A 45-year-old man presented with blurred vision and metamorphopsia in the left eye. He reported few episodes of high blood pressure in the last 3 months. Results Visual acuity was 20/40 in the left eye. Fundus oculi examination revealed central serous chorioretinopathy in the left eye. Grade 1 hypertension was found. Increased serum and urinary levels of Cortisol and reduced serum levels of ACTH were observed. Diagnosis of Cushing syndrome was made. Computed tomography scan revealed a right adrenal mass that was surgically removed; histologic examination showed an adrenocortical adenoma. Three months after surgical treatment, visual acuity improved to 20/20 and central serous chorioretinopathy completely resolved. Conclusions Central serous chorioretinopathy may be the presenting symptom of Cushing syndrome in a patient with adrenocortical adenoma.

Residual and Persistent Adie's Pupil After Pediatric Ophthalmoplegic Migraine

We report on a 9-year-old girl diagnosed with ophthalmoplegic migraines who had been previously diagnosed, at age 7 years, with typical migraines with aura. After resolution of the third ophthalmoplegic migraine attack, the only evident residual clinical sign was Adies pupil. During 24-month follow-up, at age 11 years, a neurologic examination produced completely normal results. However, Adies pupil persisted. Adies tonic pupil can be associated with extraocular diseases, which were all excluded in this patient. The mechanisms underlying tonic pupil are not fully understood. This is the first report, to the best of our knowledge, of an ophthalmoplegic migraine followed by persistent Adies pupil. Possible pathogenic mechanisms are discussed.

Clinical Features and Complications of the HLA-B27-associated Acute Anterior Uveitis: A Metanalysis

ABSTRACT In this article, we report a literature-based metanalysis we have conducted to outline the clinical features of the HLA-B27 Acute Anterior Uveitis (AAU). The examined material was based on observational studies in which participants were affected by Acute Anterior Uveitis and divided into HLA B27+ and HLA B27–. We performed a search on articles with the words “HLA B27 uveitis” dated before May 2014. Among these, 29 articles were selected for a second review. After a further evaluation, 22 articles were analyzed. The clinical characteristics studied in the metanalysis were: (1) systemic disease; (2) sex distribution; (3) laterality; (4) visual acuity; (5) hypopion; (6) anterior chamber’s fibrin; (7) elevated intraocular pressure (IOP) during inflammation; (8) glaucoma; (9) posterior synechiae; (10) cataract; (11) cystoid macular edema; (12) papillitis. We have calculated a relative risk (RR) for each outcome measured. The results obtained remark some of the peculiar features linked to the HLA B27 Acute Anterior Uveitis, such as strong association with ankylosing spondylitis (RR = 6.80) and systemic diseases (RR = 9.9), male prevalence (RR = 1.2), unilateral (RR = 1.1) or alternating bilateral (RR = 2.2) involvement, hypopion (RR = 5.5), fibrinous reaction and even papillitis (R = 7.7). Simultaneous bilateral (RR = 0.3) AAU is more frequent in HLA-B27 negative form. We report higher risk of elevated IOP and glaucoma (RR = 0.6) in B27– Acute Anterior Uveitis. No significant difference between HLA B 27 positive and negative AAU was observed according to final visual acuity and complications such as posterior synechiae, cataract, and maculare edema. We trust that this will inform on the clinical evaluation and therapeutic decision in addressing a still ill-defined ophthalmologic condition.