Luigi Sborgia

Intravitreal triamcinolone acetonide in refractory pseudophakic cystoid macular edema: functional and anatomic results.

Purpose To evaluate safety and efficacy of intravitreal triamcinolone acetonide (TAAC) injections in the treatment of refractory pseudophakic cystoid macular edema (CME). Methods Seven eyes of six patients (age range: 50–74) with pseudophakic CME resistant to standard treatment received intravitreal injections of 4 mg of TAAC with all vehicle. Mean preinjection duration of CME was 18.3 months. A mean of 2.1±1.2 (range 1 to 4) treatments were performed in four eyes (57.1%) when visual acuity deteriorated towards baseline levels. Visual acuity assessment, optical coherence tomography (OCT), and fluorescein angiography (FFA) were performed pre- and postoperatively to evaluate results of TAAC injections. Intraocular pressure (IOP) and complications related to treatment were assessed. Results After 11.1±3.9 months, mean best-corrected visual acuity (BCVA) increased (p=0.019) from 20/132 to a best value of 20/38. Mean macular thickness decreased from 517.29±146.98 mm to a best value of 263.71±83.13 mm (p=0.0018). Area of fluorescein leakage decreased (p<0.0001) from 11.84±0.93 mm2 at baseline to a minimal value of 3.86±0.98 mm2. The anatomic and functional improvement appeared after 1 month from the intravitreal injection and persisted through at least 3 months of follow-up. At the end of follow-up BCVA, macular thickness, and area of fluorescein leakage did not differ from baseline. Four eyes (57.1%) developed IOP values higher than 21 mmHg, controlled by topical treatment. Two patients developed an endophthalmitis-like reaction. Conclusions Intravitr eal TAAC was relatively safe and effective in resistant cases of pseudophakic CME with a temporary beneficial effect on visual acuity and macular edema.

Intravitreal triamcinolone acetonide: valuation of retinal thickness changes measured by optical coherence tomography in diffuse diabetic macular edema.

Purpose The authors studied the efficacy of intravitreal triamcinolone acetonide in a case series of patients with diffuse diabetic macular edema without evidence of vitreous-macular traction refractory to laser photocoagulation. Methods Six eyes with clinically diffuse diabetic macular edema that failed to respond to at least two previous sessions of laser photocoagulation were included. The mean age of selected patients was 72.5 ± 13.8 years, with a preoperative best-corrected visual acuity reduced to 1.48 ± 0.18 logMar and a mean baseline intraocular pressure (IOP) of 15.17 ± 2.64 mmHg. The authors also studied macular thickness measured by optical coherence tomography (OCT 2000 scanner, Humphrey Instruments, San Leandro, CA) – in the preoperative period it was 640.8 ± 171.1 μm – and the fluorangiographic (Heidelberg Retina Angiograph, Heidelberg Engineering GmbH, Heidelberg, Germany) patterns, which showed pooling in tardy phases and leakage. Mean follow-up was 4 months. Results In each patient the authors observed a significant improvement, both functionally and anatomically. Mean best-corrected visual acuity increased in the postoperative period to 0.94 ± 0.53 logMar. No patient showed decline of visual acuity at the end of follow-up. Base line macular thickness was reduced in the postoperative period to 312.2 ± 157.65 μm measured by OCT and fluorangiographic patterns showed a reduction of pooling and of leakage. The most common complications described in the literature were not observed and the increase of mean IOP in the postoperative period to 18.76 ± 5.72 mmHg was not significant. Conclusions Intravitreal triamcinolone acetonide may decrease macular edema and improve visual acuity in eyes with diffuse diabetic macular edema.

Intravitreal bevacizumab for treatment‐naïve subfoveal occult choroidal neovascularization in age‐related macular degeneration

Purpose:  This study aimed to evaluate the efficacy of multiple injections of intravitreal bevacizumab for treatment‐naïve subfoveal occult choroidal neovascularization (CNV) in age‐related macular degeneration (AMD).

Combined surgical ablation and intravitreal triamcinolone acetonide for retinal angiomatous proliferation

Purpose Neovascular age-related macular degeneration (ARMD) with retinal angiomatous proliferation (RAP) has a poor natural history and the efficacy of any treatment has not yet been established. The authors describe a combined surgical treatment. Methods A 76-year-old woman presented with a best-corrected visual acuity (BCVA) of 20/600 in the right eye and macula with stage 3 RAP as identified by fluorescein angiography (FA), indocyanine green angiography (ICGA), and optical coherence tomography (OCT). After a standard three-port pars plana core vitrectomy (PPV), endodiathermy of the arteriolar and venous feeder vessels of each lesion was performed, intraretinal RAP feeder vessels were cut with manual vertical intraocular scissors, and 0.1 mL of triamcinolone acetonide (TAAC) was injected intravitreally At 1 and 4 weeks and at the sixth month, the patient underwent a complete eye examination, FA, ICGA, and OCT to assess outcomes and complications. Results Six months later, BCVA was stable at 20/300, intraocular pressure was 15 mmHg, anterior segment and vitreous cavity were clear without evidence of TAAC granules, and retina was attached. FA and ICGA showed a complete occlusion of the RAP and absence of leakage or ischemia and OCT demonstrated decreased macular thickness with resolution of both intraretinal edema and pigment epithelium detachment, and the restoration of the normal macular profile. At the end of follow-up, the authors did not observe any ocular or systemic complication. Conclusions Surgical approach to RAP stage 3 with intravitreal injection of 4 mg of TAAC was safe and anatomically effective.

Ocular Toxicity in Metastatic Melanoma Patients Treated With Mitogen-Activated Protein Kinase Kinase Inhibitors: A Case Series

PURPOSE To report the clinical features and management of mitogen-activated protein kinase kinase inhibitor-associated ocular side effects in 4 patients with advanced melanoma and a review of literature. DESIGN Interventional case series. METHODS Four patients with advanced cutaneous melanoma were treated with a mitogen-activated protein kinase kinase (MEK) inhibitor as single therapy or together with a v-raf murine sarcoma viral oncogene homolog B1 (BRAF) inhibitor. All patients underwent ophthalmologic examinations at regular intervals or as needed, including visual acuity, intraocular pressure, external eye examination, and funduscopy. When pathologic findings were found, patients underwent visual field examination, optical coherence tomography (OCT), and/or fluorescein angiography. Ocular toxicity was assessed and handled according to the Common Terminology Criteria for Adverse Events. RESULTS Ocular adverse events appeared early in the treatment. In 3 patients OCT revealed subfoveal neuroretinal elevation, often asymptomatic, also after discontinuation and re-starting of MEK inhibitor. Vascular injury appeared in 2 patients, in 1 case associated with a visual field defect reduced after discontinuation of the drug and use of systemic therapy. In 1 case an inflammatory reaction was observed in the anterior chamber. Visual symptoms were usually mild and short-lived. CONCLUSIONS MEK inhibitor as a single agent or in combination with BRAF inhibitor induces transient retinopathy with time-dependent recurrence and usually mild visual symptoms. Vascular injuries can be observed and their management is essential in clinical practice. It is important to investigate all previous ocular disorders, systemic conditions, and pharmacologic interactions of MEK inhibitor that could facilitate the onset of associated ocular effects.

Combined cataract extraction and intravitreal bevacizumab in eyes with choroidal neovascularization resulting from age-related macular degeneration

PURPOSE: To evaluate the safety and efficacy of phacoemulsification, intraocular lens (IOL) implantation, and a single intravitreal injection of bevacizumab in patients with coexisting visually significant cataract and subfoveal neovascularization due to age‐related macular degeneration. SETTING: Department of Ophthalmology, University of Bari, Bari, Italy. METHODS: Eyes with predominantly classic subfoveal neovascularization and cataract had phacoemulsification, IOL implantation, and a 1.25 mg intravitreal injection of bevacizumab. One month after combined surgery, corrected distance visual acuity (CDVA), anterior chamber reaction, and intraocular pressure were evaluated and central foveal thickness was measured by optical coherence tomography. RESULTS: Twenty eyes of 20 patients were evaluated. One month postoperatively, the mean CDVA improved significantly, from 20/100 (range 20/160 to 20/80) at baseline to 20/63 (range 20/125 to 20/50) (P<.0001). The mean central foveal thickness decreased significantly, from 353.75 μm ± 12.50 (SD) (range 334 to 375 μm) at baseline to 275.7 ± 17.3 μm (range 255 to 323 μm) at 1 month (P<.0001). Intraocular pressure did not change significantly, and anterior chamber reaction was absent. No ocular or systemic adverse events were observed. CONCLUSION: Combined phacoemulsification, IOL implantation, and intravitreal bevacizumab was a safe and efficacious treatment in patients with visually significant cataract and active subfoveal neovascularization.

Three-port lens-sparing vitrectomy for aggressive posterior retinopathy of prematurity : Early surgery before tractional retinal detachment appearance

Purpose Aggressive posterior retinopathy of prematurity (APROP) may suddenly develop into tractional retinal detachment (TRD), often resulting in poor vision if untreated. The aim of the current study is to examine the anatomic results and complications of lens-sparing vitrectomy (LSV) for stage 3 APROP, before TRD appearance. Methods A retrospective, noncomparative, consecutive case series of 13 eyes of 9 patients (mean gestational age 24.1±0.9 weeks [range: 23–25 weeks], mean birthweight of 725.8±107.9 grams [range: 598–897 grams]) with stage 3 APROP was carried out. The eyes did not respond to at least one session of retinal laser photocoagulation, showing signs of disease progression. All eyes underwent 20-gauge LSV before retinal detachment appearance. Results All eyes underwent 20-gauge three-port LSV and intraoperative additional laser photocoagulation. At the end of the surgery, five eyes were tamponaded with air; in eight eyes, a balanced salt solution was left in the vitreous cavity. After 13.5±5.3 months of follow-up (range: 4–22), the retina was completely attached in all eyes, without any signs of progression. The authors did not observe any intraoperative or postoperative complications. Conclusions Surgical approach to stage 3 APROP refractory to laser photocoagulation could be effective and safe in order to avoid the progression of the disease.

Fundus Autofluorescence, Optical Coherence Tomography and Visual Acuity in Adult-Onset Foveomacular Dystrophy

Aim: We investigated fundus autofluorescence (FA) patterns and tomographic retinal changes by means of optical coherence tomography (OCT 3) in adult-onset foveomacular vitelliform dystrophy (AOFVD) and their possible correlation with best-corrected visual acuity (BCVA). Methods: Eighteen eyes of 15 consecutive patients (mean age: 73.73 ± 9.5 years) presented to our observation with a diagnosis of AOFVD underwent BCVA measurement, evaluation of FA distribution by means of a confocal laser scanning ophthalmoscope and OCT 3 tomography. Results: The mean BCVA was 20/40 (range: 20/20–20/100). The FA pattern was patchy in 9 eyes (50%), ring-like in 5 (27.7%), focal in 3 (16.6%) and linear in 1 (5.5%). No correlation between FA patterns and BCVA was found. OCT 3 showed accumulation of highly reflective material between the neurosensory retina and retinal pigment epithelium (RPE) in 12 eyes (66.6%) with an evident overlying photoreceptor layer (PRL). In 5 eyes the highly reflective material was built up between the neurosensory retina and RPE without evidence of PRL (27.7%). Only in 1 eye was the subretinal accumulation site not well defined (5.5%). The mean thickness of the deposit was 135.52 ± 47.53 µm, while the residual neurosensory retina thickness was 103.94 ± 24.21 µm. The relationship between BCVA and the thickness of the neurosensory retina over the lesion was not significant (p = 0.016, r = 0.33), while the correlation between BCVA and the material deposit thickness (p = 0.017, r = 0.12) was significant. Conclusions: In AOFVD, FA presented different patterns, while OCT usually shows a well-defined material accumulation with a generally reduced neurosensory thickness between PRL and RPE. FA imaging and OCT are useful and safe for the diagnosis and follow-up of AOFVD.

Combined radial optic neurotomy, internal limiting membrane peeling, and intravitreal triamcinolone acetonide for central retinal vein occlusion.

To evaluate the efficacy of radial optic neurotomy, internal limiting membrane peeling, and intravitreal triamcinolone acetonide for central retinal vein occlusion. Eight consecutive eyes with central retinal vein occlusion with a duration of less than 6 months, cystoid macular edema, and best-corrected visual acuity (BCVA) of less than 20/200 were enrolled. BCVA, intraocular pressure, fluorescein angiography, and optical coherence tomography were evaluated. After 4.75 +/- 0.7 months, BCVA significantly improved, intraocular pressure was well controlled, and fluorescein angiography showed perfused state and reduction of the number of retinal hemorrhages in all eyes. Optical coherence tomography revealed significant reduction of macular thickness. Bleeding in the neurotomy site occurred in 3 cases. Radial optic neurotomy, internal limiting membrane peeling, and intravitreal triamcinolone acetonide may be useful in the management of central retinal vein occlusion with macular edema.

Evaluation of corneal damage by combined phacoemulsification and passive efflux of silicone oil in vitrectomized eyes

Purpose: To evaluate the effect on the corneal endothelium of phacoemulsification combined with passive silicone oil removal and intraocular lens (IOL) implantation under topical anesthesia after pars plana vitrectomy. Setting: Department of Ophthalmology and Otolaryngology, University of Bari, Bari, Italy. Methods: This retrospective study evaluated the corneal endothelium in 17 consecutive patients (17 eyes) who had phacoemulsification with transpupillary passive silicone oil washout (1300 centistokes) through a posterior capsulorhexis and single clear corneal incision and foldable acrylic IOL implantation. The findings were compared with those in a control group of 17 patients (17 eyes) who had phacoemulsification with acrylic IOL implantation through a single clear corneal incision. All procedures were performed by the same surgeon using topical anesthesia. The preoperative and postoperative endothelial cell densities, coefficient of variation (CV), and percentage of hexagonal cells at the corneal center and peripheral temporal position, evaluated by noncontact specular microscopy, were compared between the 2 groups. The central corneal thickness and occurrence of keratopathy were also noted. Results: The mean phacoemulsification and total ultrasound times did not differ significantly between the 2 groups. At 6 months, the mean endothelial cell loss was 284.50 cell/mm2 ± 462.3 (SD) (11.2%) in the study group and 200.15 ± 117.9 cell/mm2 (8.3%) in the control group (P=.87, unpaired t test). There were no significant between‐group differences in the increase in the mean CV and the percentage of hexagonal cells. The mean pachymetry remained at preoperative values, with no difference between groups. Keratopathy was not observed in any patient. Conclusions: Passive silicone oil efflux caused significant endothelial cell loss and changes in endothelial morphology. Nevertheless, these modifications were well tolerated and minimally different from the results of trauma caused by standard phacoemulsification with posterior chamber IOL implantation.