Maria Angelica Breve

Evaluation of choroidal tumors with optical coherence tomography: enhanced depth imaging and OCT-angiography features

AimTo describe the vascular features of choroidal tumors using enhanced depth imaging (EDI), optical coherence tomography (OCT), and OCT-angiography.MethodsIn this prospective study, we evaluated 116 Caucasian patients with choroidal tumors (60 eyes with choroidal nevi, 40 with choroidal melanoma, 6 with choroidal hemangioma, 2 with optic disc melanocytoma, 6 with choroidal osteoma, and 2 with retinal metastases). Patients underwent a complete ophthalmic examination including bulbar echography, EDI-OCT, OCT-angiography, and multicolor imaging. Sixteen patients also underwent fluorescein and indocyanine angiography.ResultsThe left eye was more involved than the right eye. The mean tumor thickness was 1.23±0.17 mm in the 60 eyes with choroidal nevi; 2.75±0.83 mm in the 40 eyes with choroidal melanoma; 3.28±0.78 mm in the 6 eyes with retinal angioma; 2.02±0.001 mm in the 2 eyes with optic disc melanocytoma; 2.40±0.31 mm in the 6 eyes with choroidal osteoma; and last, 3.49±0.001 mm in the 2 eyes with retinal metastases. OCT-angiography showed: (i) a lack of blood flow in the outer retinal layer (ORL) and a normal choroid capillary layer in choroidal nevi and optic disc melanocytomas; (ii) a lack of blood flow in the ORL of choroidal metastases; and (iii) a dense irregular vascular network in the ORL and choroid capillary layers of choroidal melanomas, choroidal hemangiomas, and choroidal osteomas.ConclusionsOCT-angiography is a noninvasive reliable method with which to evaluate the vascularization of small choroidal tumors and may improve the diagnosis of these tumors.

Technical improvements in photorefractive keratectomy for correction of high myopia.

PURPOSE To evaluate the effects of hardware and software improvements in photorefractive keratectomy (PRK) for the treatment of highly myopic eyes. METHODS A retrospective study was carried out in 554 patients (582 eyes) with myopia between -7.00 and -17.00 D (mean -11.20 +/- 3.60 D) who had undergone PRK using the Aesculap Meditec laser. Group 1 with a 5-mm-diameter single ablation zone; Group 2 with a 5-mm-diameter single zone surrounded by a 2-mm tapered transitional zone; Group 3 and Group 4, same as Group 2 but with the laser upgraded with a smoke aspiration control system (Group 3), and with a computer-controlled fluence (Group 4). RESULTS In Group 1 at 2 years after PRK (50 eyes), 10 eyes (20%) were within +/-1.00 D of attempted correction and 13 eyes (26%) were within +/-2.00 D. In Group 2 at 2 years (118 eyes), 42 eyes (36%) were within +/-1.00 D of attempted correction and 65 eyes (55%) were within +/-2.00 D. In Group 3 at 2 years (43 eyes), 18 eyes (42%) were within +/-1.00 D of attempted correction and 28 eyes (65%) were within +/-2.00 D. In Group 4 at 2 years (47 eyes), 25 eyes (53%) were within +/-1.00 D of attempted correction and 29 eyes (62%) were within +/-2.00 D. CONCLUSIONS Software and hardware improvements facilitated PRK correction of high myopia with reasonable predictability, especially if a tapered transition zone was used. At 12 and 24-month follow-up, only the use of a tapered transition zone was associated with a statistically significant improvement in predictability.

Transpupillary thermotherapy as a primary treatment for circumscribed choroidal haemangioma

range: 245–684), respectively. No other significant retinal diseases were present prior to treatment in the analysed patients of either group. Despite ocriplasmin approval for the treatment of FTMHs <400 lm with VMT, subgroup analyses suggest a greater efficacy in phakic patients without an ERM (Stalmans et al. 2012). Our results demonstrate a high closure rate and good median visual acuity with surgical repair of this FTMH subset. The initial closure rate in the ocriplasmin group is significantly lower, and median final visual acuity falls slightly below the vitrectomy group. Final visual acuity in the ocriplasmin group may suffer due to an initial decrease in visual acuity and an increase in both MLD and BD in unclosed FTMHs (Gupta et al. 2009; Wakely et al. 2012). Thus, it is important to establish whether ocriplasmin treatment results in non-inferior final visual acuity. Even if visual acuity after ocriplasmin only trails slightly behind primary vitrectomy, non-inferiority becomes substantially harder to achieve. With equal visual acuity, 54 patients are required in each study arm, whereas sample size increases to 214 patients in each arm if the mean visual acuity is 2.5 ETDRS letters poorer with ocriplasmin. Calculations are based on a 5-letter non-inferiority limit, standard deviation of 10.4 letters, 80% power and significance level of 5% (Chow et al. 2008). In conclusion, our results of both primary surgical and ocriplasmin FTMH treatment demonstrate similar, but not equal, final visual acuity. We therefore wish to highlight the need for studies to rule out visual inferiority of ocriplasmin treatment in small FTMHs with VMT.

Three-Dimensional Ultrasound of Ophthalmic Pathologies

Purpose: To assess three-dimensional echography image quality and multiplanar imaging for the visualization of vitreoretinal and choroidal diseases. Methods: In an observational cross-sectional study, 20 eyes of 20 patients presenting different vitreoretinal and choroidal pathologies have been evaluated with three-dimensional ultrasonography (3DUS). Results: Of the 20 eyes, an epiretinal membrane was present in 2 eyes, diabetic macular edema in 6, a macular hole in 2, a myopic posterior detachment in 2, myopic peripapillary detachment of the pigment epithelium in 1, choroidal melanoma in 4, optic nerve glioma in 1 case, carotidocavernous fistula in 1 and an intravitreal dislocation of an intraocular lens in 1 eye. 3DUS was effective in wide-field representation of the vitreoretinal interface during macular edema, in good-quality visualization of the dislocated intraocular lens and in calculating the volume of choroidal melanoma. No advantages were found in other evaluated cases if compared with the already existing imaging techniques. Conclusions: One of the main advantages of 3DUS was the possibility to obtain a wide-field representation of spatial relationships between the lesions and the surrounding ocular structures.

OCT angiography in choroidal neovascularization secondary to choroidal osteoma.

F irst of all, we would like to thank Dr Yolcu and Dr. Civan for their interest and comments regarding our article on ‘Effect of topical prostaglandin (PG) analogues on corneal hysteresis’ recently published in Acta Ophthalmologica (Bolivar et al. 2015). As they correctly point out in their letter, there has been a great interest in the relationship between corneal viscoelastic parameters [such as central corneal thickness (CCT), corneal hysteresis (CH), etc.] and glaucoma. PG analogues seem to induce a minor change in the CCT, as Yolcu et al. correctly point out (Yolcu & Civan 2015), but it was out of scope of our study to measure the changes in CCT. Our work (Bolivar et al. 2015) was focused just on the change of the CH in newly diagnosed, previously untreated glaucomatous eyes, after topical treatment with PG analogues monotherapy. Nevertheless, the reported PG treatment induced decrease in the CCT is quite small, thus making unlikely that this minimal change, by itself, can modify the corneal response to a stress (compression by a jet of air or applanation by the Goldmann tip) (Maruyama et al. 2014). Furthermore, a change in the CCT must be induced by a change either in the stroma, in the epithelium or in both structures. In fact, Rosa et al. (2014) suggested that if it is found that PG analogue treatment does change the CH, this fact would suggest that it is not the epithelium, but the stroma, the part of the cornea affected by these drugs. In fact, our finding that CH does change in this scenario, strongly supports their hypothesis. Furthermore, the anecdotal report of a case of rapid progression of a previously stable keratoconus induced by topical treatment with latanoprost (Amano et al. 2008) further suggests that PG analogues, probably due to the upregulation of stromal metalloproteinases induced by them, do affect the stromal viscoelastic properties, at least to some extent. We completely agree with Yolcu et al. that more studies are needed to fully understand the effects of PG analogues and glaucomatous disease on the cornea.

Functional and Anatomic Response of the Retina and the Choroid to Intravitreal Bevacizumab for Macular Edema

PURPOSE This study evaluated the rate of change of best corrected visual acuity (BCVA), central retinal sensitivity, and retinal and choroidal thickness in patients with macular edema after intravitreal bevacizumab. METHODS This was a prospective, nonrandomized, interventional study. Thirty-four consecutive eyes (34 patients) with macular edema were included in the study. Choroidal neovascularization was present in 21 cases, stage 1 retinal angiomatous proliferation in 6 cases, branch retinal vein occlusion in 4 cases, and diabetic edema in 3 cases. Evaluation of BCVA (Early Treatment Diabetic Retinopathy Study [ETDRS] logarithm of the minimum angle of resolution [LogMAR]), central retinochoroidal thickness (RCT) at standardized A-scan, combined optical coherence tomography/microperimetric assessment of central retinal thickness (RT), central scotoma, and fixation behavior was performed during 12 months after treatment. Choroidal thickness was considered as the difference between RCT and RT. All patients received two initial intravitreal bevacizumab injections (1.25 mg/0.05 mL) at a 1-month interval. RESULTS BCVA and RT during follow-up were significantly better than at baseline. BCVA was improved of 0.32±0.3 LogMAR (P<0.001) at month 1, 0.18±0.4 LogMAR (P=0.05) at month 6, and 0.14±0.2 (P=0.09) at month 12. RT was reduced by 172.9±192.8 μm (P<0.001) at month 1, 157.7±134.2 μm (P=0.003) at month 6, and 164.3±122.3 (P=0.002) at month 12. Mean retinal sensitivity significantly increased during the first month; it decreased afterward, but an improvement if compared with baseline was present at each visit during follow-up. In 23.5% of cases, a choroidal thinning was present during follow-up, and in this group visual acuity at baseline and final visual improvement were significantly greater if compared with patients showing a choroidal thickening. CONCLUSION Intravitreal bevacizumab for macular edema determines significant functional and anatomic improvement at the 12-month follow-up. Visual acuity at baseline and following treatment could be influenced by the choroidal involvement.

Fundus autofluorescence of choroidal nevi and melanoma

osmotic diuretics, topical sympathomimetic or beta-adrenergic blocking agents to reduce intraocular pressure; and hyperbaric oxygen to improve oxygen delivery. In its updated review, Hedges et al. also claimed that conservative therapies were considered futile. Nevertheless, Stef ansson et al. (1985) reported a case of massive embolus of central retinal artery, treated with anterior chamber paracentesis and coughing, that resulted in restoration of retinal blood flow; however, in this case afferent pupillary defect remained present and angiography revealed occlusion of the inferior temporal arteriole with local retinal oedema. More recently, another successful conservative treatment of a likely central retinal artery thromboembolism after internal carotid artery aneurysm coil occlusion was reported; however, in this case authors reported that multiple small emboli could be seen within the peripheral branches of the retina. Moreover, both afferent pupillary defect and posttreatment angiography findings were not described (Duxbury et al. 2014). Systemic intravenous and local intra-arterial fibrinolytic therapies are now considered valid in many cases, despite controversial (Schrag et al. 2015; Page et al. 2016). As the patient was hemodynamically unstable, and the femoral access has already been closed with the Angio-Seal closure device, systemic abciximab was administered (Barreto 2012). Abciximab was the first glycoprotein IIb/IIIa inhibitor (GPI) approved by the FDA. The glycoprotein IIb/IIIa integrin receptor is the pivotal mediator of platelet aggregation, becoming abundant on the platelet surface when platelets are activated. In late 1990s, the introduction of GPI was associated with reduction of ischemic complication and clinical benefit in percutaneous coronary interventions. Abciximab is a genetically engineered, recombinant, monoclonal antibody Fab fragment. The binding of abciximab to the platelet prevents the interaction with other adhesive protein molecules (Usta et al. 2016). The most relevant point concerning thiscasereport is thefindingthatsystemic intravenous abciximab may represent a novelandpromptapproachinemergency room to CRAO induced by highly suspicious platelet thrombus. This is particularly relevant in centres with no neuroendovascularfacilitiesorinpatients where intra-arterialfibrinolytic therapy is not recommended. The potential effects of this approach in distal branch retinal artery occlusion (not accessed by catheter) may also be considered.

Evaluation of Vascular Changes with Optical Coherence Tomography Angiography after Plaque Radiotherapy of Choroidal Melanoma

Aim: The purpose of this paper was to evaluate whether optical coherence tomography angiography (OCT-A) can be used to quantify the vascular changes in radiation maculopathy, and changes in the tumor vasculature in eyes treated with plaque radiotherapy for choroidal melanoma. Methods: In this prospective study, we evaluated 39 Caucasian patients with choroidal melanoma (39 eyes) treated with ruthenium-106 plaque radiotherapy. The patients underwent complete ophthalmic examination, bulbar echography, and OCT-A before and 1 year after treatment. Results: At baseline, the mean best-corrected visual acuity (BCVA) in the affected eyes was 0.35 ± 0.40 logMAR, and the mean tumor thickness was 2.68 ± 0.25 mm at A-scan echography. After treatment, the mean BCVA increased to 0.41 logMAR, the mean tumor thickness decreased to 1.66 ± 0.23 mm, and the tumor basal diameter was significantly reduced (U = 108, p = 0.001). Moreover, the capillary vessel density was significantly lower in all Early Treatment of Diabetic Retinopathy Study sectors, and both the vessel and flow areas were significantly reduced (p = 0.030 and p = 0.001, respectively). Conclusions: OCT-A is a noninvasive, reliable method with which to quantify the vessel changes in radiation maculopathy and, given the association between vascularization and malignancy, this procedure may be an aid in treatment decision-making and in monitoring the efficacy of treatment.

Evaluation of vascular changes with optical coherence tomography angiography after ruthenium-106 brachytherapy of circumscribed choroidal hemangioma

PurposeTo describe the vascular changes of circumscribed choroidal hemangioma (CCH) after ruthenium-106 brachytherapy using optical coherence tomography angiography (angio-OCT).MethodsSeven eyes of 7 patients diagnosed with symptomatic CCH who underwent ruthenium-106 plaque radiotherapy were included in the study. Patients underwent complete ophthalmic examination, bulbar echography and angio-OCT. The same protocol was applied 1 year after ruthenium-106 brachytherapy.ResultsAt baseline, the mean best-corrected visual acuity (BCVA) in affected eyes was 0.67 ± 0.14 logMAR, and the mean tumor thickness was 4.46 ± 0.91 mm measured by standardized A-scan echography. After ruthenium-106 plaque treatment, the mean BCVA increased to 0.17 ± 0.10 logMAR (p = 0.001) and the mean tumor thickness to 2.29 ± 0.71 mm (p = 0.003). Moreover, there was a significant reduction of the tumor basal diameter (p= 0.009). Intra-tumor angio-OCT measurements revealed a statistically significant reduction of the vessel and flow areas (p = 0.006 and p = 0.002, respectively) 1 year after brachytherapy.ConclusionsAngio-OCT is a non-invasive reliable method with which to evaluate the vascular features of CCH and consequently to monitor changes after conservative treatment.

Multimodal imaging of combined hamartoma of the retina and retinal pigment epithelium.

Editor, W e evaluated the structural and functional features of combined hamartoma of the retina and retinal pigment epithelium using multimodal imaging technologies, including the new technique of optical coherence tomography (OCT) angiography, which has previously not been used to examine this rare condition. Nine eyes of nine Caucasian patients (median age at presentation: 8 years; range: 1 36 years) were evaluated in the Eye Clinic of the University of Naples ‘Federico II’ between September 2014 and February 2015. Patients underwent complete ophthalmic examination, bulbar echography, enhanced depth imaging optical coherence tomography (EDI-OCT), wide-field en-face OCT, multicolour imaging, fluorescein and indocyanine angiography and OCT angiography. (A) (B)