Mariachiara Morara

Swelling of the arcuate nerve fiber layer after internal limiting membrane peeling.

Purpose: The purpose of the study is to report the incidence of changes of the retinal nerve fiber layer in the early postoperative period after internal limiting membrane peeling for idiopathic macular hole and epiretinal membrane surgery. Methods: Interventional, noncomparative retrospective case series. Fifty-six eyes of 55 patients with an epiretinal membrane and 33 eyes of 31 patients with macular hole underwent pars plana vitrectomy and internal limiting membrane peeling. All patients received a complete ophthalmic examination, infrared and autofluorescence photography, and spectral-domain optical coherence tomography preoperatively and also at approximately 1 week, 1 month, and 3 months postoperatively. Vitrectomy and gas tamponade were performed with internal limiting membrane peeling after staining with Brilliant Peel. The main outcome measures were the presence of postoperative swelling of the arcuate retinal nerve fiber layer on spectral-domain optical coherence tomography, infrared and autofluorescence photographs, and its effect on best-corrected visual acuity. Results: On infrared and autofluorescence photographs, 28 (31.46%) of 89 eyes with internal limiting membrane peeling exhibited swelling of the arcuate retinal nerve fiber layer 1 week to 1 month postoperatively. Swelling of the arcuate retinal nerve fiber layer increased during the first month after surgery and resolved after a mean period of 2 months. These features were best visualized by autofluorescence imaging, as three to five dark striae originating from the optic nerve head, radiating in an arcuate pattern toward the macula. Simultaneous spectral-domain optical coherence tomography scanning through the striae indicated that they correspond to areas of focal swelling of the arcuate nerve fiber layer. No significant differences were found in eyes with or without swelling of the arcuate retinal nerve fiber layer for mean age or pre- and postoperative best-corrected visual acuity (P > 0.05). Conclusion: Swelling of the arcuate retinal nerve fiber layer often occurs after internal limiting membrane peeling for macular hole and epiretinal membrane. It is a transient feature after surgery that does not affect visual recovery. It is best visualized using infrared and autofluorescence imaging. Simultaneous infrared and spectral-domain optical coherence tomography imaging after macular surgery can detect transient inner retinal changes, which are not visible on clinical examination.

Spectral domain optical coherence tomography findings in patients with acute syphilitic posterior placoid chorioretinopathy.

Purpose: To describe the appearance of acute syphilitic posterior placoid chorioretinitis, a rare ocular manifestation of syphilis, on spectral domain optical coherence tomography (SD OCT) both before and after treatment. Methods: Ophthalmic examination and imaging studies of 30 eyes of 19 confirmed cases were analyzed both at the time of presentation and at each follow-up visit. Patients with SD OCT and fluorescein angiography at the time of presentation, and at least three documented follow-up visits after initiation of therapy, were included in the study. Standard treatment of neurosyphilis was given to each patient, including 4 million units of penicillin G administered intravenously every 4 hours for 14 days. Results: Fundus examination and imaging studies were consistent with previous reports and confirmed the diagnosis of acute syphilitic posterior placoid chorioretinitis. In 13 eyes (43.3%), baseline SD OCT scans were performed within 1 to 2 days of presentation and revealed a small amount of subretinal fluid, disruption of the inner segment/outer segment junction, and hyperreflective thickening of the retinal pigment epithelium (RPE). All 30 eyes were again scanned between Days 7 and 9 after presentation and revealed loss of the inner segment/outer segment and OS/RPE bands, and irregular hyperreflectivity of the RPE with prominent nodular elevations but without subretinal fluid. Early disruption of the external limiting membrane and punctate choroidal hyperreflectivity were seen in 1 of the 30 eyes (3.3%) and 14 of the 30 eyes (46.6%), respectively. Vision improved and the outer retinal abnormalities normalized in 28 of the 30 eyes (93.3%) after the treatment of neurosyphilis. The external limiting membrane, inner segment/outer segment band, and/or linear outer segment/RPE junction remained substantially abnormal despite treatment in 2 eyes left with 20/200 vision. Conclusion: Patients with acute syphilitic posterior placoid chorioretinitis show characteristic outer retinal abnormalities on SD OCT imaging, including disruption of the inner segment/outer segment band, nodular thickening of the RPE with loss of the linear outer segment/RPE junction, and, in some cases, loss of the external limiting membrane, accumulation of subretinal fluid, and punctate hyperreflectivity in the choroid. Vision improved and these abnormalities reversed after treatment of neurosyphilis in most of the patients. Persistently, poor vision despite treatment was associated with long-term loss or disruption of outer retinal anatomy on SD OCT.

Retinal nerve fiber layer thickness modification after internal limiting membrane peeling.

Purpose: To identify early and late retinal nerve fiber layer thickness (RNFLT) modification after internal limiting membrane peeling for idiopathic macular hole or epiretinal membrane and to correlate RNFLT to visual field indices. Methods: Single-center, prospective, interventional consecutive case series. Complete ophthalmic examination, fundus images, and spectral domain optical coherence tomography were performed in 30 eyes of 30 patients before and 1, 3, and 6 months after surgery. Six peripapillary sectors (superotemporal, temporal, inferotemporal, inferonasal, nasal, superonasal) and global RNFLT were evaluated. Visual field was performed preoperatively and 6 months postoperatively. Results: Significant RNFLT modification was found after surgery (P < 0.0001). Specifically, RNFLT significantly increased in all, but the temporal sectors, 1 month after surgery, and it returned to preoperative values at the third month. Six months after surgery, RNFLT was lower than basal values in the superotemporal, inferotemporal, and temporal sectors (P < 0.001, P < 0.05, and P < 0.001, respectively) with an average reduction of 18.2 ± 9.8 µm. No correlation was found between RNFLT and the visual field indices. Conclusion: The diffuse RNFLT increase 1 month postoperatively could be because of inflammatory responses. The reduction of RNFLT in the temporal sectors 6 months postoperatively could indicate damage to the macular retinal nerve fiber layer caused by internal limiting membrane peeling.

Perivenular Whitening in Central Vein Occlusion Described by Fundus Autofluorescence and Spectral Domain Optical Coherence Tomography

In the retinal tissue, transparency is a clinical index of tissue oxygenation. With central retinal vein occlusion, the most sensitive tissue for manifesting decreased oxygenation will be perivenular, especially in the posterior pole, where oxygen use is higher than in the retinal periphery. Patchy ischemic retinal whitening is located preferentially in a perivenular distribution near the macula. A 40-year-old man came to our institution complaining of loss of vision in the right eye, which had started 2 days previously. His medical and ophthalmologic histories were unremarkable. Initial examination in our department showed visual acuity of 20/32, right eye, and 20/20, left eye. Fundus examination showed dilated veins and scattered hemorrhages, along with a whitening of the macula (Figure 1A, white arrow) and of the perivenular retinal (Figure 1A, black arrow), and fluorescein angiogram showed delayed transit during the venous phase, but no capillary closure or blood retinal barrier rupture (Figure 1B), thus confirming the diagnosis of a mild form of central retinal vein occlusion with thrombus located more posteriorly relative to the lamina cribrosa. Autofluorescence imaging revealed a normal fundus autofluorescence corresponding to the arterioles and patchy hypoautofluorescence located preferentially in a perivenular distribution near the macula because of blockage of autofluorescence from inner retinal edema, which on spectral domain optical coherence tomographic scans corresponded to patchy retinal opacification extended from the inner to the outer plexiform layers (Figure 2, A and B) that may be secondary to ischemia of intermediary neurons within the inner nuclear and inner plexiform layers. One month later, autofluorescence and spectral domain optical coherence tomography showed improvement of symptoms (Figure 3, A and B) and visual acuity of 20/20. We report the presence of perivenular retinal edema in a patient with recent-onset central retinal vein occlusion, best visualized by autofluorescence as a hypoautofluorescent fern-like appearance. The perivenular location of ischemic edema is because of decreased arterial flow that leads to preferential oxygenation of the periarterial retina, which uptakes the available oxygen and subsequently desaturates hemoglobin before it can reach the perivenular space.

Combination Therapy With Dexamethasone Intravitreal Implant and Macular Grid Laser in Patients With Branch Retinal Vein Occlusion

PURPOSE To test a combination of dexamethasone intravitreal implant with macular grid laser for macular edema in patients with branch retinal vein occlusion (BRVO). DESIGN Prospective interventional, randomized, multicenter study. METHODS Patients with macular edema secondary to BRVO underwent an Ozurdex intravitreal implant at baseline. After 1 month, patients were randomly assigned to 2 study groups. Patients in Group 1 were followed up monthly and retreated with Ozurdex implant whenever there was a recurrence of macular edema or a decrease in best-corrected visual acuity (BCVA). In Group 2 patients macular grid laser was performed between weeks 6 and 8. After that, patients were followed up and retreated as for Group 1. RESULTS In Group 1 at 4 months, mean BCVA was 0.49 ± 0.35 logMAR and central retinal thickness (CRT) was 391 ± 172 μm; both improved significantly at 6 months, to 0.32 ± 0.29 logMAR and 322 ± 160 μm, respectively. In Group 2, CRT was reduced significantly to 291 ± 76 μm at 4 months, and BCVA improved to 0.25 ± 0.20 logMAR. At the final visit, BCVA was 0.18 ± 0.14 logMAR and mean CRT was 271 ± 44 μm. The number of Ozurdex implants at 4 months was 12 of 25 (48%) in Group 1 patients vs 3 of 25 (12%) in Group 2 patients (P = .012). At 6 months 3 of 25 patients (12%) in Group 1 vs 0 of 25 (0%) in Group 2 (P = .23) were retreated. CONCLUSIONS The combination of Ozurdex implant and macular grid laser is synergistic in increasing BCVA and lengthening the time between injections.

Multimodal Imaging in Hereditary Retinal Diseases

Introduction. In this retrospective study we evaluated the multimodal visualization of retinal genetic diseases to better understand their natural course. Material and Methods. We reviewed the charts of 70 consecutive patients with different genetic retinal pathologies who had previously undergone multimodal imaging analyses. Genomic DNA was extracted from peripheral blood and genotyped at the known locus for the different diseases. Results. The medical records of 3 families of a 4-generation pedigree affected by North Carolina macular dystrophy were reviewed. A total of 8 patients with Stargardt disease were evaluated for their two main defining clinical characteristics, yellow subretinal flecks and central atrophy. Nine male patients with a previous diagnosis of choroideremia and eleven female carriers were evaluated. Fourteen patients with Best vitelliform macular dystrophy and 6 family members with autosomal recessive bestrophinopathy were included. Seven patients with enhanced s-cone syndrome were ascertained. Lastly, we included 3 unrelated patients with fundus albipunctatus. Conclusions. In hereditary retinal diseases, clinical examination is often not sufficient for evaluating the patients condition. Retinal imaging then becomes important in making the diagnosis, in monitoring the progression of disease, and as a surrogate outcome measure of the efficacy of an intervention.

Argon laser vs. subthreshold infrared (810-nm) diode laser macular grid photocoagulation in nonexudative age-related macular degeneration

BACKGROUND A diode laser can be used to create a subthreshold (invisible end point) lesion in patients with age-related macular degeneration (AMD). This has the potential benefit of localizing the treatment effect to the retinal pigment epithelium and sparing more of the overlying sensory retina. We performed a study to compare the safety and efficacy of argon laser and subthreshold infrared (810-nm) diode laser macular grid photocoagulation in reducing the number of drusen in patients with AMD. METHODS We reviewed the charts of 144 patients with bilateral early-stage nonexudative AMD, characterized by soft drusen. One eye of each patient was treated, and the other eye served as a control. Seventy-eight eyes of 78 patients with a mean age of 67.5 (standard deviation [SD] 8.3) years underwent argon laser macular grid photocoagulation at a university-affiliated hospital in Bologna, Italy, and 66 eyes of 66 patients with a mean age of 66.4 (SD 6.3) years underwent subthreshold infrared (810-nm) diode laser macular grid photocoagulation at a private clinic in Bologna. Each group was classified into three subgroups based on the number of drusen (more than 20, 10 to 20, or less than 10). The patients underwent fluorescein angiography, fundus examination, measurement of far (Snellen chart) and near (Jaeger chart) best corrected visual acuity, and visual field and contrast sensitivity testing. The mean length of follow-up was 18 (SD 0.5) months. RESULTS At 18 months, far and near best corrected visual acuity were statistically significantly improved in the treatment groups compared with the untreated group (p < 0.001, Mann-Whitney U test). There was no significant difference in visual acuity between the treatment groups. Compared with baseline, the number of drusen was significantly reduced in both treatment groups (p < 0.001). Evolution of the disease was observed in the untreated group. The visual field was slightly but significantly reduced after argon laser treatment (p < 0.001) but not diode laser treatment; the difference in visual field between the two groups was not significant. There was a slight reduction in contrast sensitivity, particularly with night vision, after argon laser treatment but not diode laser treatment. The difference between the two treatment groups was significant (p < 0.01). INTERPRETATION Subthreshold infrared diode macular grid photocoagulation may be a safe and viable method for preventing progression of nonexudative AMD.

Standard Enucleation with Aluminium Oxide Implant (Bioceramic) Covered with Patient's Sclera

Purpose. We describe in our study a modified standard enucleation, using sclera harvested from the enucleated eye to cover the prosthesis in order to insert a large porous implant and to reduce postoperative complication rates in a phthisis globe. Methods. We perform initially a standard enucleation. The porous implant (Bioceramic) is then covered only partially by the patients sclera. The implant is inserted in the posterior Tenons space with the scleral covering looking at front. All patients were followed at least for twelve months (average followup 16 months). Results. We performed nineteen primary procedures (19 patients, 19 eyes, x M; x F) and secondary, to fill the orbital cavity in patients already operated by standard evisceration (7 patients, 7 eyes). There were no cases of implant extrusion. The orbital volume was well reintegrated. Conclusion. Our procedure was safe and effective. All patients had a good cosmetic result after final prosthetic fitting and we also achieved good prothesis mobility.

Bilateral serous retinal detachments following organ transplantation.

Purpose The authors report the physiopathogenetic features of bilateral serous neurosensory retinal detachments occurring in patients who have undergone organ transplantation. Methods The clinical and photographic findings of four patients who have undergone renal (3 cases) and liver (1 case) transplantation in whom bilateral serous retinal detachment developed early after surgery were reviewed. The patients were processed for clinical symptoms, visual acuity evaluation, slitlamp and fundus examinations, tonometry and fluorescein angiography. Results Ocular examination, in patients complaining of blurred vision and metamorphopsia, revealed loss of visual acuity, bullous serous neurosensory retinal detachment with retinal pigment epithelial detachments in fundus examination and areas of dye leakage in fluorescein angiography, despite tonometry and slitlamp examination were unremarkable. These alterations were spontaneously resolved with the normalization of renal function. Conclusion The only common factor in each of the four patients resulted in alterations of the kidney function. This finding provides further evidence that renal failure may cause alterations in electrolytes extracellular distribution, leading to the formation of serous neurosensory retinal detachments.

Double-vitrectomy for optic disc pit maculopathy.

Background: The origin of the fluid and precise pathophysiology of optic pit maculopathy remain unclear. It has been suggested that submacular fluid originates either from vitreous or cerebrospinal fluid. We report a case of optic pit maculopathy which was unsuccessfully treated with vitrectomy and internal limiting membrane (ILM) peeling, and subsequently resolved with revision of vitrectomy and gas tamponade. Methods: We report a case of optic disc pit maculopathy, well documented by spectral- domain optical coherence tomography, before and after pars plana vitrectomy with ILM peeling, and its revision with gas tamponade. Results: After ILM peeling, there was no improvement either in visual acuity or in the tomographic aspect of the retina. A revision of the surgery was then needed and gas tamponade was performed, which resulted in a complete resolution of the optic pit maculopathy. Conclusion: The absence of improvement after ILM peeling during the first surgical procedure, accompanied by resolution of the clinical picture with gas tamponade during the second surgical procedure, sustained the hypothesis of a subarachnoidal origin of the fluid.