Marilita M. Moschos

Cystoid macular edema

We review the epidemiology, pathophysiology, and etiology of cystoid macular edema (CME). Inflammatory, diabetic, post-cataract, and macular edema due to age-related macular degeneration is described. The role of chronic inflammation and hypoxia and direct macular traction is evaluated in each case according to different views from the literature. The different diagnostic methods for evaluating the edema are described. Special attention is given to fluoroangiography and the most modern methods of macula examination, such as ocular coherence tomography and multifocal electroretinography. Finally, we discuss the treatment of cystoid macular edema in relation to its etiology. In this chapter we briefly refer to the therapeutic value of laser treatment especially in diabetic maculopathy or vitrectomy in some selected cases. Our paper is focused mainly on recent therapeutic treatment with intravitreal injection of triamcinolone acetonide and anti-VEGF factors like bevacizumab (Avastin), ranibizumab (Lucentis), pegaptamid (Macugen), and others. The goal of this paper is to review the current status of this treatment for macular edema due to diabetic maculopathy, central retinal vein occlusion and post-cataract surgery. For this reason the results of recent multicenter clinical trials are quoted, as also our experience on the use of intravitreal injections of anti-VEGF factors and we discuss its value in clinical practice.

Morphologic changes and functional retinal impairment in patients with Parkinson disease without visual loss.

Purpose TO investigate the anatomic and electrophysiologic changes of the macula and the optic nerve in patients with Parkinson disease (PD) without visual impairment. Methods Thirty-two eyes of 16 patients with PD (group A) without visual impairment were tested. Visual acuity was 20/20 or better and visual fields as well as color vision testing results were normal. Also, no retinal lesions were assessed. Patients in group B (40 eyes of 20 patients) were age- and sex-matched control subjects. All study participants underwent a comprehensive ophthalmic examination, multifocal electroretinogram (mfERG) recording, and optical coherence tomography (OCT) scan. Thickness of retinal nerve fiber layer (RNFL) along a 3.4-mm-diameter circle centered on the optic nerve head was evaluated using third-generation OCT. Results The mean P1-response density amplitude of ring 1 of mfERG was 136.69 nV/deg2 in patients with PD and 294 nV/deg2 in control subjects and the difference was highly significant. On the contrary, these values in ring 2 and 3 did not differ statistically between controls and patients with PD. The mean inferior and temporal RNFL thickness was significantly lower in patients with PD than in control subjects (p<0.0001 and p=0.0045, respectively). Conclusions In patients with PD with normal vision, we found a decrease in the electrical activity of the fovea as well as in the thickness of the RNFL. Multifocal electroretinogram and OCT scan objectively detect early subclinical PD-associated visual functional impairment.

Polypoidal choroidal vasculopathy and exudative age-related macular degeneration in Greek population

AbstractPurpose To study the prevalence, the clinical features, and the visual prognosis without treatment of polypoidal choroidal vasculopathy (PCV) in a large series of Greek patients presenting with exudative maculopathy.Methods The medical records, photographs, as well as fluorescein and indocyanine green (ICG) angiograms of a series of 268 consecutive elderly white Greek patients, who were originally diagnosed as having exudative age–related macular degeneration (AMD) were reviewed retrospectively.Results  In all, 22 of the 268 (8.2%) patients initially suspected of having AMD were ultimately diagnosed with PCV. In 15 of the 22 (68.2%) patients with PCV, the polypoidal lesions were located in the peripapillary area. Large soft drusen were present in only two fellow eyes of the 10 (20%) patients with unilateral PCV compared with 120 fellow eyes of the 148 (81.1%) patients with unilateral AMD. At the last examination, 11 of the 22 (50%) patients with PCV and 120 of the 246 (48.8%) patients with AMD presented a visual acuity of less than 6/60 in at least one eye due to scar formation in the macula.Conclusions PCV is not an infrequent disease in Greece. A measurable number of Greek patients with findings suggestive of exudative AMD will instead have PCV. ICG angiography is important in differentiating between these two clinical entities. In Greeks, polypoidal lesions are predominately peripapillary and are not usually associated with macular drusen in the fellow eye. PCV and exudative AMD do not differ significantly in terms of their natural course and visual prognosis in Greek patients.

Intravitreal ranibizumab, intravitreal ranibizumab with PDT, and intravitreal triamcinolone with PDT for the treatment of retinal angiomatous proliferation: a prospective study.

Purpose: To compare 1) intravitreal ranibizumab, 2) intravitreal ranibizumab plus photodynamic therapy (PDT), and 3) intravitreal triamcinolone plus PDT in retinal angiomatous proliferation. Methods: In this prospective study, 37 eyes of 37 patients with retinal angiomatous proliferation were randomly assigned in 1 of the 3 groups. The patients in Group 1 (n = 13) received 3 monthly injections of 0.5 mg of ranibizumab. The patients in Group 2 (n = 13) received one session of PDT and 3 monthly intravitreal injections of 0.5 mg ranibizumab and the patients in Group 3 (n = 11) received one session of PDT and 1 injection of 4 mg triamcinolone. Retreatment, with the same therapeutic scheme in each group, was considered in case of persistence or recurrence of subretinal fluid or intraretinal fluid. Results: All the patients completed at least 6 months of follow-up. A total of 61.53% patients in Group 1, 76.92% in Group 2, and all in Group 3 had the same or better visual acuity at the end of the follow-up (P = 0.0232). The mean central retinal thickness reduction in Group 1 was 32.23 &mgr;m (P = 0.548), in Group 2 20.31 &mgr;m (P = 0.042), and in Group 3 73.92 &mgr;m (P < 0.0001). Also, the patients in Group 3 received on average the lowest number of injections (P < 0.0001). Conclusion: All groups resulted in stabilization of the disease, while a significant trend towards better visual acuity and anatomic restoration of the affected area was observed in the intravitreal triamcinolone & PDT group.

Structural and Functional Impairment of the Retina and Optic Nerve in Alzheimer’s Disease

PURPOSE The purpose of this study was to evaluate the macular and retinal nerve fiber layer (RNFL) thickness, and the electrical activity of the macula in patients with Alzheimers disease (AD). MATERIAL AND METHODS 30 patients with AD and 30 age and sex matched healthy controls were studied. The thickness and the electrical activity of the macula were evaluated by means of optical coherence tomography (OCT) and multifocal-electroretinogram (mf-ERG). RESULTS Visual acuity, as well as visual fields and colour vision testing of all patients were normal. However, the mean foveal thickness was 148.50 μm (vs. 171.50 μm in the control group, p=0.001) and the RNFL thickness was 104.5 μm in the superior area (vs 123 μm in the control group, p < 0.0001) and 116.5 μm in the inferior area (vs. 138 μm in the control group, p < 0.0001) around the optic nerve. The mean P1 response density amplitude of the foveal area was 146.50 nV/deg2 (vs. 293 nV/deg2 in the control group, p < 0.0001) and the perifoveal area was 56.60 nV/deg2 (vs. 81.50 nv/deg2 in the control group, p < 0.001). CONCLUSION Our study showed that in patients with AD, even without visual failure there was a decrease in macular and RNFL thickness, as well as a decrease of the electrical activity of the macula.

Intravitreal use of bevacizumab (Avastin) for choroidal neovascularization due to ARMD: a preliminary multifocal-ERG and OCT study. Multifocal-ERG after use of bevacizumab in ARMD.

PurposeTo evaluate by MFERG and OCT the macular function before and after intravitreal use of bevacizumab (Avastin) in eyes suffering from CNV due to ARMD.MethodsEighteen eyes with subfoveal CNV due to ARMD were studied before and after intravitreal use of bevacizumab with MFERG and OCT. The post treatment follow up was three months.ResultsBefore treatment, OCT shows an increase of the retinal thickening of the fovea and the electrical response densities in the fovea and parafovea were decreased in all patients. Three months after treatment, OCT showed a real resolution of the subretinal fluid. The electrical responses in the fovea and parafovea remained the same or slightly improved in some cases. The intraocular pressure remained normal and no inflammation was observed.ConclusionThe intravitreal use of bevacizumab may provide anatomical correlates that support the concept of disease amelioration but the functional improvement of the macula three months after treatment is not obvious. However the method is promising and needs further evaluation.

Orbital cellulitis, orbital subperiosteal and intraorbital abscess. Report of three cases and review of the literature

INTRODUCTION Orbital cellulitis is usually a complication of paranasal sinus infection. Either the infection may dissect under the periosteum and lead to subperiosteal abscess (SPA) or intraorbital abscess may be formed secondary to a progressive and localized cellulitis. Without appropriate treatment orbital infection may lead to serious complications, even death. REPORT OF CASES Three cases are described, one of orbital cellulitis, one of SPA and one of intraorbital abscess and the literature is being reviewed. CONCLUSION Prompt treatment is mandatory to avoid visual loss or intracranial complications. Initially, IV antibiotics may be administered, but if no improvement appears within 48h, surgical drainage of the orbit and the affected sinuses must be performed. In medial or medial-inferior SPA a transnasal approach is used, but in superior orbital abscess an external incision is required.

Intraocular triamcinolone acetonide for pseudophakic cystoid macular edema: optical coherence tomography and multifocal electroretinography study.

Purpose: To evaluate pseudophakic cystoid macular edema (CME) by optical coherence tomography (OCT) and multifocal electroretinography (mf-ERG) and determine the efficacy of intravitreal triamcinolone acetonide injections. Methods: In this nonrandomized retrospective study, 14 eyes of 14 patients with persistent pseudophakic CME were treated with triamcinolone acetonide injection and were followed up for 1 year. All patients underwent complete ophthalmologic examination including determination of best-corrected visual acuity, slit-lamp examination, tonometry, and funduscopy. Results of OCT and mf-ERG were also recorded before and after the injection. Results: Visual acuity and mf-ERG values increased in all patients after intravitreal triamcinolone acetonide injections. OCT showed improvement of the retinal thickness in the macular area. Temporary increase of intraocular pressure was controlled with topical use of antiglaucoma drops. Conclusion: Intravitreal triamcinolone acetonide injection is a promising therapeutic tool for chronic pseudophakic edema resistant to other medical treatment. However, further study is needed to assess the treatments long-term efficacy, its safety, and the need for retreatment.

Assessing hydroxychloroquine toxicity by the multifocal ERG.

Twenty patients on Plaquenil treatment were evaluated for retinal toxicity using the (EOG) and the mfERG. Group 1 comprises 15 patients (30 eyes) with normal EOG. From these patients 11 (22 eyes) showed normal RRD of mfERG in area 1 and area 2. The rest four patients (8 eyes) the RRD were reduced. Six months after interruption of HC, the mfERG improved in three cases. Group 2 comprises 5 patients (10 eyes) with subnormal EOG. Four (8 eyes) of these showed a decrease of RRD of the mfERG in area 1 and 2. In the rest one (2 eyes) the RRD were normal. Six months after interruption of HC the mfERG and the EOG improved in 2 cases. These results postulate that the mfERG may be used as an alternative method, perhaps more sensitive, for the detection of the HC retinopathy and the follow up of the patients on hydroxychloroquine.

Foveal thickness after phacoemulsification as measured by optical coherence tomography

Background Despite a significant body of research, no consistency on postoperative foveal thickness as measured by optical coherence tomography (OCT), can be recorded. The purpose of our study was to evaluate the effect of uncomplicated cataract surgery in the thickness of the retina in the foveal area during the early postoperative period. Methods In a prospective study, 79 eyes were assessed by OCT, on day 1, and weeks 2 and 4 after uncomplicated phacoemulsification with intraocular lens implantation in the Athens University Clinic. The outcome measure was the thickness of the retina in the foveal area. Results The thickness of the retina preoperatively is significantly smaller (150.4 ± 18.8) (p < 0.05) than the thickness of the retina on day 1 (171.8 ± 21) and week 2 (159.7 ± 19) and returned to the initial levels on week 4 (152 ± 17.1). The estimated correlation coefficients between preoperative and postoperative thickness of the retina were significant (p < 0.05). Conversely, no association was found between postoperative visual acuity and thickness of the retina, neither between the phacoemulsification energy and retinal thickness. Operation time, although inversely related with postoperative visual acuity, was not associated with the thickness of the retina. Conclusions Following phacoemulsification, an increase in the foveal thickness was detected in the early postoperative period, quantified and followed up by OCT. The foveal thickness returned to the preoperative level, 1 month following surgery in our study. No association was shown between intraoperative parameters and increased postoperative retinal thickness.