Marta S. Figueroa

LASER PHOTOCOAGULATION TO TREAT MACULAR SOFT DRUSEN IN AGE-RELATED MACULAR DEGENERATION

Purpose To evaluate the effect on subfoveal and nasal drusen when laser treatment is applied only to the soft drusen located in the temporal macula. Methods A prospective pilot study of 20 patients with confluent soft drusen involving the fovea was conducted. One spot of argon green laser (100-μm spot at 100 mW for 0.1 sec) was applied to each soft druse in the temporal macula. Results Treated and untreated drusen disappeared in all patients after mean times of 2 months and 10 months, respectively. The treated temporal drusen disappeared first, followed by the subfoveal and then the nasal drusen. Superonasal drusen persisted longer. Visual acuity improved by one line or more in 6 (30%) patients, remained unchanged in 13 (65%), and worsened in 1 (5%) patient. No treatment-related complications were observed after an 18-month follow-up period. Conclusion Treatment with laser photocoagulation caused resolution not only of treated soft drusen but also of untreated soft drusen located far from the laser scars in the nasal macula.

Surgical and anatomical outcomes of pars plana vitrectomy for diffuse nontractional diabetic macular edema.

Purpose: To prospectively determine the efficacy of vitrectomy combined with intravitreal triamcinolone acetonide (IVTA) injection, internal limiting membrane (ILM) peeling, or both in treating diffuse nontractional diabetic macular edema (ME). Methods: Patients with diffuse ME of <6 months who had no evidence of macular traction or macular ischemia were included in the study. Patients previously diagnosed with glaucoma underwent vitrectomy with ILM peeling. All other patients were randomly assigned to vitrectomy or vitrectomy with ILM peeling followed by IVTA injection. Results: Forty-two eyes of 38 patients were included in the study. Mean follow-up was 12 months. A statistically significant reduction in macular thickness was found at 1 month to 6 months, disappearing at 12 months. No differences in visual acuity between treatment groups were found during follow-up. Visual acuity improved in 5 (12%) of 42 eyes, remained unchanged in 32 (76%) of 42 eyes, and worsened in 5 (12%) of 42 eyes. Complications included increase in intraocular pressure in 8 (26%) of 31 eyes, mild vitreous hemorrhage in 6 (14%) of 42 eyes, central retinal pigment epithelium changes in 5 (12%) of 42 eyes, and cataract progression in 11 (38%) of 29 phakic eyes. Conclusion: In diffuse diabetic ME with no retinal traction, vitrectomy with either ILM peeling or IVTA injection at the end of surgery produces a short-term improvement in retinal thickness but no long-term anatomical or functional improvements.

Results of bevacizumab as the primary treatment for retinal vein occlusions

Background The purpose of this study is to evaluate the efficacy of intravitreal bevacizumab as the primary treatment of macular oedema due to retinal vein occlusions. Methods Patients diagnosed as having central retinal vein occlusion (CRVO) or branch retinal vein occlusion (BRVO) with visual acuity of less than 20/40 and macular oedema with more than 300 μm central retinal thickness were recruited. Patients that had received any prior treatment were excluded. After an initial intravitreal injection of bevacizumab, re-treatment was performed if intraretinal or subretinal fluid with distortion of the foveal depression was found in optical coherence tomography. Results 18 eyes with CRVO and 28 eyes with BRVO were included. During a 6-month period, the mean number of injections per patient was 3.7 (BRVO group) and 4.6 (CRVO group). In the BRVO group, mean baseline logMAR visual acuity was 0.80 (SD 0.38) and macular thickness was 486.9 μm (SD 138.5 μm). After 6 months, mean logMAR visual acuity improved significantly to 0.44 (SD 0.34), p<0.001. Mean macular thickness decreased significantly to 268.2 μm (SD 62.5 μm), p<0.001. In the CRVO group, mean baseline logMAR visual acuity was 1.13 (SD 0.21) and macular thickness was 536.4 μm (SD 107.1 μm). Mean final logMAR visual acuity improved significantly to 0.83 (SD 0.45), p<0.001. Mean macular thickness decreased significantly to 326.17 μm (SD 96.70 μm), p<0.001. Conclusions Intravitreal bevacizumab seems to be an effective primary treatment option for macular oedema due to retinal occlusions. Its main drawback is that multiple injections are necessary to maintain visual and anatomic improvements.

Laser photocoagulation for macular soft drusen. Updated results.

Purpose: To update the results of a study on the disappearance of macular soft drusen after laser treatment in the natural evolution of age‐related macular degeneration. Methods: A total of 46 patients with confluent soft drusen and pigmentary changes were studied prospectively. Group 1 was composed of 30 patients with bilateral drusen; the authors randomly assigned one eye of each patient for treatment and the fellow eye for the control. In 16 patients a choroidal neovascular membrane was present in one eye, and treatment was applied to the fellow eye (group 2). Argon green laser treatment was applied directly to the soft drusen in the temporal macula. Results: All treated drusen disappeared in a mean of 3.5 months after treatment, and untreated drusen disappeared in all but three patients in an average of 8.5 months. After an average period of 3 years, only one control eye and none of the treated eyes in group 1 developed a choroidal neovascular membrane (P = 0.500). In group 2, neovascularization occurred in 18% of the patients. The initial improvement in Snellen acuity after subfoveal drusen disappearance diminished as a consequence of cataract progression. Conclusions: Although no definitive conclusions should be made because of the small number of patients studied, results seem to show that this treatment does not reduce the risk of choroidal neovascularization in the treated eye of patients with a history of exudative disease in the fellow eye. It may be effective in patients with high‐risk bilateral soft drusen, that is, in less advanced stages of the disease.

Diagnostic value of polymerase chain reaction in blood and aqueous humor in immunocompetent patients with ocular toxoplasmosis.

Purpose: To evaluate the diagnostic value of polymerase chain reaction (PCR) in blood and aqueous humor samples from immunocompetent patients with reactivated ocular toxoplasmosis. Methods: Group 1 was composed of seven patients with a clinical diagnosis of reactivated ocular toxoplasmosis. Group 2 consisted of 33 controls. In each subject, blood and aqueous humor samples were obtained for detection of Toxoplasma gondii DNA by means of simple PCR, seminested PCR, and Southern blot hybridization. Results: Group 1: Simple PCR was positive in 3 of 7 blood samples (42%) and in 2 of 7 (28%) aqueous humor samples. Seminested PCR was positive in 4 of 7 (57%) blood samples and in 3 of 7 (42%) aqueous humor samples. Group 2: Simple and seminested PCR were positive in both samples in 2 of 33 (6%) and 4 of 33 (12%), respectively. Sensitivity 57% (18.41‐90.10), specificity 87% (71.80‐96.60); positive and negative likelihood ratio 4.38 and 0.49, respectively. Conclusions: Polymerase chain reaction can be useful for confirming the diagnosis of ocular toxoplasmosis, especially in those eyes where fundus examination does not yield conclusive results. The detection of T gondii DNA in blood suggests that reactivation of ocular toxoplasmosis cannot be considered a local event.

A Review of Current Management of Vitreomacular Traction and Macular Hole

The paper presents a review of the sequence of events of posterior vitreous detachment (PVD), vitreomacular adhesion (VMA), vitreomacular traction (VMT), and macular hole (MH) from their pathophysiological aspects, clinical features, diagnostic implications, and current management strategies. A treatment algorithm to be used in clinical practice in patients with VMA, VMT, and MH based on the presence of symptoms, visual acuity, associated epiretinal membrane, and width of the vitreous attachment is presented. Observation, pharmacologic vitreolysis with ocriplasmin, and surgical treatment are positioned as treatment options in the different steps of the therapeutic algorithm, with clear indications of the paths to be followed according to the initial presenting manifestations and the patients clinical course.

INTRAVITREAL ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY FOR CHOROIDAL NEOVASCULARIZATION SECONDARY TO PATHOLOGIC MYOPIA: SIX YEARS OUTCOME.

Purpose: To report the visual outcome after 6-year follow-up in highly myopic eyes with choroidal neovascularization treated with anti-vascular endothelial growth factor drugs. Methods: Retrospective, nonrandomized, multicenter, consecutive, and interventional case series. Results: Seventy-eight patients were treated with intravitreal bevacizumab and 19 with ranibizumab. Mean age of the patients was 56.5 years (SD, 13.3). The average number of letters read was 56.7 (SD, 19.0) at baseline; 65.7 (SD, 18.4) at 12 months; 63.6 (SD, 20.6) at 24 months; 62.4 (SD, 21.4) at 36 months; 60.6 (SD, 22.0) at 48 months; 58.9 (SD, 22.9) at 60 months, and 58.4 (SD, 22.7) at 72 months (P < 0.01, between initial vs. 12, 24, and 36 months; P = 0.07, 0.3, and 0.5 between initial vs. 48, 60, and 72 months, respectively; Students t-test paired data). The mean total number of intravitreal injections was 3.3 (SD, 2.3; range, 1–9). Conclusion: Bevacizumab and ranibizumab are effective therapies and show similar clinical effects in myopic eyes with choroidal neovascularization. Visual acuity gain is maintained at a 3-year follow-up. The improvement is no longer statistically significant at Years 4, 5, and 6.

Intraocular pressure elevation after uncomplicated pars plana vitrectomy: results of the Pan American Collaborative Retina Study Group.

Purpose: To compare the incident rates of sustained elevation of intraocular pressure (IOP) after uncomplicated pars plana vitrectomy for idiopathic epiretinal membrane and the unoperated fellow eye. Methods: Retrospective multicenter study of 198 patients who underwent pars plana vitrectomy for an idiopathic epiretinal membrane that was followed for at least 12 months. The diagnosis of sustained IOP elevation was defined as an elevation of IOP ≥24 mmHg or an increase of ≥5 mmHg in the IOP from baseline on 2 separate visits that warranted the initiation of ocular hypotensive therapy. The main outcome measured was the development of sustained IOP elevation as defined above. Results: Patients were followed for an average of 47.3 ± 24 months (range, 12–106 months). In the vitrectomized eyes, 38 of the 198 (19.2%) patients developed elevated IOP compared with 9 of the 198 (4.5%) unoperated fellow eyes (P < 0.0001, Fisher exact test; odds ratio, 4.988). Possible risk factors include a family history of open-angle glaucoma (P = 0.0004 Fisher exact test; odds ratio, 7.206) and cataract surgery (P = 0.0270 Fisher exact test; odds ratio, 2.506). Conclusion: Uncomplicated PPV seems to increase the IOP, particularly in those who are pseudophakic and have a family history of open-angle glaucoma. This increase in IOP may lead to glaucomatous damage if not managed appropriately. Patients with a previous PPV need to be followed by an ophthalmologist to monitor the IOP in the vitrectomized eye.

Macular structure on optical coherence tomography after lamellar macular hole surgery and its correlation with visual outcome

OBJECTIVE To report macular structure on optical coherence tomography (OCT) after lamellar macular hole surgery and its relationship with visual outcome. DESIGN Retrospective interventional case series; private practice setting. PARTICIPANTS Twelve patients diagnosed with a lamellar hole who had undergone vitrectomy and who had OCT scanning before and after surgery and at least 6 months follow-up were included. METHODS Surgery consisted of 25 g vitrectomy, peeling of epiretinal and internal limiting membrane, fluid/air/gas exchange, and 2 weeks of face-down positioning. RESULTS OCT showed an epiretinal membrane in all cases. After a mean follow-up of 16.7 months, VA improved by ≥2 lines in nine patients and remained stable in three. There was a complete closure of the lamellar hole in ten patients; in four a retinal pseudocyst was found during the healing process, resolving spontaneously in two and persisting in the other two after 8 and 9 months, respectively. Two patients developed a full-thickness macular hole that closed successfully after surgical repair. All patients had a VA ≥ 20/32 at the end of follow-up. CONCLUSION Epiretinal membranes appear to have a role in the pathogenesis of lamellar macular holes. Vitrectomy is a useful technique to obtain closure of the lamellar hole and visual improvement. The presence of a retinal pseudocyst is a common feature during the healing process and is compatible with a favorable visual outcome. A full-thickness macular hole is a severe and not uncommon complication of this procedure.

Anti-angiogenic drugs as an adjunctive therapy in the surgical treatment of diabetic retinopathy.

Anti-VEGF drugs may be employed in the surgical treatment of diabetic retinopathy: 1. Prior to surgery. The intravitreal injection of anti-VEGF drugs leads to a significant reduction of neovascularization, with a reduction in the adherence of the fibrovascular complex to the retina. This simplifies viscodelamination and reduces intraoperative bleeding during delamination and segmentation. To minimize the risk of tractional retinal detachment due to the contraction of fibrovascular tissue, vitrectomy must be performed within one week after the injection. 2. To decrease the risk of postoperative bleeding. Recurrent vitreous hemorrhages after vitrectomy are often due to small bleeding from persistent neovascularization. The injection of anti-VEGF drugs at the end of vitrectomy could prevent bleeding from these vessels by blocking the pro-inflammatory stimulus of the surgical procedure. 3. To treat postoperative vitreous hemorrhage. The intravitreal injection of anti-VEGF drugs in patients with postoperative bleeding leads to resolution of the hemorrhage. 4. To treat rubeosis iridis. In eyes with complete panretinal photocoagulation, the combination of cryotherapy and intravitreal anti-VEGF injection in the same surgical procedure produces a disappearance of iris neovascularization together with a long term effect with no recurrences. In neovascular glaucoma, anti-VEGF drugs can also facilitate filtrating surgery.