Michael Apostolopoulos

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.

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.

Evaluation of successful macular hole surgery by optical coherence tomography and multifocal electroretinography.

PURPOSE To evaluate successful macular hole surgery using optical coherence tomography (OCT) and multifocal electroretinography (MFERG). DESIGN Interventional case series. METHODS In a prospective study, 20 eyes of 20 patients with successful surgery for stage II, III, or IV idiopathic macular hole were evaluated by best-corrected visual acuity (BCVA), ocular examination, OCT, and MFERG preoperatively and 1, 3, 6, and 12 months postoperatively. For statistical analysis, the paired t test and nonparametric methods were used, as well as the Spearman analysis. RESULTS Postoperatively, all 20 eyes of 20 patients had anatomic closure of the macular hole confirmed by OCT. The center of the fovea, measured by OCT from the retinal pigment epithelium to the inner retinal surface, had a mean +/- SD thickness of 116.5 +/- 30.9 microm (range, 68-175 microm) 1 year postoperatively. Best-corrected visual acuity significantly improved (preoperative mean +/- standard deviation [SD] value, 0.131 +/- 0.081 and 1 year postoperative mean +/- SD value, 0.407 +/- 0.193). Multifocal electroretinography values area 1 (0-2.8 degrees) and area 2 (2.8-9 degrees from the center of the fovea) significantly improved (preoperative mean +/- SD values 3.10 +/- 1.334 nV/deg(2) and 3.573 +/- 1.545 nV/deg(2), respectively, and 1 year postoperative +/- SD mean values, 5.53 +/- 1.208 nV/deg(2) and 4.748 +/- 1.404 nV/deg(2), respectively). The thickness of the fovea, measured by OCT, significantly correlated with the BCVA 1 year postoperatively. One year postoperative MFERG values areas 1 and 2 were not correlated with 12-month BCVA and OCT findings. CONCLUSIONS Twelve months postoperatively BCVA and MFERG values significantly improved in this series of eyes with successful macular hole surgery. Optical coherence tomography findings were correlated to BCVA, but MFERG values were not correlated to BCVA and OCT findings, 1 year postoperatively.

Assessment of macular function by multifocal electroretinogram before and after epimacular membrane surgery.

Purpose To evaluate macular function before and after successful surgical peeling of idiopathic epimacular membranes by means of multifocal electroretinogram (ERG) and measuring the first order Kernel. Methods Multifocal ERG of 10 patients (10 eyes) with idiopathic epimacular membrane were recorded before and after successful macular peeling. The retinal response densities of areas 1 and 2 were compared pre- and postoperatively and the functional state of the retina beneath the epimacular membrane was evaluated. The postoperative period was 3–6 months. Results Preoperatively, the electrical retinal response densities in the foveal and the perifoveal area were apparently decreased. After a mean postoperative period of 3 months the electrical response densities of the above areas improved. This improvement continued 6 months after the operation. Conclusion In idiopathic epimacular membranes, the decrease in retinal electrophysiologic response was not limited to the fovea but also involved the perifoveal area. The electrical retinal response density of these areas gradually improved after peeling of the epimacular membrane.

The Ice Pack Test in the Differential Diagnosis of Myasthenic Diplopia

PURPOSE To investigate the diagnostic value and to establish threshold criteria for the ice pack test as an office preliminary test in the differential diagnosis of myasthenic diplopia in comparison with blepharoptosis. DESIGN Prospective, comparative cohort study. PARTICIPANTS Eighty-nine patients with a recent onset of diplopia, blepharoptosis, or both were evaluated with orbital cooling in a prospective manner. Forty-eight patients presented with diplopia, 25 patients with both blepharoptosis and ophthalmoplegia and 16 patients with blepharoptosis. TESTING All patients had the ice pack applied for 5 minutes on both eyelids at the initial orthoptic evaluation. Increasing the duration of cooling to 10 minutes was investigated in 36 diplopic patients. A complete diagnostic work-up was ordered and patients were followed up for a minimum of 6 months before diagnosis of myasthenia gravis was ascertained. MAIN OUTCOME MEASURES Difference in cover test measurements in primary position or marginal reflex distance before and after the application of the ice pack, specific cause for diplopia and blepharoptosis. RESULTS Fifteen patients were diagnosed as myasthenic. The optimal cutoff point for a positive response to the ice pack test proved to be a reduction in ocular deviation in primary position by 50% or by 10 prism diopters (PD) or more for presenting deviations larger than 20 PD. By this criterion, sensitivity for the detection of myasthenic diplopia was 76.9% (95% confidence interval [CI], 49.06%-92.50%) for the 5-minute application, compared with 92.3% (95% CI, 63.5%-98.9%) sensitivity demonstrated for blepharoptosis. Increasing the time of application to 10 minutes did not improve the diagnostic value of the test. Specificity was high (98.3%; 95% CI, 90.3%-99.9%) and was demonstrated even in patients with coexisting myasthenic and dysthyroid ophthalmopathy. Patients with oculomotor nerve paresis and Horner syndrome invariably were nonresponsive to the test. CONCLUSIONS The ice pack test demonstrated high specificity and an acceptable sensitivity in the differential diagnosis of myasthenic diplopia. Data from this series suggest that a partial rather than a complete response to the ice pack test may be expected for myasthenic diplopia. Standardization of the method of application of the ice pack is critical for the interpretation of its effect.

Severe toxic effect of methylene blue 1% on iris epithelium and corneal endothelium.

Purpose: To report a case of corneal endothelial decompensation and iris pigment dispersion following the inadvertent use of methylene blue 1% for capsular staining during cataract surgery. Design: Case report. Methods: During an otherwise routine phacoemulsification cataract surgery, inadvertent anterior capsule staining with methylene blue 1% instead of trypan blue 0.025% was performed. Copious irrigation of the anterior chamber with balanced salt solution was initiated upon identification of the wrong dye. The operation was completed with minimal ultrasound energy without complications. Results: Iris discoloration and severe corneal edema developed in the early postoperative period, resulting in severe visual loss. The patient developed bullous keratopathy and underwent penetrating keratoplasty 16 months later. Conclusions: In vivo intracameral injection of methylene blue 1% induces extreme cytotoxicity, primarily on the corneal endothelium and iris epithelium.

Massive choroidal hemorrhage after intravitreal administration of bevacizumab (Avastin ® ) for AMD followed by controlateral sympathetic ophthalmia

Purpose: To report a severe ocular complication initiated ten days after intravitreal administration of bevacizumab (Avastin®), in a patient with exudative age-related macular degeneration (AMD). Patients and method: Case report. Results: Ten days after intravitreal injection of 1.25 mg Avastin®, the patient manifested acute loss of vision with excruciating pain. An extensive choroidal detachment was evident in close contact with the lens, which necessitated an emergency sclerotomy with reconstruction of the anterior chamber. Four months later, the eye proceeded to phthisis bulbi. Five months after the injection, the patient complained of mild pain, photophobia, and visual acuity deterioration from the fellow eye. The diagnosis of sympathetic ophthalmia was suggested and treated with intravitreal injections of triamcinolone acetonide every three months with good response, complicated by elevation of intraocular pressure which we managed with Ahmet valve implantation. Conclusion: Serious ocular complications after intravitreal of Avastin® can not be excluded, including massive choroidal hemorrhage and sympathetic ophthalmia of the fellow eye.

Macular hole surgery with short-acting gas and short-duration face-down positioning

Purpose To report on the outcomes of vitrectomy and sulfur hexafluoride (SF6) gas tamponade for idiopathic macular holes with 2 days of face-down positioning. Patients and methods This was a prospective, nonrandomized, observational sequential case-series study on 23 consecutive patients receiving macular hole surgery using 20% SF6 and advised to stay in a face-down position for 2 days postoperatively (SF6 group). These patients were compared to 23 consecutive patients who had previously undergone macular hole surgery, had received 14% C3F8, and were advised to maintain a face-down position for 2 days (C3F8 group). Patients in both groups underwent vitrectomy, internal limiting membrane peeling, and fluid gas exchange using either SF6 or C3F8. Preoperative and postoperative data included best corrected visual acuity recorded in LogMAR units, slit-lamp biomicroscopy, and optical coherence tomography. Results At a 6-month follow-up, macular hole closure was noted in 23/23 eyes (100%) and in 22/23 eyes (96%) in the SF6 and C3F8 groups, respectively. The improvement in visual acuity (measured through Snellen acuity lines both preoperatively until 6 months postoperatively) was 4.08 ± 2.31 (95% confidence interval [CI]: 3.08–5.08) for the SF6 group and 2.87 ± 2.30 (95% CI: 1.87–3.86) for the C3F8 group; this difference was not statistically significant (P = 0.06). Conclusion Vitrectomy with internal limiting membrane peeling and a short-acting gas tamponade using SF6 with posture limitation for 2 days may give a high success rate in macular hole surgery.

Quantitative determination of glycosaminoglycans in tears of diabetic patients

Purpose To determine the amount of glycosaminoglycans (GAGs) in tears of patients with diabetic retinopathy (DR) and to compare it with normal subjects. Methods 38 patients with DR and 24 normal volunteers were included. Thirty subjects suffered from background diabetic retinopathy (BDR) and 8 from proliferate diabetic retinopathy (PDR). For the GAGs assay, the uronic carbazole reaction was used. Results The mean concentration of GAGs was significantly higher in patients with DR than in normal subjects. The GAGs concentration in patients with BDR or PDR was significantly higher than in normal subjects. Conclusion The measurement of GAGs in tears of diabetic patients could be a tool in order to assess the stability or not of the disease.