Michaella Goldstein

HYPERHOMOCYSTINEMIA IN PSEUDOEXFOLIATION GLAUCOMA

PurposeTo determine the prevalence of hyperhomocystinemia in patients with pseudoexfoliation glaucoma. Patients and MethodsThis prospective study included 30 patients with glaucoma and 30 age-matched controls with no history of ocular disease who were undergoing routine physical checkups. Plasma homocysteine levels of all the study participants were determined using high-performance liquid chromatography, and values exceeding 15 &mgr;mol/L were considered elevated. ResultsThe mean plasma homocysteine level was 16.80 ± 3.20 and 12.39 ± 1.97 &mgr;mol/L in glaucoma patients and controls, respectively (P <0.0001). Fifteen glaucoma patients (50%) had hyperhomocystinemia compared with 3 controls (10%) (P = 0.0015). ConclusionHyperhomocystinemia may be associated with pseudoexfoliation glaucoma, which may partially explain the increased risk of vascular diseases among patients with pseudoexfoliation syndrome.

Retinal pigment epithelial tear following photodynamic therapy for choroidal neovascularization secondary to AMD.

PurposeTo describe retinal pigment epithelial tear following photodynamic therapy (PDT) for subfoveal choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD).DesignRetrospective interventional case series.MethodsA retrospective study in an institutional practice. We describe seven cases of retinal pigment epithelial (RPE) tear, which developed in seven eyes of seven patients following PDT. All eyes had subfoveal CNV secondary to AMD.ResultsSix eyes had occult subfoveal CNV, and one eye had recurrent classic subfoveal CNV. In five patients, the eye that developed the tear was the second eye, whereas the first eye had a disciform scar. In four eyes, the RPE tear developed after one PDT, in one eye the RPE tear developed after the second PDT, and in two eyes the RPE tear developed after the third PDT. In five of seven cases, there was a significant visual deterioration following the RPE tear.ConclusionsRPE tear is a complication that may occur following PDT in particular when the PDT is applied to an occult subfoveal CNV.

Treatment of diabetic retinopathy with anti‐VEGF drugs

The aim of this review is to summarize the latest developments in the treatment of diabetic retinopathy (DR) with anti‐vascular endothelial growth factor (VEGF) drugs. We reviewed recent studies that evaluated the role of the anti‐VEGF agents bevacizumab, ranibizumab and pegaptanib in the treatment of DR. There was only one large randomized controlled trial that evaluated the role of ranibizumab in diabetic macular oedema (DME). Other prospective and retrospective studies provided important insight into the role of anti‐VEGF drugs in DR, but most of them were not conducted in large scales. The growing evidence indicates that anti‐VEGF drugs are beneficial in DR, especially in DME. Further studies are needed to fully evaluate the role of these agents, especially in proliferative DR and in DR candidates for vitrectomy surgery.

Targeting vascular endothelial growth factor: a promising strategy for treating age-related macular degeneration.

Age-related macular degeneration (AMD) is the leading cause of irreversible visual loss in the industrialised world. While treatment options for advanced AMD have been rather limited until recently, the introduction of intravitreal injections of anti-angiogenic agents appears to be a promising and revolutionary mode of treatment for this blinding disease. Vascular endothelial growth factor (VEGF) appears to play a pivotal role in the pathogenesis of choroidal neovascularisation, one of the cornerstones of advanced AMD. Pegaptanib, the first anti-VEGF treatment approved for AMD patients, is a VEGF-neutralising aptamer that specifically inhibits one isoform of VEGF (VEGF-165). Although evidence suggested that pegaptanib was superior to previous treatment options, results with this agent were still unsatisfactory. Ranibizumab is a humanised anti-VEGF monoclonal antibody fragment that inhibits all isotypes of VEGF. This new drug has demonstrated a high efficacy profile in terms of inhibiting disease progression and even improving visual acuity. Bevacizumab is a full-length anti-VEGF antibody that was originally approved for use in metastatic colon cancer and is under investigation as a low-cost off-label alternative for patients with AMD. There is growing evidence that this drug may be an effective and safe alternative to the more expensive ranibizumab, although prospective multicentre trials are required to fully investigate this issue. Undoubtedly, the concept of directly injecting anti-VEGF drugs into the vitreal cavity brings new hope to many AMD patients.

Hyperhomocysteinemia in patients with diabetes mellitus with and without diabetic retinopathy

AbstractObjective To evaluate the prevalence of hyperhomocysteinaemia in diabetic patients with no diabetic retinopathy (no DR), with nonproliferative diabetic retinopathy (NPDR) and with proliferative diabetic retinopathy (PDR).Research design and methods This prospective, case-control study, included 179 diabetic patients and 156 age-matched controls with no diabetes and no history of ocular disease, who were undergoing routine physical checkups. Plasma homocysteine levels of all study participants were measured using high-performance liquid chromatography (HPLC). Hyperhomocysteinaemia was defined when homocysteine levels were higher than 15 μmol/l.Results The mean plasma homocysteine level was 11.75±0.24 in the control group, 13.46±0.74 in the no DR group, 14.56±0.64 in the NPDR group and 15.86±1.34 in the PDR group. Mean homocysteine levels were significantly elevated in the NPDR and PDR groups compared to the control group (P=0.001 and <0.0001, respectively). The prevalence of hyperhomocysteinaemia was also higher in the NPDR and PDR groups compared to the control group (P=0.032 and 0.011, respectively). No statistically significant difference was found between the no DR and the control group.Conclusions Our findings suggest that hyperhomocysteinaemia may be associated with diabetic retinopathy and partially explain the increased risk of microvascular angiopathy occurring in these patients.

Long-term evaluation of patients treated with dexamethasone intravitreal implant for macular edema due to retinal vein occlusion

PurposeTo evaluate the long-term visual prognosis and complications of patients who received intravitreal Ozurdex injections for the treatment of macular edema (ME) due to retinal vein occlusion (RVO).MethodsA total of 17 patients who received Ozurdex injections in our institution as part of the GENEVA study were recalled for examination. Recorded parameters included final visual acuity (VA), final retinal thickness by optical coherence tomography, persistence of ME, and the occurrence of any complications.ResultsMean follow-up time was 50.5 months. Patients with branch RVO (BRVO) had a more favorable prognosis than central RVO (CRVO), and their mean VA had improved significantly, whereas the mean VA for the patients with CRVO did not improve significantly. Retinal thickness had reduced significantly in the whole group and in each subgroup separately. Complications included 10 patients with cataract progression, 1 with elevated intraocular pressure, and 1 with neovascularization and vitreous hemorrhage.ConclusionsThis is the first reported long-term evaluation of patients treated with Ozurdex. Our results indicate that it has favorable long-term safety profile, and may have a beneficial effect on the visual prognosis in BRVO even in the absence of continuous treatment. Further research is required to establish the optimal retreatment schedule for Ozurdex.

Clinical characteristics of endophthalmitis after an injection of intravitreal antivascular endothelial growth factor.

Purpose: The purpose of this study was to describe the clinical characteristics and management of patients with bacterial endophthalmitis after an intravitreal antivascular endothelial growth factor injection. Methods: This is a retrospective chart review of all patients admitted with suspected endophthalmitis from 2006 to 2008. Results: Endophthalmitis was verified by positive Gram stain and culture in nine eyes. The mean preinjection visual acuity of the 9 eyes was 0.02 ± 0.021 diopters (decimal visual acuity scale) and dropped to 0.01667 ± 0.02449 diopters in the eyes with endophthalmitis. All nine patients presented with reduced visual acuity, of whom seven also had ocular pain. Initial treatment was administered without delay and consisted of vitreous tap and intravitreal antibiotics injection in five cases and pars plana vitrectomy with intravitreal antibiotics injection in the other four cases. Vitreous tap failed in one case. Seven patients underwent a second procedure and two underwent a third procedure. The mean posttreatment visual acuity in all 9 eyes improved significantly (0.19 ± 0.24, P = 0.0071). Five patients had major complications (e.g., retinal detachment, phacolytic glaucoma, and recurrent endophthalmitis). Conclusion: Acute endophthalmitis following anti-VEGF injection appears within days and can result in severe loss of vision if not treated promptly. In our series the clinical and prognostic characteristics were considerably different between culture positive endophthalmitis cases and culture negative cases.

Vitreal, retinal, and choroidal findings in active and scarred toxoplasmosis lesions: a prospective study by spectral-domain optical coherence tomography.

BackgroundThe aim of our study was to investigate vitreal, retinal, and choroidal morphologic changes in active and scarred toxoplasmosis lesions using spectral-domain optical coherence tomography (SD-OCT).MethodsIn this prospective study, 19 eyes of 15 consecutive patients with ocular toxoplasmosis were included. Complete ophthalmologic examination and SD-OCT were done at the initial visit and during follow-up. Retina and choroid SD-OCT protocols directed to macular area and lesions observed on clinical examination were used.ResultsSeventeen active lesions and 56 retinochoroidal scars were studied. In the acute phase, disruption, thickening, and hyper-reflectivity of the neurosensory retina with photoreceptor (PR) interruption and retinal pigment epithelial (RPE) elevation were found. The choroid became thickened and hyporeflective. During follow-up, neurosensory retinal layers thinning and disorganization, PR interruption, and RPE elevation and/or atrophy were demonstrated. The choroid returned to normal thickness and became more hyperreflective. Five active lesions presented with hyperreflective oval deposits within the vitreoretinal interface, adjacent to or far away from the lesions. During follow-up, the deposits became smaller, entered into the inner retina layers and faded with time until complete resolution. Multiple hyperreflective dots in the vitreous cavity, compatible with vitritis, and posterior hyaloid thickening were demonstrated in the acute phase, with complete resolution and detachment of the posterior hyaloid during follow-up. Four types of scars were specified according to outer retina–choroid interface changes; atrophic, elevated, deep, and combined (atrophic & elevated). Epiretinal membrane segments were found over active and scarred lesions.ConclusionsSD-OCT imaging showed toxoplasmic retinochoroidal lesions and scars to be complex and characterized acutely by thickening and disorganization of both the retina and underlying choroid, and following scar formation by varying degrees of thinning, often in conjunction with irregularity of the outer retinal layers.

Spectral domain optical coherence tomography classification of acute posterior multifocal placoid pigment epitheliopathy.

Purpose: To study the retinal morphologic changes occurring in acute posterior multifocal placoid pigment epitheliopathy using spectral domain optical coherence tomography. Methods: Prospective observational case series of 12 eyes (6 consecutive patients) diagnosed with acute posterior multifocal placoid pigment epitheliopathy. All patients underwent complete ophthalmologic examination, fundus photography, fluorescein angiography, and spectral domain optical coherence tomography at the initial visit. During follow-up, ophthalmologic examination and spectral domain optical coherence tomography scans were performed. The scans were directed to the lesions observed on the clinical examination and fluorescein angiography. Results: Spectral domain optical coherence tomography classification containing four distinct stages for acute posterior multifocal placoid pigment epitheliopathy is proposed. Stage 1 demonstrates a dome-shaped elevation with disruption of the photoreceptor junction that flattens shortly after. Stage 2, occurring 2 weeks later, demonstrates distinct separation between the photoreceptor junction and the retinal pigment epithelium (RPE). Stage 3, visible 6 weeks post disease initiation, demonstrates accentuated RPE hyperreflectivity and union of the RPE and photoreceptor junction. Stage 4, the resolution phase, starts at 3 months demonstrating reformation of 2 distinct visible layers of photoreceptors and RPE. Conclusion: The morphologic retinal findings in acute posterior multifocal placoid pigment epitheliopathy visible by the spectral domain optical coherence tomography occur in the outer retina, mainly the photoreceptors and RPE. Most findings reached nearly complete resolution and were correlated with improvement in visual acuity.

Heidelberg spectral-domain optical coherence tomographic findings in retinal artery macroaneurysm.

Purpose: To describe the morphologic variables of macroaneurysms, to assess their diameter in comparison to their upstream/downstream vessel diameter as visualized on spectral-domain optical coherence tomography, and to describe morphologic changes in the retina adjacent to macroaneurysm. Methods: A retrospective case series of adult patients who were clinically diagnosed with retinal macroaneurysms and who underwent Heidelberg spectral-domain optical coherence tomography (OCT) between June 2009 and October 2010. Results: A total of 12 patients (age range, 31–95 years, 2 men) in whom macroaneurysms were demonstrated by spectral-domain OCT (12 eyes). All the macroaneurysms had a typical OCT appearance, and a diameter of 285.33 ± 76.98 &mgr;m. The diameter of the upstream/downstream vessel was 117.5 ± 17.13 &mgr;m (P = 0.0001 vs. the mean macroaneurysm diameter). Other related OCT findings were superficial retinal hemorrhage, intraretinal lipids, and intraretinal edema prominently involving the outer retinal layers. Conclusion: Spectral-domain OCT is an effective tool for detecting retinal macroaneurysms. It also provides important supplementary clinical information that may be helpful in planning the management of macroaneurysm, without the need for ancillary tests.