Michelle V Carle

Successful use of anti-VEGF treatment for subretinal hemorrhage and fluid in a young patient with choroidal osteoma.

The authors report the use of an anti-VEGF agent in the resolution of subretinal fluid and hemorrhage with improvement in best corrected visual acuity (BCVA) in a patient with choroidal osteoma. The reported case involves a 20-year-old man who presented with a choroidal osteoma and chronic subretinal fluid associated with hemorrhage. He was treated with six intravitreal doses of bevacizumab over a 13-month period. The fluid resolved and his BCVA improved with these treatments. Intravitreal bevacizumab can be used to successfully treat subretinal fluid associated with choroidal osteomas and may lead to an improvement in BCVA.

Tears of the Retinal Pigment Epithelium during Aflibercept Therapy: PED and Treatment Characteristics

Background: Tears of the Retinal Pigment Epithelium (RPE) are associated with Age-Related Macular Degeneration (AMD) in the setting of a pigment epithelial detachment (PED). Methods: Chart review of patients treated with intravitreal (IV) Aflibercept for neovascular AMD (nvAMD). Clinical course and OCT images were analyzed to compare characteristics for patients who experienced RPE tears during treatment of symptomatic PED with IV Aflibercept. Results: 8 eyes of 8 patients were included in the study. All cases were being treated for nvAMD with IV aflibercept. The average maximal height of PED was 475 μm (172-874 μm), and the mean linear diameter was 3426 μm, (1004-5185 μm). All eyes had associated subretinal fluid; 4 had RPE folds and irregularities, and one had subretinal hemorrhage. Four eyes experienced an RPE tear after the first injection of Aflibercept. Two eyes had received more than 10 injections of aflibercept prior to the development of RPE tear. Two patient’s eyes were previously treated with other anti-VEGF agent (one bevacizumab, and one ranibizumab). The visual acuity improved by 2 or more lines in 3 eyes, and worsened by 2 or more lines in no eyes. The final BCVA was ≥ 20/40 in 2 eyes, 20/50-20/100 in 5 eyes, and </= 20/200 in 1 eye. Conclusion: IV Aflibercept has been recommended for treatment of PED in the setting of nvAMD. In our study, 8 patients with PED experienced a tear of the RPE during the early course of treatment with Aflibercept. Aflibercept’s mechanism of action is such that it binds to multiple targets with higher affinity than other anti-vascular-endothelialgrowth- factors. This proposed mechanism may increase its efficacy in the setting of PED. This mechanism, however, may also augment the risk for RPE tears. Therefore, consideration for RPE tear should be given in the setting of large PED in nvAMD.

Patients with Advanced Diabetic RetinopathyâÂÂs Understanding of DiabetesMellitus and Their Diabetic Eye Disease: A Survey of 100 Patients CurrentlyUndergoing Treatment for Diabetic Retinopathy in a Large Retinal Practice

Objective: To better understand what patients with advanced diabetic retinopathy understand about their DED and treatment, control of their diabetes, and risk factors for disease progression, and to assess which areas clinicians may want to target for education to increase patient understanding. Methods: 100 consecutive patients with at least 5 previous visits to a retinal clinic were surveyed to better understand patients’ understanding of DM, DED, and the treatments they were receiving for DM and their DED. Demographic information (age, gender, educational status, ethnicity, language, duration and treatments for DM) was collected, along with information about treatments and understanding of risk and modifiable factors about DM. Data was verified against the chart. Results: 100 surveys were completed; 97% of patients said they “understand DM”. 61% of patients were 60 years or older, and half of the patients had done some post-secondary educational training. The ethnic breakdown included 27% Caucasian and 38% Hispanic. Fasting blood glucose (FBG) was known in 89% of patients and when asked the range of FBG: 6% did not know; 17% had FBG as >160 mg/dl; and 35% had a FBG of 150mmHg. Patients were asked to identify DM related ocular complications: 23% said bleeding; 7% said diabetic macular edema; and 73% said blindness or visual loss. As patient age increased, the ability to correctly identifying current treatments, and knowledge of hemoglobin A1C (HbA1C), decreased. Ability to correctly identify HbA1C increased with increasing education. Conclusions: This survey shows patient misunderstanding in: how DM is treated, risk factors for DM, and how monitoring should be done. Emphasis is likely needed in diet modification and exercise for control of DM. Patients may be at risk for poor understanding of DM care/treatment (particularly those with lower educational achievement, or more elderly). Additional resources may need to be developed for sub-sets of patients.

Occlusion caused by cosmetic facial filler injection - reply.

motivated ophthalmology learners in the CSP group, we hope these results will be helpful in furthering the important missions of improving ophthalmic care to the underserved and improving undergraduate ophthalmology education. We and others have demonstrated that medical students’ direct ophthalmoscopy skills decrease over time without longitudinal skill reinforcement, signaling the importance of medical school curriculum reform to facilitate increased longitudinal exposure to ophthalmoscopy.2-4 In a study of 119 first-year medical students, Kelly et al5 assessed the use of fundus photographs in medical education in the Teaching Ophthalmoscopy to Medical Students (TOTeMS) study and compared the accuracy and preferences of medical students using direct ophthalmoscopy and fundus photographs. Students were more accurate and preferred using fundus photographs over direct ophthalmoscopy. In a 1-year follow-up study (TOTeMS II)2 of 107 of the students who participated in the original TOTeMS study, we demonstrated that the increased accuracy and student preference for fundus photographs over direct ophthalmoscopy persisted after 1 year, with no additional training. However, both the direct ophthalmoscopy and fundus photograph groups performed worse than 1 year prior, likely related to a lack of interim fundus examination skill reinforcement. Indeed, the self-reported median frequency of fundus examination during a general physical examination was less than 10%, and 20% of students cited discouragement from their preceptor as the primary reason for omitting a fundus examination. Certainly, continuing efforts are needed to combat the rising tide of indifference to ocular fundus examination in medical education and clinical practice. As innovative methods such as immersion experiences in ophthalmology-based CSPs and the increasing availability of nonmydriatic fundus cameras have the potential to infuse enthusiasm for ocular fundus examination into medical education, there is hope for the future of ophthalmoscopy.

A New Choroidal Mass In A Patient With Known Metastatic Leiomyosarcoma: Importance Of Fine-needle Aspirate Biopsy In Diagnostic Certainty And Treatment Planning

PURPOSE To report a patient with known metastatic leiomyosarcoma and a new choroidal mass wherein a fine-needle aspirate biopsy was performed to achieve diagnostic and treatment certainty. METHODS A retrospective case report of one patient. RESULTS A 63-year-old woman with known metastatic leiomyosarcoma presented with a new choroidal mass. Metastatic leiomyosarcoma to the choroid has been previously reported. An ab externo fine-needle aspirate biopsy was performed to achieve diagnostic and therapeutic certainty (metastatic leiomyosarcoma is considered radiation insensitive and requires local excision, and choroidal melanoma is treated with I135 plaque brachytherapy). The results were positive for choroidal melanoma as read by two different pathologists at two different sites, and the patient was treated in the conventional manner. The response to treatment at 30 months has been excellent. CONCLUSION When there is diagnostic uncertainty and treatment regimens vary, a fine-needle aspirate biopsy can be diagnostic and can provide direction for care. De novo tumors can be confounded with a metastatic disease in patients with complex histories.

Congenital optic nerve anomaly and migration of subretinal oil: case report and observations in one family.

PURPOSE To describe a case of optic nerve (ON) anomaly and retinal detachment with extensive subretinal silicone oil after repair of retinal detachment. A three-generation family history of ON anomaly, two generations with detachment, is presented. METHODS Retrospective chart review. A multigenerational family with ON anomalies and macular detachment. RESULTS Final repair of retinal detachment was achieved using retinotomy for removal of subretinal 5,000-centistoke silicone oil, gas-fluid exchange, and peripapillary photocoagulation. Silicone oil had been previously used successfully in this eye, yet on subsequent use resulted in subretinal migration. A four patient-three-generation family history of ON anomalies was elicited, and three members were photographed for documentation. CONCLUSION Optic nerve anomalies and macular detachment present a treatment dilemma because they are associated with poor vision and often a suboptimal visual outcome after surgery. This case demonstrates a large amount of subretinal silicone oil, which migrated over a 2-month period. This case series is a report of a three-generational family demonstrating variable expressivity of ON anomalies complicated by macular detachment in two generations.

Fluocinolone acetonide (Iluvien) extended-release intravitreal implant for diabetic macular edema

Fluocinolone acetonide (FAc) is a corticosteroid used in the FAc implant, a novel drug-delivery device currently approved in Europe but not yet approved in the USA. The drug delivery system for FAc implant allows a sustained delivery in a more posterior location in the eye and can be delivered in an outpatient setting. It has been shown to reduce diabetic macular edema via multiple mechanisms including the VEGF pathway. This allows for a more complete resolution in foveal thickness and leakage on fluorescein angiography, which increases best corrected visual acuity. Side effects, such as cataract and increased intraocular pressure, are common for ocular steroids.

Punctate inner choroidopathy and optic neuropathy: simultaneous presentation in a patient - a case report

BackgroundWe present a case of a patient initially presenting with multifocal choroiditis (MFC) in one eye. She subsequently developed lesions most consistent with punctate inner choroidopathy (PIC) in the contralateral eye, followed by acute vision loss from retrobulbar optic neuropathy. Optic neuropathy has been well described in the setting of MFC. There is, however, only one report of its association with PIC. Punctate inner choroidopathy and MFC have many similarities, with visual loss generally resulting from choroidal neovascularization. In this case, the patient had significant visual loss from presumed retrobulbar optic neuropathy.FindingsThe patient responded well to immunomodulation with subsequent return of vision to baseline.ConclusionsMultifocal choroiditis and punctate inner choroidopathy may be a spectrum of the same disease with many overlapping presentations, including optic neuropathy. Good visual recovery and remission were attained with mycophenolate mofetil and systemic corticosteroid treatment.

Intravitreal aflibercept use in the treatment of macular edema from central retinal vein occlusion

Aflibercept is a recently US FDA-approved anti-VEGF agent designed for intravitreal injection. Anti-VEGF agents have recently been demonstrated to be potent inhibitors of neovascular growth and vascular permeability in large clinical trials. The majority of studies of anti-VEGF agents are in the setting of age-related macular degeneration, but studies looking at diabetic macular edema and macular edema from central retinal vein occlusion (CRVO) and branch retinal vein occlusion are increasing the scope of utility of anti-VEGF drugs. Aflibercept for single-use intravitreal injection has been approved in the setting of age-related macular degeneration and in macular edema caused by CRVO in the USA (approval has been sought in Europe). The purpose of this review is to examine the use of aflibercept in the setting of CRVO and the role it may potentially play in the expanding indications for anti-VEGF agents.