N. Delle Noci

Orbital and ocular manifestations of acute childhood leukemia: Clinical and statistical analysis of 180 patients

Purpose To investigate the association between presence of orbital or ocular lesions and type and stage of leukemia and to investigate whether orbital and ocular lesions are significant in predicting leukemia prognosis. Methods The authors evaluated 180 patients with acute childhood leukemia. Lesions associated with leukemia may be classified as specific (due to leukemic infiltration of various ocular tissues), nonspecific (due to one of the secondary complications), or iatrogenic manifestations caused by chemotherapy. Risk-based treatment assignment is based on clinical and laboratory features at diagnosis. Children with presenting white blood cell count below 50,000 mm3 are considered at standard risk for treatment failure, while all others are considered at high risk for treatment failure. Results Specific lesions were noted in 66% of patients with acute myeloid leukemia (AML) and 11.5% patients with acute lymphocytic leukemia (ALL) (p±0.05), and were more severe in patients with high risk leukemia than in patients with standard risk leukemia. Orbital or ocular lesions were noted more commonly in patients with AML (66.6%) compared to patients with ALL (15.1%). In both the AML and ALL groups, there was a higher frequency of leukemic relapses in the bone marrow and/or central nervous system in patients with specific lesions (63.1%) compared to patients with nonspecific lesions (42%), and in patients without orbital or ocular lesions (29.2%) (p±0.05). Conclusions In both the AML and ALL groups, the presence of specific orbital or ocular lesions was associated with a higher frequency of bone marrow relapses and CNS involvement (p±0.05), leading to a lower survival rate.

Nonpenetrating deep sclerectomy with reticulated hyaluronic acid implant versus punch trabeculectomy: a prospective clinical trial.

Purpose To compare the intraocular pressure (IOP)-lowering effect and complication rate of nonpenetrating deep sclerectomy (NPDS) with reticulated hyaluronic acid (SK-GEL®) scleral implant versus traditional punch trabeculectomy (PT) in the management of primary open angle glaucoma (POAG). Methods Prospective, randomized comparative study including 93 patients with uncontrolled POAG. Group 1 (43 eyes) underwent NPDS with SK-GEL® scleral implant; Group 2 (50 eyes) underwent PT Mitomycin C (0.2 mg/mL) was applied intraoperatively in both techniques. Study follow-up evaluations were conducted at 36 and 48 months. Complete success indicated the achievement of the target IOP without antiglaucoma medications, while qualified success indicated the same goal with medications. These categories were assessed at two target IOP levels, <21 mmHg and <18 mmHg. Results At 36 months for complete and qualified success with a <21 and <18 mmHg target IOP, no significant differences were noted between the two groups. At 48 months postprocedure when a <21 mmHg IOP target was considered, the rate of eyes that achieved complete success was 51.1% in the NPDS group versus 72% in the PT group (p<0.05). As for the <18 mmHg IOP target, the rate of eyes that achieved complete success was 32.5% in the NPDS group versus 44% in the PT group (p<0.05). Complications occurred significantly more frequently after PT than after NPDS. Conclusions The IOP-lowering effects of the two procedures were comparable at 36 months. At 48 months PT showed a significantly higher rate of complete success compared with NPDS. Complications were more frequent after PT than after NPDS.

Combined surgical ablation and intravitreal triamcinolone acetonide for retinal angiomatous proliferation

Purpose Neovascular age-related macular degeneration (ARMD) with retinal angiomatous proliferation (RAP) has a poor natural history and the efficacy of any treatment has not yet been established. The authors describe a combined surgical treatment. Methods A 76-year-old woman presented with a best-corrected visual acuity (BCVA) of 20/600 in the right eye and macula with stage 3 RAP as identified by fluorescein angiography (FA), indocyanine green angiography (ICGA), and optical coherence tomography (OCT). After a standard three-port pars plana core vitrectomy (PPV), endodiathermy of the arteriolar and venous feeder vessels of each lesion was performed, intraretinal RAP feeder vessels were cut with manual vertical intraocular scissors, and 0.1 mL of triamcinolone acetonide (TAAC) was injected intravitreally At 1 and 4 weeks and at the sixth month, the patient underwent a complete eye examination, FA, ICGA, and OCT to assess outcomes and complications. Results Six months later, BCVA was stable at 20/300, intraocular pressure was 15 mmHg, anterior segment and vitreous cavity were clear without evidence of TAAC granules, and retina was attached. FA and ICGA showed a complete occlusion of the RAP and absence of leakage or ischemia and OCT demonstrated decreased macular thickness with resolution of both intraretinal edema and pigment epithelium detachment, and the restoration of the normal macular profile. At the end of follow-up, the authors did not observe any ocular or systemic complication. Conclusions Surgical approach to RAP stage 3 with intravitreal injection of 4 mg of TAAC was safe and anatomically effective.

Correlation of visual function impairment and OCT findings in patients with Stargardt disease and fundus flavimaculatus

Purpose To investigate the relationship between morphologic lesions of the retina and functional abnormalities in patients with Stargardt disease (STGD) and fundus flavimaculatus (FFM). DESIGN. Case-controlled, prospective, comparative observational study. Methods A complete ophthalmologic examination, including best-corrected visual acuity (BCVA) and optical coherence tomography (OCT), was performed in 61 eyes of 32 consecutive patients with STGD/FFM and in 60 eyes of 30 matched healthy control subjects. Furthermore, fundus-related perimetry was performed in 12 of the affected eyes. Results The age ranged from 21 to 71 years in STGD/FFM patients and from 21 to 72 years in controls. BCVA ranged from 20/20 to 20/400 and from 20/20 to 20/32, respectively, in STGD/FFM patients and in controls. A foveal thinning was found by OCT Stratus in almost all cases (average 160 μm) compared with controls (average 210 μm) (pp<0.001). BCVA impairment significantly correlated to the degree of foveal thinning (r2=0.16; p=0.0014). Moreover, in STGD/FFM patients the authors observed two types of hyperreflective deposits which were not correlated with BCVA impairment or foveal thinning. In addition, fundus-related perimetry revealed a stable fixation in 8/12 eyes, that was predominantly central in only 4 of these eyes. A smaller degree of foveal thinning correlated to a more stable fixation (p=0.0108), even if not predominantly central (p=0.0218). Conclusions In this series, lower visual acuity and unstable fixation correlated with a greater transverse foveal thinning. OCT and fundus-related perimetry may be useful tools in STGD/FFM patients.

Intravitreal pegaptanib sodium for Irvine-Gass syndrome.

Purpose To report the novel use of intravitreal pegaptanib sodium for the treatment of refractory cystoid macular edema (CME) following cataract extraction. Methods A 72-year-old man presented with decreased visual acuity in his right eye 8 months after uncomplicated phacoemulsification cataract extraction and intraocular lens implantation. His best-corrected visual acuity (BCVA) was 20/125 in the affected eye, and fundus examination revealed CME despite 6 months of oral and topical indomethacin therapy. Fluorescein angiography (FA) showed leakage in the central region with no signs of neovascularization, and optical coherence tomography (OCT) confirmed the diagnosis with thickening of the fovea. Because of his history of glaucoma, the patient chose to be treated with intravitreal pegaptanib sodium 0.3 mg. Results At the 1-week follow-up, BCVA was 20/25, and the FA and OCT revealed almost total resolution of the CME with no adverse sequelae. Six months postinjection, the patients BCVA remained 20/25 with no recurrence of CME. Perimetry revealed a stable fixation within 4° with slight reduction of sensitivity. Conclusions Vascular endothelial growth factor inhibition with intravitreal pegaptanib sodium appears to be of benefit in the treatment of chronic refractory CME with improvement of visual acuity. Studies evaluating pegaptanibs use in this setting with long-term follow-up are warranted to confirm its efficacy and safety.