Paolo Ferreri

Intravitreal triamcinolone acetonide in refractory pseudophakic cystoid macular edema: functional and anatomic results.

Purpose To evaluate safety and efficacy of intravitreal triamcinolone acetonide (TAAC) injections in the treatment of refractory pseudophakic cystoid macular edema (CME). Methods Seven eyes of six patients (age range: 50–74) with pseudophakic CME resistant to standard treatment received intravitreal injections of 4 mg of TAAC with all vehicle. Mean preinjection duration of CME was 18.3 months. A mean of 2.1±1.2 (range 1 to 4) treatments were performed in four eyes (57.1%) when visual acuity deteriorated towards baseline levels. Visual acuity assessment, optical coherence tomography (OCT), and fluorescein angiography (FFA) were performed pre- and postoperatively to evaluate results of TAAC injections. Intraocular pressure (IOP) and complications related to treatment were assessed. Results After 11.1±3.9 months, mean best-corrected visual acuity (BCVA) increased (p=0.019) from 20/132 to a best value of 20/38. Mean macular thickness decreased from 517.29±146.98 mm to a best value of 263.71±83.13 mm (p=0.0018). Area of fluorescein leakage decreased (p<0.0001) from 11.84±0.93 mm2 at baseline to a minimal value of 3.86±0.98 mm2. The anatomic and functional improvement appeared after 1 month from the intravitreal injection and persisted through at least 3 months of follow-up. At the end of follow-up BCVA, macular thickness, and area of fluorescein leakage did not differ from baseline. Four eyes (57.1%) developed IOP values higher than 21 mmHg, controlled by topical treatment. Two patients developed an endophthalmitis-like reaction. Conclusions Intravitr eal TAAC was relatively safe and effective in resistant cases of pseudophakic CME with a temporary beneficial effect on visual acuity and macular edema.

Efficacy of the fixed combinations of bimatoprost or latanoprost plus timolol in patients uncontrolled with prostaglandin monotherapy: A multicenter, randomized, investigator-masked, clinical study

Purpose To compare the efficacy and tolerability of a once-daily evening dose of bimatoprost/timolol fixed combination (BTFC) with that of a once-daily evening dose of latanoprost/timolol fixed combination (LTFC) in patients not controlled with prostaglandins analogues monotherapy. Methods A total of 82 patients on prostaglandin analogues monotherapy were enrolled in this prospective, multicenter, investigator masked, clinical study and were randomized to either BTFC (n=47) or LTFC (n=35) topical therapy once at night for 12 weeks. The primary endpoint of the study was to compare the mean daily intraocular pressure (IOP) reduction from baseline between the two treatment arms. Secondary endpoints included the mean daily IOP at 1 and 3 months compared to baseline and the percentage of patients showing a mean IOP reduction from baseline greater than or equal to 15% or 20%. Results Mean IOP at baseline was 22.7±2.0 and 22.1±2.6 mmHg in the BTFC and LTFC groups, respectively (p=0.23). Both treatments were effective in reducing the IOP from baseline. The mean IOP reduction was significantly greater in the BTFC group than in the LTFC group (–21.4% vs −13.7%, p<0.001). A higher percentage of patients in the BTFC group showed a mean IOP reduction from baseline ≥ 15% (72.3% vs 40.0%) and ≥ 20% (61.7% vs 17.1%) compared to patients in the LTFC group. Conclusions Both BTFC and LTFC were more effective versus the monotherapy with prostaglandin analogues. BTFC demonstrated higher performance than LTFC in terms of relative IOP reduction.

Intravitreal triamcinolone acetonide: valuation of retinal thickness changes measured by optical coherence tomography in diffuse diabetic macular edema.

Purpose The authors studied the efficacy of intravitreal triamcinolone acetonide in a case series of patients with diffuse diabetic macular edema without evidence of vitreous-macular traction refractory to laser photocoagulation. Methods Six eyes with clinically diffuse diabetic macular edema that failed to respond to at least two previous sessions of laser photocoagulation were included. The mean age of selected patients was 72.5 ± 13.8 years, with a preoperative best-corrected visual acuity reduced to 1.48 ± 0.18 logMar and a mean baseline intraocular pressure (IOP) of 15.17 ± 2.64 mmHg. The authors also studied macular thickness measured by optical coherence tomography (OCT 2000 scanner, Humphrey Instruments, San Leandro, CA) – in the preoperative period it was 640.8 ± 171.1 μm – and the fluorangiographic (Heidelberg Retina Angiograph, Heidelberg Engineering GmbH, Heidelberg, Germany) patterns, which showed pooling in tardy phases and leakage. Mean follow-up was 4 months. Results In each patient the authors observed a significant improvement, both functionally and anatomically. Mean best-corrected visual acuity increased in the postoperative period to 0.94 ± 0.53 logMar. No patient showed decline of visual acuity at the end of follow-up. Base line macular thickness was reduced in the postoperative period to 312.2 ± 157.65 μm measured by OCT and fluorangiographic patterns showed a reduction of pooling and of leakage. The most common complications described in the literature were not observed and the increase of mean IOP in the postoperative period to 18.76 ± 5.72 mmHg was not significant. Conclusions Intravitreal triamcinolone acetonide may decrease macular edema and improve visual acuity in eyes with diffuse diabetic macular edema.

Combined radial optic neurotomy, internal limiting membrane peeling, and intravitreal triamcinolone acetonide for central retinal vein occlusion.

To evaluate the efficacy of radial optic neurotomy, internal limiting membrane peeling, and intravitreal triamcinolone acetonide for central retinal vein occlusion. Eight consecutive eyes with central retinal vein occlusion with a duration of less than 6 months, cystoid macular edema, and best-corrected visual acuity (BCVA) of less than 20/200 were enrolled. BCVA, intraocular pressure, fluorescein angiography, and optical coherence tomography were evaluated. After 4.75 +/- 0.7 months, BCVA significantly improved, intraocular pressure was well controlled, and fluorescein angiography showed perfused state and reduction of the number of retinal hemorrhages in all eyes. Optical coherence tomography revealed significant reduction of macular thickness. Bleeding in the neurotomy site occurred in 3 cases. Radial optic neurotomy, internal limiting membrane peeling, and intravitreal triamcinolone acetonide may be useful in the management of central retinal vein occlusion with macular edema.

Ex-PRESS miniature glaucoma device in vitrectomized eyes.

Purpose To evaluate the clinical efficacy and safety of the Ex-PRESS miniature glaucoma device placed under scleral flap for the treatment of ocular hypertension in eyes that underwent vitreoretinal surgery. Methods Vitrectomized patients who required glaucoma surgery for persistent ocular hypertension were included. The Ex-PRESS miniature glaucoma device was implanted under scleral flap. Postsurgical clinical outcomes and intraocular pressure (IOP) was monitored for 6 months after surgery. Results At 6 months, all the patients had an IOP lower than 18 mmHg, 3 of them without topical therapy. Conclusions The use of the Ex-PRESS implant under scleral flap in eyes that underwent vitreoretinal surgery was effective for lowering IOP

Primary open angle glaucoma: an overview on medical therapy.

The purpose of this review is to discuss the topics relevant to the use of intraocular pressure-lowering strategies, which remains the first line in the management of glaucoma. Estimates of blindness from glaucoma and identification of risk factors remain of interest for all ophthalmologists. New functional tests offer promise for better detection and more accurate diagnosis of glaucoma. We finally discuss the impact of various glaucoma therapies, the principles of monotherapy and fixed combinations, which offer benefits of convenience, cost, and safety.

Surgical reposition of a dislocated Ex-PRESS miniature device

Purpose TO present a technique of surgical reposition of the Ex-PRESS miniature glaucoma device when dislocated in corneal limbus. Methods A 54-year-old woman diagnosed with glaucoma, with a 3-month history of Ex-PRESS miniature implant, was referred to our department because of progressive intraocular pressure (IOP) rise. Slit-lamp biomicroscopy showed the posterior flange of the implant located in the corneal limbus; IOP was 34 mmHg. Surgical technique consisted of reopening of the conjunctiva and the scleral flap, excision of the corneal tissue covering the flange, and stitching the implant to the sclera with polyprolene suture. Results Postoperatively, IOP rapidly reduced to 5 mmHg and was balanced to 10 mmHg in the follow-up. Conclusions Corneal dislocation of the Ex-PRESS implant, when associated with ocular hypertension, needs surgical treatment. Before considering a trabeculectomy, it could be valuable to attempt an implant reposition.

Is There Still a Clinical Use for Scanning Laser Polarimetry with Fixed Corneal Compensator

Purpose: To compare the scanning laser polarimetry device with a fixed corneal compensator (GDx FCC) with the new version with a variable corneal compensator (GDx VCC) in healthy subjects. Methods: A prospective, nonrandomized, comparative trial was carried out with both the FCC and the VCC systems on 130 healthy volunteers. The FCC measurements were divided into 2 subgroups, in accordance with the appearance of the macula. Subjects with a uniform aspect of the macula were included in the macula-‘negative’ group (macula–), whereas subjects with an irregular macular appearance with FCC were included in the macula-‘positive’ group (macula+). Data relative to all the GDx parameters were examined. For each parameter, we compared the data obtained by the FCC to the VCC models. Subsequently we compared each FCC subgroup (macula+ and macula–) to VCC. Results: A total of 67 subjects entered the macula– group and 63 the macula+ group. FCC significantly overestimated the average parameters and underestimated the number, the modulation and also the ratio parameters. The only parameter showing no difference was symmetry. Similar trends were also evident when the subjects were divided into the macula+ and – subgroups. Conclusion: Individual variations of corneal birefringence, which are not completely corrected by FCC, result in over- or underestimation of retinal nerve fiber layer parameters. This measurement error cannot be eliminated, not even by only selecting patients with a uniform aspect of macular scan. For this reason GDx FCC does not seem to be an acceptable tool in the early diagnosis of glaucoma, and modern versions of this device should be preferred.

Intravitreal triamcinolone acetonide: valuation of retinal thickness changes measured

PURPOSE The authors studied the efficacy of intravitreal triamcinolone acetonide in a case series of patients with diffuse diabetic macular edema without evidence of vitreous-macular traction refractory to laser photocoagulation. METHODS Six eyes with clinically diffuse diabetic macular edema that failed to respond to at least two previous sessions of laser photocoagulation were included. The mean age of selected patients was 72.5 13.8 years, with a preoperative best-corrected visual acuity reduced to 1.48 0.18 logMar and a mean baseline intraocular pressure (IOP) of 15.17 2.64 mmHg. The authors also studied macular thickness measured by optical coherence tomography (OCT 2000 scanner, Humphrey Instruments, San Leandro, CA) in the preoperative period it was 640.8 171.1 m and the fluorangiographic (Heidelberg Retina Angiograph, Heidelberg Engineering GmbH, Heidelberg, Germany) patterns, which showed pooling in tardy phases and leakage. Mean follow-up was 4 months. RESULTS In each patient the authors observed a significant improvement, both functionally and anatomically. Mean best-corrected visual acuity increased in the postoperative period to 0.94 0.53 logMar. No patient showed decline of visual acuity at the end of follow-up. Base line macular thickness was reduced in the postoperative period to 312.2 157.65 m measured by OCT and fluorangiographic patterns showed a reduction of pooling and of leakage. The most common complications described in the literature were not observed and the increase of mean IOP in the postoperative period to 18.76 5.72 mmHg was not significant. CONCLUSIONS Intravitreal triamcinolone acetonide may decrease macular edema and improve visual acuity in eyes with diffuse diabetic macular edema. (Eur J Ophthalmol 2004; 14: 321-4).

RE-PERG, a new procedure for electrophysiologic diagnosis of glaucoma that may improve PERG specificity

Purpose A significant variability of the second harmonic (2ndH) phase of steady-state pattern electroretinogram (SS-PERG) in intrasession retest has been recently described in glaucoma patients (GP), which has not been found in healthy subjects. To evaluate the reliability of phase variability in retest (a procedure called RE-PERG or REPERG) in the presence of cataract, which is known to affect standard PERG, we tested this procedure in GP, normal controls (NC), and cataract patients (CP). Methods The procedure was performed on 50 GP, 35 NC, and 27 CP. All subjects were examined with RE-PERG and SS-PERG and also with spectral domain optical coherence tomography and standard automated perimetry. Standard deviation of phase and amplitude value of 2ndH were correlated by means of one-way analysis of variance and Pearson correlation, with the mean deviation and pattern standard deviation assessed by standard automated perimetry and retinal nerve fiber layer and the ganglion cell complex thickness assessed by spectral domain optical coherence tomography. Receiver operating characteristics were calculated in cohort populations with and without cataract. Results Standard deviation of phase of 2ndH was significantly higher in GP with respect to NC (P<0.001) and CP (P<0.001), and it correlated with retinal nerve fiber layer (r=−0.5, P<0.001) and ganglion cell complex (r=−0.6, P<0.001) defects in GP. Receiver operating characteristic evaluation showed higher specificity of RE-PERG (86.4%; area under the curve 0.93) with respect to SS-PERG (54.5%; area under the curve 0.68) in CP. Conclusion RE-PERG may improve the specificity of SS-PERG in clinical practice in the discrimination of GP.