Pedro Paulo Bonomo

Selective occlusion of subfoveal choroidal neovascularization in pathologic myopia using a new technique of ingrowth site treatment.

PURPOSE To evaluate the visual and angiographic effects as well as optical coherence tomography findings after a new technique of ingrowth site treatment of subfoveal choroidal neovascularization (CNV) secondary to pathologic myopia with the use of indocyanine green (ICG)-mediated photothrombosis. DESIGN Interventional, noncomparative case series. METHOD In the setting of a tertiary referral center, patients with pathologic myopia in whom fluorescein and conventional ICG angiography demonstrated distinct CNV vessels supplying the subfoveal neovascular complex were submitted to focal ingrowth site treatment using a new therapeutic modality termed ICG-mediated photothrombosis. Prospective evaluation including visual acuity assessment, fluorescein and ICG angiography, and optical coherence tomography (OCT) evaluation was performed at weeks 1, 12, 24, and 48 after treatment. RESULTS Six consecutive patients (six eyes) had treatment using a single session of ICG-mediated photothrombosis at the CNV ingrowth site. Obliteration of the entire neovascular complex was achieved immediately after treatment in all patients. At last follow-up, visual acuity improvement of 1 or more Early Treatment Diabetic Retinopathy Study lines was observed in five of six patients, and fluorescein angiography showed an absence (four eyes) or minimal leakage (two eyes) from CNV. Indocyanine green angiography demonstrated selective obliteration of the neovascular complex. Accordingly, reduction of retinal edema was observed in the OCT evaluation in all patients. There was no significant complication related to the procedure. CONCLUSIONS The use of lower irradiances of 810- nm continuous light application and intravenous ICG infusion for neovascular ingrowth site photothrombosis induced selective CNV hypoperfusion, as demonstrated by fluorescein and ICG angiography in patients with pathologic myopia. These findings were either consistent with the visual acuity improvement observed in five of six patients or with the partial restoration of the retinal architecture seen in OCT evaluation 12 months after treatment.

Ultrasound biomicroscopy in recently postoperative 23-gauge transconjunctival vitrectomy sutureless self-sealing sclerotomy.

Purpose: To evaluate the ultrasound biomicroscopy (UBM) images of recent postoperative 23-gauge vitrectomy using single- and 2-step techniques. Methods: Twelve consecutive eyes were randomized and submitted to 23-gauge sutureless transconjunctival vitrectomy surgery divided in 2 groups: 1) using a beveled trocar to insert the microcannula (single step) and 2) using a stiletto blade to perform first a tunnel incision and then insert the microcannula (2 steps). All patients underwent 3-port vitrectomy with a straight angled incision of 20° to 30°. Ultrasound biomicroscopy examination was performed after 8 days to 10 days of surgery to locate and document the sclerotomy sites. Results: All patients had at least two diameters of the incision measured, and all wounds were constructed obliquely. Single-step sclerotomy mean size was 375.40 μm ± 83.70 μm (range, 280.4–695 μm) and coefficient of variation (CV) was 0.21. Two-step sclerotomy mean size was 315.5 μm ± 56.8 μm (range, 253.2–362.5 μm; CV = 0.26; P = 0.556). Two patients had an intraocular 5,000 centistokes silicone oil injection, one for each group. Only in the single-step incision was silicone oil observed in the wound. Conclusion: Twenty-three-gauge single- and two-step sclerotomies showed no statistical difference in site diameter at UBM. Postoperative UBM examination allowed the evaluation of the wound architecture. A large sample size comparing both surgical techniques should provide a statistical difference.

Prevalence of retinopathy of prematurity: an institutional cross-sectional study of preterm infants in Brazil

OBJECTIVE Retinopathy of prematurity (ROP) is the leading cause of childhood blindness in most developed countries. This study aimed to verify ROP prevalence among all very low birth weight (VLBW) preterm infants admitted to a level-3 teaching hospital in Porto Alegre, Rio Grande do Sul, Brazil. METHODS Institutional cross-sectional study of 407 premature infants with birth weight < or = 1,500 g or gestational age (GA) < or =32 weeks between 2002 and 2007. All infants screened for ROP were examined after the fourth week of life and followed up until the 45th week of adjusted GA. ROP prevalence was estimated at a 95% confidence level. RESULTS Some degree of ROP in one or both eyes occurred in 25.5% (104) of all screened infants, and severe ROP (threshold stage 3 or higher, requiring treatment to prevent vision loss, as per the criteria of the U.S.-based Multicenter Trial of Cryotherapy for Retinopathy of Prematurity, CRYO-ROP) occurred in 5.8% (24). Based on the criteria of The International Classification for Retinopathy of Prematurity (ICROP, 1984/1987), the disease reached stages 1, 2, and 3 in 11.3% (46), 8.4% (34), and 5.4% (22), respectively. One infant developed the disease up to stage 4 (partial retinal detachment), and one progressed to stage 5 (complete retinal detachment, resulting in 0.2% overall prevalence for ROP-induced blindness). CONCLUSIONS Overall incidence of ROP in this institutional study (25.5%) was comparable to international results from developed countries. A comprehensive countrywide survey on ROP in Brazil is recommended to determine any regional differences in disease prevalence.

Clinical Course of Choroidal Neovascularization Secondary to Angioid Streaks Treated With Intravitreal Bevacizumab

BACKGROUND AND OBJECTIVE To evaluate visual acuity and anatomical outcomes of choroidal neovascularization (CNV) associated with angioid streaks after treatment with intravitreal bevacizumab injections. PATIENTS AND METHODS Best-corrected visual acuity, optical coherence tomography measurements (OCT), fluorescein and indocyanine green angiography, and ophthalmoscope examination at baseline and at each follow-up visit were performed. Five patients with CNV associated with angioid streaks were treated with injections of intravitreal bevacizumab (1.25 mg/0.05 mL). Re-treatment was recommended with symptomatic lesions, new subretinal hemorrhages, leakage on fluorescein and indocyanine green angiography, and/or fluid documented by OCT. Follow-up ranged between 18 and 32 months. RESULTS All eyes showed an improvement of visual acuity and were treated with at least four injections of intravitreal bevacizumab. Reduction of the leakage shown by fluorescein angiography and OCT was noted in all patients. CONCLUSION Intravitreal bevacizumab appears to be effective in stabilizing and recovering visual acuity in eyes with CNV associated with angioid streaks. Patients with early symptoms might benefit more.

Agreement between optical coherence tomography and fundus fluorescein angiography in post-cataract surgery cystoid macular edema

PURPOSE: To evaluate the agreement between optical coherence tomography (OCT) and fundus fluorescein angiography (FFA) regarding the detection of cystoid macular edema (CME) following cataract surgery. METHODS: Retrospective comparative observational series of 25 eyes with suspected CME. Patients with low visual acuity and alterations in fundus biomicroscopy after cataract surgery underwent OCT scanning followed by FFA on the same visit. The diagnosis of CME was established considering fluorescein leakage on FFA and retinal thickness and/or cystoid spaces and/or subretinal fluid on OCT. RESULTS: Twenty-five eyes of 25 patients were enrolled. Twenty-two eyes had similar results on both OCT and FFA, of which 15 eyes had CME and 7 eyes had no CME. Two eyes had CME detected only by FFA and one eye only by OCT. The agreement between the two examinations was good (Kappa = 0.7331; p=0.0001) with no tendency to have neither more positive nor negative findings (p=1.0). CONCLUSION: According to these preliminary data, OCT seems to be as effective as FFA to detect CME with a good agreement between the two techniques.

Prevalência de tracoma em crianças pré-escolares e escolares da periferia da cidade de Joinville, Estado de Santa Catarina, Brasil

Joinville e a maior cidade do Estado de Santa Catarina. Gracas ao seu desenvolvimento industrial, principalmente nos ultimos 15 anos, a cidade tem recebido muitos migrantes vindos de area rurais, na maioria dos Estados de Santa Catarina e Parana. Um estudo de prevalencia de tracoma foi realizado entre 2.822 criancas pre-escolares e escolares, com idade variando de 3 meses a 15 anos (media igual a 8,4 anos), que frequentavam 6 instituicoes educacionais publicas localizadas em diferentes regioes da periferia de Joinville. 53,2% das criancas eram do sexo masculino. O tracoma foi avaliado de acordo com o esquema simplificado de gradacao da OMS. A prevalencia de TF foi de 7.9% e a de TS foi de 1,1%. Nao se observou TI, TT ou CO. 65% das criancas tracomatosas eram procedentes de centros urbanos e 35% eram de areas rurais. A citologia com a coloracao pelo anticorpo monoclonal fluorescente foi positiva em 57% dos casos de TF

Regression of Drusen After Combined Treatment Using Photodynamic Therapy With Verteporfin and Ranibizumab

Drusen are the clinical hallmark of age-related macular degeneration. The regression of these deposits in patients treated with argon, krypton, or diode laser photocoagulation has been reported previously. However, previous protocols with conventional laser for drusen may result in retinal pigment epithelium (RPE) damage and unwanted scotomas. The authors report a case of complete regression of soft drusen in a 65-year-old man with central visual loss and metamorphopsia due to a drusenoid RPE detachment and soft drusen who underwent reduced-fluence photodynamic therapy (PDT) and three monthly intravitreal injections of ranibizumab. Reduced-fluence PDT combined with anti-VEGF therapy may reduce drusen without inducing RPE cell damage.

Susac syndrome: diverse clinical findings and treatment

We report a case of a 19-year-old woman presenting bilateral neurosensorial hearing loss, mental abnormalities, and loss of visual field in the left eye. Visual acuity was 20/20 in OD and 20/25 in OS. Patient was examined systemically. Audiometry showed sensorineural hearing loss in both ears. The magnetic resonance imaging (MRI) of brain revealed multiple small lesions in the white matter in both cerebral hemispheres and at the corpus callosum. Fundoscopy showed bilateral normal optic disc and sheathing of the arterioles in the middle periphery of OD. Retinal edema and cotton-wool spots were observed. Fluorescein angiography showed bilateral peripheral occlusive arterial vasculopathy. The patient was diagnosed with Susac syndrome and treated with quetiapine fumarate, flunitrazepam, and prednisone, which resulted in stabile outcome. This case shows that a high index of suspicion leading to early recognition and treatment is important to avoid irreversible damage.

Retinopatia da prematuridade limiar em crianças submetidas à terapia com surfactante exógeno endotraqueal

OBJECTIVE: To study the frequency of retinopathy of prematurity (ROP) in any stage and its threshold form in premature infants, either treated or non-treated with exogenous surfactant to neonatal respiratory distress syndrome, and evaluate the response of eyes with threshold retinopathy to ablation treatment. METHODS: One hundred and sixty eight premature infants who weighed 1500 grams or less and/or who had a gestational age of 32 weeks or less, were screened for ROP by ophthalmoscopy. We compared findings in 40 patients treated with exogenous endotracheal surfactant, with those of 128 patients who did not require such therapy. Ablation of ischaemic peripheral retina, either with laser or cryotherapy, was applied in cases of threshold ROP. For statistical analysis Students t, qui-square, Kruskal-Wallins and Fishers exact tests were used, with p value of < 0.05 considered as significant. RESULTS: ROP, in any stage, occurred in 51,2% of children. Threshold ROP, requiring treatment, was found in 12 (7,4%) of them and regressed in 9. There was no significant difference between surfactant treated and non-treated patients, regarding the occurrence of ROP and threshold ROP. CONCLUSION: In this study frequency of ROP can be considered high, when compared with other series. Children with distress respiratory syndrome, treated with surfactant, did not show a higher risk of threshold ROP. Treatment was successfull in promoting disease regression.

Indocyanine green-mediated photothrombosis for choroidal neovascularization in angioid streaks

PURPOSE To investigate the effect of indocyanine green-mediated photothrombosis on choroidal neovascularization secondary to angioid streaks. METHODS Six eyes of 5 patients with an average age of 70 years were diagnosed to have subfoveal choroidal neovascularization secondary to angioid streaks. Therapy was indicated if choroidal neovascularization was considered to be active, according to evidence of fluorescein leakage on angiograms, as well as presence of intra- or subretinal fluid on optical coherence tomography. Patients received photothrombosis at baseline with retreatment as necessary at 3, 6 and 9 months follow-up. Fluorescein leakage was assessed at 3, 6 and 9 months, along with foveal thickness measured by optical coherence tomography. Indocyanine green angiography was performed initially and whenever retreatment was considered. Retreatment was performed whenever there was evidence of increased leakage on fluorescein angiograms at follow-up visits. RESULTS The mean follow-up was 13.3 months. All eyes had at least 12 months follow-up. Two eyes underwent retreatment. Three eyes had visual acuity improvement and three eyes had stabilization. All patients showed less fluorescein leakage on final angiograms and reduced foveal thickness upon optical coherence tomography measurement. CONCLUSION Photothrombosis is a feasible procedure for choroidal neovascularization secondary to angioid streaks. Lesion analysis showed anatomical improvement in most cases in this series. Further studies are warranted to evaluate long-term results of this treatment.