Pilar Calvo

Dexamethasone intravitreal implant as adjunct therapy for patients with wet age-related macular degeneration with incomplete response to ranibizumab

Purpose To evaluate the visual and anatomical outcomes of dexamethasone intravitreal implant (DXI; 700u2005μg, Ozurdex; Allergan, Irvine, California, USA) as adjunctive therapy for patients with refractory wet age-related macular degeneration (AMD). Methods Retrospective review of the medical records of seven patients (seven eyes) who initially responded well to intravitreal ranibizumab but subsequently developed persistent intra/sub-retinal fluid (IRF/SRF) and underwent a single injection of DXI, between May 2012 and May 2013. Two weeks after DXI, the patients continued with their monthly ranibizumab injections. Best corrected visual acuity (BCVA) logarithm of the minimum angle of resolution (logMAR) and central retinal thickness (CRT) were recorded at baseline, 2u2005weeks, 6u2005weeks, 3u2005months and 6u2005months after DXI injection. Complications were recorded too. Results All patients had at least 24u2005months of ranibizumab treatment. Mean age was 81.5±5.8u2005years. At baseline, mean BCVA was 0.53±0.13 logMAR (20/70 Snellen) and mean CRT was 273.14±50.94u2005μm. BCVA did not change significantly after DXI over the follow-up period. However, all eyes had lost fewer than 0.3u2005logMAR units. Complete resolution of the persistent IRF/SRF was achieved in five eyes (71.4%) at 6u2005weeks, and remained stable at 3u2005months. Two weeks after DXI injection, the mean CRT diminished compared with baseline (248.28±31.8u2005µm; p=0.03) and the greatest reduction was observed at 3u2005months after DXI injection (241.5±36.6u2005µm; p=0.04). Progression of lens opacity was detected in one case (50% of phakic eyes). Retreatment with DXI was performed in two eyes. Conclusions DXI appears to be effective in vision stabilisation, decreasing IRF/SRF and improvement of CRT in eyes with refractory wet AMD.

Threatened preterm labor is a risk factor for impaired cognitive development in early childhood

BACKGROUND: Threatened preterm labor is a leading cause of hospital admission during pregnancy. Patients with an episode of threatened preterm labor who deliver at term are considered to have false preterm labor. However, threatened preterm labor has been proposed as a pathologic insult that is not always sufficient to induce irreversible spontaneous preterm birth but that could alter the normal course of pregnancy. OBJECTIVE: The aim of this study was to evaluate threatened preterm labor during pregnancy as a risk factor of neurodevelopmental deficits of children at 2 years of age. STUDY DESIGN: Two‐year‐old children who were born late preterm (n=22) or at term after threatened preterm labor (n=23) were compared with at‐term control children (n=42). Neurodevelopment was evaluated at a corrected age of 24–29 months with the use of the Merrill‐Palmer‐Revised Scales of Development. RESULTS: Children who were born at term after threatened preterm labor had lower scores than control children on global cognitive index (95.4 vs 104.2; P=.011), cognition (95.1 vs 103.1; P=.021), fine motor (95.2 vs 103.4; P=.003), gross motor (84.7 vs 99.8; P=.001), memory (92.9 vs 100.4; P=.015), receptive language (93.9 vs 102.9; P=.03), speed of processing (105.7 vs 113.3; P=.011), and visual motor coordination (98.8 vs 106.7; P=.003) subtests. Children born at term after threatened preterm labor had an increased risk of mild neurodevelopmental delay compared with control children (odds ratio for global cognitive index, 2.06; 95% confidence interval, 1.09–3.88; P=.033). There were no significant differences in any cognitive domain between children who were born late preterm and children who were born at term after threatened preterm labor. CONCLUSIONS: Threatened preterm labor is a risk factor for impaired cognitive development at 2 years of age, even if birth occurred at term.

Use of a New Ocular Insert versus Conventional Mydriasis in Cataract Surgery

Background. To compare the efficacy and safety of a new ocular insert versus conventional mydriasis in cataract surgery. Methods. We selected 70 patients undergoing cataract surgery. Thirty five patients (Group 1) received instillation of mydriatic drops (tropicamide 1%, phenylephrine 10%, and cyclopentolate 1%) prior to surgery, and 35 patients (Group 2) had a Mydriasert insert (Théa Pharma) (0.28u2009mg of tropicamide and 5.4u2009mg of phenylephrine hydrochloride) placed in the inferior fornix. Pupil size before and after surgery, blood pressure, and heart rate were measured. Results. Before surgery, pupil diameter was 9.44 ± 1.17u2009mm in Group 1 and 9.05 ± 1.54 in Group 2 (P > 0.05). Twenty four hours after surgery, pupil diameter was 5.20 ± 1.54u2009mm in Group 1 and 3.33 ± 1.15 in Group 2 (P < 0.001). There were no statistically significant differences in blood pressure or heart rate between groups. Conclusions. The effect of the Mydriasert insert was similar to conventional mydriatic agents. Pupil size was restored to normal faster when using the Mydriasert insert compared with conventional mydriatic agents for pupil dilation.

Long-term outcomes of intravitreal ranibizumab for choroidal neovascularization secondary to Best’s disease: 3-year follow-up

and vitreous haemorrhage occasionally preclude adequate laser therapy. An alternative treatment could ameliorate these difficulties. Intravitreal bevacizumab combined with PRP resulted in better regression of Neovascularisation (NV) and less vision loss compared with PRP alone (Mason et al. 2008; Tonello et al. 2008). We investigated intravitreal bevacizumab injections alone without prior PRP in a prospective, paired-eye, randomized pilot study. Potential benefits of intravitreal bevacizumab include preventing macular oedema, treating both PDR and macular oedema concurrently prior to performing PRP, and temporising until vitreous haemorrhage cleared to allow adequate PRP. Patients with type 2 diabetes mellitus and symmetric untreated severe NPDR or PDR without macular oedema or prior intraocular surgery were included. Informed consent was obtained which clearly explained that the standard treatment for their condition was PRP. The patients were notified the eye treated with intravitreal bevacizumab probably would require PRP at the end of the study. Best corrected visual acuity (BCVA), ophthalmologic examination, macular OCT, fundus photography and fluorescein angiography were performed at baseline and serially. Patients were evaluated every 2 months for 12 months total follow-up. The right eye was randomly assigned to treatment with PRP or intravitreal bevacizumab, and the left eye received the other treatment. Eyes randomized to bevacizumab 2.5 mg (0.1 ml) (Avastin, Genentech, San Francisco, CA, USA) were injected every 2 months during the study. Fellow eyes randomized to PRP were treated in two sessions, with a third session only if there was angiographic evidence of neovascular activity at month 4. Fifteen patients were enrolled. Unfortunately, five patients were lost to follow up between the baseline exam and the 2month visit, and we were unable to ascertain the reasons these patients left. Ten patients (20 eyes) were followed for 12 months. Seven were women and the average age was 53 ± 9 years. Five patients had PDR and five had severe NPDR. Baseline BCVA and central macular thickness (CMT) were not statistically different between groups (p = 0.67 and p = 0.38, Mann–Whitney U test). None of 10 eyes with severe NPDR developed PDR. In 10 eyes with PDR, neovascular leakage completely resolved in four of five eyes treated with bevacizumab and in one of five eyes treated with PRP (p = 0.11, chi-square mid-P exact). Final CMT was significantly less in eyes treated with bevacizumab compared to those treated with PRP, 197 ± 17 lm versus 243 ± 49 lm, respectively (p = 0.012). BCVA (logMAR) pretreatment was )0.12 ± 0.22 and )0.14 ± 0.23 compared with )0.14 ± 0.19 and )0.17± 0.10 post-treatment (p = 0.52 and 0.64, bevacizumab and PRP groups, respectively). None of 10 eyes treated with bevacizumab injections every 2 months developed a complication. Two eyes treated with PRP developed vitreous haemorrhage. Three of 10 eyes treated with PRP developed macular oedema compared with none in the bevacizumab group. As this was a fellow eye controlled study, the effects of glycaemic and blood pressure control would equally impact both eyes of each patient. Intravitreal bevacizumb 2.5 mg injections every 2 months effectively controlled NV and resulted in a thinner CMT than PRP at 1 year. There were no differences in mean BCVA, which was expected given the good baseline vision and the small sample size. In a total of 60 bevacizumab injections, there were no complications, such as endophthalmitis or tractional retinal detachment. The main limitations of this study are the small sample size and the large proportion of patients lost to follow up. Despite the small sample size, the difference in final CMT achieved statistical significance. In summary, repeated intravitreal bevacizumab injections controlled NV in treatment-naı̈ve eyes with PDR and severe NPDR for 1 year, but this finding needs to be confirmed by a larger study. PRP remains the gold-standard treatment for these eyes. In the future, longer-lasting anti-VEGF agents may be able to avoid the complications associated with PRP. Intravitreal bevacizumab may be a useful temporising measure in eyes with macular oedema or vitreous haemorrhage until adequate PRP can be performed, but further study is required.

Diabetic Macular Edema: Options for Adjunct Therapy.

Diabetes mellitus (DM) is a chronic disease that affects 387 million people worldwide. Diabetic retinopathy (DR), a common complication of DM, is the main cause of blindness in the active population. Diabetic macular edema (DME) may occur at any stage of DR, and is characterized by vascular hyperpermeability accompanied by hard exudates within the macula. Medical and surgical therapies have dramatically reduced the progression of DR, and timely intervention can reduce the risk of severe vision loss by more than 90xa0%. In 2012, intravitreal ranibizumab became the first antivascular endothelial growth factor (anti-VEGF) agent approved for DME and, since then, many reports of the use of ranibizumab for DME have been promising. Randomized, prospective, multicenter clinical trials—most notably, RESOLVE, READ-2, RISE/RIDE, RESTORE, DRCR.net protocol I, and RETAIN—reported improvements in best-corrected visual acuity and decreased central retinal thickness as measured with optical coherence tomography in patients with DME. Similar treatment benefits have also been noted in clinical trials evaluating intravitreal aflibercept and bevacizumab (DAVINCI, VISTA/VIVID, and BOLT) and more recently DRCR.net protocol T. Intravitreal steroids (dexamethasone intravitreal implant and fluocinolone acetonide), particularly in refractory cases, also play a significant role in the management of DME (MEAD/CHAMPLAIN and FAMOUS/FAME studies). In summary, over the last 5xa0years, blocking VEGF and inflammation has been shown to improve visual outcomes in patients with macular edema due to DM, revolutionizing the treatment of center-involved DME and establishing a new standard of care.

Clinical Applications of Dexamethasone for Aged Eyes

The risk of severe eye problems has been found to increase significantly with age, particularly between the fifth and sixth decades of life. Cataracts, dry eye, neovascular age-related macular degeneration, diabetic retinopathy and retinal vein occlusion (RVO) are very common and very different age-related ocular diseases that reduce the patient’s quality of life. The rationale for using corticosteroids to treat anterior and posterior ocular segment diseases is driven by inflammation. Dexamethasone, one of the most powerful corticosteroids available, is widely used for topical or intravitreal administration. Topical dexamethasone has proven efficacy for the management of postoperative inflammation in the anterior segment after cataract surgery and symptom relief in dry-eye disease. A new sustained-release 700xa0µg dexamethasone intravitreal implant (DEX) was recently approved for the treatment of macular edema following RVO, diabetic macular edema, or non-infectious uveitis, and its use is increasing, especially when other therapeutic agents have failed. The most common side effects are increased intraocular pressure and cataract formation. The potency of DEX, alone or in combination with other agents, makes DEX a promising option for treating several retinal diseases.

Assessment of the retinal nerve fiber layer in individuals with obstructive sleep apnea

BackgroundThe effect of obstructive sleep apnea (OSA) syndrome in the peripapillary retinal nerve fiber layer (RNFL) thicknesses remains unclear. The purpose of this study was to assess RNFL measurements acquired using scanning laser polarimetry (SLP) and optical coherence tomography (OCT) in patients with OSA.MethodsThe sample of this cross-sectional study included 40 OSA patients and 45 age-matched controls, consecutively and prospectively selected. All participants underwent at least one reliable standard automated perimetry (SAP) test, while RNFL measurements were obtained using the SLP and OCT. The OSA group was divided into 3 sub-groups based on the apnea/hypopnea index (AHI): mild, moderate, or severe OSA. SAP, SLP, and OCT outcomes were compared between the control and OSA groups. The relationship between AHI and RNFL parameters was also evaluated.ResultsAge was not different between both groups. Mean deviation of SAP was −0.47u2009±u20090.9xa0dB and −1.43u2009±u20092.3xa0dB in the control and OSA groups, respectively (pu2009=u20090.01). RNFL thickness measured with OCT was similar between groups. OSA patients showed increased nerve fiber indicator (NFI; 20.9u2009±u20097.9 versus 16.42u2009±u20097.82; pu2009=u20090.01) and decreased superior average (59.74u2009±u200910.35 versus 63.73u2009±u20096.58; pu2009=u20090.03) obtained with SLP compared with healthy individuals. In the total sample, NFI and AHI were moderately correlated (ru2009=u20090.358; pu2009=u20090.001). In severe OSA subjects (nu2009=u200922), NFI and AHI had a Spearman correlation coefficient of 0.44 (pu2009=u20090.04).ConclusionRNFL thickness measured with OCT did not differ significantly between groups. Severe OSA was related to a reduction of the RNFL thickness assessed by SLP.

Treatment of Acanthamoeba neurotrophic corneal ulcer with topical matrix therapy

BackgroundThis study was done to evaluate the visual and anatomical outcomes of topical regenerating agents as a novel therapy for neutrophic corneal ulcer (NCU) secondary to acanthamoeba infection.FindingsA 20-year-old woman with a history of contact lens wear was referred to our hospital for keratitis after responding poorly to conventional treatment. In vivo confocal microscopy images suggested acanthamoeba keratitis with double-walled cysts in the anterior corneal stroma. Acanthamoeba infection was confirmed by laboratory findings. She was started on 0.1 % propamidine and 0.02 % chlorhexidine drops every hour. The antibiotic and antifungal drops were stopped when bacterial and fungal cultures proved negative. A central neurotrophic corneal ulcers (NCU) appeared, and despite treatment with artificial tears, bandage contact lens, and autologous serum, the ulcer worsened and she was treated with topical CACICOL20 (1 drop every 2xa0days) for 8xa0weeks. The corneal defect was completely repaired in 3xa0weeks. The treatment was well tolerated, and no local or systemic side effects were noted. Visual acuity remained 20/400. Two months later, the defect was still closed and the patient continued with 0.1 % propamidine and 0.02 % chlorhexidine drops, bandage contact lens, artificial tears, and autologous serum.ConclusionsTopical regenerating agents interact with components of the extracellular matrix, binding matrix proteins and protecting them from proteolysis, restoring the matrix environment, and improving tissue healing. In this case, CALCICOL20 was effective for vision stabilization, wound healing, and was well tolerated for NCU secondary to acanthamoeba infection.

Anatomical Retinal Changes after Photodynamic Therapy in Chronic Central Serous Chorioretinopathy

Purpose To evaluate anatomical retinal changes measured by spectral-domain optical coherence tomography (SD-OCT), after applying photodynamic therapy (PDT) for treatment of chronic central serous chorioretinopathy (CSC). Methods A retrospective analysis was conducted on 43 patients (48 eyes) with chronic CSC treated with PDT. Visual acuity (VA), central retinal thickness (CRT), outer nuclear layer (ONL) thickness, subretinal fluid (SRF), and photoreceptor ellipsoid zone (EZ) measured by SD-OCT were collected at baseline and at 3, 6, and 12 months after PDT. Differences between normally distributed variables were calculated by a paired-sample t-test; p < 0.05 was considered statistically significant. Results Mean age was 50u2009±u20099.8 years. Mean time from diagnosis to PDT was 12.5 months. Baseline VA was 0.51u2009±u20090.24 and significantly improved (p < 0.001) to 0.74u2009±u20090.26 one year after PDT. CRT and SRF significantly decreased (p < 0.001) at 3, 6, and 12 months after treatment. ONL thickness and EZ did not significantly change at any point during follow-up. Conclusions Not significant changes were found in the ONL or EZ 12 months after PDT.