Theodoros Empeslidis

24-hour efficacy of the bimatoprost–timolol fixed combination versus latanoprost as first choice therapy in subjects with high-pressure exfoliation syndrome and glaucoma

Aim To compare the 24-h intraocular pressure (IOP) control obtained with the bimatoprost–timolol fixed combination (BTFC) versus latanoprost in newly diagnosed, previously untreated exfoliation syndrome (XFS) or exfoliative glaucoma (XFG) patients with baseline morning IOP greater than 29 mm Hg. Methods One eye of 41 XFS/XFG patients who met inclusion criteria was included in this prospective, observer-masked, crossover, comparison protocol. All subjects underwent a 24-h untreated curve and were then randomised to either evening administered BTFC or latanoprost for 3 months and then switched to the opposite therapy. At the end of each treatment period, patients underwent a treated 24-h IOP assessment. Results 37 patients completed the trial. At baseline, mean untreated 24-h IOP was 31.1 mm Hg. Mean 24-h IOP with BTFC was significantly lower than with latanoprost (18.9 vs 21.2 mm Hg; p<0.001). Furthermore, BTFC reduced IOP significantly more than latanoprost at every time point, for the mean peak and trough 24-h IOP (p<0.001). There was no difference, however, in mean 24-h IOP fluctuation between the two medications (3.8 with BTFC vs 4.2 with latanoprost; p=0.161). Both treatments were well tolerated and there was no statistically significant difference for any adverse event between them. Conclusions As first choice therapy in high-pressure, at-risk exfoliation patients, BTFC controlled mean 24-h IOP significantly better than latanoprost monotherapy.

Intravitreal aflibercept treatment of retinal angiomatous proliferation: a pilot study and short-term efficacy

Retinal angiomatous proliferation (RAP) is a type of neovascular age-related macular degeneration (AMD) with a reportedly poor prognosis and limited response to several therapies including direct laser photocoagulation, transpupillary thermotherapy, surgical removal, and photodynamic therapy (PDT) [1]. However, the introduction of intravitreal anti-vascular endothelial growth factor (anti-VEGF) medications has offered a novel alternative for RAP treatment. Multiple studies have shown that ranibizumab may be effective in these cases especially those in stages 1 and 2 [2, 3]. Following the approval of aflibercept for use in the British national health system, we have designed a pilot study to investigate the short-term results of intravitreal aflibercept administered to RAP patients with no previous treatments. Notably, previous studies confirmed the efficacy of aflibercept in wet age-related macular degeneration and macular edema due to retinal vein occlusions [4, 5]. Twelve patients (12 eyes; mean age, 80±7.08 years) with RAP lesions at stage 1 and 2 without any previous treatments were recruited from the outpatient medical retina service of the University Hospital of Leicester, in the UK, between November 2013 and January 2014 and were enrolled in a prospective, consecutive, and nonrandomized manner. The study conformed to the tenets of the Declaration of Helsinki. All participants provided written informed consent after verbal explanation. Before therapy, all patients were examined thoroughly with visual acuity (LogMAR) measurement, optical coherence tomography (3D OCT-1000, Topcon Corporation, Tokyo, Japan), and fluorescein angiography performed to confirm the diagnosis. Patients were administered 2 mg of aflibercept (Eylea, 40 mg/ml, Bayer, Germany) intravitreously every 30 days for a total three injections. One month after the third treatment, the patients were reexamined and numerical data were collected. The primary study outcomes were the change in central subfield (1 mm as indicated in the ETDRS grid) retinal thickness (CRT), and the bestcorrected distance visual acuity (BCDVA, LogMAR). Secondary indices for statistical analysis were retrieved from the optical coherence tomography report: (1) average macular thickness (μm) (nine subfields of 6 mm area in an ETDRS grid); (2) central foveal point thickness (μm); and (3) total volume (mm) in a 6 mm macular area. Difference between the pretreatment and posttreatment values were determined using one-way analysis of variance (ANOVA) with a 5 % significance level. Data were collected prospectively, and analyzed using Microsoft Excel 2007 for Windows (Microsoft Corporation, Redmond, WA, USA) and SPSS version 16.0 for Windows (SPSS Inc., Chicago, IL, USA). All subjects showed a decrease in the central retinal thickness (mean 128±62.94 μm). In 10/12 eyes visual acuity improved following treatment (mean 0.14±0.16 LogMAR). Posttreatment visual acuity significantly correlated with the pretreatment visual acuity (p<0.001) (Fig. 1). The gain in BCDVA improvement was not correlated with the decrease in the 1 mm central subfield thickness (p=0.252) but was significantly correlated with the decrease in the central foveal point thickness (p=0.034) (Fig. 2). The results show that aflibercept is efficacious in cases of retinal angiomatous proliferation; after three treatments, the central retinal thickness decreased, and the retinal architecture K. T. Tsaousis :V. E. Konidaris : S. Banerjee : T. Empeslidis Ophthalmology Department, Leicester Royal Infirmary, Leicester, UK

Dexamethasone intravitreal implant for idiopathic retinal vasculitis, aneurysms, and neuroretinitis.

Purpose To present the short-term favorable clinical results with the dexamethasone intravitreal implant in a patient with florid idiopathic retinal vasculitis, aneurysms, and neuroretinitis syndrome (IRVAN). Methods A 26-year-old man presented with significant bilateral deterioration of vision due to vitreous hemorrhage and neuroretinitis with a background of vasculitis and neovascularization. The patient was initially treated with high doses of oral steroids (80 mg prednisolone), which were gradually tapered, and also received extensive argon laser photocoagulation in ischemic areas in both eyes. Despite vigorous treatment and an initial positive response to treatment, pars plana vitrectomy was eventually needed to address the recurrent vitreous hemorrhages in the left eye. Consequently, visual acuity improved from 0.1 to 0.2 (Snellen) and there was no relapse of vitreous hemorrhage. Persistent macular edema was noted, however, and it was decided to treat with a dexamethasone 0.7 mg intravitreal implant. Results Following the dexamethasone implant OS, visual acuity improved significantly from 0.2 to 0.5 (Snellen), the patient reported much less distortion, and there was marked reduction in central retinal thickness from 467 to 234 microns. The patient remains in remission without any exudation in the macula at 4 months follow-up. Conclusions Dexamethasone 0.7 mg intravitreal implant appears to be a safe and effective solution in the treatment of macular edema in patients with IRVAN syndrome and could possibly be a treatment option for other cases of inflammatory induced macular edema.

Kyrieleis plaques in herpes zoster virus-associated acute retinal necrosis: a case report.

Sir, Kyrieleis plaques were described in 1933 in ocular tuberculosis.1 They have been primarily described in association with infections of the retina, Toxoplasma gondii chorioretinitis being the most common.2 Other described associated causes include cytomegalovirus (CMV) retinitis, syphilitic retinitis, acute retinal necrosis (ARN) due to Herpes Simplex Virus-2, Varicella-Zoster Virus, and Rickettsia conorii infections.3, 4, 5 Orzalesi and Ricciardi6 suggested they are an immune response, resulting from deposition of immune cells and inflammatory debris in arterial walls. Others have debated this hypothesis as these plaques can persist despite resolution of the infection and treatment with steroids.7

The concept of virtual clinics in monitoring patients with age-related macular degeneration

To present clinical results regarding the treatment of patients with age‐related macular degeneration (neovascular form) after the implementation of a ‘virtual’ type of follow‐up in a single retina service centre.

Use of Intravitreal Bevacizumab in a 9-year-old Child with Choroidal Neovascularization Associated with Autosomal Recessive Bestrophinopathy

Abstract Introduction: Bestrophinopathies result from mutations within the BEST1 gene; although multiple gene mutations have been identified, the recessive form is often the form which gives rise to the rarer complication of choroidal neovascularization. We describe a child with treated choroidal neovascularization secondary to Best disease with a newly identified genetic mutation. Methods: Case report. Results: A 9-year-old child reported unilateral blurred vision; the acuity deteriorated over the following months to 3/18 due to the development of a choroidal neovascular membrane. She was treated with three injections of bevacizumab with recovery to 6/12 vision and no subsequent recurrence over the follow-up period of 2 years, and no secondary complications from the drug. Genetic analysis revealed a novel heterozygous mutation in the BEST1 gene, with no evidence of disease in the family. Conclusions: We describe a novel mutation within the BEST1 gene of the heterozygous form giving rise to vitelliform lesions and secondary neovascularization successfully treated in a child with a course of bevacizumab. The genetic testing has implications on genetic counseling in such patients and the genetic analysis of all such patients ought to be routinely considered.

Incidence of Retinal Pigment Epithelial Tears and Associated Risk Factors After Treatment of Age-Related Macular Degeneration with Intravitreal Anti-VEGF Injections §

Purpose : To study the incidence and risk factors for retinal pigment epithelium tears following intravitreal anti-vascular endothelial growth factor (VEGF) injections. Methods : Retrospective longitudinal study. 4027 intravitreal anti-VEGF injections in 628 patients (676 eyes) for choroidal neovascularisation associated with age related macular degeneration in a period of 18 months were studied. Results : Seventeen patients (mean age 83.95±5.84) developed retinal pigment epithelium tears. The incidence rate was 0.4%. Fibrovascular pigment epithelium detachment (PED) was previously observed in all cases. In 88 % (15/17) of AMD patients that had a RPE tear, PED height was found to be less than 400 microns at presentation. In 5 of 7 patients with RPE tear grade <4, continuing of anti-VEGF treatment resulted to improvement of visual acuity. Conclusion : Critical risk factors for RPE tears are presence of PED as well as advanced age. Visual improvement appears to depend more on the extent and location of the RPE tear and less on the PED height.

Tear of Retinal Pigment Epithelium following YAG Laser Posterior Capsulotomy in a Patient on Anti-VEGF Treatment for AMD: Six Months' Follow-Up.

Purpose: To present a rare case of retinal pigment epithelium (RPE) rupture following YAG laser posterior capsulotomy (YAG PC) in a patient with exudative age-related macular degeneration (AMD). Materials and Methods: An 85-year-old pseudophakic male patient on ranibizumab 0.5 mg/0.05 ml treatment due to exudative AMD received YAG PC for dense posterior capsule opacification (PCO) in his right eye. The patient had received his last intravitreal ranibizumab injection 3 months before YAG PC; his macula appeared stable on fundoscopy and optical coherence tomography scans at repeated visits, but his vision deteriorated to counting fingers due to PCO. Results: Following left eye posterior YAG PC, his best-corrected visual acuity (BCVA) improved to 6/12 (Snellen chart). Despite satisfactory visual results, the patient developed a parafoveal inferotemporal RPE rupture. A decision for further treatment with ranibizumab (0.5 mg/0.05 ml) intravitreal injections was made. After a total of 7 injections, the patient was clinically stable and his BCVA was 6/18 (Snellen chart). Conclusions: RPE rupture is a well-known, serious complication in patients with exudative AMD, which often has devastating results on patients’ vision. Offering YAG PC to those patients could lead to a rupture of the RPE even in cases which appear to be stable and well controlled. Clinicians should be aware of this complication and inform the patients accordingly.

Fourth Cranial Nerve Palsy and Bilateral Acute Retinal Necrosis following Human Herpesvirus 6 Infection of the Central Nervous System

Abstract Acute retinal necrosis (ARN) is a rare, potentially blinding condition typically affecting immunocompetent individuals. It is defined by the clinical triad of vitreous inflammation, occlusive vasculopathy, and progressive retinal necrosis, usually located in peripheral retina with circumferential extension. Varicella zoster virus (VZV), herpes simplex virus (HSV), Epstein-Barr virus (EBV) and occasionally cytomegalovirus (CMV) are the common causative agents of ARN. Reports of human herpesvirus 6 (HHV6) infection of the central nervous system (CNS) associated with ocular inflammatory disease are extremely rare. We here report the case of a 22-year-old immunocompetent male who presented with acute bilateral ARN and fourth nerve palsy, following HHV6 infection of the CNS and EBV infectious mononucleosis.

Multifocal chorioretinitis caused by Bartonella henselae: imaging findings of spectral domain optical coherence tomography during treatment with trimethoprim-sulfamethoxazole

Multifocal chorioretinitis caused by Bartonella henselae : imaging findings of spectral domain optical coherence tomography during treatment with trimethoprim-sulfamethoxazole