Thomas G. Chu

Dopamine use is an indicator for the development of threshold retinopathy of prematurity

AIM To assess whether treatment of premature infants with dopamine is a risk factor for development of retinopathy of prematurity (ROP). METHODS A retrospective case series analysis of two groups was utilised with a minimum follow up of 6 months. Clinical profiles and patient risk factors were identified along with an evaluation of ROP progression and an analysis of clinical outcome. All infants were seen in a single community neonatal intensive care unit (NICU). 41 consecutive high risk infants were identified during a 36 month period whose birth weight was less than 1000 grams and who remained in the NICU without transfer until at least 28 days of age. Dilated indirect ophthalmoscopy fundus examinations were performed on all infants to identify the degree of and progression to threshold ROP. RESULTS 18 of 41 infants were treated with dopamine for hypotension. The group of infants requiring dopamine differed statistically from the non-dopamine treated group by having a slightly higher birth weight, a greater incidence of hypotension and colloid treatment, and in manifesting more advanced respiratory disease. Within the dopamine treated group, 12 of 18 infants (67%) reached prethreshold ROP and seven infants (39%) reached threshold ROP requiring laser treatment. In contrast, only three of the infants (13%) who did not require dopamine for hypotension progressed to prethreshold (p=0.001) and only one of these infants (4%) progressed to threshold ROP (p = 0.02). Logistic regression analysis among other variables demonstrated that dopamine use and gestational age are important factors in this low birthweight population for predicting the development of threshold ROP (dopamine use: adjusted odds ratio = 119.88, p = 0.0061; gestational age: adjusted odds ratio = 0.061, p = 0.0043). CONCLUSIONS Dopamine use in low birthweight infants may therefore be a risk factor for the development of threshold ROP. More vigilant screening of high risk infants requiring dopamine therapy for systemic hypotension may be warranted.

Scleromalacia After Retinal Detachment Surgery

PURPOSE/METHODS A 34-year-old man developed severe scleral thinning with imminent prolapse after conventional retinal detachment repair, including pars plana vitrectomy, endolaser photocoagulation, and perfluoropropane injection. Cadaveric dura mater was used to repair the scleral defect. RESULTS/CONCLUSION The cause of scleromalacia in this case remains to be determined. Commercially prepared cadaveric dura mater can be successfully used as a tectonic graft for the treatment of scleral thinning.

Efficacy of verteporfin photodynamic therapy on laser-induced choroidal neovascularization and the ancillary effect on diabetic microvasculopathy

Purpose. To demonstrate the efficacy of photodynamic therapy (PDT) in treating choroidal neovascularization (CNV) induced by laser photocoagulation for diabetic macular edema and its ancillary effect on surrounding diabetic microvascular abnormalities. Methods. A retrospective interventional case series study in a clinical practice setting of four patients with proliferative diabetic retinopathy and clinically significant macular edema who had developed classic CNV in proximity to the area of previous laser photocoagulation. The lesions were treated with verteporfin PDT and followed with serial fluorescein angiography. Results. Compared to the pre-treatment angiogram, an acute reduction in leakage from CNV was noted as soon as 5 days post-PDT and persisted in some areas up to three months post-treatment within the zone of the typical dark choroid pattern. No evidence of any closure of microaneurysms was noted. Conclusions. Serial fluorescein angiograms demonstrate that PDT appears to have a beneficial effect on CNV induced by laser photocoagulation for diabetic macular edema without any tangible beneficial effect on diabetic microvasculopathy. PDT had no effect on existing microaneurysms.

Successful use of anti-VEGF treatment for subretinal hemorrhage and fluid in a young patient with choroidal osteoma.

The authors report the use of an anti-VEGF agent in the resolution of subretinal fluid and hemorrhage with improvement in best corrected visual acuity (BCVA) in a patient with choroidal osteoma. The reported case involves a 20-year-old man who presented with a choroidal osteoma and chronic subretinal fluid associated with hemorrhage. He was treated with six intravitreal doses of bevacizumab over a 13-month period. The fluid resolved and his BCVA improved with these treatments. Intravitreal bevacizumab can be used to successfully treat subretinal fluid associated with choroidal osteomas and may lead to an improvement in BCVA.

Tears of the Retinal Pigment Epithelium during Aflibercept Therapy: PED and Treatment Characteristics

Background: Tears of the Retinal Pigment Epithelium (RPE) are associated with Age-Related Macular Degeneration (AMD) in the setting of a pigment epithelial detachment (PED). Methods: Chart review of patients treated with intravitreal (IV) Aflibercept for neovascular AMD (nvAMD). Clinical course and OCT images were analyzed to compare characteristics for patients who experienced RPE tears during treatment of symptomatic PED with IV Aflibercept. Results: 8 eyes of 8 patients were included in the study. All cases were being treated for nvAMD with IV aflibercept. The average maximal height of PED was 475 μm (172-874 μm), and the mean linear diameter was 3426 μm, (1004-5185 μm). All eyes had associated subretinal fluid; 4 had RPE folds and irregularities, and one had subretinal hemorrhage. Four eyes experienced an RPE tear after the first injection of Aflibercept. Two eyes had received more than 10 injections of aflibercept prior to the development of RPE tear. Two patient’s eyes were previously treated with other anti-VEGF agent (one bevacizumab, and one ranibizumab). The visual acuity improved by 2 or more lines in 3 eyes, and worsened by 2 or more lines in no eyes. The final BCVA was ≥ 20/40 in 2 eyes, 20/50-20/100 in 5 eyes, and </= 20/200 in 1 eye. Conclusion: IV Aflibercept has been recommended for treatment of PED in the setting of nvAMD. In our study, 8 patients with PED experienced a tear of the RPE during the early course of treatment with Aflibercept. Aflibercept’s mechanism of action is such that it binds to multiple targets with higher affinity than other anti-vascular-endothelialgrowth- factors. This proposed mechanism may increase its efficacy in the setting of PED. This mechanism, however, may also augment the risk for RPE tears. Therefore, consideration for RPE tear should be given in the setting of large PED in nvAMD.

Wide-Field Fluorescein Angiography

In 1886, the first ophthalmic photographs were taken by Jackman and Webster with an improvement in technique by Dr. Frederick Dimmer, who, in 1921, published an ophthalmic textbook on his images. The first commercially available fundus camera was produced by Carl Zeiss and had a 20° field of vision.

Patients with Advanced Diabetic RetinopathyâÂÂs Understanding of DiabetesMellitus and Their Diabetic Eye Disease: A Survey of 100 Patients CurrentlyUndergoing Treatment for Diabetic Retinopathy in a Large Retinal Practice

Objective: To better understand what patients with advanced diabetic retinopathy understand about their DED and treatment, control of their diabetes, and risk factors for disease progression, and to assess which areas clinicians may want to target for education to increase patient understanding. Methods: 100 consecutive patients with at least 5 previous visits to a retinal clinic were surveyed to better understand patients’ understanding of DM, DED, and the treatments they were receiving for DM and their DED. Demographic information (age, gender, educational status, ethnicity, language, duration and treatments for DM) was collected, along with information about treatments and understanding of risk and modifiable factors about DM. Data was verified against the chart. Results: 100 surveys were completed; 97% of patients said they “understand DM”. 61% of patients were 60 years or older, and half of the patients had done some post-secondary educational training. The ethnic breakdown included 27% Caucasian and 38% Hispanic. Fasting blood glucose (FBG) was known in 89% of patients and when asked the range of FBG: 6% did not know; 17% had FBG as >160 mg/dl; and 35% had a FBG of 150mmHg. Patients were asked to identify DM related ocular complications: 23% said bleeding; 7% said diabetic macular edema; and 73% said blindness or visual loss. As patient age increased, the ability to correctly identifying current treatments, and knowledge of hemoglobin A1C (HbA1C), decreased. Ability to correctly identify HbA1C increased with increasing education. Conclusions: This survey shows patient misunderstanding in: how DM is treated, risk factors for DM, and how monitoring should be done. Emphasis is likely needed in diet modification and exercise for control of DM. Patients may be at risk for poor understanding of DM care/treatment (particularly those with lower educational achievement, or more elderly). Additional resources may need to be developed for sub-sets of patients.

Fluocinolone acetonide (Iluvien) extended-release intravitreal implant for diabetic macular edema

Fluocinolone acetonide (FAc) is a corticosteroid used in the FAc implant, a novel drug-delivery device currently approved in Europe but not yet approved in the USA. The drug delivery system for FAc implant allows a sustained delivery in a more posterior location in the eye and can be delivered in an outpatient setting. It has been shown to reduce diabetic macular edema via multiple mechanisms including the VEGF pathway. This allows for a more complete resolution in foveal thickness and leakage on fluorescein angiography, which increases best corrected visual acuity. Side effects, such as cataract and increased intraocular pressure, are common for ocular steroids.

Intravitreal aflibercept use in the treatment of macular edema from central retinal vein occlusion

Aflibercept is a recently US FDA-approved anti-VEGF agent designed for intravitreal injection. Anti-VEGF agents have recently been demonstrated to be potent inhibitors of neovascular growth and vascular permeability in large clinical trials. The majority of studies of anti-VEGF agents are in the setting of age-related macular degeneration, but studies looking at diabetic macular edema and macular edema from central retinal vein occlusion (CRVO) and branch retinal vein occlusion are increasing the scope of utility of anti-VEGF drugs. Aflibercept for single-use intravitreal injection has been approved in the setting of age-related macular degeneration and in macular edema caused by CRVO in the USA (approval has been sought in Europe). The purpose of this review is to examine the use of aflibercept in the setting of CRVO and the role it may potentially play in the expanding indications for anti-VEGF agents.