Three-dimensional imaging of the inner limiting membrane folding on the vitreomacular interface in diabetic macular edema.

PURPOSE: To report the findings of fine folds on the retina obtained by spectral-domain optical coherence tomography (OCT). METHODS: A retrospective non-comparative case series; 26 eyes of diabetic macular edema (DME) patients who underwent vitrectomy were observed using three-dimensional (3D) images of OCT preoperatively and postoperatively. The specimens were investigated immunohistochemically. RESULTS: Using only tomography, non-tractional vitreoretinal interfaces were observed in 15 eyes and tractional vitreoretinal interfaces in the other 11 eyes. Using 3D imaging, we observed fine folds in 11 eyes among 15 cases showing non-tractional interfaces. Based on these findings, the state of the vitreoretinal interface was classified into 3 patterns. Group 1, both tomography and 3D imaging showed smooth retinal surfaces. Group 2, tomography showed a smooth retinal surface, but 3D imaging showed fine folds on the retina. Group 3, both tomography and 3D imaging showed a tractional vitreoretinal interface with an obvious epiretinal membrane and/or taut posterior vitreous cortex. The fine folds in group 2 disappeared and macular edema improved after inner limiting membrane (ILM) peeling, and the CRT of groups 2 and 3 reduced significantly. The fine folds were confirmed to involve the ILM because type IV collagen expression was detected in the surgically obtained specimens. CONCLUSION: We observed tangential fine folds of the ILM. These were detected by using only 3D imaging, and might be useful for investigating the optimal indication of vitrectomy for DME.

Risk of cardiovascular diseases is increased even with mild diabetic retinopathy: the Japan Diabetes Complications Study.

OBJECTIVE: Diabetic retinopathy (DR) is linked to cardiovascular risk in diabetic patients. This study examined whether mild-stage DR is associated with risk of coronary heart disease (CHD) and stroke in type 2 diabetic patients of the Japan Diabetes Complications Study (JDCS). DESIGN: Prospective cohort study. PARTICIPANTS: In the JDCS, there were 2033 Japanese persons with type 2 diabetes free of cardiovascular diseases at baseline. METHODS: Diabetic retinopathy was ascertained from clinical and photographic grading (70%) following the international clinical diabetic retinopathy and diabetic macular edema disease severity scales. Incident CHD and stroke were followed up prospectively annually up to 8 years. MAIN OUTCOME MEASURES: Eight-year incidence of CHD and stroke compared between persons with or without DR. RESULTS: After adjusting for traditional cardiovascular risk factors, persons with mild to moderate nonproliferative DR had a higher risk of CHD (hazard ratio [HR], 1.69; 95% confidence interval [CI], 1.17-2.97) and stroke (HR, 2.69; 95% CI, 1.03-4.86). Presence of retinal hemorrhages or microaneurysms was associated with risk of CHD (HR, 1.63; 95% CI, 1.04-2.56) but was not associated with stroke (P = 0.06). Presence of cotton-wool spots was associated with risk of incident stroke (HR, 2.39; 95% CI, 1.35-4.24) but was not associated with CHD (P = 0.66). When information about DR was added in the prediction models for CHD and stroke based on traditional cardiovascular risk factors, the area under the receiver operating curve improved from 0.682 to 0.692 and 0.640 to 0.677, and 9% and 13% of persons were reclassified correctly for CHD and stroke, respectively. CONCLUSIONS: Type 2 diabetic patients with even a mild stage of DR, such as dot hemorrhages, are already at higher risk of CHD and stroke independent of traditional risk factors.

Treatment of diffuse diabetic macular oedema using steroid eye drops.

PURPOSE: To evaluate the efficacy of treatment of diffuse diabetic macular oedema (DME) with difluprednate ophthalmic emulsion 0.05% (Durezol™) in eyes before vitrectomy. METHODS: This study enrolled patients with diffuse DME for whom more than 3 months had passed since prior treatment. Nineteen eyes in 15 subjects were treated with difluprednate ophthalmic emulsion 0.05% four times daily for the first month and then twice daily for 2 months (treatment group). As a control group, 22 eyes in 11 subjects with DME were selected from subjects who underwent the steroid responder test. RESULTS: In the treatment group, the mean visual acuity (VA) (±SD) was 0.38 ± 0.25 logMAR and mean retinal thickness was 461.1 ± 109.9 µm at baseline. After 1 month of treatment, the mean VA had improved to 0.29 ± 0.25 (Wilcoxon rank-sum test, p = 0.30), while mean retinal thickness had decreased to 372.1 ± 70.0 µm (p = 0.006). The rate of effective improvement in retinal thickness was 42% and that of VA was 26%. In the control group, changes in neither VA nor retinal thickness were significant. CONCLUSIONS: Eye drop therapy using difluprednate ophthalmic emulsion 0.05% is a useful and effective treatment modality without surgical intervention or severe side-effects.

Difluprednate ophthalmic emulsion 0.05% as adjunctive treatment to panretinal photocoagulation for proliferative diabetic retinopathy with clinically significant macular edema.

PURPOSE: The purpose of this study was to evaluate the efficacy of topical difluprednate ophthalmic emulsion in controlling progressive diabetic macular edema after panretinal photocoagulation. METHODS: This was a case report of two patients with proliferative diabetic retinopathy combined with diabetic macular edema who underwent panretinal photocoagulation combined with use of a topical difluprednate ophthalmic emulsion. RESULTS: In the Case 1, retinal thickness was decreased 29% 1 month after the start of difluprednate treatment and best-corrected visual acuity was improved 20/40 to 20/25. In Case 2, retinal thickness was decreased 43% after 1 month, and best-corrected visual acuity was improved 20/100 to 20/60 after 3 months. During the follow-up period, elevation of intraocular pressure, ocular infection, and progression of cataract were not detected, though superficial punctuate keratitis was observed in one case. CONCLUSION: Topical difluprednate ophthalmic emulsion was one of the possible choices to treat progressive diabetic macular edema after panretinal photocoagulation. It is mandatory to evaluate the effects and safety in further studies including many cases.

[Binocular diplopia and ptosis due to snakebite (Agkistrodon blomhoffi "mamushi")--a case report].

We treated a patient who developed binocular diplopia and ptosis after being bitten by an Agkistrodon blomhoffi (mamushi). The patient was a 49-year-old man who presented with binocular diplopia after the snakebite on the second finger of his right hand. He experienced local pain and swelling and a few hours later, he developed diplopia. In the primary position he had no tropia. On the basis the ocular angle of deviation measured by a Hess chart test, he was diagnosed with paresis of the medial rectus muscle paresis. Binocular diplopia persisted for 2 weeks. The venom of A. blomhoffi venom mainly consists of hemolytic toxins, but it also contains 2 types of neurotoxins--an alpha-toxin and a beta-toxin. Neurotoxins affects the neuromuscular junction (NMJ). The alpha-toxin acts postsynaptic inhibition as a competitive inhibitor of acetylcholine and causes postsynaptic inhibition; these effects are similar to those of the anti-acetylcholine receptor antibody identified in patients with myasthenia gravis. The beta-toxin inhibits acetylcholine release by disrupting the presynaptic membrane, and thus, its effects cannot be blocked by the anticholinesterase edrophonium chloride. Although both antiserum and cepharanthine are widely used for the treatment of snakebites, there is no evidence of a specific effective therapy for the eye manifestation after snakebite. However, it these manifestation improves in about 2 weeks without any specific treatment. Our case suggested that the occurrence of subjective binocular diplopia without objective tropia could be caused by snakebite.

Three-Dimensional Features of Polypoidal Choroidal Vasculopathy Observed by Spectral-Domain OCT.

Five eyes of five patients with polypoidal choroidal vasculopathy (PCV) without acute hemorrhagic changes or subretinal proliferative tissue to observe the three-dimensional structures and to demonstrate the nature of these images and their interpretation. The abnormal networks surrounding polypoidal lesions were considered to be abnormal pathological blood vessels. The segmentation analysis of spectral-domain optical coherence tomography (OCT) has revealed the three-dimensional features of polypoidal lesions and surrounding abnormal blood vessel networks beneath retinal pigment epithelium. The changes of pathological findings of PCV were also detected, including the enlargement of hemorrhagic pigment epithelium detachment (PED). The segmentation analysis is useful to observe PCV lesions from the bird's eye view.

Steroid eye drop treatment (difluprednate ophthalmic emulsion) is effective in reducing refractory diabetic macular edema.

PURPOSE: To evaluate the efficacy of treatment of refractory diabetic macular edema (DME) after vitrectomy with difluprednate ophthalmic emulsion 0.05% (Durezol(TM)), and to compare this treatment with sub-Tenon's injection of triamcinolone (STTA). METHODS: This study enrolled patients with refractory diabetic macular edema that persisted despite pars plana vitrectomy in our clinic. In all subjects, more than 3 months had passed since prior treatment. Eleven eyes in ten subjects were treated with STTA (STTA group), and 11 eyes in seven subjects were treated with difluprednate ophthalmic emulsion 0.05% (Durezol(TM), Sirion Therapeutics Inc., USA) 4 times daily for the first month and then twice daily for 2 months (eye drop group). RESULTS: In the eye drop group, mean VA (+/- SD) was 0.67 +/- 0.35 logMAR and mean retinal thickness was 500.6 +/- 207.7 mum at baseline. After 3 months of treatment, mean VA was 0.67 +/- 0.29 and mean retinal thickness had decreased to 341.2 +/- 194.8 mum. The mean minimum value of RT during the treatment period was 300.6 +/- 123.2 mum, and significantly lower than that at baseline (Mann-Whitney U test: P = 0.003). In the STTA group, mean VA (+/- SD) was 0.67 +/- 0.35 logMAR, and mean retinal thickness was 543.3 +/- 132.6 mum at baseline. After 3 months of treatment, mean VA was 0.49 +/- 0.67, and mean retinal thickness had decreased to 378.6 +/- 135 mum. The mean minimum value of RT during the treatment period was 349.9 +/- 113.8 mum, and significantly lower than at baseline (Mann-Whitney U test: P = 0.003). The rate of effective improvement in RT did not differ between the eye drop group (73%) and STTA group (84%) (Fisher's exact test: P = 1). CONCLUSIONS: Comparable improvements of retinal thickness were observed in the STTA and eye drop groups. Instillation of difluprednate ophthalmic emulsion 0.05% is a safe and effective treatment that does not require surgical intervention and does not produce severe side-effects.

Cup-shaped choroidal excavation detected by optical coherence tomography: a case report.

PURPOSE: The purpose of this study was to report a case with a cup-shaped choroidal excavation in the fovea. This condition was detected only by optical coherence tomography (OCT) and seems to be rare. METHOD: This was an observational case report. RESULT: A 29-year-old man had a central scotoma in his right eye. Color photography showed a reddish lesion in the fovea of the right eye, which was shown as a window defect on fluorescein angiography. Tomography with time-domain OCT showed a retinal pigment epithelial and choroidal excavation corresponding to the reddish macular lesion in the right eye. By using spectral-domain OCT, the inner segment and outer segment junctions of photoreceptors line thickening was detected by tomography, and the retinal pigment epithelium line was observed in the area of choroidal excavation by segmentation analysis. CONCLUSION: The reddish lesion on ophthalmoscope corresponded to the excavation lesion, detected in the fovea only by OCT; this indicates a new clinical availability of OCT in clinical diagnosis.