Surgical Innovations in the Treatment of Diabetic Macular Edema and Diabetic Retinopathy.

PURPOSE OF REVIEW: Diabetic macular edema (DME) and complications of proliferative diabetic retinopathy (PDR) are the primary causes of vision loss in patients with diabetic retinopathy. As the incidence of diabetes increases worldwide, new, cost-effective treatments for DME and PDR will become paramount. Currently, anti-vascular endothelial growth factor (anti-VEGF) medications are considered first-line treatment. However, multiple visits for injections and the economic and time burden they entail make this treatment modality less than ideal. Early vitrectomy as well as depot delivery systems for medications could potentially reduce the treatment burden of patients with diabetes, prevent visual loss, and provide long-term stabilization of retinopathy in patients with diabetes. Newer port delivery systems for anti-VEGF medications could one day make this treatment modality better suited for patients across the globe. RECENT FINDINGS: Real-world data shows poor compliance with treatment among patients with diabetes. Recent publications show catastrophic results when anti-VEGF treatments are stopped abruptly. The port delivery system for ranibizumab shows maintenance of adequate anti-VEGF levels in the vitreous cavity for many months. Early vitrectomy can provide cost-effective long-term stabilization in eyes with diabetic retinopathy. Microincisional vitrectomy as a treatment for DME and PDR remains controversial and larger trials are needed to definitively prove its superiority over other modalities; however, small-scale data point towards its usefulness in specific populations. Newer port delivery systems of anti-VEGF show promise in decreasing the number of office visits in patients with diabetic retinopathy.

Sub-internal limiting membrane hemorrhage associated with Weil's disease.

PURPOSE: Leptospirosis is a rare, typically tropical disease associated with water sources infected with rat urine. Symptoms can range from asymptomatic to a severe, deadly form known as Weil's disease, and ocular manifestations can arise. As global temperatures continue to rise, leptospirosis will become a larger problem worldwide. Here we describe the first case to our knowledge of foveal sub-internal limiting membrane (sub-ILM) hemorrhage due to Weil's disease. OBSERVATIONS: A 56-year-old female presented with floaters and decreased vision to 20/200 in the right eye after being hospitalized for Weil's disease. Funduscopic examination and optical coherence tomography (OCT) demonstrated a foveal sub-ILM hemorrhage in the right eye. The patient was treated with pars-plana vitrectomy with internal limiting membrane removal and blood aspiration, and her best corrected visual acuity improved to 20/60. CONCLUSIONS AND IMPORTANCE: Here we report the first case of sub-ILM hemorrhage following Weil's disease. Patients with leptospirosis and Weil's disease can develop retinal complications and therefore should be followed with fundoscopic eye examination after resolution of systemic symptoms. For those with retinal hemorrhages, OCT evaluation should be used to differentiate sub-hyaloid and sub-ILM hemorrhages.

Sex experience increases delta FosB in male and female hamsters, but facilitates sex behavior only in females.

Motivated behaviors share the common feature of activating the mesolimbic dopamine system. Repeated experience with motivated behaviors can cause long-lasting structural changes in the nucleus accumbens (NAc). The molecular mechanisms underlying this experience-dependent plasticity in the NAc have been well described following experience with drugs of abuse. In particular, the transcription factor Delta FosB (ΔFosB) is a key regulator of drug-related neuroplasticity. Fewer studies have examined the molecular mechanisms underlying experience-dependent plasticity in the NAc following naturally motivated behaviors, but previous research has demonstrated that sexual experience increases the accumulation of ΔFosB in the NAc of female hamsters and male rats. Sex behavior is unique among motivated behaviors in that the expression of the behavior varies drastically between males and females of the same species. Despite this, a quantitative comparison of ΔFosB following sex experience in males and females of the same species has never been conducted. We therefore used Western blotting to test the hypothesis that sex experience increases ΔFosB in both male and female Syrian hamsters following repeated sexual experience. We found that sex experience significantly increases ΔFosB protein in male and female Syrian hamsters. Further, ΔFosB protein levels did not differ between males and females following sex experience. Interestingly, repeated sex experience only led to increased copulatory efficiency in female hamsters; male copulatory efficiency did not improve with repeated experience. Together, these data demonstrate that ΔFosB is increased following sexual reward in both males and females but may be uncoupled from behavioral plasticity in males. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Management of Giant Retinal Tear Detachments.

Giant retinal tears (GRTs) are full-thickness circumferential tears of more than 90 degrees of the retina that are associated with vitreous detachment. They are related to ocular trauma, high myopia, aphakia, pseudophakia, genetic mutations involving collagen and young age. GRTs comprise 1.5% of all rhegmatogenous retinal detachments and the average age of incidence is 42 years. GRTs are more common in males, as 72% of all cases occur in males. The incidence of GRTs in the general population is estimated to be 0.05 per 100,000 individuals. Common techniques used in the management of GRTs include fluid-air exchange, pneumatic retinopexy, scleral buckling, primary vitrectomy with gas or silicone oil tamponade, and combined scleral buckle-vitrectomies. However, management of GRTs poses a great challenge to physicians due to the high risk of intra- and post-operative complications and the many technical difficulties involved. The advent of perfluorocarbon liquids (PFCL) and the use of micro-incisional surgery for the treatment of GRTs has provided new opportunities for the management of GTRs. Today, retinal reattachment can be achieved in 94-100% of cases.

Surgery for Diabetic Eye Complications.

New modalities for the treatment of diabetic eye complications have emerged in the past decade. Nevertheless, many severe diabetic retinopathy complications can only be treated with vitreoretinal surgery. Technological advances in pars plana vitrectomy have expanded the gamut of pathologies that can be successfully treated with surgery. The most common pathologies managed surgically include vitreous opacities and traction retinal detachment. The indications, surgical objectives, adjunctive pharmacotherapy, microincisional surgical techniques, and outcomes of diabetic vitrectomy for proliferative diabetic retinopathy and diabetic tractional retinal detachment will be discussed. With the availability of new microincisional vitrectomy technology, wide angle microscope viewing systems, and pharmacologic agents, vitrectomy can improve visual acuity and achieve long-term anatomic stability in eyes with severe complications from proliferative diabetic retinopathy.

Terson's Syndrome in a Patient with von Hippel-Lindau Disease.

PURPOSE: Terson's syndrome is a condition where a preretinal hemorrhage forms as a result of increased intracranial pressure. The elevated intracranial pressure is thought to be transmitted through the veins and the optic nerve sheath to the optic disc and retina, causing the thin capillary walls to rupture. The authors present a unique case of Terson's syndrome in a patient who underwent recent surgical management for cerebellar hemangioblastomas related to von Hippel-Lindau disease. CASE REPORT: A 17-year-old African American female patient with a history of von Hippel-Lindau disease presented with pain in her right eye. She had recently undergone surgery to remove cerebellar hemangioblastomas. Preliminary fundus imaging was performed, but before formal ophthalmic testing could be conducted, the patient seized and was taken directly to the emergency room. When the patient returned for a formal evaluation 3 weeks later, a new preretinal "boat-shaped" hemorrhage was now present. Additionally, reports from the emergency room suggested that she had bled into the cavity where the previous cerebellar resection had taken place. This hemorrhage likely led to an increase in intracranial pressure, causing a Terson's-like event. CONCLUSIONS: A Terson's event may be caused by high intracranial pressure secondary to the surgical removal of von Hippel-Lindau syndrome-associated cerebellar tumors and should be included as a possible complication of surgical management.

Surgical management of retinal diseases: proliferative diabetic retinopathy and traction retinal detachment.

Current indications for pars plana vitrectomy in patients with proliferative diabetic retinopathy (PDR) include vitreous hemorrhage, tractional retinal detachment (TRD), combined tractional and rhegmatogenous retinal detachment (CTRRD), diabetic macular edema associated with posterior hyaloidal traction, and anterior segment neovascularization with media opacities. This chapter will review the indications, surgical objectives, adjunctive pharmacotherapy, microincision surgical techniques, and outcomes of diabetic vitrectomy for PDR, TRD, and CTRRD. With the availability of new microincision vitrectomy technology, wide-angle microscope viewing systems, and pharmacologic agents, vitrectomy can improve visual acuity and achieve long-term anatomic stability in eyes with severe complications from PDR.

Aleukemic leukemia cutis preceding acute monocytic leukemia: a case report.

Aleukemic leukemia cutis is an extremely rare clinical presentation in patients who eventually develop acute leukemia, usually of monocytic lineage. This condition is associated with a very poor prognosis and is often difficult to diagnose. We report a case of a 33 years old female with leukemia cutis preceding the onset of acute monocytic leukemia by four months. The patient received induction and consolidation chemotherapy followed by allogeneic bone marrow transplant and has been free of disease for six years. To our knowledge, this is the first documented case in Puerto Rico with the diagnosis of leukemia cutis preceding acute monocytic leukemia.