Reversible Choriocapillaris Flow Voids in Acute Syphilitic Posterior Placoid Chorioretinitis.

PURPOSE: To report two cases of acute syphilitic posterior placoid chorioretinitis (ASPPC) with choriocapillaris flow voids that partially resolved with systemic antibiotic treatment. METHODS: Observational case report with multimodal imaging. RESULTS: Two young healthy men suffered an acute monocular loss of vision. Spectral domain optical coherence tomography (SD-OCT) and OCT angiography (OCT-A) revealed outer retinitis with loss of the ellipsoid layer and choriocapillaris flow voids. Systemic work-up revealed syphilis. Upon systemic treatment with antibiotics, the patients recovered their vision and the OCT and OCT-A abnormalities partially resolved. CONCLUSIONS: Transient choriocapillaris flow voids characterize ASPPC and may be responsible for the visual loss seen in these patients.

Idiopathic macular telangiectasia type 2 (idiopathic juxtafoveolar retinal telangiectasis type 2A, Mac Tel 2).

Macular telangiectasia type 2-also known as idiopathic perifoveal telangiectasia and juxtafoveolar retinal telangiectasis type 2A or Mac Tel 2-is an acquired bilateral neurodegenerative macular disease that usually manifests itself during the fourth to sixth decades of life and is characterized by minimal dilatation of the parafoveal capillaries with graying of the retinal area involved, a lack of lipid exudation, right-angled retinal venules, refractile deposits in the superficial retina, hyperplasia of the retinal pigment epithelium, foveal atrophy, and subretinal neovascularization (SRNV). Optical coherence tomography images typically demonstrate intraretinal hyporeflective spaces that are usually not related to retinal thickening or fluorescein leakage. The typical fluorescein angiographic finding is a deep intraretinal hyperfluorescent leakage in the temporal parafoveal area. With time the leakage may involve the whole parafovea, but does not extend to the center of the fovea. Long-term prognosis for central vision is variable and depends on the development of SRNV or macular atrophy. Pathogenesis remains unclear, but Müller cells and macular pigment appear to play a central role. Currently there is no known treatment for the underlying cause of this condition, but treatment of the SRNV may be beneficial.

Effectiveness at 1 year of monthly versus variable-dosing intravitreal ranibizumab in the treatment of choroidal neovascularization secondary to age-related macular degeneration.

PURPOSE: To evaluate the visual acuity results of monthly ranibizumab injections compared with a variable-dosing schedule for the treatment of neovascular age-related macular degeneration. METHODS: A retrospective study that compared two cohorts of consecutive patients. All patients were treatment naive, with baseline visual acuity of 20/400 or better, and completed 12 months of therapy. In the first group all patients received monthly injections. In the other group, after 3 monthly loading doses, a variable-dosing schedule was used, based on a monthly clinical assessment and optical coherence tomography. RESULTS: Fifty-six consecutive patients (60 eyes) were included. At 12 months the median number of injections were 12 and 8, respectively, and the mean change in Snellen visual acuity was an improvement of 0.27 logarithm of the minimum angle of resolution in the monthly treated group versus 0.21 logarithm of the minimum angle of resolution improvement in the variable-dosing group (P = 0.53). In the monthly treated group 96.8% of eyes lost <0.3 logarithm of the minimum angle of resolution versus 96.6% of eyes in the variable-dosing group (P = 1.0). CONCLUSION: We were able to show that in our clinical setting patients achieved similar visual acuity results with either monthly injections or with a variable-dosing protocol. There was a trend toward better results with monthly treatment.

An intravenous microdose of bevacizumab for the treatment of pigment epithelial detachment associated to age-related macular degeneration refractory to intravitreal bevacizumab: a case report.

PURPOSE: The purpose of this study was to report the visual and anatomical outcomes of an intravenous microdose of 10 mg of bevacizumab in a patient with a vascularized pigment epithelial detachment (PED) associated with exudative age-related macular degeneration refractory to several intravitreal bevacizumab injections. METHODS: Interventional case report and literature review. RESULT: A 62-year-old female patient with a PED secondary to age-related macular degeneration was treated with 9 consecutive intravitreal injections of 2.5 mg of bevacizumab. Despite an initial response where the PED decreased in size, the subretinal fluid reabsorbed and the visual acuity improved; after the seventh injection, the PED started to grow in size again causing a drop in visual acuity. After an intravenous injection of 10 mg of bevacizumab, the patient experienced an improvement in visual acuity and a flattening of her PED. CONCLUSION: An intravenous injection of a microdose of bevacizumab appears to have resolved the PED with a sustained improvement of visual acuity.

Comparing outcomes in patients with subfoveal choroidal neovascularization secondary to age-related macular degeneration treated with two different doses of primary intravitreal bevacizumab: results of the Pan-American Collaborative Retina Study Group (PACORES) at the 12-month follow-up.

PURPOSE: To compare the total number of injections and the anatomic and best-corrected visual acuity (VA) response after injecting 1.25 or 2.5 mg of bevacizumab as needed in patients with primary choroidal neovascularization secondary to age-related macular degeneration (AMD) at 12 months. METHODS: This was a retrospective, interventional, comparative multicenter study of 60 eyes treated with intravitreal bevacizumab (35 eyes, 1.25 mg; 25 eyes, 2.5 mg). RESULTS: The mean number of injections per eye was 3.8 in the 1.25-mg group and 3.2 in the 2.5-mg group (P = 0.2752). At 12 months, in the 1.25-mg group, 16 (46%) eyes gained > or =3 lines of Early Treatment Diabetic Retinopathy Study (ETDRS) VA and seven (20%) lost > or =3 lines of ETDRS VA. In the 2.5-mg group, 11 (44%) eyes improved by > or =3 lines, and four (16%) lost > or =3 lines (P = 1.000). At 12 months, in the 1.25-mg group, the mean central macular thickness decreased from 419 +/- 201 microm at baseline to 268 +/- 96 microm, compared with a decrease from 388 +/- 162 to 296 +/- 114 microm in the 2.5-mg group (P = 0.7896). CONCLUSION: There were no statistically significant differences between the two dose groups with regard to the number of injections, anatomic and VA outcomes.

Intravitreal bevacizumab for choroidal neovascularization secondary to Vogt-Koyanagi-Harada syndrome.

BACKGROUND: Vogt-Koyanagi-Harada (VKH) syndrome is characterized by bilateral diffuse uveitis associated with auditory, neurological, and cutaneous signs and symptoms. VKH syndrome is a cell-mediated autoimmune disease against melanocytes. Choroidal neovascularization (CNV) occurs in 15% of VKH patients and is associated with poor visual prognosis. CASES: We report on two patients with VKH syndrome and CNV that were treated with intravitreal bevacizumab. OBSERVATIONS: One of the VKH patients also had an extrafoveal CNV membrane and underwent multiple intravitreal injections of bevacizumab in combination with laser photocoagulation, with subsequent improvement in visual acuity. The second had a subfoveal CNV that responded to a single intravitreal injection of bevacizumab. CONCLUSION: Intravitreal bevacizumab may be a useful drug to treat CNV in eyes with VKH syndrome.

Comparison of two doses of intravitreal bevacizumab (Avastin) for treatment of macular edema secondary to branch retinal vein occlusion: results from the Pan-American Collaborative Retina Study Group at 6 months of follow-up.

PURPOSE: To report the 6-month anatomical and visual outcomes after injecting two different doses of intravitreal bevacizumab in patients with macular edema secondary to branch retinal vein occlusion (BRVO). METHODS: An interventional, retrospective multicenter study of 45 eyes that were treated with at least one intravitreal injection (24 eyes, 1.25 mg; 21 eyes, 2.5 mg) of bevacizumab is reported. The main outcome measures were the central 1-mm macular thickness (CMT) and the change in ETDRS lines of best-corrected visual acuity (BCVA) at 6 months. RESULTS: Forty-five eyes were injected on average 26.1 months (range, 3-86 months) after the diagnosis. The average follow-up was 35.2 weeks (range, 24-52 weeks). All patients completed at least 6 months of follow-up. In the 1.25-mg dose group, at 1 month, there was an average gain of 4.5 lines of BCVA; at 3 months, 5.1 lines of BCVA; and at 6 months, 5.1 lines of BCVA (P < 0.005). In the 2.5-mg dose group, at 1 month, there was an average gain of 2.3 lines of BCVA; at 3 months, 3.8 lines of BCVA; and at 6 months, 4.8 lines of BCVA (P = 0.05). In the 1.25-mg dose group, the mean CMT +/- SD decreased from 461 +/- 211 microm at baseline to 321 +/- 152 microm at 1 month, 273 +/- 99 microm at 3 months, and 277 +/- 114 microm at 6 months (P = 0.0002). In the 2.5-mg group, the mean CMT +/- SD decreased from 385 +/- 168 microm at baseline to 279 +/- 111 microm at 1 month, 249 +/- 97 microm at 3 months, and 240 +/- 93 microm at 6 months (P = 0.011). CONCLUSION: There were no statistically significant differences between the two dose groups with regard to the number of injections and anatomical and functional outcomes. Intravitreal injection of bevacizumab at doses up to 2.5 mg appears to be effective in improving BCVA and reducing CMT in BRVO in the short term. Multiple injections are needed in a large number of eyes for continued control of macular edema and preservation of visual acuity in the short term. Longer studies are needed to determine what role if any intravitreal injection of bevacizumab may play in the long-term treatment of this condition.

Long-term effect of intravitreal triamcinolone in the nonproliferative stage of type II idiopathic parafoveal telangiectasia.

PURPOSE: To report the visual outcomes and ocular complications of intravitreal triamcinolone acetonide (IVTA) in the treatment of the nonproliferative stage of type II idiopathic parafoveal telangiectasia (IPT). METHODS: Retrospective, multicenter, uncontrolled interventional case series of 19 eyes of 14 consecutive patients with the nonproliferative stage of IPT that had undergone at least one intravitreal injection of 4 mg of triamcinolone acetonide. Demographic, medical, and ocular data were obtained through chart review. The main outcome measures included best-corrected visual acuity at several timepoints of follow up and ocular complications. RESULTS: At baseline the mean logMAR visual acuity was 0.83 +/- 0.41 (Snellen 20/135, range 0.3-2). After an average follow-up of 21.2 months (range 6-44 months), the mean logMAR visual acuity remained essentially unchanged from baseline. At 3 months, the logMAR visual acuity was 0.86 +/- 0.44 (Snellen 20/145, P = 0.8378), at 6 months 0.86 +/- 0.42 (Snellen 20/145, P = 0.8149), at 12 months 0.87 +/- 0.46 (Snellen 20/148, P > 0.9999), at 18 months 0.84 +/- 0.35 (Snellen 20/138, P = 0.8385), and at the last follow-up 0.82 +/- 0.44 (Snellen 20/132, P = 0.9301). Seven eyes were reinjected once. Ten of 19 eyes (53%) developed cataract (3 eyes underwent phacoemulsification and intraocular lens implantation) and 7 of 19 eyes (37%) had an elevated intraocular pressure, none of which required surgical treatment. CONCLUSION: IVTA does not seem to improve visual acuity in most eyes with the nonproliferative stage of IPT.

Aneurismas gigantes / Giant intracranial aneurysms

Se presentan siete casos clínicos de aneurismas gigantes atendidos en el Servicio de Neurocirugía del Hospital México, entre enero y noviembre de 1999, estudiados por tomografía axial (TAC), resonancia magnética (IRM), angiografía convencional (AC) y angiografía digital sustraída (ADS). Cinco casos se presentaron con una hemorragia subaracnoidea, un caso fue diagnosticado por un TAC de rutina por trauma de cráneo y solo un caso presentó un síndrome pseudotumoral. Cuatro de ellos a nivel de la arteria carótida interna, dos en el sistema vertebro-basilar y uno en la arteria cerebral media que se operó y falleció por vaso espasmo y edema cerebral. Cuatro, recibieron tratamiento quirúrgico por abordaje directo de la lesión, tres de la arteria carótida interna y uno de la arteria cerebral media; uno de los pacientes con aneurisma de la basilar, falleció sin poder ser operado y dos están bajo vigilancia clínica. Sus abordajes quirúrgicos, complicaciones y evolución postoperatoria según el tipo de lesión. Se presenta una revisión de las conductas actuales sobre esta patología vascular cerebral. Palabras Clave: aneurisma gigante, poligono de Willis, turbulencia, abordaje directo, terapia endovascular

Tumores de hipófisis, síndrome de Cushing / Pituitary tumors, Cushing's syndrome

La enfermedad de Cushing, representa para el neurocirujano y el endocrinólogo un reto interesante en su diagnóstico y tratamiento. Se han realizado numerosas investigaciones al respecto, desde que el Doctor Harvey W. Cushing describiera ésta patología como un Sindrome Basofílico en 1932. Los cuatro casos clínicos presentados en este artículo, tienen las características clínicas como hormonales de la clásica Enfermedad de Cushing. Se realizaron pruebas hormonales basales que demostraron, el hipercortisismo, la pérdida del ritmo circadiano de la secreción del cortisol y la supresión parcial con dexametasona en los niveles de cortisol. La región de la Silla Turca fue estudiada por radiografías simples, tomografía axial computarizada y las imágenes por resonancia magnética. Estas últimas demostraron las lesiones tumorales bien delimitadas a nivel de hipofisis. Los tumores fueron resecados pos vía transfrontal con una recuperación adecuada; el análisis histopatológico demostró las características células basófilas sin embargo, en uno de los casos bien documentado, éstas estaban acompañando una mayor cantidad de células nerviosas y fibras nerviosas algunas con aspecto displásico. Algunos tumores que producen esta enfermedad se pueden originar del lóbulo intermedio de la hipofisis.