Progressive Massive Choroidal Neovascularization, an Aggressive Phenotype: Case Report.

We report 2 cases of an aggressive choroidal neovascularization phenotype. A 77-year-old hypertensive woman, with a 4-year history of visual loss in her left eye, due to vitreous hemorrhage associated with a dome-shaped mass lesion underwent pars plana vitrectomy. An extensive subretinal hemorrhage was found, associated with extensive subretinal fibrosis, which was treated with endophotocoagulation and intravitreal injection of anti-VEGF. Best-corrected visual acuity after surgery was light perception. A 74-year-old woman with a 4-year history of treatment for choroidal neovascularization in both eyes presented with an extensive subretinal hemorrhage associated with exudation in the temporal peripheral retina. Lesions became larger despite monthly intravitreal anti-VEGF injections (14 injections) and verteporfin photodynamic therapy in both eyes. Throughout the years, the choroidal neovascular lesion continued to enlarge until it developed a severe vitreous hemorrhage. The patient rejected treatment and ended up with no light perception at the end of the follow-up (8 years). A rare severe choroidal neovascularization phenotype is presented here and would be considered to be at the aggressive extreme of the spectrum of a neovascular age-related macular degeneration or polypoidal choroidal vasculopathy that presents massive hemorrhage and exudation as much as in the posterior pole as in the peripheral retina.

Autologous Retinal Transplantation with the Use of Air Tamponade for the Treatment of a Primary Large Chronic Macular Hole.

The purpose of this case report is to describe a chandelier-assisted bimanual autologous retinal transplantation (ART) with air tamponade technique for the treatment of a large macular hole (MH). A patient with a primary chronic large MH, who underwent chandelier-assisted bimanual ART with the use of air tamponade is described. The MH diameter was 888 µm. Changes in best-corrected visual acuity (BCVA) were measured postoperatively; clinical pictures and optical coherence tomography were analyzed. Baseline preoperative BCVA was 20/400. Closure of the MH was achieved. At 7 months, post-surgery BCVA improved to 20/50. Optical coherence tomography examinations showed the integration of the autologous transplant with the adjacent macular tissue and continuity preservation of the ellipsoid layer. In conclusion, chandelier-assisted bimanual ART with air tamponade technique was effective in achieving complete MH closure and long-term visual improvement.

Autofluorescence indexes as biomarkers for antiangiogenic loading dose outcome in diabetic macular edema.

PURPOSE: To evaluate the combination of fundus autofluorescence results with several clinical and structural variables into mathematical indexes to enhance their ability to predict visual and anatomical changes after the antivascular endothelial growth factor loading dose. METHODS: Patients with diabetic macular edema were enrolled. Each patient had a comprehensive ophthalmological examination, contrast sensitivity, optical coherence tomography, and fundus autofluorescence assessment. All patients received three monthly doses of ziv-aflibercept and were followed each month for response assessment. Autofluorescence was classified according to its level into five grades. The grades were combined with other variables (best-corrected visual acuity, contrast sensitivity, central macular thickness, macular cube volume, and macular cube average thickness) into normalized indexes. Statistical assessment was done using a Spearman's rank correlation coefficient, linear regression, and interobserver-agreement analysis. RESULTS: There was a strong correlation between the fundus autofluorescence/baseline best-corrected visual acuity index and the fundus autofluorescence/contrast-sensitivity index at baseline with the best-corrected visual acuity after the third dose of ziv-aflibercept (rs = -0.78, p = .000 and rs = -0.68, p = .0009 respectively). The fundus autofluorescence/baseline best-corrected visual acuity index and the fundus autofluorescence/contrast-sensitivity index, both at baseline had a mild correlation with the macular volume at 1 month of follow-up (rs = 0.56, p = .008 and (rs = 0.64, p = .002, respectively). CONCLUSION: This study suggests that it is possible to combine fundus autofluorescence results with functional and structural variables into normalized indexes that could potentially predict outcomes after antivascular endothelial growth factor loading dose in patients with diabetic macular edema.

Cromoforo fotoactivado con crosslinking como tratamiento para la queratitis por Acanthamoeba / Photoactivated chromophore with crosslinking as treatment for Acanthamoeba keratitis

RESUMEN Se reporta el uso del crosslinking como tratamiento de la queratitis por Acanthamoeba en una serie de 7 pacientes quienes acudieron al Servicio de Córnea por queratitis multitratadas. Se les realizó biopsia corneal, la cual se cultivó en solución de Page. Los pacientes fueron tratados con un protocolo de PACK-CXL durante más de 5 minutos y fueron sometidos a la exposición a la luz UV-A. El edema del nuevo epitelio era de 2 cruces a las 24 horas, y desapareció a las dos semanas del procedimiento en todos los casos. El porcentaje de desepitelización basal al momento del diagnóstico fue de 75,7 por ciento. La agudeza visual mejor corregida fue de entre 20/20 y 20/30. Se concluye que el uso de crosslinking en pacientes con Acanthamoeba en fases inicales pudiera ser una opción terapéutica segura y efectiva(AU)

ABSTRACT A report is presented of the use of crosslinking as treatment for Acanthamoeba keratitis in a series of 7 patients attending the Cornea Service for multitreated keratitis. Corneal biopsy was performed, which was cultured in Page solution. The patients were treated with a PACK-CXL protocol for more than 5 minutes and subjected to UV-A light exposure. Edema of the new epithelium was 2 crosses at 24 hours and disappeared 2 weeks after the procedure in all cases. Basal de-epithelialization percentage at diagnosis was 75.7 percent. Best corrected visual acuity ranged between 20/20 and 20/30. It is concluded that the use of crosslinking in patients with Acanthamoeba keratitis in its initial stages could be a safe and effective therapeutic option(AU)

Correlation analysis of fundus autofluorescence, spectral domain optical coherence tomography, and visual function in patients with diabetic macular oedema treated with intravitreal ziv-aflibercept.

PURPOSE: The aim of this study was to evaluate the correlations between fundus autofluorescence and morphologic parameters as well as visual function in patients with diabetic macular oedema treated with intravitreal ziv-aflibercept. METHODS: A total of 34 eyes of 20 patients with untreated diabetic macular oedema received an intravitreal injection of ziv-aflibercept at baseline, and 1 and 2 months later. The baseline, 1-month, and two-month best corrected visual acuity determination, contrast sensitivity, spectral domain optical coherence tomography, mean central macular thickness, mean macular cube volume, mean macular cube average thickness, and fundus autofluorescence (decreased, normal, or increased; and single or multiple spots) were measured. Correlation analysis with a determination of Spearman's rank correlation coefficient, regression analysis, agreement between investigators, and Friedman's test were used for statistical analyses. RESULTS: A direct correlation was observed between baseline fundus autofluorescence and macular cube average thickness at 1 month (r = 0.51, p = 0.020) and between fundus autofluorescence at 1 month and baseline macular cube average thickness (r = 0.50, p = 0.021). Regression analysis showed a coefficient of determination of 0.29 (p = 0.016) between baseline fundus autofluorescence and macular cube average thickness at 1 month. CONCLUSION: In patients with diabetic macular oedema, the pretreatment baseline degree of foveal fundus autofluorescence might be helpful in predicting macular cube average thickness in patients undergoing treatment with intravitreal ziv-aflibercept in the short term.

Cilioretinal Artery Branch Avulsion Secondary to Surgical Embolectomy: Management and Outcome.

We report the trans-operative approach and short-term outcome of a patient who suffered a traumatic avulsion of the cilioretinal artery branch during the surgical management of a cilioretinal arterial branch occlusion (CRABO) with intraocular embolectomy. A patient with acute CRABO underwent a pars plana vitrectomy with in situ embolectomy. The blocked artery was incised using 25 gauge vertical scissors, and embolus manipulation was done using microsurgical forceps. During embolus extraction, the occluded cilioretinal artery and its branch were inadvertently avulsed and torn with subsequent intense bleeding. Laser and endodiathermy were used for acute hemostasis. The maneuvers created an unintended retinochoroidal anastomosis. Visual field improvement was noted 3 months after the surgery. In the event of a complicated surgical embolectomy with the avulsion of the artery, the formation of a retinochoroidal anastomosis and reperfusion of the occluded may occur along with the improvement of visual fields in some cases.

Expression of dopamine D2 and D3 receptors in the human retina revealed by positron emission tomography and targeted mass spectrometry.

Dopamine D2 receptors (D2R) are expressed in the human retina and play an important role in the modulation of neural responses to light-adaptation. However, it is unknown whether dopamine D3 receptors (D3R) are expressed in the human retina. Using positron emission tomography (PET), we have observed significant uptake of the D3R-preferring agonist radiotracer [11C]-(+)-PHNO into the retina of humans in vivo. This led us to examine whether [11C]-(+)-PHNO binding in the retina was quantifiable using reference tissue methods and if D3R are expressed in human post-mortem retinal tissue. [11C]-(+)-PHNO data from 49 healthy controls (mean age: 39.96 ± 14.36; 16 female) and 12 antipsychotic-naïve patients with schizophrenia (mean age: 25.75 ± 6.25; 4 female) were analyzed. We observed no differences in [11C]-(+)-PHNO binding in the retina between first-episode, drug-naïve patients with schizophrenia and healthy controls. Post-mortem retinal tissues from four healthy persons (mean age: 59.75 ± 9.11; 2 female) and four patients with schizophrenia (mean age: 54 ± 17.11; 2 female) were analyzed using a targeted mass spectrometry technique: parallel reaction monitoring (PRM) analysis. Using targeted mass spectrometry, we confirmed that D3R are expressed in human retinal tissue ex vivo. Notably, there was far greater expression of D2R relative to D3R in the healthy human retina (∼12:1). Moreover, PRM analysis revealed reduced D2R, but not D3R, expression in the retinas of non-first episode patients with schizophrenia compared to healthy controls. We confirm that D3R are expressed in the human retina. Future studies are needed to determine what proportion of the [11C]-(+)-PHNO signal in the human retina in vivo is due to binding to D3R versus D2R. Knowledge that both D2R and D3R are expressed in the human retina, and potentially quantifiable in vivo using [11C]-(+)-PHNO, poses new research avenues for better understanding the role of retinal dopamine in human vision. This work may have important implications for elucidating pathophysiological and antipsychotic induced visual deficits in schizophrenia.

Inverted ILM flap, free ILM flap and conventional ILM peeling for large macular holes.

BACKGROUND: To assess closure rate after a single surgery of large macular holes and their visual recovery in the short term with three different surgical techniques. METHODS: Prospective multicenter randomized controlled trial. We included treatment-naïve patients with diagnosis of large macular hole (minimum diameter of > 400 µm). All patients underwent a comprehensive ophthalmological examination. Before surgery, the patients were randomized into three groups: group A: conventional internal limiting membrane peeling, group B: inverted-flap technique and group C: free-flap technique. All study measurements were repeated within the period of 1 and 3 months after surgery. Continuous variables were assessed with a Kruskal-Wallis test, change in visual acuity was assessed with analysis of variance for repeated measurements with a Bonferroni correction for statistical significance. RESULTS: Thirty-eight patients were enrolled (group A: 12, group B: 12, group C: 14). The closure rate was in group A and B: 91.6%; 95% CI 61.52-99.79%. In group C: 85.71%; 95% CI 57.19-98.22%. There were no differences in the macular hole closure rate between groups (p = 0.85). All groups improved ≈ 0.2 logMAR, but only group B reached statistical significance (p < 0.007). CONCLUSIONS: Despite all techniques displayed a trend toward visual improvement, the inverted-flap technique seems to induce a faster and more significant recovery in the short term.

An Office-Based Fluid to Fluid Exchange Technique for the Treatment of Postvitrectomy Vitreous Cavity Hemorrhage and Secondary Glaucoma.

A case of postvitrectomy hemorrhage with secondary glaucoma successfully treated with an office-based fluid to fluid exchange is described. A 25 Ga trocar was placed 3 mm from the sclerocorneal limbus at the 2 o'clock position and connected to a 250 cc elevated bottle of balanced salt solution (BSS) through an intravenous (IV) line and an infusion cannula. Afterward, a 25 Ga needle was inserted 3 mm from the limbus at the 5 o'clock position approximately. The BSS fluid entered the eye through the 25 Ga trocar lavaging the vitreous cavity and the anterior chamber. About 4 to 6 cc of hemorrhagic fluid egressed the eye through the 25 Ga needle.

Safety of intravitreal quinupristin/dalfopristin in an animal model.

AIM: To determine whether different intravitreal doses of quinupristin/dalfopristin lead to electroretinographic or histological changes in the rabbit retina over one month period after injection. METHODS: Eighteen New Zealand white rabbits were divided into three treatment groups (groups 1 to 3) and different intravitreal doses of quinupristin/dalfopristin were tested in each group. The right eye was injected with the drug and the left eye received intravitreal injection of 5% dextrose water and served as control eye. The doses delivered to each group were 0.1 mg/0.1 mL, 1 mg/0.1 mL and 10 mg/0.1 mL. Simultaneous, bilateral, dark-adapted electroretinography and clinical images of both eyes were obtained in all groups before injection (baseline) and after 7, 14, 21 and 28d, followed by enucleation for histological examination. RESULTS: Subjects in the group 1 showed no signs of toxicity in the electroretinogram when compared with groups 2 and 3 (Kruskall-Wallis test, P=0.000). By day 7, no electrical response to light stimuli was recorded in the treated eyes in groups 2 and 3, consistent with severe damage due to retinal toxicity. Light microscopy revealed no significant histopathological changes in the group 1, while rabbits in groups 2 and 3 had signs of granulomatous inflammation in most cases. CONCLUSION: Intravitreal 0.1 mg/0.1 mL doses of quinupristin/dalfopristin do not lead to electroretinographic or histological signs of retinal toxicity compared with 1 mg/0.1 mL and 10 mg/0.1 mL in this rabbit model.

TGFBI, CHST6, and GSN gene analysis in Mexican patients with stromal corneal dystrophies.

OBJECTIVES: The purpose of our study was to describe the results of molecular screening of TGFBI, CHST6, and GSN genes in a group of Mexican patients with different stromal corneal dystrophies (CD). MATERIAL AND METHODS: A total of 16 CD Mexican patients pertaining to nine different pedigrees were subjected to a complete ophthalmological investigation. A clinical diagnosis of lattice CD was performed in 10 patients from five pedigrees. Three patients from two pedigrees were diagnosed with granular CD type 2, two patients with unrelated probands had Finnish-type corneal amyloidosis, and one patient had macular CD. Genetic analysis included DNA isolation from blood leukocytes and polymerase chain reaction (PCR) amplification and direct nucleotide sequencing of TGFBI, CHST6, and GSN genes. RESULTS: Seven lattice CD patients from four unrelated families had an identical p.H626R mutation in TGFBI, three patients from a single lattice CD family carried a p.R124C substitution in TGFBI, and a granular type 2 CD pedigree was demonstrated to carry a heterozygous TGFBI p.M619K substitution. A patient having Finnish-type corneal amyloidosis had a p.D187N mutation in GSN. Finally, molecular analysis of CHST6 in a patient with macular CD disclosed the presence of a homozygous p.Y110C change. CONCLUSIONS: This study improves the knowledge of the genetic features of Mexican patients with corneal stromal dystrophies by identifying mutations in the TGFBI, CHST6, and GSN genes. Genetic screening of larger samples of patients from distinct ethnic groups would be of great importance for a better understanding of the mutational spectrum of stromal CD.

[Corneal transplant in a second level hospital. A survival analysis]. / Trasplante corneal en hospital de segundo nivel. Un análisis de supervivencia.

OBJECTIVE: To determine the long-term corneal graft survival in patients of General Hospital Dr. Miguel Silva. MATERIALS AND METHODS: This was a retrospective cohort study. Records from patients who underwent corneal transplant surgery at General Hospital Dr. Miguel Silva were analyzed. The percentages of graft failure were obtained. Kaplan-Meier survival analysis was performed to evaluate the long-term cumulative probability of graft non-rejection in all patients according to diagnosis. RESULTS: Overall, 71.9% (CI 95%: 64.8-78.9) of the patients did not have any graft rejections, and 12.5% (CI 95%: 7-18) required a regraft and were considered graft failures. Patients with posttraumatic leucoma had a cumulative probability of non-rejection of 100%. Subjects with keratoconus had a 65% likelihood of non-rejection after 40 months of follow-up. The likelihood of non-rejection was greater than 80% at 100 months of follow-up in pseudophakic bullous keratopathy patients and 60% at 20 months of follow-up in inactive herpetic leucoma patients. CONCLUSIONS: Posttraumatic leucoma patients had the greatest cumulative survival probability compared with postherpetic leucoma patients and other patient groups.

Vitrectomy with or without preoperative intravitreal bevacizumab for proliferative diabetic retinopathy: a meta-analysis of randomized controlled trials.

PURPOSE: To compare safety and functional outcomes of vitrectomy with or without preoperative intravitreal bevacizumab (IVB) for proliferative diabetic retinopathy (PDR). DESIGN: A meta-analysis of randomized controlled trials. METHODS: PubMed, Medline, EMBASE, and Cochrane Controlled Trials Register were searched to identify potentially relevant randomized controlled trials. A total of 394 participants with 414 eyes in 8 trials were analyzed using RevMan 5.1 software. The primary measures included intraoperative bleeding, total surgical time, and early and late recurrent hemorrhage. RESULTS: Vitrectomy with IVB pretreatment achieved shorter overall surgical time (mean difference = -26.89 minutes, 95% confidence interval [CI] -31.38 to -22.39, P < .00001) and smaller number of endodiathermy applications (mean difference = -3.46, 95% CI -6.43 to -0.49, P = .02) compared to vitrectomy alone. The IVB group was also associated with less intraoperative bleeding (odds ratio [OR] = 0.10; 95% CI 0.02 to 0.46; P = .003) and recurrent vitreous hemorrhage within first month (OR = 0.35; 95% CI 0.21 to 0.58; P < .0001), but the proportion of recurrent vitreous hemorrhage after the first month was comparable between both groups. There were no significant differences in other complication rates between the 2 groups, with the exception of iatrogenic retinal break, which was more likely with the vitrectomy-alone group (OR = 0.27, 95% CI 0.12 to 0.63, P = .003). Results were robust to sensitivity analyses. CONCLUSIONS: Adjuvant intravitreal injection of bevacizumab prior to vitrectomy in PDR patients significantly eased the procedure, diminished intraoperative complications, and reduced early postoperative hemorrhage without increasing the risk of vision-threatening complications. Further trials should determine the optimal interval and dosage for IVB injection.

Limbal Stem Cell Allografts and Corneal Transplant in a Patient with Severe Corneal Melting and Perforation due to Thermokeratoplasty and Cross-Linking Treatment Burn.

PURPOSE: To report corneal stem cell allografts in a patient with a persistent epithelial defect as well as corneal melting and perforation due to severe ultraviolet light burn and thermokeratoplasty treatment for keratoconus. METHODS: A 21-year-old female patient with corneal melting, perforation and a persistent epithelial defect in her left eye secondary to iatrogenic treatment for keratoconus, thermokeratoplasty and cross-linking was treated with penetrating keratoplasty, using a 9.0-mm diameter corneal graft and limbal stem cell allograft implants. At the end of the procedure, subtenonian injections of a combination of bevacizumab and triamcinolone were given. RESULTS: The patient had a favorable outcome 48 h after surgery, with an improvement of symptoms and a complete corneal healing. By the third week after surgery, she had a best-corrected visual acuity of 20/60 and a clear corneal graft, which remained stable for the 9 months of follow-up. CONCLUSIONS: Treatment with limbal stem cell allografts and penetrating keratoplasty in a female patient with a large corneal defect and melting in her left eye was effective. Larger studies are warranted to explore the real impact of this procedure.

Lupus relapse presented as frosted branch retinal angiitis: case report.

PURPOSE: To describe a systemic lupus erythematosus (SLE) relapse, which presented as frosted branch retinal angiitis. DESIGN: Clinical case report. METHODS: A 16-year-old female patient had an SLE relapse that appeared as frosted branch angiitis while being treated with deflazacort and azathioprine. RESULTS: Complete resolution of the vasculitis was achieved with a 3-day course of pulsed intravenous methylprednisolone and oral prednisone 3 weeks later. CONCLUSIONS: Even with proper immunosuppressive treatment, SLE can relapse. This case presented as frosted branch retinal angiitis, which is a clinical picture that is rarely described in SLE.

Posttraumatic giant macular hole.

INTRODUCTION: Large macular holes secondary to blunt trauma are sometimes seen in young patients within the spectrum of alterations produced by ocular trauma. METHODS: Observational case report. A 32-year-old woman who had received a blunt trauma (a blow from a fist) to her right eye 10 years previously had experienced a decrease in visual acuity ever since. RESULTS: Clinical photographs, fluorescein angiography and optic coherent tomography images revealed a very large macular hole of approximately 1,920 µm in diameter. CONCLUSION: This case is an uncommonly large variant of a macular hole secondary to blunt trauma in a young patient.

Ultraviolet-a light and riboflavin therapy for acanthamoeba keratitis: a case report.

PURPOSE: To report ultraviolet-A (UV-A) light treatment in a patient with Acanthamoeba keratitis (AK). METHODS: Interventional case report. A standard protocol for ultraviolet corneal therapy, with a power emission of 3 mW/cm(2) and a wavelength of 370 nm, was used. The protocol included an 8-nm bandwidth at a 54-mm distance measured with a collimation system of diodes as well as a protective shield of riboflavin in a case of documented AK. RESULTS: A 54-year-old female patient with AK, showing no therapeutic response to a wide variety of topical antimicrobial agents and with a visual acuity of 20/400, was treated with UV-A therapy. The patient displayed a favourable response in the first 24 h after treatment, with improvement of symptoms, visual acuity (to 20/200) and biomicroscopy cornea with haze degree I. By the third week post-treatment, the patient was symptom-free. Her visual acuity was 20/30, and the affected cornea was clear. Five months after treatment, there had been no recurrence, and her vision was 20/20. CONCLUSIONS: Treatment with UV-A light was an effective therapy in this case of AK.