EFFECT OF RANIBIZUMAB AND AFLIBERCEPT ON RETINAL PIGMENT EPITHELIAL DETACHEMENT, SUBRETINAL AND INTRARETINAL FLUID IN AGE-RELATED MACULAR DEGENERATION.

PURPOSE: The aim of the study was to compare the effect of three initial doses of the anti-VEGF ranibizumab and aflibercept medication on serous pigment epithelial detachment (PED), subretinal fluid (SRF) and intraretinal fluid (IRF) in the macula of treatment naive neovascular AMD (nvAMD) patients. MATERIAL AND METHODS: The cohort consists of 148 patients, of which 74 patients were treated with ranibizumab (51 females and 23 males) and 74 with aflibercept (46 females and 28 males). The data was recorded prospectively from the moment of diagnosis and start of treatment for a period of 3 months. At the moment of diagnosis and 3 months later, an OCT examination (Spectralis OCT, Heidelberg Engineering, Heidelberg, Germany) was performed. The OCT examination included a macular scan with 25 scans. Using the OCT instrument software, we measured the maximum anterior-posterior elevation of serous PED, the highest thickness of SRF and the largest diameter of the intraretinal cystic space. The statistical significance of differences between groups was evaluated using the t-test for continuous data and the Fisher exact test for categorical data. Changes in values of continuous variables over time were evaluated using the Wilcoxon paired test. Paired comparisons of binary parameters were determined by the McNemar test. RESULTS: Full regression of PED, SRF and IRF occurred in 3 (4.1%), 25 (39%) and 20 (51%) patients treated with ranibizumab, and in 5 (7.9%, p = 0.470), 28 (47%, p = 0.470) and 25 (57%, p = 0.827) patients treated with aflibercept, respectively. The average regression of PED, SRF and IRF was -60.4 μm (median -37.5 μm), -84.3 μm (median -85 μm) and -109.3 μm (median -81 μm) in patients treated with ranibizumab, and -46.3 μm (median -30 μm, p = 0.389), -127.7 μm (median -104 μm, p = 0.096) and -204.4 μm (median -163 μm, p = 0.005) in patients treated with aflibercept, respectively. We did not show a statistically significant difference in the regression rates of PED, SRF and IRF between the ranibizumab and aflibercept groups. (in patients with IRF after adjustment of the higher baseline IRF volumes in patients treated with aflibercept, p = 0.891). CONCLUSION: We are convinced that ranibizumab and aflibercept have the same effect on serous PED, SRF and IRF in the macula in patients with treatment naive nvAMD during the initial loading phase.

[Benefits and Negatives of Corticosteroid Therapy in Corneal Pathologies]. / Prínos a kontraproduktivita terapie kortikosteroidy u afekcí rohovky.

INTRODUCTION: Corticosteroid therapy is very beneficial in many types of eye diseases. Corticosteroids are used in the treatment of inflammatory and immunological diseases of the eye. PURPOSE: The aim is to present basic informations about effects of steroids in tissues, their side effects and treatment strategy. METHODS AND RESULTS: Authors process overview of local and systemic steroids and their dosage forms. They refer to the most common problems associated with corticosteroid therapy. CONCLUSION: Although corticosteroids include medicine across to one of the most frequently prescribed drugs at all, it is always necessary to treat very carefully indicate any corticosteroid preparation and prior to its administration to eliminate all infectious diseases, take a thorough anamnesis and complete examine the patient.Key words: cornea, corneal healing, inflammatory cascade, corticosteroids.

[The Current Diagnostic Possibilities and Cooperation of Oftalmologist and Neurologist Concerning in Patients with Idiopatic Intracranial Hypertension]. / Soucasné moznosti oftalmologické diagnostiky a spolupráce oftalmologa s neurologem u pacientu s idiopatickou intrakraniální hypertenzí.

PURPOSE: The aim of this paper is to present the current possibilities in idiopatic intracranial hypertension (IIH) diagnostics. Optical coherence tomography belongs to these possibilities in last few years. The necesarry interdisciplinary co-operation of ophthalmologist and neurologist concerning in IIH patients is pointed out in the mentioned case reports. MATERIAL AND METHODS: The issue of diagnostics and care of IIH patients is presented in two case reports. RESULTS: After ophthalmological and neurological examination the diagnosis of idiopathic intracranial hypertension was assessed and the treatment with acetazolamide was started. The patients have been observed in The department of ophthalmology University hospital in Pilsen during the run of the disease by the neoroophthalmologist. The edema of optic nerve has been monitored by fundoscopy and optical coherence tomography. Initially highly distended retinal nerve fiber layer thickness has been decreased with the normalizing of optic nerve head appearence. The patient´s difficulties have gone off during couple of month and the edema of optic nerve papilla has disappeared. According to the education and the regime acquisition our two patients reduced their body weight, so that they influenced favourably the development of their disorder. CONCLUSION: IIH is consequential disorder causing patient´s crucial restriction in an ordinary lifestyle. It could cause difficult changes in vision. The early diagnosis and proper leading of the therapy is fundamental for the next development of patient´s health. KEY WORDS: idiopatic intracranial hypertension, optical coherence tomography, edema of optic nerve head, papilloedema.

[Central Serous Chorioretinopathy as a Masquerading Syndrome of Choroidal Hemangioma]. / Centrální serózní chorioretinopatie jako maskující syndrom choroidálního hemangiomu.

INTRODUCTION: The finding of the neuroretinal ablation in fovea centralis area on Optic Coherence Tomography (OCT) examination in young men is a typical finding for central serous choroidoretinopathy. This finding may masquerade the presence of the choroidal hemangioma. CASE REPORT: The author presents case reports of two young men, in which, according to the finding of neuroretinal ablation on OCT, the diagnosis of central serous choroidoretinopathy was established. Using following examinations, especially fluorescence angiography, the correct diagnosis of choroidal hemangioma was set. In both patients, the photodynamic therapy with Visudyne was consequently indicated. CONCLUSION: In young patients with slightly decreased visual acuity, neuroretinal ablation finding in the macula on OCT, and without the tendency to spontaneous improvement, it is necessary to keep in the mind the possible presence of choroidal hemangioma.Key words: hemangioma, central serous choroidoretinopathy, misdiagnosis, ablation of the neuroretina, macula, choroid.

[Retinal tubulation]. / Retinální tubulace.

The aim of this study is to present a new retinal structure which is detectable on OCT scans - outer retinal tubulations (ORT). The discovery of these structures is related to more and more perfect retinal imaging using the spectral domain optical coherence tomography (SD OCT). Outer retinal tubulations were first described by Zweifel et al. in the year 2009 in patients with age-related macular degeneration. These branching tubular structures are localized in the outer nuclear layer of the retina. They are of circular or ovoid shape, with hyporeflectivity in the center, their borders are hyperreflective. Retinal tubulations are mostly seen together with choroid neovasculare membrane or with retinal pigment epithelium atrophy. Typically, they are adjacent to the area of wide damage of the outer retinal structure combined with relatively good preserved photoreceptor layer (respectively junctions between inner and outer photoreceptors segments), often they overlap the area of subretinal fibrosis or RPE (retinal pigment epithelium) damage. In eyes with anti-VEGF (vascular endothelial growth factor) treatment, they do appear in the area, where, before the treatment, the intraretinal fluid was present. These structures may simulate CME or the presence of subretinal fluid, so their determination plays an important role in the indications of next anti-VEGF drugs applications. Their non-detection may cause unneeded re-applications of anti-VEGF drugs into the viterous. This study was presented as a lecture at the Congress of the Czech VitreoRetinal Society in Dolní Morava (Czech Republic, E.U.) in the year 2014.

[The Use of anti-VEGF preparations and PDT in the treatment of retinal juxtapapillary hemangioma - a case report]. / Vyuzití anti VEGF preparátu a PDT v lécbe retinálního juxtapapilárního hemangiomu.

AIM: The aim of this paper is to present clinical experience with the therapy of retinal juxtapapillary hemangioma using the intravitreal application of anti-VEGF substance (bevacizumab) and photodynamic therapy (PDT) with verteporfine (Visudyne). MATERIAL AND METHODS: The authors present a case of a 34 years old male patient with diagnosed retinal hemangioma localized on the optic disc. Subjectively, the patient noticed decrease of vision, and during the clinical examination, the edema in the macula region spreading from the hemangioma with hard exsudates was found; the best-corrected visual acuity (BCVA) was 4/20 (0.2). RESULTS: First, the patient was treated by intravitreal applications of bevacizumab; after the first application, the edema from the macula subsided, and the best-corrected visual acuity improved to 4/12 (0.33). After one month of the first application, a recurrence of the edema occurred and other two injections of bevacizumab were applied; despite this treatment, further worsening of the exsudation from the hemangioma and worsening of the BCVA to 4/32 (0.125) occurred. Subsequently, one session of photodynamic therapy with verteporfine was held. After this therapy, the finding on the posterior ocular pole was stabilized; the BCVA was 4/40 (0.1). Even one year after the PDT therapy, no recurrence was present. CONCLUSION: According to our experience, the PDT with Visudyne appears as promising therapy method of juxtapapillary capillary hemangiomas. The PDT decreases the leaking of the fluid from hemangioma and decreases the size of hemangioma.

[Diagnostic pitfalls of pseudo-foster kennedy syndrome - a case report]. / ÚSKALIA DIAGNOSTIKY PSEUDO-SYNDRÓMU FOSTERA KENNEDYHO.

To the outpatient facility of the Department of Ophthalmology, Faculty Hospital Brno, Czech Republic, E.U., was in June 2013 referred a 24 years old man with the suspicion of Foster Kennedy syndrome. On the fundus examinations, the findings were in correlation with the symptoms of this syndrome: slightly pale optic disc of the right eye and edema with the anterior extension of the optic nerve head of the left eye. The perimetric examination revealed bilateral visual fields defects, mainly in the nasal parts of the visual fields which is not typical for this syndrome. The native magnetic resonance imaging (MRI) examination was negative. Due to the suspicion of pathologic finding in the visual pathway area, the blood levels of pituitary gland hormones were examined and revealed elevated prolactin levels. In the indicated MRI examination with contrast, in the revised reading, a suspicious microadenoma of the pituitary gland was detected. Due to the atypical changes in the perimetric examinations, other possible causes of visual fields defects as coincidence of multiple, each other independent pathologies (neuritis or neuropathy of the optic nerve, neuromyelitis optica (Devic disease), Lebers hereditary optic neuritis (LHON) etc.) to exclude or to confirm the Pseudo-Foster Kennedy syndrome were taken into account. The patient is regularly followed up at our outpatient facility as well as at the outpatient facility of the Department of Neurosurgery, where, until now, the follow up only was recommended. The diagnosis of this case was, until now, set as Pseudo- Foster Kennedy syndrome, with unclarified cause of the clinical findings.

[Contraception and ocular thromboembolic episodes - a case report]. / Kontracepce a ocní trombembolické príhody.

The aim of the paper is to warn of the retinal vein occlusion possibility due to the using of hormonal contraceptive pills in young female patients. A case report of 22 years old female patient hospitalized at the Department of Ophthalmology, School of Medicine, Masaryk University, Brno, Czech Republic, E.U., with sudden decrease of the left eye visual acuity is presented. After excluding other causes of visual acuity decrease, the diagnosis of prethrombotic state was made and anticoagulant treatment was started. Key words: optic disc edema, prethrombotic state, retinal vein occlusion, visual acuity decrease, hormonal contraception.

[Photodynamic therapy with Verteporfin in treatment of wet form ARMD - long term results]. / Lécba vlhké formy vekem podmínené makulární degenerace fotodynamickou terapií s verteporfinem - dlouhodobé výsledky.

Photodynamic therapy with Verteporfin (Visudyne - Novartis AG, Basel, Switzerland) is a method designed for treatment of the wet form of age-related macular degeneration. Effectiveness of photodynamic therapy with Verteporfin we approved on our department in group of 301 patients (114 males, 187 women) of average age 73.5 years with predominantly classic choroidal neovascular membrane in subfoveal localization in wet form of age-related macular degeneration. The follow up period in this group was from 6 to 36 month (mean 21 months). Patients with predominantly classic choroidal neovascular membrane underwent during the observation period from 1 to 5 treatments (mean 1.45 treatments). Mean best corrected visual acuity was before treatment 0.708 ± 0.24 logMAR. At the end of three-year observation period was the mean best corrected visual acuity 1.016 ± 0.36 logMAR. Best corrected visual acuity dropped during this time by 3.08 lines (15.4 letters) of ETDRS (early treatment diabetic retinopathy study) visual charts. Decrease of mean best corrected visual acuity less than 3 lines on ETDRS charts is considered as stabilisation. This goal was achieved in our group during observation period in 2/3 of patients.

[Photodynamic therapy with verteporfin in treatment of myopic neovascular choroideal membranes]. / Vyuzití fotodynamické terapie v lécbe myopických neovaskulárních membrán.

The aim of this study was to evaluate efficiency and long-term stabilization effect in patients with classic type of myopic choroidal neovascular membrane (CNV), treated with photodynamic therapy (PDT) with verteporfin (Visudyne - Novartis AG, Basel, Switzerland). We have verified the efficiency of photodynamic therapy with verteporfin in group of 51 eyes (17 men, 34 women), mean age 49,5 years with subfoveal localized predominantly classic neovascular membranes in pathologic myopia. The average follow up period was 23,7 months (± 2,3 month). Patients underwent during follow-up period 1 to 3 sessions of photodynamic therapy (PDT average number 1,25 sessions). The average best corrected visual acuity (BCVA) before treatment was 0,302 (0,65 logMAR) and the average BCVA at the end of follow up was 0,356 (0,46 log MAR). The improvement of best corrected visual acuity up to 5 letters on ETDRS (Early Treatment Diabetic Retinopathy Study) charts was observed in 23% of patients at the end of follow up.

[Ranibizumab in the ARMD wet form of age-related macular degeneration treatment - two years results obtained from the AMADEuS Registry]. / Ranibizumab v lécbe vlhké formy VPMD - dvouleté výsledky lécby z registru AMADEuS.

AIM: The aim of this study was the retrospective follow up of Age-Related Macular Degeneration (ARMD) wet form patients treated with ranibizumab during 24 months period. The data were recorded into the AMADEuS (Age-related MAcular DEgeneration in patientS in the Czech Republic) Registry and after their evaluation compared with treatment results obtained from other departments of ophthalmology collaborating in the AMADEuS project or results of some foreign studies as well. PATIENTS AND METHODS: The group consisted of patients registered since October 1, 2008 until June 11, 2012, followed up for 24 months period. There were 90 eyes of 89 patients. All patients were completely examined in the Macular ambulance of the Department of Ophthalmology in the Faculty Hospital Brno-Bohunice, Czech Republic, E.U., and consequently the ranibizumab (Lucentis, Novartis) was applied intravitreally in three initials doses one month apart. Thereafter, ranibizumab was applied "on demand". In 43.3 % of eyes the mostly classical, in 27.8 % of eyes occult, and in 28.9 % of eyes the minimally classical choroid neovascular membrane was present. The initial visual acuity was in 3.3 % of eyes in the range 15 - 30 letters of ETDRS optotypes (20/500 - 20/200), in 61.1 % of eyes in the range 31 - 60 letters (20/200 - 20/63), and the visual acuity better than 61 letters of ETDRS optotypes (better than 20/63) was in 35.6 % of eyes. RESULTS: The average initial best-corrected visual acuity (BCVA) in our group of patients was 54.2 letters of EDTRS (SD ± 14.4). At the visit at three months after the start of the treatment the BCVA was 59.6 letters of EDTRS (SD ± 15.0), at the visit after 6 months 57.3 letters of EDTRS (SD ± 14.7), after one year of the study 54.8 letters of EDTRS (SD ± 16), after 18 months of the study 53.4 letters of EDTRS (SD ± 16,8), and after 24 months of the study was the BCVA 51.7 letters of EDTRS (SD ± 16.9). The average CRT (central retinal thickness) value by means of the OCT (optic coherence tomography) examination was at the beginning of the treatment 311.4 µm (SD ± 117.9), after 3 months of treatment 233.5 µm, (SD ± 85.4), after 6 months of treatment 262.2 µm, (SD ± 102,4), after 12 months 261 µm (SD ± 88,4), after 18 months 254.9 µm (SD ± 70.0), and after 24 months 249 µm (SD ± 87.5). The average number of ranibizumab doses during the follow-up period was 5.6. After the 24 months follow-up period, the gain of 15 or more letters of EDTRS was recorded in 11.1 % of patients, the gain of 1 - 14 letters of EDTRS optotypes was recorded in 32.2 % of patients, the decrease of 14 or less letters of EDTRS optotypes was found in 21.2 % of patients, and the decrease of 15 or more letters was found in our group in 22.2 % of patients. CONCLUSION: The ARMD wet form treatment using ranibizumab is up to date the most effective available therapy. The AMADEuS registry is of great importance in the reviewing of the effectiveness of the ARMD wet form treatment.

[The ERG contribution in early diagnosis of chloroquine and hydroxychloroquine maculopathy]. / Prínos ERG v casné diagnostice chlorochinové a hydroxychlorochinové makulopatie.

Derivates of chloroquine (Plaquenil, Delagil), used for long-term treatment of rheumatic diseases, may cause clinically proven irreversible maculopathy, which may progress even after the discontinuation of their application. The optimal early diagnosis of ocular toxicity of chloroquine or hydroxychloroquine drug remains controversial up to now. The aim of this review paper was to evaluate how appropriate is the indication of the electroretinographic (ERG) examination due to the early diagnosis of cumulative drug-related maculopathy. Photopic, pattern, and multifocal ERG (Retiscan, according to the ISCEV methodology) were examined in 10 patients (20 eyes) treated by means of antimalarics, 9 due to the rheumatoid arthritis (RA) and 1 due to the systemic lupus erythremathodes (SLE). The average age of the patients was 60 +/- 15 years, the treatment period was 10 +/- 11 years; the median of the treatment period was 5 years. The control group consisted of 12 healthy, age matched patients (20 eyes) without any obvious ocular pathology. In all of them, the complete ophthalmologic examination was performed: the best corrected visual acuity (BCVA) for far using the Snellen charts, intraocular pressure (IOP) measured by means of the non contact tonometer NIDEK NT-2000, the Amsler grid test, examination of the anterior segment and the posterior segment with the slit lamp. The entry criteria in both groups were BCVA 5/7,5 (0.67) and better, the IOP in the normal range, negative Amsler grid test, anterior segment without significant decrease of the transparency, and physiological posterior segment or with subtle granular pigment dysgrupancies in the macula only. The significant difference between the group treated with chloroquine or hydrochloroquine and the control group at the 1% level of significance was found in following parameters: in the photopic ERG the value of the b wave latency [ms], in pattern ERG, the values of the waves N35 - P50 [microV] and P50 - N95 [microV] amplitudes, and at the 5 % level of significance in photopic ERG, the wave a amplitude value [microV] and in multifocal ERG, the value of the P1 [ms] a N1 [ms] parts latency in the pericentral ring. It follows from the results, that the ERG examination is suitable for the early diagnosis drug cumulative maculopathy caused by chloroquine derivates. Optimal is the individual comparison of the ERG values of the patient before and in certain time intervals after the beginning of the chloroquine derivates treatment.

[The possibility of the treatment of bilateral macular edema without the anti VEGF treatment--a case report]. / Moznost lécby oboustranného makulárního edému bez anti VEGF lécby.

UNLABELLED: Aim of this case report is to present a case of a female patient with bilateral macular edema successfully treated by the systemic antibiotic. MATERIAL AND METHODS: The authors present a case of 58 years old female with bilateral cystoid macular edema. In this patient, the central retinal thickness of the right eye was 550 microm, and 600 microm of the left eye. The best-corrected visual acuity (BCVA) of the right eye was 4/10 (0.4) and 4/12 (0.33) of the left eye. The patient underwent complex ophthalmologic examination. During the examination of the posterior pole, there were found no signs of the diabetic changes, or signs of the uveitis. The fluorescein angiography did not prove the presence of the choroidal neovascular membrane or vasculitis. The serological tests (toxoplasmosis, toxocariasis, borreliosis, syphilis--TPHA, RRR), and immunologic tests were performed as well. Toxoplasma positive IgG antibodies were found. According to these serological results, the systemic oral antibiotic treatment was started: clindamycin 300 mg three times daily for 14 days. After the termination of the treatment, improvement of the BCVA to 4/5 (0.8) in both eyes occurred. The OCT examination showed the foveolar depression in both eyes. Two months after the termination of the antibiotic treatment, the relapse of the macular edema occurred (BCVA 4/6 (0.66) in both eyes). According to the consultation with the doctor from the Department of Infectious Diseases, the treatment with clindamycin was started again (300 mg three times daily) for three weeks. After termination of this treatment, the foveolar depression on the OCT examination was evident and the BCVA was 4/4 (1.0) in both eyes (central retinal thickness of the right eye was 215 microm, and of the left eye it was 225 microm). This condition is stable and lasts for more than one year. CONCLUSION: In the differential diagnosis of the bilateral macular edema also the inflammatory etiology should be always considered. According to our experience, the bilateral macular edema may be the only presentation of toxoplasmosis.