OCULAR COMPLICATIONS OF DIABETES MELLITUS IN PREGNANCY - CASE REPORT.

Pregnancy is associated with increased risk of progression of diabetic retinopathy (DR), the greatest risk of worsening occurs during the second trimester of pregnancy and persists as long as one year after the childbirth. The risk factors include duration of the diabetes, insufficient metabolic control, severity of DR at the time of conception and presence of coexisting vascular disease, such as arterial hypertension, and pregnancy itself. The recommendations for retinopathy screening in pregnancy vary significantly. A dilated fundus exam should be done in the beginning of pregnancy, the next follow-up throughout pregnancy depends on the severity of ocular findings. The cooperation of multi-disciplinary team consisting of ophthalmologist, obstetrition and endocrinologist is essential to provide the best health care. The authors present a case report of a pregnant woman with type 1 diabetes mellitus (DM), who had a progression of DR and diabetic macular edema (DME) in both eyes during pregnancy. She has had DM for 24 years and has been treated with insulin. The patient was examined at the 23rd week of the second pregnancy (first pregnancy was terminated because of missed miscarriage). The diagnosis of advanced proliferative DR and advanced DME in both eyes was made so we performed panretinal laser photocoagulation of the retina of both eyes. Despite that the ocular findings got worse and we found vitreous haemorrhage in the left eye. We performed pars plana vitrectomy (PPV) of the left eye at the 28th week of pregnancy, nevertheless the DME got worse in both eyes, so we recommended to terminate the pregnancy at the 31st week because of the risk of loss of vision. The visual acuity of the left eye improved, but suddenly there was vitreous haemorrhage in the right eye after the delivery. We indicated PPV of the right eye, the outcome of the surgery was satisfying. We still take care about this patient.

[The benefit of pars plana vitrectomy for the resolution of complications of proliferative diabetic retinopathy]. / Prínos pars plana vitrektomie pro resení komplikací proliferativní diabetické retinopatie.

Between 1997 and 2007, we have conducted eye surgery on 72 patients (i.e. 72 eyes) as a consequence of proliferative diabetic retinopathy complications. The patients' average age was 61; the follow-up observations were carried out over a period of one year after the surgery. When we compare the initial vision with the visual acuity measured during the last follow-up examination in the late post-operative period, i.e. one year after the surgery, we can conclude that the vision of46 eyes (63%) had improved, 17 eyes (24%) did not show any change in vision, and the vision of nine eyes (13%) had deteriorated. Visual acuity of 1/60 (metric system) or better was found in 55 eyes (76%) during the late post-operative period; 6/60 vision or better was found in 29 eyes (40%), and four eyes (6%) showed 6/12 vision or better. If we compare the vision in the early post-operative period with the visual acuity during the last follow-up examination in the late post-operative period, we can conclude that in most cases, i.e. in 45 eyes (62.5%), the vision did not change any further during the months after the surgery, and one eye (1.5%) even showed improvement in visual acuity. It was confirmed that a positive result of pars plana vitrectomy observed in the early post-operative period may indeed persist even during the following months and years of the patient's life.

[Diabetic macular oedema in the third trimester of pregnancy]. / Diabetický makulární edém v posledním trimestru gravidity.

The authors describe a case of a female patient with diabetes mellitus (DM) type 1 who faced a progress of diabetic retinopathy (DR) during her pregnancy with a development of diabetic macular oedema (DMO) and a deterioration of visual acuity (VA) in the right eye. The patient had been under observation for DM for 18 years, the last six years for the onset of the non-proliferative form of DR. During the 28th week of pregnancy, a significant reduction of visual acuity in the patient's right eye occurred as a result of a fast developing DMO. The patient was generally given corticosteroids for a gynaecological indication to accelerate the maturing of the foetus. Betamethasone (Diprophos) in dose 12 mg with intramuscular application was administered twice in total, i.e. in the 29th and the 32rd week of pregnancy. After each application, a good effect was observed on the improvement of the visual acuity accompanied by a DMO reduction. However, the effect of corticosteroids was only temporary and at the end of their application in each case, a fast reduction of VA and a progression of DMO were observed, even though retinal laser photocoagulation was initiated. Delivery via Caesarean section was indicated in the 35th week of pregnancy, after a consultation with a diabetologist, gynaecologist and ophthalmologist. The delivery went without complications; both the child and the mother were in a normal condition after the delivery. A gradual improvement in VA was observed during the post-delivery period, with a reduction of DMO until a level of VA that corresponded to the status before the pregnancy was reached.

[The effect comparison of ranibizumab and sodium pegaptanib on the retinal pigment epithelium ablation size in the treatment of age-related macular degeneration]. / Porovnání úcinku ranibizumabu a pegaptanibu sodného na velikost ablace RPE pri lécbe vlhké formy vekem podmínené makulární degenerace.

AIM: To evaluate the effect difference of ranibizumab and sodium pegaptanib in the ablation treatment of the retinal pigment epithelium (RPE) in age-related macular degeneration MATERIAL AND METHODS: Retrospective analysis of data of patients with age-related macular degeneration treated by means of anti-VEGF therapy at the Department of Ophthalmology, School of Medicine, Palacky University, Olomouc, Czech Republic, E.U. during the period May 2009 - October 2010. For the analysis were used data from patients with follow-up period longer than 6 months and present serous RPE ablation caused by occult choroidal neovascularization (CNV), verified by optic coherence tomography (OCT) and fluoresceine angiography (FAG). STUDY GROUP: Ranibizumab was used as treatment during the period in 37 eyes of 37 patients (average age 73.2 years; right eye (RE) in 20 cases, left eye (LE) in 17 cases. Sodium pegaptanib was applied in 17 eyes of 17 patients (average age 72.4 years; RE in 10 cases and LE in 7 cases), The follow-up period in the ranibizumab group was 8.51 (SD 3.32) months, and in the pegaptanib group 9.94 (SD 5.50) months. RESULTS: In the ranibizumab group decreased the average RPE ablation base from 2865 microm (SD 810 microm) to 2270 microm (SD 1265 microm) and the prominence of the ablation from 334 microm (SD 160) to 238 microm (SD 178 microm). In patients treated by pegaptanib, decreased the average basis from 3245 microm (SD 930 microm) to 2159 microm (SD 1185 microm), and the prominence of the ablation from 354 microm (SD 173 microm) to 208 microm (SD 107 microm). The statistical significance test did not prove significant differences (level of significance p = 0.05) in the change either of the base or the prominence of the RPE ablation in any group of patients (prominence p = 0.09, base p = 0.21; Mann-Whitney test). In three patients (8.1%) treated by ranibizumab, the RPE rupture occurred. No RPE rupture was recorded in patients treated by sodium pegaptanib. CONCLUSION: Although no statistically significant difference in the efficacy of both drugs in the treatment of the RPE ablation was found, in patients treated by sodium pegaptanib, there is evident tendency of higher efficacy in decrease of the RPE ablation prominence, and lower incidence of RPE rupture. The study is limited by small number of patients and short follow-up period.

[Sodium pegaptanib and ranibizumab in the treatment of the retinal pigment layer ablation in a patient with age-related macular degeneration--a case report]. / Pegaptanib sodný a ranibizumab v lécbe ablace pigmentového listu sítnice u pacienta s vekem podmínenou makulární degenerací-kazuistika.

The case report presents the difference of the effect of two drugs blocking vascular endothelial growing factor (anti-VEGF)--sodium pegaptanib and ranibizumab--in a female patient with the retinal pigment epithelium (RPE) layer ablation as a part of the exsudative age-related macular degeneration. Fifty-five years old female patient with RPE ablation as a sign of exsudative ARMD and central visual acuity 79 letters of the EDTRS chart in the left eye was treated by 5 intravitreal injections of sodium pegaptanib. The treatment was not sufficiently effective according to the fluorescein angiography (FAG) and optic coherence tomography (OCT) findings and was accompanied by further decrease of the visual acuity to 55 letters of the EDTRS chart. After the medication was switched to ranibizumab with 3 intravitreal applications, the RPE ablation flattened according to the OCT findings and the fluorescein leakage during the FAG markedly decreased. The central visual acuity improved to 63 letters of the EDTRS chart. The decreased activity of the choroidal neovascularization (CNV) is observed during the following 4 months after the last intravitreal application of ranibizumab. Ranibizumab seems to be more effective drug comparing to the sodium pegaptanib in patients with the RPE ablation, but it is necessary to consider the increased probability of the RPE rupture risk.

[The intravitreal application of the tissue plasminogen activator in the treatment of submacular hemorrhage--a case report]. / Intravitreální aplikace tkánového aktivátoru plazminogenu v lécbe submakulární hemoragie--kazuistika.

The authors present the possibility to influence therapeutically the submacular hemorrhage caused by age-related macular degeneration in the presence of choroidal neovascular membrane by means of recombinant plasminogen tissue activator (rt-PA) and expansive gas intravitreal injection followed by pneumatic relocation of the hemorrhage out of the foveolar region. The therapy is presented in a case report. The submacular hemorrhage without treatment causes serious decrease of visual functions. The human recombinant plasminogen tissue activator that is a glycoprotein, activating the transformation of plasminogen directly to plasmin has a trombolytic effect. Rt-PA is activated by binding to fibrin with high affinity. This minimally invasive procedure gives the possibility to treat this prognostic unfavorable finding, so after the lysis and pneumorelocation of the hemorrhage from the macular region we can treat the choroidal neovascular membrane.

[The ultrasound findings in posttraumatic endophthalmitis]. / Ultrazvukové nálezy u poúrazových endoftalmitid.

The aim of this study was to evaluate the ultrasound findings in eyes with endophthalmitis following penetrating injury and to establish unfavorable predictive signs of this serious disease. In a retrospective study we evaluated findings in 7 eyes of 7 patients followed up because of posttraumatic endophthalmitis at the Department of Ophthalmology, School of Medicine, in Olomouc, Czech Republic, EU, during the period September 1999-December 2004. The mean age of the patients was 37.3 years (range 22-49 years). The mean duration of the period between the injury and the formation of the endophthalmitis was 8.4 days (range 1-21 days). The visual acuity at the time of admittance was very low; it ranged between light perception and 1/60 (0,016 or 20/1200). All patients underwent diagnostic-therapeutic pars plana vitrectomy with vitreous samples taken for microbiological examination and intravitreal antibiotic application. The final visual acuity (VA) ranged from 1/60 (0,016 or 20/1200) to 6/12 (0.5 or 20/40), so it was very variable and that gave us the possibility to follow the connection between the final VA and seriousness of the penetrating injury, and also with the interval between the emergence of the endophthalmitis and beginning of its treatment. During the ultrasound examination, the presence of membranes in the vitreous body, posterior vitreous detachment, thickening of the choroid, detachment of the choroid and detachment of the retina were of concern to us. Membranes were present in the vitreous in 5 eyes. Without membranes detected by the ultrasound, there were 2 eyes; in both of them the final VA was better than 6/36 (0,1667 or 20/120). The posterior vitreous detachment was detected in 3 eyes, and not detected in four eyes. We didn't find any connection between the final VA and posterior vitreous detachment. The thickening of the choroid was present at the ultrasound examination in all seven eyes. The detachment of the choroid was not found in any eye. The retina was detached in two eyes. In three eyes only, the final central VA was better than 6/36 (0.1667 or 20/120). In two of them, the intraocular foreign body was found and in both the bacteria Staphylococcus epidermidis was detected. In the third eye, the soil bacteria Enterococcus and Klebsiela were cultivated. The ultrasound findings in these three eyes are identical only in the term of thickening of the choroid, similar to other eyes. In two of them no membranes were detected by ultrasound and no posterior vitreous detachment was found. The ultrasound examination in eyes with endophthalmitis after penetrating injury is specific in particular because of the mechanism of the injury. In contrast to the cases of the postoperative endophthalmitis, no prognostic unfavorable sings in the ultrasound examination can be strictly identified.