Diabetic Macular Edema - Diagnostics and Treatment Guidelines.

Together with diabetic retinopathy, diabetic macular edema (DME) ranks among the most common causes of severe loss of vision in working adults. Due to recent developments in imaging methods, new classification schemes of DME have been created. In addition to this, new treatment options have been introduced (new intravitreal drugs as well as treatment protocols). At the same time laser, surgical as well as combination therapy is still available. In this paper we evaluate the current knowledge about DME diagnostic and treatment options and formulate recommended guidelines for the management of DME.

Diabetic Retinopathy ­ Diagnostics and Treatment Guidelines

Diabetic retinopathy is one of the most common complications of diabetes mellitus and represents a serious health, social and economic problem. With the expected increase in the number of patients with diabetes, it is becoming the leading cause of severe vision loss in the working-age population.  The presented guidelines summarize the current knowledge about this disease in order to standardize and update the procedures for the diagnosis, classification and treatment of diabetic retinopathy.

Diabetic Retinopathy and Diabetic Macular Edema - Screening.

Diabetic retinopathy (DR) and diabetic macular edema (DME) are leading causes of severe visual loss in the working population. Therefore, both DR and DME have a significant socioeconomic and health impact, which taking into account the epidemiologic predictions is expected to increase.  A crucial role in the management of DR and DME (not only for individuals, but also for the population) is played by an adequate screening program. This is based on the structure and organization of the healthcare system, the latest scientific developments in diagnostics (imaging) as well as technological advancements in computing (artificial intelligence, telemedicine) and their practical use. The recommendation presented by World Health Organization is also important. This paper evaluates all these factors, including evidence-based medicine reports and experience from existing DR and DME screening programs in comparable countries. Based on an evaluation of these parameters, recommended guidelines have been formulated for screening for DR and DME in the Czech Republic, including linkage to the Czech National Screening Center and the organization of the healthcare system.

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.

UVEAL MELANOMA IN A 15-YEAR-OLD GIRL. CASE REPORT.

Uveal melanoma is the most common intraocular tumour in adults, it is a form of cancer that affects mostly older adults, as the average age at detection of this tumour is 60 years, but it can occur in any age group with no significant gender difference. However, uveal melanoma is very rare in children compared to the adult population, accounting for 1 % of all cases. In pediatric patients, malignant uveal melanoma is more frequently manifested during puberty, leading to speculation of an association between uveal melanoma and growth hormone levels. Prognostic factors for uveal melanoma include tumour histology, chromosomal abnormalities, tumour size, extrascleral spread and tumour location. Risk factors for uveal melanoma include melanocytosis, neurofibromatosis type 1 and dysplastic naevus syndrome. Some studies point to a significantly lower risk of developing metastases in younger patients, but the prognosis of uveal melanoma in children is not yet fully known. Clinical signs and treatment options for malignant uveal melanoma in children are still under discussion. Differential diagnosis of uveal lesions in children can sometimes be very difficult, as evidenced by following case report in which authors describe a case of choroidal melanoma in a 15-year-old girl.

Idiopathic Chodoidal Neovascular Membrane in a 12-year-old Girl.

Choroidal neovascularization (CNV) is a rare but serious cause of visual impairment in children. The case report of a girl with a unilateral classical choroidal neovascular membrane has been presented. The differential diagnosis of possible etiology and the clinical course of this sight threatening condition during treatment have been documented. The similar cases in pediatric patients in foreign literature have been discussed. Current anti VEGF therapy is also available for pediatric patients and play a key role in improvement and stabilization of visual acuity in children with this disease.

[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 use of intravitreal ranibizumab application in the treatment of post-inflammatory neovascular membranes--a case report]. / Vyuzití intravitreální aplikace ranibizumabu v lécbe pozánetlivých neovaskulárních membrán--kazuistické sdelení.

The aim of this case report is to represent our experience with intravitreal application of ranibizumab in a patient with post-inflammatory neovascular membrane. Patient, a 46 years old male, complained about 3 months lasting metamorphopsia in the left eye. The classic post-inflammatory neovascular membrane was diagnosed by means of fluorescein angiography. The initial BCVA of the left eye was 4/6 (or 0.67). Two intravitreal injections of 0.5 mg ranibizumab each were applied. After two applications, the BCVA was 4/4 (or 1.0), there was no biomicroscopically detectable edema, and the OCT revealed reestablished foveolar depression. This condition remains stable even after 10 months after beginning of the treatment. The anti-VEGF treatment represents another possibility of the treatment of post-inflammatory neovascular membranes.

[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.

[Radial neurotomy of the optic nerve in central retinal vein occlusion (case reports)]. / Radiální neurotomie optiku u kmenové okluze vena centralis retinae (kazuistiky).

The basic aim of this paper is to introduce the case reports of two patients with the ischaemic form of the central vein occlusion with very low preoperative best-corrected visual acuity (BCVA) and with very unfavorable prognosis, treated by means of radial neurotomy of the optic nerve disc (RNO) during the pars plana vitrectomy (PPV). Radial neurotomy of the optic nerve disc (RNO) was performed in two patients with ischaemic form of the central vein occlusion with very unfavorable prognosis during the pars plana vitrectomy in the nasal part of the rim of the optic nerve disc between nasal retinal vascular arcades with specially designed knife (Spaide CRVO knife), as described by Opremcak. The surgery was supplemented with the peeling of the epiretinal membranes and inner limiting membrane, using the Membrane blue. Both eyes were due to uncomplicated course of the operations left without the inner tamponade. RNO represents surgical treating method reserved for ischaemic CRVO with unfavorable prognosis. The key role in the pathological physiology of the RNO plays not only the breaking of the compartment system, but also acceleration of the collateral chorioretinal circulation, as we observed in both of our patients. The BCVA in the first patient improved from 1/50 (0.02 or 3/150) to 3/50 (0.06 or 20/333), and in the second one from 1/50 (0.02 or 3/150) to 5/30 (0,17 or 20/120). In both patients, the retinal hemorrhages and the edema markedly resorbed, the dilatation of the venous vessels disappeared as well as the edema of the optic nerve disc. The region of the scar after the neurotomy remained quiet without signs of retinal or choroidal neovascularizations. The authors demonstrate on their own case reports the efficacy of the RNO in two patients with prognosticaly unfavorable ischaemic form of the BRVO. The RNO seems to be a promising method suitable for the treatment in prognosticaly unfavorable ischaemic forms of the BRVO.

[Results of implantation of endocapsular distance rings]. / Výsledky implantací endokapsulárních distancních prstencu.

Endocapsular distance ring increases possibilities of extraction subluxated cataract. Its importance consists of stabilisation of capsular bag and with the possibility of implantation posterior intraocular lens. In the group there are 20 patients with implanted 21 distance rings. The period of follow up was 4-24 months. We used of a polymethyl methacrylate distance ring from firms Erilens, Morcher and IOLTechnology. Indication for the implantation of a distance ring was dialysis less than 2 quadrants, it depends on size and type of distance ring. The authors evaluate complications during the operation and early and later results after operation.