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.

Topical Triamcinolone Acetonide-Loaded Liposome Formulation Used as an Adjuvant to Intravitreal Ranibizumab Therapy for Neovascular Age-Related Macular Degeneration.

Novel strategies have been developed to reduce or avoid intravitreal injections (IVTs) of the antiangiogenic (ranibizumab (RBZ)) and anti-inflammatory (triamcinolone acetonide (TA)) agents used to treat vitreoretinal diseases. One of the strategies includes liposomes. This study evaluated the safety and efficacy of a topical triamcinolone-loaded liposome formulation (TALF) as an adjuvant to intravitreal RBZ therapy in treatment- naïve patients with neovascular age-related macular degeneration (nAMD). Subjects were randomly assigned to the RBZ-TALF or the RBZ-pro re nata (RBZ-PRN) groups. Patients from the RBZ-TALF group were instructed to apply TALF for 12 months after a single dose of RBZ. Patients from the RBZ-PRN group received three monthly RBZ-IVTs. Retreatment with RBZ was considered in the case of nAMD reactivation. Regarding safety, non-ocular abnormalities were observed during TALF therapy. Concerning efficacy, non-significant differences were identified in terms of visual acuity or central foveal thickness when the RBZ-PRN and RBZ-TALF groups were compared. It is worth noting that the average number of RBZ injections was significantly lower in the RBZ-TALF group (2.5 ± 1.4 vs. 6.1 ± 1.3 IVTs; p = 0.0004). Therefore, TALF used as an adjuvant to RBZ reduces the need for RBZ-IVT retreatment with optimal visual and anatomic results.

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)

Clasificación de patrones anormales de autofluorescencia retiniana en el edema macular diabético.

INTRODUCTION: Patients with diabetic macular edema can develop fundus autofluorescence alterations; thus far, these alterations have been more widely studied with scanning or confocal laser systems. OBJECTIVE: To describe and classify fundus autofluorescence abnormal patterns in patients with diabetic macular edema using the fundus autofluorescence system with a flash camera. METHOD: Observational, retrospective, cross-sectional, descriptive study. Fundus autofluorescence digital images of non-comparative cases with untreated diabetic macular edema, obtained and stored with a flash camera system, were assessed. Inter-observer variability was evaluated. RESULTS: 37 eyes of 20 patients were included. Lens opacity was the most common cause of inadequate image quality. Five different fundus autofluorescence patterns were observed: decreased (13%), normal (40%), focal hyper-autofluorescent (17%), multi-focal hyper-autofluorescent (22%) and plaque-like hyper-autofluorescent (8%). The kappa coefficient was 0.906 (p = 0.000). CONCLUSIONS: Different fundus autofluorescence phenotypic patterns are observed with flash camera systems in patients with diabetic macular edema. A more accurate phenotypic classification could help establish prognostic factors for visual loss or for the design of clinical trials for diabetic macular edema.

INTRODUCCIÓN: Los pacientes con edema macular diabético pueden presentar alteraciones en la autofluorescencia retiniana, que hasta el momento han sido analizadas más con sistemas de láser de barrido o confocales. OBJETIVO: Describir y clasificar los patrones anormales de autofluorescencia retiniana en pacientes con edema macular diabético mediante el sistema de autofluorescencia retiniana con cámara de flash. MÉTODO: Estudio observacional, retrospectivo, transversal y descriptivo. Se evaluaron imágenes digitales de autofluorescencia retiniana de casos no comparativos con edema macular diabético no tratado, obtenidas y almacenadas con el sistema de cámara de flash.Se evaluó la variabilidad interobservador. RESULTADOS: Se incluyeron 37 ojos de 20 pacientes. La opacidad de medios fue la causa más común de calidad inadecuada de imagen. Se observaron cinco diferentes patrones de autofluorescencia retiniana: disminuida (13 %), normal (40 %), hiperautofluorescente unifocal (17 %), hiperautofluorescente multifocal (22 %) e hiperautofluorescente en placa (8 %). El coeficiente kappa fue de 0.906 (p = 0.000). CONCLUSIONES: En pacientes con edema macular diabético se presentan diferentes patrones fenotípicos de autofluorescencia retiniana con los sistemas de cámara de flash. Una clasificación fenotípica más precisa pudiera ayudar a establecer factores pronósticos de pérdida visual o al diseño de ensayos clínicos relativos a edema macular diabético.

Classification of fundus autofluorescence abnormal patterns in diabetic macular edema

Introduction: Patients with diabetic macular edema can develop fundus autofluorescence alterations; thus far, these alterations have been more widely studied with scanning or confocal laser systems. Objective: To describe and classify fundus autofluorescence abnormal patterns in patients with diabetic macular edema using the fundus autofluorescence system with a flash camera. Method: Observational, retrospective, cross-sectional, descriptive study. Fundus autofluorescence digital images of non-comparative cases with untreated diabetic macular edema, obtained and stored with a flash camera system, were assessed. Inter-observer variability was evaluated. Results: 37 eyes of 20 patients were included. Lens opacity was the most common cause of inadequate image quality. Five different fundus autofluorescence patterns were observed: decreased (13%), normal (40%), single-spot hyper-autofluorescent (17 %), multiple-spot hyper-autofluorescent (22 %) and plaque-like hyper-autofluorescent (8 %). The kappa coefficient was 0.906 (p = 0.000). Conclusions: Different fundus autofluorescence phenotypic patterns are observed with flash camera systems in patients with diabetic macular edema. A more accurate phenotypic classification could help establish prognostic factors for visual loss or for the design of clinical trials for diabetic macular edema.

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.

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.

[Neurodevelopment in patients with retinopathy of prematurity treated with intravitreal bevacizumab. Case series]. / Neurodesarrollo en pacientes con retinopatía del prematuro tratados con bevacizumab intravítreo. Serie de casos.

BACKGROUND: Retinopathy of prematurity (ROP) is an eye disease caused by an alteration in retinal vasculogenesis that may lead to partial or complete vision loss with a harmful impact in terms of neurodevelopment. The purpose of the present study was to determine the neurodevelopment in patients with type i retinopathy of prematurity treated with intravitreal bevacizumab. MATERIAL AND METHODS: Case series. The inclusion criteria were: patients with type I ROP treated with a dose of 0.625mg/0.025ml of intravitreal bevacizumab. Demographic data and comorbidities were documented. Neurodevelopment was evaluated with the screening test of the Bayley Scale of Infant Development (BSID) in all patients between 11 and 28 weeks of age. RESULTS: Seven patients were included in the study. Four patients showed normal neurodevelopment according to the overall scores of the BSID scale. The distribution of high risk for neurodevelopmental delay in the different areas evaluated were as follows: 3 patients presented it in the cognitive area, one in the receptive communication area, one in the expressive area, one in the fine motor skills and 3 patients in the gross motor skills area. CONCLUSIONS: In these case series, the majority of patients treated with intravitreal bevacizumab for ROP showed normal neurodevelopment scores.

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.

[Modified technique of autologous transplantation of internal limiting membrane for macular hole]. / Técnica modificada de trasplante autólogo de membrana limitante interna en agujero macular.

BACKGROUND: Autologous internal limiting membrane transplantation has allowed some cases of macular holes refractory to conventional surgery techniques to be treated. The purpose of this study is to describe the anatomical and functional outcomes of a modification of this technique in a case series of naïve macular hole patients. MATERIAL AND METHODS: A consecutive case series study was performed on patients with naïve macular holes with a diameter greater than 600 µ. Best corrected visual acuity, clinical features of the macular area, and optical coherence tomography were recorded before the operation and at the end of follow-up in all patients studied. All patients underwent 23 Ga core vitrectomy, posterior hyaloid separation, and brilliant-blue assisted internal limiting membrane peeling. A small piece of the internal limiting membrane was peeled off to make a free flap, and this was trasplanted and placed inside the macular hole under perfluorocarbon liquids. Air-fluid exchange was performed and SF6 gas was injected at a non-expansile concentration. RESULTS: The study included 5 eyes of 5 patients who underwent internal limiting membrane autograft. The mean age was 50.6 (SD 12.3) years. Four of the 5 cases had macular hole closure. The case where there was no closure of the macular hole was secondary to trauma. There was an improvement in visual acuity in all patients where the closing of the macular hole was achieved at the end of follow-up. CONCLUSIONS: In this cases series of macular hole patients, the autologous internal limiting membrane transplantation was associated with an anatomical closure of the macular hole and functional improvement in most of the patients studied.

[Atypical presentation of central serous choroidopathy. Case report]. / Presentación atípica de coroidopatía serosa central. Reporte de caso.

BACKGROUND: Central serous choroidopathy is a macular disease, usually with a self-limited and benign course, and predominantly affects male patients between 20 and 45 years old. CLINICAL CASE: A 68 year-old female patient complained of decreased visual acuity of her right eye of approximately 3 weeks of onset. Best corrected visual acuity in her right eye was 20/100. Fundus examination revealed a macular serous detachment involving its centre, as well as the presence of multiple calcified drusen. Fluorescein angiography showed late parafoveal leakage in a "smokestack" pattern in the right macular area. Optical coherence tomography showed a dome-shape macular detachment, also in the right eye. The patient was observed every 2 weeks and spontaneous resolution of the macular detachment was seen a month later. Based on these clinical features, a diagnosis was made of central serous choroidopathy of atypical presentation. CONCLUSIONS: Atypical presentation cases of serous central choroidopathy might be seen occasionally. Hence, it is an important differential diagnosis of age related macular degeneration in patients older than 60 years.

Use of Internal Limiting Membrane Autograft in Primary Vitrectomy for Rhegmatogenous Retinal Detachment.

During a pars plana vitrectomy, an unplanned retinotomy in the raphe was performed in a 55-year-old female patient with rhegmatogenous retinal detachment and proliferative vitreoretinopathy. Since diathermy and laser therapy were not available at that moment, it was decided to peel off a small graft of the internal limiting membrane adjacent to the retinotomy site which had been previously stained with Brilliant Blue G. The graft was displaced under perfluorocarbon fluids and placed inside the retinotomy. Three weeks after surgery, the apparent closure of the retinotomy was observed clinically.

[Acute posterior multifocal placoid pigment epitheliopathy. Case report]. / Epiteliopatía pigmentaria placoide multifocal posterior aguda. Reporte de caso.

BACKGROUND: Acute posterior multifocal placoid pigment epitheliopathy is an unusual, self-limited, inflammatory disease that affects the choriocapillaris, and external retinal layers. CLINICAL CASE: A 26 year-old male patient complained of decreased visual acuity, as well as photopsia in both eyes for the past three days. Best corrected visual acuity was 20/200 in the right eye and 20/80 in the left eye. There was no anterior chamber inflammation or vitritis in either eye. There were plaque-like, cream-coloured sub-retinal lesions with ill-defined borders in the posterior pole of both eyes. Fluorescein angiography showed hypofluorescent lesions in early phases that corresponded to the lesions seen in the clinical examination. These lesions were hyperfluorescent in later phases of the angiography. Based on the clinical and angiographic findings, an acute posterior multifocal placoid pigment epitheliopathy diagnosis was made. CONCLUSIONS: Acute posterior multifocal placoid pigment epitheliopathy is an inflammatory condition of unknown origin that is part of the differential diagnosis of placoid retinal diseases.

[Pro-inflammatory serum cytokines in diabetic retinopathy]. / Citoquinas séricas proinflamatorias en retinopatía diabética.

BACKGROUND: Pro-inflammatory cytokines play an important role in diabetic retinopathy. There is conflicting evidence about their serum elevation in this condition and that they also may be possible serum inflammatory biomarkers of diabetic retinopathy. OBJECTIVE: To evaluate the presence of serum pro-inflammatory cytokines and acute phase reactants in the serum of patients with and without diabetic retinopathy. MATERIAL AND METHODS: Comparative case series with 36 patients divided into three groups were included: 12 patients with diabetes mellitus and diabetic retinopathy (group 1), 12 diabetic patients without diabetic retinopathy (group 2), and 12 healthy patients as a control group. Serum levels of the following pro-inflammatory cytokines were measured in all patients: TNF-α, IL-1ß and IL-6. Pro-inflammatory biomarkers measurements were also performed, such as erythrocyte sedimentation rate and C-reactive protein. RESULTS: The levels of TNF-α and IL-6 were higher in group 1 (TNF-α: 19.4 ± 10.9 pg/ml, IL-6: 5.75 ± 7 pg/ml) compared to the other two groups, although the difference was statistically significant only in the case of TNF-α (group 1: 19.4 ± 10.9 pg/ml, group 2: 14 ± 4.3 pg/ml and control: 8.49 ± 3.69 pg/ml, p = 0.001). There were no differences among pro-inflammatory biomarkers such as erythrocyte sedimentation rate and C reactive protein. among the three groups (p > 0.05). CONCLUSIONS: Pro-- inflammatory serum cytokine levels were higher in the diabetes mellitus with diabetic retinopathy group. Larger studies are warranted to establish the real impact of this finding.