Optical coherence tomography (OCT) and OCT angiography allow early identification of sickle cell maculopathy in children and correlate it with systemic risk factors.

PURPOSE: To determine the presence of sickle cell retinopathy and maculopathy and to identify associations between markers of hemolysis and systemic and ocular manifestations in children affected by sickle cell disease. METHODS: Eighteen children with sickle cell disease, aged 5-16 years, underwent complete eye examination including best-corrected visual acuity, slit-lamp biomicroscopy, ophthalmoscopy after pharmacological mydriasis, spectral-domain optical coherence tomography (SD-OCT), and optical coherence tomography angiography (OCTA). Blood test results and clinical history information were collected for each child, including fetal hemoglobin (HbF), hemoglobin (Hb), hematocrit (Htc), mean corpuscular volume (MCV), mean corpuscular hemoglobin concentration (MCHC), reticulocytes percentage (%ret), lactic dehydrogenase (LDH), total and direct bilirubin, glomerular filtration rate, number of painful crises, acute chest syndromes, and splenic sequestration. Therapeutic regimen and transfusion therapy were also evaluated. RESULTS: Sixteen of 36 eyes (44.4%) had non-proliferative sickle cell retinopathy on ophthalmoscopic evaluation. No patients had proliferative sickle cell retinopathy. In 13 of 36 eyes (36.1%), SD-OCT and OCTA detected signs of sickle cell maculopathy. Nine eyes (25%) presented sickle cell retinopathy and maculopathy, 7 eyes (19.4%) sickle cell retinopathy alone, and 4 eyes (11.1%) sickle cell maculopathy alone. A statistically significant association was found between sickle cell retinopathy; lower levels of HbF, Hb, and Htc; and higher MCV and percentage of reticulocytes. Sickle cell maculopathy was associated with lower values of H and Htc and higher levels of reticulocytes and total bilirubin. CONCLUSIONS: We identified early signs of sickle cell retinopathy and maculopathy in a pediatric population with SD-OCT and OCTA. These two retinal complications were more frequent in children with higher hemolytic rates.

Dexamethasone implant in diabetic macular edema in real-life situations.

PURPOSE: To report outcome of eyes with recalcitrant and naive eyes with diabetic macular edema (DME) treated with intravitreal dexamethasone implants (Ozurdex) injection. METHODS: Retrospective multicenter data analysis of eyes with DME treated with Ozurdex implant and with minimum follow-up of at least one year after the first implant. Data collected included demographic details, history of presenting illness, past treatment history, clinical examination details including visual acuity at presentation, and follow-up with imaging and treatment details. Paired sample t-test was used to measure mean differences between pre- and post-implant values obtained at baseline and last follow-up. RESULTS: A total of 79 eyes (62 subjects) were included. Sixty-four eyes had been previously treated; 15 eyes were naive. Among the previously treated eyes, mean interval between first Ozurdex injection and any previous treatment was 7.69±8.2 months. In naive eyes, the visual acuity improved from baseline 0.58±0.25 to 0.44±0.33 logMAR at last follow-up (P=0.05). In eyes that had been previously treated, the improvement was from 0.65±0.34 at baseline to 0.48±0.35 logMAR (P=0.01). Mean treatment-free interval was 6.5±4.5 months. Nine eyes were steroid responder with controlled intraocular pressure (IOP), none showed any spike in IOP during the follow-up period. CONCLUSIONS: Ozurdex implant could be a good alternative for recalcitrant as well as naive eyes with DME. The visual gain after initial implant injection was fairly maintained, with additional treatment usually after 6 months in naive eyes. Ozurdex appeared safe even in steroid responders with good control of IOP with antiglaucoma medications.

Ranibizumab (Lucentis) in neovascular age-related macular degeneration: evidence from clinical trials.

BACKGROUND: Neovascular age-related macular degeneration (AMD) has a poor prognosis if left untreated, frequently resulting in legal blindness. Ranibizumab is approved for treating neovascular AMD. However, further guidance is needed to assist ophthalmologists in clinical practice to optimise treatment outcomes. METHODS: An international retina expert panel assessed evidence available from prospective, multicentre studies evaluating different ranibizumab treatment schedules (ANCHOR, MARINA, PIER, SAILOR, SUSTAIN and EXCITE) and a literature search to generate evidence-based and consensus recommendations for treatment indication and assessment, retreatment and monitoring. RESULTS: Ranibizumab is indicated for choroidal neovascular lesions with active disease, the clinical parameters of which are outlined. Treatment initiation with three consecutive monthly injections, followed by continued monthly injections, has provided the best visual-acuity outcomes in pivotal clinical trials. If continued monthly injections are not feasible after initiation, a flexible strategy appears viable, with monthly monitoring of lesion activity recommended. Initiation regimens of fewer than three injections have not been assessed. Continuous careful monitoring with flexible retreatment may help avoid vision loss recurring. Standardised biomarkers need to be determined. CONCLUSION: Evidence-based guidelines will help to optimise treatment outcomes with ranibizumab in neovascular AMD.

Nonvisible subthreshold micropulse diode laser (810 nm) treatment of central serous chorioretinopathy. A pilot study.

PURPOSE: To verify the efficacy of nonvisible micropulse diode laser irradiation in the treatment of central serous chorioretinopathy (CSC). METHODS: Twenty-two patients with CSC for a total of 24 eyes with a disease duration longer than 3 months were included in a prospective study. Patients underwent Early Treatment Diabetic Retinopathy Study visual acuity (VA) examination, dilated ophthalmoscopy, fluorescein angiography, and optical coherence tomography before treatment and during follow- up. Treatment with a micropulse diode laser was given with a duty cycle of 15%. Multiple spots were placed over and adjacent to the area of retinal pigment epithelium leak or decompensation. RESULTS: Mean follow-up was 14 months (range 3-36 months). Powers used ranged from 1 to 2 W (mean 1.35 W). Mean number of spots was 215 (range 90-400). Fourteen eyes were treated once, nine eyes received two to three treatments, and one eye had five treatments during a follow-up of 3 years. Subretinal fluid was resolved or improved in two third of cases 1 month after laser treatment, and in three-quarters at the end of follow-up. Mean retinal thickness was 328 microm, 197 microm, and 168 microm before, 1 month after irradiation, and at the end of follow-up, respectively. No evidence of RPE or retinal changes due to laser treatment were discernible in most of the eyes. Median VA was 20/32 (range 20/100-20/20) before treatment and 20/25 (range 20/200-20/20) at the end of the follow-up. CONCLUSIONS: Nonvisible micropulse diode laser may have efficacy in the treatment of CSC. A randomized study with larger series is needed.

Peribulbar tramadol, clonidine, and ropivacaine in blind and seeing painful eyes.

PURPOSE: To report on the treatment of painful eyes by peribulbar injection of tramadol, clonidine, and ropivacaine. METHODS: The authors treated a 72-year-old woman with chronic prephthisical pain in the left eye secondary to graft rejection after penetrating keratoplasty and an 81-year-old woman with severe ocular pain in her left eye for neovascular glaucoma secondary to an ischemic central vein occlusion. They were treated with a medial canthus injection of tramadol (100 mg/2 mL ampules), clonidine (0.15 mg/1 mL ampules), and 1% ropivacaine. RESULTS: Both injections were very well tolerated and neither transient nor lasting complications were reported. Complete pain relief was obtained in both patients within 1 day and was maintained throughout the follow-up (11 months and 7 months). CONCLUSIONS: Peribulbar tramadol, clonidine, and ropivacaine injection may represent a safe and effective treatment modality in the management of chronic ocular pain.

Quality of vision: A consensus building initiative for a new ophthalmologic concept.

PURPOSE: Many studies have addressed the quantification of visual acuity, and the conventional method of measuring it has so far demonstrated serious limitations. Vision testing requires new methods that can more precisely express the quality of vision as perceived by the patient. METHODS: This study employed the Delphi method of consensus building. Concepts associated with quality of vision (QoV) were identified by a board of experts and proposed to participating specialists in two subsequent questionnaires. Upon receipt of the completed questionnaires, the replies were classified to determine the building blocks of a consensus. RESULTS: By analyzing the replies to the two questionnaires, the authors determined the key elements of QoV on which a consensus was found among the respondents. CONCLUSIONS: A consensus was reached on the opinion that the quantification of visual acuity by traditional means is inadequate for investigating QoV. Although visual acuity is still a basic element for testing, the experts believe that contrast sensitivity, reading speed, and microperimetry are additional parameters necessary for quantifying QoV. The use of a psychometric questionnaire on visual function could allow a better interpretation of visual impairment.

Initial clinical experience using a diode red laser (670 nm) in the treatment of retinal disease.

AIM: To investigate the clinical use of a 670-nm diode red laser in the treatment of a number of retinal conditions. METHODS: In all, 17 eyes of 17 patients were treated for conditions such as proliferative diabetic retinopathy, retinal neovascularization in central retinal vein occlusion, rhegmatogenous retinal lesions and retinal breaks, and prophylactic peripheral retinopexy prior to silicone oil removal after three port pars plana vitrectomy. RESULTS: Regression of neovascularization was observed in all the eyes treated for vascular proliferation at the 3-month follow-up visit. Adhesive pigmented scars were observed in the remaining eyes 1 month after treatment. No major complications were recorded. CONCLUSIONS: In this pilot study, the 670-nm diode laser appears to be a promising modality for laser photocoagulation of the retina.

Major ocular complications after organ transplantation.

We reviewed the existing literature on major ocular complications after organ transplantation. Disorders of the ocular surface were not considered. Published reports were selected through a computerized MEDLINE search of the literature. The incidence of cataract or increased intraocular pressure due to immunosuppressant therapy are common; although retinopathy, optic neuropathy, or central nervous system involvement are less frequent they may be related to severe and irreversible visual loss. Patients undergoing organ transplantation should receive careful and regular ocular examinations.

[ICG angiography and retinal pigment epithelial decompensation (CRSC and epitheliopathy)]. / ICG et décompensation de l'épithélium pigmenté rétinien (CRSC et épithéliopathies).

PURPOSE: To evaluate the prognosis of chronic central serous chorioretinopathy (CSC) and to assess whether certain clinical and angiographic features are associated with increased risk of vision loss. METHODS: All of the 51 patients with chronic CSC, who had received a baseline evaluation with fluorescein angiography (FA) and indocyanine green angiography (ICGA), during the last 5 years were retrospectively included in the study. RESULTS: The mean age was 49 years (range: 28-77 years). Sixteen out of 102 eyes (15.7%) of 14 patients lost at least 3 lines (0.3logMAR) after a mean follow-up of 34.7 months (range: 12-72 months). Logistic regression showed that CSC onset more than 7 years before inclusion (odds ratio: 4.3, p=0.024) and having areas of confluent RPE atrophy with FA at baseline (at least 2 disc diameters, odds ratio: 4.9,p=0.020) were independently associated with vision loss. Choroidal neovascularization was observed during follow-up in 4 eyes of 3 patients. CONCLUSION: Disease duration of more than 7 years and the presence of confluent RPE atrophy independently characterized CSC patients at higher risk for visual loss in our series.

Theoretical bases of non-ophthalmoscopically visible endpoint photocoagulation.

Laser photocoagulation is a photothermal process in which heat is produced by the absorption of laser energy by targeted tissues. The purpose of the treatment is to induce thermal therapeutic damage, which causes biological reactions and ultimately beneficial effects. The current endpoint of laser photocoagulation of the chorioretina is an ophthalmoscopically visible retinal whitening. Retinal blanching is the sign that the retina itself has been thermally damaged and results in a number of undesired adverse events. The mechanisms underpinning the efficacy of laser photocoagulation are still poorly understood. However, recent hypotheses postulate that full thickness retinal damage may not be needed to obtain beneficial therapeutic effectiveness. Preliminary studies with laser photocoagulation on animals demonstrated the ability to create therapeutic lesions confined around the Retinal Pigment Epithelium (RPE) cells without causing apparent damage to the overlying retina. The laser impacts were not visible by slit lamp biomicroscopy at the time of laser delivery. Recent experiments showed that the beneficial effect of retinal photocoagulation is mediated by factors derived from the RPE. Non Ophthalmoscopically Visible Endpoint Photocoagulation (NOVEP) protocols might allow treatments that confine minimal therapeutic damage around the cells of the RPE and minimize the damage to the neurosensory retina.

Light panretinal photocoagulation (LPRP) versus classic panretinal photocoagulation (CPRP) in proliferative diabetic retinopathy.

PURPOSE: We misled to verify whether a panretinal photocoagulation (PRP) performed using low levels of ARGON laser energy (light PRP) has the same efficacy as a PRP performed in a conventional fashion using argon green wavelengths (classic PRP) in eyes with high-risk proliferative diabetic retinopathy (HRPDR). Furthermore, we misled to compare the session number performed and the side effects produced by the two techniques. METHODS: Sixty-five eyes with HRPDR of 50 consecutive patients were enrolled in a prospective randomized controlled trial. In eyes selected for light PRP, a very light biomicroscopic effect on the retina was obtained for each spot. In eyes assigned to classic PRP, each spot produced a white-yellow biomicroscopic effect. Mean follow-up was 22.4 months +/- 9.7 in the light PRP and 21.6 months +/- 9.3 in the classic PRP group (p = 0.727). RESULTS: The initial mean logMAR visual acuity (VA) in the light PRP group was 0.12 +/- 0.13 and in the classic PRP group 0.14 +/- 0.15 (p = 0.493). The final mean VA in the former was 0.18 +/- 0.25, and in the latter 0.27 +/- 0.30 (p = 0.231). Median power was 235mW (100-540mW) for light and 420mW (200-950mW) for classic PRP (p < 0.001). Regression of HRPDR at the end of the follow-up was obtained in 30/31 eyes (97%) treated with classic PRP and in 31/34 eyes (91%) treated with light PRP (p = 0.615). The total mean session number was 7.4 +/- 2.4 for light and 9.9 +/- 2.2 for the classic PRP group (p < 0.001). Complications were more frequent in the classic PRP group. CONCLUSIONS: The efficacy of Light PRP is similar to that of classic Light PRP in eyes with HRPDR. Light PRP is associated with fewer complications and allows the reduction of the number of treatment sessions.

Optical coherence tomography of subfoveal choroidal neovascularization treated with transpupillary thermotherapy.

Transpupillary thermotherapy (TTT) has been proposed as a new treatment modality for choroidal neovascularization (CNV). Most studies conducted show decreased exudation due to CNV and reduction of subretinal elevation. Optical coherence tomography (OCT) shows a dynamic sequence of changes early after treatment. Within 1 hour after TTT, OCT shows increased retinal thickness and intraretinal fluid with retinal elevation. One week after treatment, OCT shows decreased subretinal and intraretinal fluid and diminished retinal elevation. OCT can be a valuable method to assess the early effect of TTT. A placebo-controlled, multi-center trial (TTT4CNV) evaluating the long-term efficacy and visual implications of TTT in occult CNV is underway.

Fluorescein and indocyanine green angiography after transpupillary thermotherapy of choroidal neovascularization. Early vascular changes.

Transpupillary thermotherapy (TTT) is currently being evaluated in clinical trials for the treatment of choroidal neovascularization (CNV). Preliminary results show that TTT achieves closure of CNV and reduction in subretinal exudation while preserving visual acuity. Fluorescein and indocyanine green angiography reveal increased leakage activity from CNV and collateral choroid within 1 hour after TTT and absence of dye leakage from CNV at 1 week after treatment. Optical coherence tomography confirms the angiographic findings. The early vascular changes after TTT of CNV are similar to those observed after PDT of CNV. Transpupillary thermotherapy and PDT might share common mechanisms of action. A placebo-controlled, multi-center trial (TTT4CNV) evaluating the long-term efficacy and visual implications of TTT in occult CNV is underway.

Perilimbal topical anesthesia for clear corneal phacoemulsification.

PURPOSE: To evaluate the efficacy of perilimbal topical anesthesia for clear corneal cataract surgery. SETTING: Department of Ophthalmology, University of Udine, Udine, Italy. METHODS: Seventy-five consecutive patients were studied for perioperative pain, visual outcome, and intraoperative complications. Topical anesthesia was administered with a cellulose sponge soaked in preservative-free lidocaine 2%. The perilimbal area was touched 360 degrees for 30 seconds with the sponge tip under the operating microscope just before surgery. No sedation or adjunctive anesthetic drops were given. Surgery was performed through a temporal corneal tunnel with the easy-chop technique. Pain was scored on a subjective scale from 0 (no pain) to 3 (severe pain). Visual acuity was measured 1 day and 1 week after surgery. Mean operating time was recorded. RESULTS: Sixty-nine patients (92%) tolerated the procedure well, giving a pain score of 0 or 1. Six (8%) of the 40 patients who had a single stitch at the end of surgery scored 2. No patient reported pain during iris touch, intraocular lens implantation, or conjunctiva manipulation. No intraoperative complications were recorded. Mean operating time was 12.7 minutes +/- 3.7 (SD) (range 7 to 34 minutes). Mean preoperative visual acuity was 0.4 +/- 0.2 (range 0.01 to 0.80). Visual acuity of 0.5 or better was attained in 93.6% of eyes 1 day and in 96% 1 week postoperatively. CONCLUSIONS: Perilimbal topical anesthesia was an effective and easy-to-administer anesthetic procedure for phacoemulsification, providing good perioperative pain tolerance by patients and rapid visual recovery.

Bilateral juxtafoveolar telangiectasis in monozygotic twins.

PURPOSE: To report the clinical and angiographic features of two monozygotic twins affected by bilateral group 2 idiopathic juxtafoveolar telangiectasis. METHOD: Case reports. RESULTS: Two 64-year-old women, who were identical twins, were suffering from visual loss. One twin had suffered from visual loss for 1 year and had a visual acuity of 20/25 in both eyes, and the other twin had suffered for 2 years and had a visual acuity of 20/30 in both eyes. Fluorescein angiography disclosed similar fundus features. An analogous area of capillary telangiectasis and leakage was observed in the right macula, where no intraretinal pigment was seen; the left macula showed a similar amount of intraretinal pigment associated with tiny right-angle venules and minimal leakage. CONCLUSION: This observation raises the issue of genetic influences in the pathogenesis of this disease.