Three episodes of non-arteritic posterior ischemic optic neuropathy in the same patient treated with intravenous prostaglandin E1.

Non-arteritic posterior ischemic optic neuropathy (NA-PION) is a disorder involving reduced blood flow to the retrobulbar portion of the optic nerve. This disorder usually develops acutely, and research has suggested that high-dose steroid therapy soon after the onset of visual loss can result in significant visual improvement. This treatment, however, is not universally successful. The addition of a potent vasodilator could help to restore ocular blood flow. This case report describes the use of prostaglandin E1 (PGE1), a powerful vasodilator of the microcirculation, to treat three separate episodes of NA-PION over five years in the same patient. A 68-year-old white male was first seen in June 2009 with NA-PION in the left eye, and the condition was treated with steroids and PGE1. The patient had a subsequent episode in July 2010 that was treated with steroids and PGE1 and another in May 2014 that was treated with PGE1 alone. Visual acuity improved from 4/10 to 11/10 in 2009, from 4/10 to 11/10 in 2010, and from 5/10 to 10/10 in 2014. No complications due to the use of PGE1 were noted. PGE1 should be considered as a treatment for NA-PION to immediately restore blood flow and potentially improve vision.

An ultra-low-molecular-weight heparin, fondaparinux, to treat retinal vein occlusion.

Retinal vein occlusions may decrease visual acuity. There is no known therapy to treat ocular thrombosis. The authors used fondaparinux, an ultra-low-molecular-weight heparin, to treat 13 consecutive cases of recent-onset retinal vein occlusions. Two patients with renal insufficiency were not included. Eight central retinal vein occlusions and 5 branch retinal vein occlusions in 13 patients were treated with subcutaneous fondaparinux 2.5 mg once a day. The patients were seen every 2 weeks. Macular edema was treated with intravitreal injections of anti-vascular endothelial growth factor or steroids. Two patients elected to discontinue treatment. Of the remaining 11, 9 occlusions resolved in 1.5 to 13.5 months with rapid resolution of retinal edema and hemorrhage as soon as the occlusions resolved. One patient had a retinal vein that was still occluded after 8 months of therapy and 1 had retinal vein occlusion that partially resolved after 15 months of treatment. Of the 9 eyes with occlusions that resolved, visual acuity improved in 7. In 2, visual acuity decreased due to macular ischemia. Occlusion recurred in 1 2.5 months after the suspension of initial treatment. This patient is again being treated with fondaparinux 2.5 mg. No hemorrhaging occurred. Fondaparinux 2.5 mg can be given subcutaneously once a day to patients with recent-onset retinal vein occlusions without renal insufficiency. An occlusion may take a number of months to resolve. Once the vein occlusion has resolved, retinal edema and hemorrhage rapidly resolve and vision improves. Macular edema should be treated while waiting for the vein occlusion to resolve.

An ischemic diabetic eye treated with intravenous prostaglandin E1.

PURPOSE: To present the use of intravenous prostaglandin E1 (PGE1), a powerful vasodilator of the microcirculation, in the treatment of an ischemic diabetic eye. METHODS: A 27-year-old diabetic man with ischemic diabetic retinopathy and glaucoma had a decreased visual acuity of no light perception in his right eye and hand motions in his left eye. He was started on intravenous PGE1 and has been treated for over 4.5 years. RESULTS: The visual acuity in his right eye remained unchanged and in his left eye improved gradually to 1.5/30. He has been stable for 4.5 years. CONCLUSION: Intravenous PGE1 may be useful in ischemic diabetic eyes to improve the ocular blood flow and visual acuity. It is safe and tolerated well.

Multifocal and pattern-reversal visual evoked potentials vs. automated perimetry frequency-doubling technology matrix in optic neuritis.

BACKGROUND: To compare the usefulness of the traditional pattern-reversal Visual Evoked Potentials (VEP) with multifocal VEP (mfVEP) and Frequency-Doubling Technology (FDT) perimetry in the evaluation of the ocular abnormalities induced by acute or subacute optic neuritis (ON). MATERIALS AND METHODS: The test results of 24 ON patients were compared with those obtained in 40 normal control subjects. MfVEP recordings were obtained by using an Optoelectronic Stimulator that extracts topographic VEP using a pseudorandom m-sequence stimulus. Receiver operator characteristic (ROC) curves were calculated to determine the sensitivity and specificity of abnormal values. RESULTS: The frequency of the abnormal ocular findings differed in the ON patients according to the used technique. Reduced visual sensitivity was demonstrated in 12 eyes (54.5%) using FDT perimetry; 17 eyes (77.2%) showed decreased amplitude and/or an increase in the implicit time of the P1 wave in mfVEP and 20 eyes (90.9%) showed an abnormal decrease in the amplitude and/or an increase in the latency of the P100 peak at VEP examination. The areas under the ROC curves ranged from 0.743 to 0.935, with VEP having the largest areas. The VEP and mfVEP amplitudes and latencies yielded the greatest sensitivity and specificity. CONCLUSIONS: The mfVEP and the FDT perimetry can be used for the evaluation and monitoring of visual impairment in patients with ON. The most sensitive and practical diagnostic tool in patients with ON is, however, the traditional VEP. The mfVEP can be utilized in those cases with doubtful or negative VEP results.

Retina in rheumatic diseases: standard full field and multifocal electroretinography in hydroxychloroquine retinal dysfunction.

BACKGROUND: The purpose of this study was to evaluate and compare full-field electroretinography (ERG) and multifocal electroretinography (mfERG) results in detecting retinal dysfunction in a large number of asymptomatic patients treated with hydroxychloroquine (Hy). METHODS: Fifty eyes in 50 patients with rheumatic diseases who had been using Hy for a period of time ranging from 30 months to 15 years, and 25 eyes in 25 healthy controls, were evaluated. Receiver operator characteristic (ROC) curves were calculated to determine the sensitivity and specificity of abnormal values in patients compared to the normal controls. RESULTS: Signal depression was observed on the mfERG of Hy-treated patients. The most prevalent pattern was pericentral loss (19 eyes, 54.3 per cent), followed by full-field loss (11 eyes, 31.4 per cent), and central loss (five eyes, 14.3 per cent). Conversely, depression of the amplitude responses to the full field ERG was observed in only 16 per cent of the cases. The areas under the ROC curves ranged from 0.4056 to 0.9012, with the mfERG values having the largest areas, whereas the full-field ERG curves had the smallest area. The mfERG responses yielded the greatest sensitivity and specificity. In particular, the P1-N1 wave amplitude (ring 2) and root mean square (RMS) amplitude (ring 1) had specificities of 76 and 88 per cent, respectively, at sensitivities of 90 and 86 per cent. CONCLUSION: A statistically significant retinal functional impairment was demonstrated by mfERG in the central two to 10 degrees in Hy-treated patients. Therefore, mfERG may provide an objective measurement of retinal dysfunction in patients receiving Hy therapy.

Branch retinal arterial occlusion treated with intravenous prostaglandin e1 and steroids.

PURPOSE: To present the use of 6-methylprednisolone IV and prostaglandin E1 IV, a powerful vasodilator of the microcirculation, in the treatment of a branch retinal arterial occlusion. METHODS: A 63-year-old man presented with a 3-hour history of a sudden loss of vision in the right eye. On ophthalmic examination, the diagnosis of a superior temporal branch retinal arterial occlusion was made. The patient was immediately given 40 mg of 6-methylprednisolone IV for more than 5 minutes followed by 80 µg of prostaglandin E1 with 2 milliequivalents of potassium IV for more than 3 hours. The same treatment was repeated the following morning. RESULTS: The visual acuity in the right eye improved from 2/10 at presentation to 7/10 at the end of the second day of treatment. Clinically, there was a reduction of the posterior pole edema. Eleven days after treatment, the visual acuity was 9/10 with no retinal edema. CONCLUSION: Immediate prostaglandin E1 IV and steroids should be considered in cases of recent-onset branch retinal arterial occlusion to restore retinal blood flow and improve visual acuity.

Non-arteritic Posterior Ischaemic Optic Neuropathy Treated with Intravenous Prostaglandin E1 and Oral Corticosteroids.

Intravenous prostaglandin E1 and oral corticosteroids were used to treat the ischaemic phase of a non-arteritic posterior ischaemic optic neuropathy with immediate visual improvement. Non-arteritic posterior ischaemic optic neuropathy is a disorder of reduced blood flow to the retrobulbar optic nerve, usually of acute onset. It has been suggested that high-dose steroid therapy given soon after the onset of visual loss can result in significant visual improvement. This treatment, however, is not universally successful. The addition of a potent vasodilator to the corticosteroids could help restore ocular blood flow and improve visual acuity. This paper presents the use of prostaglandin E1 (PGE1), a powerful vasodilator of the microcirculation, to treat non-arteritic posterior ischaemic optic neuropathy. In this case report a 68-year-old white male with hereditary haemochromatosis was seen 8 hours after sudden loss of visual acuity in his left eye (OS) to 4/10. The diagnosis of non-arteritic posterior ischaemic optic neuropathy was made and he was immediately given oral corticosteroids. Intravenous PGE1 was given the next morning, 24 hours after the sudden loss of vision, once ischaemia of the optic nerve was confirmed by colour Doppler imaging. The visual acuity in the OS improved from 4/10 to 11/10 within 1 day. A visual field (VF) post treatment showed a peripheral scotoma without a central scotoma. At 12 months post treatment the vision OS remained 11/10. No complications due to the use of PGE1 were seen. The authors conclude that PGE1 should be considered in addition to steroids in cases of NA-PION to immediately restore blood flow to the optic nerve and improve visual acuity.

Mirtogenol potentiates latanoprost in lowering intraocular pressure and improves ocular blood flow in asymptomatic subjects.

PURPOSE: The dietary supplement Mirtogenol((R)) was previously shown to lower elevated intraocular pressure (IOP). We here present the effects of this supplement on IOP in comparison as well as in combination with latanoprost eye drops. METHODS: Seventy-nine patients with asymptomatic ocular hypertension were randomly assigned to three groups receiving either the supplement, or latanoprost eye drops, or both in combination. Intraocular pressure and retinal blood flow were investigated in monthly intervals over 24 weeks. RESULTS: Mirtogenol alone lowered IOP from baseline 38.1 to 29.0 mmHg after 16 weeks, with little further improvement during the following eight weeks. Latanoprost rapidly lowered IOP from baseline 37.7 to 27.2 mmHg within four weeks, without further effects thereafter. The combination of the supplement and latanoprost lowered IOP from 38.0 to 27.3 mmHg after four weeks, and further decreased IOP to 24.2 mmHg after six weeks. After 24 weeks IOP with the combination treatment (23.0 mmHg) was significantly lower than with latanoprost alone (27.2 mmHg). Mirtogenol and latanoprost individually showed comparable effects for gradually increasing central artery blood flow with treatment duration. Combination treatment showed higher systolic blood flow velocity throughout the trial period. The diastolic blood flow velocity gradually increased with treatment duration in all three groups. From twelve weeks onwards, the diastolic component with combination treatment was higher than with individual treatments. CONCLUSIONS: Mirtogenol lowered elevated IOP in patients almost as effectively as latanoprost, however, it takes much longer (24 vs 4 weeks). The combination of both was more effective for lowering IOP and the combination yielded better retinal blood flow. No serious side effects occurred during the study, apart from standard side effects in patients related to Latanoprost. These promising results warrant further research of Mirtogenol with a larger patient group.

Retinal Angiomatous Proliferation Successfully Treated with Indocyanine Green Dye-Enhanced Photocoagulation.

This case series presents the use of indocyanine green dye-enhanced photocoagulation (ICG-DEP) for the treatment of retinal angiomatous proliferation (RAP). Five RAP lesions in 4 eyes of 3 patients were identified by fluorescein and indocyanine green dye angiography. The RAP lesions were treated with focal ablation of the intraretinal component using a ICG-DEP protocol. The 810-nm infrared laser in the pulsed millipulsed mode was used. The visual acuity and angiographic findings in the 3 patients with a follow-up from 18 months to 4 years are reported. The five RAP lesions were closed angiography in the 4 eyes of the 3 patients. All of the eyes had visual improvement for at least 8 months. In one stage 3 RAP lesion, there was visual improvement for 8 months until the choroidal neovascular membrane grew again. In this limited series, the procedure appeared to be safe and well tolerated with stable or improved visual acuity.

Arteritic anterior ischemic optic neuropathy treated with intravenous prostaglandin E(1) and steroids.

Arteritic anterior ischemic optic neuropathy (AAION) is an acute ischemia of the posterior ciliary arteries and/or ophthalmic artery due to inflammation. Therapy is immediate intervention with systemic steroids, especially to protect against vision loss in the other eye. The addition of a potent vasodilator to the steroids could help restore ocular blood flow and improve visual acuity. The objective of the current report was to present the use of prostaglandin E(1) (PGE(1)) - a powerful vasodilator of the microcirculation - in the treatment of AAION. Two patients with AAION were treated with intravenous steroids and PGE(1). The visual acuity improved from 4/50 (less than 20/200) to 6/10 (20/35) in one patient and from 1/50 (20/400) to 1/10 (20/200) in the second patient. The visual fields in both patients maintained small central islands of vision. No complications due to the use of PGE(1) were seen. Intravenous PGE(1) should be considered in addition to steroids in cases of AAION to immediately restore blood flow to the optic nerve and improve visual acuity while the steroids reduce the inflammation.

Ocular ischemia in high myopia treated with intravenous prostaglandin e1.

BACKGROUND: High myopia is associated with a decreased ocular blood flow. In some cases this ocular ischemia may be the cause of severe visual loss. METHODS: Three patients with high myopia and progressive loss of visual acuity had a diagnosis of ocular ischemia by color Doppler. Intravenous prostaglandin E1, a powerful vasodilator of the microcirculation, was used to treat the ocular ischemia in all 3 patients. RESULTS: The visual acuity improved in all three cases with one patient improving from 20/100 to 20/30. The mean deficit of the visual fields in this patient improved from -19.08 to -9.52 after treatment. The treatment was repeated every 6 weeks to 8 weeks. CONCLUSION: Patients with high myopia and progressive visual acuity loss should be evaluated for ocular ischemia. Intravenous prostaglandin E1 should be considered in those cases of ocular ischemia with visual loss. Unfortunately the effect does not last for more than 6 weeks to 8 weeks and needs to be repeated at this interval for extended periods.

Effects of Mirtogenol on ocular blood flow and intraocular hypertension in asymptomatic subjects.

PURPOSE: The most important variable risk factor for developing glaucoma is intraocular hypertension. Timely lowering of high intraocular pressure (IOP) significantly lowers the likelihood of developing glaucoma. The aim of this study was to evaluate the effects of the food supplement Mirtogenol (Mirtoselect and Pycnogenol on IOP and ocular blood flow in a product evaluation study. METHODS: Thirty-eight asymptomatic subjects with intraocular hypertension were either given Mirtogenol (20 subjects) or were not treated (18 subjects). The visual acuity, IOP, and ocular blood flow were measured at two, three, and six months. RESULTS: After two months of supplementation with Mirtogenol, the mean IOP decreased from a baseline of 25.2 mmHg to 22.2 mmHg. After three months of treatment with Mirtogenol, the IOP was significantly lowered compared to that of untreated controls (p<0.05) to 22.0 mmHg. No further improvement was found after six months. Nineteen of the twenty patients taking Mirtogenol had a decreased IOP after three months. Only marginal effects on the IOP were found in the 18 control subjects. No side effects were observed. Ocular blood flow (central retinal, ophthalmic, and posterior ciliary arteries) improved both in the systolic and diastolic components as measured by Color Doppler imaging. After three months of treatment, the improvement of ocular blood flow was significant as compared to both baseline and control group (p<0.05). CONCLUSIONS: An improved ocular blood flow may contribute to the prevention of glaucoma. The results of this study indicate that Mirtogenol may represent a safe preventative intervention for lowering the risk for developing symptomatic glaucoma by controlling IOP and improving ocular blood flow.

Retinal and orbital venous occlusions treated with enoxaparin.

BACKGROUND: Retinal and orbital vein occlusions may cause a decrease in visual acuity. There is no known therapy to resolve ocular thrombosis. The authors used enoxaparin, a low-molecular-weight heparin, to treat 8 consecutive cases of retinal vein occlusions in 7 patients and 1 case of a superior orbital vein occlusion. METHODS: Four (4) central retinal vein occlusions in 3 patients, 4 branch retinal vein occlusions in 4 patients, and 1 superior orbital vein occlusion in 1 patient were treated with subcutaneous (SC) enoxaparin 100 IU/kg twice a day. The treatment lasted from 2 to 19 weeks. Eight (8) patients with retinal vein occlusions treated with ticlopidine were used as controls. RESULTS: The 8 retinal vein occlusions opened up in all 7 patients with the absorption of the retinal edema and hemorrhage as soon as the occlusions were open. The orbital vein occlusion resolved with the absorption of the orbital edema. Visual acuity improved in 7 of the venous occlusions and was unchanged in 2. Visual acuity in the 8 controls improved in 4, was unchanged in 2, and was worse in 2. CONCLUSIONS: Enoxaparin can be given SC twice a day in patients with retinal or orbital vein occlusions. The occlusions may take from 2 to 19 weeks to open up. Once the vein occlusions are open, the retinal edema, hemorrhage, and the orbital edema can rapidly absorb with visual improvement.

Nonarteritic anterior ischemic optic neuropathy treated with intravenous prostaglandin E1 and steroids.

BACKGROUND: Acute nonarteritic anterior ischemic optic neuropathy (NAION) is considered to be acute ischemia of the posterior ciliary arteries. Prostaglandin E1 (PGE1), a powerful microcirculation vasodilator, has been shown to improve ocular blood flow. DESIGN: A nonrandomized, comparative trial. METHODS: Eight consecutive cases of NAION were treated with intravenous steroids and PGE1. Seven control cases of NAION were treated with acetylsalicylic acid and oral steroids. Fisher's exact test was used for statistical analysis. RESULTS: The visual acuity improved in seven cases of NAION treated with PGE1 and was unchanged in one. Of the seven control cases, four had no change in vision and three lost further visual acuity on follow-up visits. CONCLUSIONS: Intravenous PGE1 and steroids should be considered in cases of NAION to immediately restore blood flow to the optic nerve and improve visual acuity.

Acute branch retinal arterial embolism successfully treated with intravenous prostaglandin E1--case reports.

The purpose of this paper is to report the use of intravenous prostaglandin E1, a potent vasodilator, to rapidly restore blood flow and vision in a patient with an acute branch retinal arterial occlusion. An 82-year-old woman with an acute decrease in the visual acuity of her left eye due to an acute superior temporal branch retinal arterial embolus was treated with 140 microg of intravenous prostaglandin E1. The medicine was repeated the following day. At the onset of the branch arterial occlusion her vision in the left eye was 20/50, the embolus could be seen in the superior temporal branch, and a white retinal edema extended down into the macula. At her first eye examination 4 days after treatment, her visual acuity had returned to 20/20, the retinal embolus was still present, but the white macular edema had disappeared. Intravenous prostaglandin E1 is a safe, potent vasodilator for the peripheral vascular system. If used immediately to treat acute branch arterial retinal occlusions, it can restore good vision. The authors report the first case of the use of intravenous prostaglandin E1 to treat a spontaneous acute branch retinal arterial embolus.