Role of echocardiography and cardiac MRI in depicting morphological and functional imaging findings useful for diagnosing hypertrophic cardiomyopathy.

PURPOSE: Hypertrophic cardiomyopathy (HCM) is a hereditary disease characterised by primary hypertrophy of the left and/or right ventricle. The reference standard for imaging diagnosis is echocardiography. The aim of our study was to prospectively compare the diagnostic accuracy of echocardiography and cardiac magnetic resonance (MR) imaging in patients with HCM. MATERIALS AND METHODS: Twenty-two consecutive patients with a known diagnosis of HCM were prospectively evaluated, with echocardiography and cardiac MR imaging performed within 2 weeks of each other (mean interval 7 days, range 2-14 days). Two experienced radiologists blinded to the previous clinical and imaging findings separately reviewed the images. The following parameters were calculated for both techniques: myocardial mass, wall thickness, end-diastolic volume (EDV), end-systolic volume (ESV), ejection fraction (EF), systolic anterior motion (SAM) of the mitral valve and degree of myocardial fibrosis (based on the ultrasonic reflectivity at echocardiography and degree of late enhancement at cardiac MR imaging). The statistical correlation was calculated with Student's t test, Spearman coefficient and Fisher's exact test. A value of p<0.05 was considered significant. RESULTS: The diagnosis of HCM was confirmed in all patients with both techniques, with absolute agreement in terms of the site of disease. The mean value of myocardial mass presented a statistically significant difference between the two techniques (114 g, p<0.001). In contrast, a nonsignificant difference between echocardiography and cardiac MR imaging was found for EDV (102 ml vs 111 ml; p=0.31), ESV (30 ml vs 38 ml; p=0.1), EF (74% vs 68%, p=0.5), SAM (p=0.1) and myocardial fibrosis (p=0.15). CONCLUSIONS: Cardiac MR imaging correlates well with echocardiography in defining the morphological and functional parameters useful for the imaging diagnosis of HCM and therefore, in selected cases (poor acoustic window, doubtful echocardiography findings), it may be a valid alternative to echocardiography.

Conventional and diffusion-weighted MRI in progressive multifocal leukoencephalopathy: new elements for identification and follow-up.

PURPOSE: Progressive multifocal leukoencephalopathy (PML) is a serious disorder that primarily affects individuals with a suppressed immune system. Few semiological elements help clearly distinguish PML from other diseases included in the differential diagnosis. Moreover, the clinical course of disease may be chronic or rapidly progressive, with different magnetic resonance imaging (MRI) patterns. The purpose of this study was to confirm the diagnostic value of conventional MRI sequences combined with diffusion-weighted imaging (DWI) in PML to identify those patients with worst prognosis. MATERIALS AND METHODS: We used both conventional MRI sequences and DWI to monitor four male patients aged between 40 and 50 years affected by PML. In two patients, the disease rapidly led to death whereas the other two patients presented a chronic course. RESULTS: Conventional MRI sequences enable detection of the extension of white matter lesions. DWI permits more accurate differentiation of the disease progression front, which exhibits low signal intensity in apparent diffusion coefficient (ADC) maps, from the central gliotic area of demyelinisation, characterised by high ADC values. Patients with rapidly evolving PML have a clear progression front on DWI, which seems to be very tenuous, if not absent, during the quiescent phases of the disease. CONCLUSIONS: The addition of DWI sequences to conventional MRI seems to be a valid method for accurately diagnosing PML and establishing the degree of disease progression.

Atypical pattern of retardation on GDx-VCC and its effect on retinal nerve fibre layer evaluation in glaucomatous eyes.

PURPOSE: To assess the effect of atypical pattern of retardation (APR) on retinal nerve fibre layer (RNFL) measurements made by scanning laser polarimetry (SLP) with variable corneal compensation (GDx-VCC) in glaucomatous eyes. METHODS: One eye each of 30 glaucomatous patients (average mean deviation (MD): -6.4+/-4.8) with APR on GDx-VCC retardation map were selected. In total, 34 glaucomatous, age- and severity-matched eyes (average MD: -7.0+/-5.3) and 36 age-matched healthy subjects, both with a normal pattern of retardation (NPR) represented control groups. APR on retardation maps was characterized by alternating peripapillary circumferential bands of low and high retardation, or high retardation areas arranged in a spokelike pattern, or high retardation nasal and temporal splotchy areas. Typical scan score (TSS) was extracted for each included eye. GDx-VCC parameters (mean+/-SD) in the two groups of glaucomatous eyes were compared with healthy eyes' corresponding values (Mann-Whitney U-test). Areas under receiver operating characteristic (AUROC) curves were generated to assess the APR effect on the parameters' diagnostic ability. RESULTS: All parameters discriminated adequately between healthy and glaucomatous eyes with NPR (AUROCs > or =0.9 for nine parameters). On the contrary, considering healthy and glaucomatous eyes with APR, four thickness parameters could not separate the two groups and AUROCs > or =0.85 appeared only for Inferior and Superior Ratio, NFI, Max Modulation. CONCLUSION: APR may void the effect of custom compensation and provide spurious RNFL thickness measurements. When a printout of glaucomatous eyes with APR is evaluated, it is proper to rely on ratios, modulation parameters, and NFI, since the diagnostic ability of thickness parameters is significantly reduced.

Comparing measurements of retinal nerve fiber layer thickness obtained on scanning laser polarimetry with fixed and variable corneal compensator.

PURPOSE: To compare retinal nerve fiber layer (RNFL) thickness measurements obtained on scanning laser polarimetry (SLP) with commercially available instruments coupled with fixed (FCC) and variable corneal compensator (VCC). METHODS: Forty-two eyes of 42 patients underwent a complete ophthalmologic evaluation and achromatic automated perimetry (24-2 program, SITA standard strategy). Nineteen eyes were healthy (average mean deviation: -0.12 dB +/- 2.26) and 23 glaucomatous (average mean deviation: -4.92 dB +/- 6.49). All patients underwent SLP with both FCC and VCC. Adequate compensation of corneal birefringence on FCC-SLP was checked acquiring macular retardation map (MRM). RNFL thickness was evaluated considering superior and inferior maximum (SM, IM), average thickness and ellipse average (AT, EA), and superior and inferior average (SA, IA). Mean values (+/-SD) for each parameter measured by the two polarimeters were compared and linear regression calculated. The ability of each parameter to discriminate between normal and glaucomatous eyes was evaluated on both polarimeters calculating area under ROC curve. RESULTS: A significant linear correlation for all parameters was noted (r range: 0.65-0.78). VCC produced slightly higher thickness values than FCC, both in normal and glaucomatous eyes. On both polarimeters, area under ROC curve for all parameters discriminated adequately healthy from glaucomatous eyes (range: 0.68-0.81). CONCLUSIONS: In a highly comparable and selected group of normal and glaucomatous eyes, FCC-SLP and VCC-SLP showed considerable concordance in measuring peripapillary RNFL thickness, both for sectorial and global parameters. Proper corneal birefringence compensation provided separation of normal from glaucomatous eyes on both polarimeters.

Angiographic pattern of recurrent choroidal neovascularization in age-related macular degeneration.

PURPOSE: To evaluate the angiographic characteristics of recurrent choroidal neovascularization (R-CNV) in age-related macular degeneration (AMD). METHODS: A prospective investigation on 107 consecutive patients with exudative AMD and CNV not involving the fovea was conducted. Fluorescein angiography (FA) and indocyanine green angiography (ICGA) were planned before krypton laser treatment, and after 3 weeks, 2, 3, 4, 6, 9, 12, 18, and 24 months from photocoagulation. Laser treatment was FA-guided in eyes with classic CNV, and ICGA-guided in eyes with occult CNV on FA. RESULTS: At baseline on FA, 23.3% had classic CNV, whereas, 76.6% showed occult CNV. On ICGA, CNV assumed a focal and a plaque pattern in 81.3 and 18.6% of cases, respectively. Overall, post-laser CNVs occurred in 56 eyes. FA identified well-defined and ill-defined R-CNV in 25 and 75% of cases, respectively. ICGA identified three different R-CNV patterns: focal, annular, and plaque. Focal R-CNV was defined as a single dot-like hyperfluorescence, which was detected in 69.6% of cases, with subfoveal location in half of them. Annular R-CNV was identified by a hyperfluorescent lesion, partially or completely encircling treated area, which was visible in 19.6% of cases, all with subfoveal involvement. Plaque R-CNV was defined as a hyperfluorescent lesion larger than 1 disc diameter in size, and was seen in 10.7% of cases, all with subfoveal location. CONCLUSIONS: ICGA is able to improve R-CNV visualization identifying three different R-CNV patterns. Focal R-CNV is the most frequent pattern and can be re-treated in half of the cases.

Angiographic features after photodynamic therapy for choroidal neovascularisation in age related macular degeneration and pathological myopia.

AIM: To describe the angiographic features after photodynamic therapy (PDT) with verteporfin in choroidal neovascularisation (CNV) associated both with age related macular degeneration (AMD) and pathological myopia (PM). METHODS: 36 patients affected by subfoveal CNV in AMD and 25 patients with subfoveal CNV in PM underwent an ophthalmological examination including fluorescein angiography (FA) and indocyanine green angiography (ICGA) using the IMAGEnet System. Post-PDT examinations were performed 7, 30, and 90 days later. RESULTS: The typical angiographic aspect after PDT for AMD related CNV was a round hypofluorescence visible both on FA and on ICGA, which included both CNV and the surrounding tissues and corresponded to the area exposed to laser light. In PM the CNV appeared hypofluorescent during the early phases and gradually became hyperfluorescent during the late phases on FA, whereas on ICGA it was detectable in its whole extension as a hyperfluorescent lesion since the early phases. Differently from AMD, there was no round hypofluorescence surrounding the CNV on FA or on ICGA. Moreover, five patients in the AMD group showed hot spots on ICGA, which spontaneously disappeared during the follow up. Classic and occult components of the AMD related CNV revealed a different angiographic response to PDT, showing with the latter only a partial closure 1 week after PDT followed by a complete reopening at the first month in 100% of cases. CONCLUSION: The post-PDT hypofluorescence typical of AMD related CNV, especially visible on FA, might be secondary to a combination of choriocapillary occlusion and masking effect due to swelling of retinal pigment epithelium cells. Hot spots in the AMD affected patients could be interpreted as the expression of a non-thermal choroidal vasculitis secondary to PDT.

Occult choroidal neovascularization in adult-onset foveomacular vitelliform dystrophy.

AIMS: To report 6 cases in which indocyanine green angiography (ICGA) failed to convert occult choroidal neovascularization (CNV) into well-defined CNV in adult-onset foveomacular vitelliform dystrophy (AOFVD). METHODS: Patients with AOFVD observed from 1993 to 1999 were prospectively followed up. Whenever the development of CNV was suspected, ICGA was performed to detect the precise location and extension of CNV by means of the IMAGEnet System. RESULTS: Six out of 51 patients (11.7%) developed CNV during the follow-up. The CNV was of the occult type, with an associated detachment of the pigment epithelium in 1 eye. On ICGA, a large hyperfluorescent lesion appeared after about 10 min, irregularly increasing with time, without a clear visualization of site and extension of CNV. CONCLUSIONS: In AOFVD, ICGA may fail to convert occult CNV into well-defined CNV, which is amenable to laser treatment, since hyperfluorescence caused by the probably vitelliform material binding to the ICG molecule and the CNV-induced hyperfluorescence cannot be angiographically distinguished from each other.

Thalidomide effectiveness for bilateral chronic idiopathic anterior uveitis in a three-year-old child.

The authors report their experience with thalidomide in the treatment of a bilateral chronic idiopathic uveitis, in a 3-year-old female. This case was complicated by the presence of a cataract and an iris neovascularization in the right eye; furthermore it was partially unresponsive to a conventional anti-inflammatory and immunosuppressive therapy. Oral thalidomide induced slow but dramatic regression of the inflammation, and a significant reabsorption of neovascular tufts, both in slitlamp examination and on iris fluorescein angiography. The authors emphasize the efficacy of thalidomide as anti-inflammatory agent and as inhibitor of neoangiogenesis, reporting the recent literature about the use of this drug in ophthalmology.

A pilot study of ICG-guided laser photocoagulation for occult choroidal neovascularization presenting as a focal spot in age-related macular degeneration.

PURPOSE: To evaluate the effect of indocyanine green angiography (ICG)-guided laser photocoagulation in eyes with age-related macular degeneration (AMD) and occult choroidal neovascularization (O-CNV), appearing as a well-defined focal spot on ICG. METHODS: Eyes with extrafoveal or juxtafoveal focal spot on ICG, either without PED (Group A) or with PED (Group B) at baseline, were selected. The hyperfluorescent area was photocoagulated by krypton red laser within 24 hours from diagnosis on ICG guide. At 1, 3, 6, 9 and 12 months from treatment, all eyes underwent clinical examination, FA and ICG. Parameters as best corrected visual acuity (BCVA), CNV closure and recurrence onset were analyzed. RESULTS: 53 eyes were enrolled in Group A and 33 in Group B. After 1 year from treatment, a stabilized (+/-1 Snellen line) or improved (2 or more Snellen lines) visual acuity was measured in 37 eyes (43%), 32 in Group A and 5 in Group B. After 1 year, a complete resolution of exudative signs was achieved with one or more laser sessions in 41 eyes (48%), 34 in Group A and 7 in Group B. After 1 year, 50 eyes (58%) had one or more episodes of recurrent CNV, appearing in 51% of eyes of Group A and in 70% of eyes of Group B. Most of the recurrences (86%) occurred during the first trimester after photocoagulation. CONCLUSIONS: ICG-guided laser photocoagulation for O-CNV appearing as a focal spot produced encouraging anatomical and functional outcome in eyes without PED at presentation. When focal CNV is associated with a PED, our treatment technique produced disappointing results.

Early angiographic changes after laser treatment of choroidal neovascularisation in age-related macular degeneration.

PURPOSE: To describe angiographic features detectable on fluorescein angiography (FA) and indocyanine green angiography (ICGA) early after laser photocoagulation of choroidal neovascularisation (CNV) in age-related macular degeneration (AMD). METHODS: Thirty-five eyes of patients with AMD and juxtafoveal or extrafoveal CNV referred to the angiographic centre of the Eye Clinic of Trieste were considered. Ophthalmological assessment included FA and ICGA performed 2 days before and 30 min after laser treatment, and then 1, 2, 7, 14, 21 and 28 days after photocoagulation. Further clinical angiographic examinations were carried out 2, 3, 4 and 6 months after treatment. Photocoagulation was performed for classic CNV on FA and occult CNV on FA, appearing as well-defined focal spot on ICGA. RESULTS: Our results show that interpretation of early post-treatment angiographic examinations may be awkward because diffuse leakage on FA and hot spots on ICGA are normally detectable soon after laser treatment and thereafter during the first 2 weeks. Later, at the 3-week control, leakage on FA and hot spots on ICGA are visible in 62.8% and in 37% of cases respectively; they disappear completely by the 4-week control. CONCLUSION: Difficulty in analysing FA and ICGA in the early post-photocoagulation period underlines the importance of the decision regarding when to perform the first reliable post-laser control and how to improve its interpretation. We suggest that the first angiographic control be performed 3 weeks after treatment, strictly monitoring those eyes showing leakage or marginal hot spots over the following weeks. Overlapping the post-laser hypofluorescent area on the pre-laser lesion can ensure the complete coverage of CNV, and analysis of the retinal and choroidal vascular pattern inside and near the photocoagulated area during the different angiographic phases, albeit difficult, is essential for the interpretation of the angiographic lesions.

Ocular injuries by elastic cords in children.

BACKGROUND: Elastic cords hitting the eyeball as high-speed projectiles can severely damage ocular structures and can produce permanent visual function impairment. OBJECTIVES: To evaluate the frequency, mechanics, and severity of eye injuries caused by elastic cords in children to adopt the most appropriate preventive measures. METHODS: A retrospective medical records review of hospital admissions secondary to ocular trauma between 1991 and 1997 in a pediatric ophthalmology unit at an urban tertiary care pediatric hospital was performed to select all children admitted for ocular injury caused by an elastic cord. RESULTS: Eight children fulfilled the inclusion criteria; the prevalence ratio was 2% of all pediatric trauma admissions. In all cases the mechanics of trauma was a combination of blunt and high-speed projectile injury. The mechanism of trauma in younger patients was typically a cord that was misused during unsupervised playtime, whereas cord slipping from car roof racks was noted in older patients. One patient suffered a severe permanent visual impairment caused by retinal detachment. All other children regained full visual acuity at the time of discharge and maintained it through a mean follow-up of 22 months (range: 18-29). CONCLUSION: Circumstances of injury in younger children are different from those found in older children, the latter being similar to those reported for adults. Prevention is the primary measure to be taken to reduce the prevalence of this injury and to lower the risk for ocular severe anatomic damage as much as possible. This can be achieved primarily by modifying the design of the hooks, intensifying educational campaigns, and keeping elastic cords out of children's reach.

Iris arteriovenous communication: clinical and angiographic features.

BACKGROUND: Iris arteriovenous communication (IAVC) represents a quite rare congenital anomaly, consisting of abnormal vascular connection bypassing the iris capillary bed. The aim of the present study is to describe clinical and angiographic pattern of IAVC on iris fluorescein angiography (IFA) and on indocyanine green videoangiography (IICGV). METHODS: During a mean follow-up period of 33.5 months, eight patients affected by IAVC underwent at least three ophthalmological examinations completed by IFA and IICGV. RESULTS: IFA allows the detection of IAVC vascular structures, evidencing afferent and efferent branches, which show a rapid filling, without any evidence of leakage or iris hypoperfusion. IICGV shows more precisely the entire vascular pattern of IAVC, revealing also the presence of iris hypoperfusion in the sector in which the IAVC lay. One patient underwent cataract surgery; three months later, two neovascular tufts appeared in the hypoperfused area related to IAVC. In all other patients, periodical examinations did not reveal any clinical or angiographic changes. CONCLUSION: In IAVC, the clinical picture appears stable throughout the follow-up; both angiographic techniques seem able to precisely delineate the vascular pattern. Nevertheless, IICGV is superior in showing iris hypoperfusion surrounding the vascular abnormality. Particular care must be drawn to patients affected by IAVC who need cataract surgery.

Branch retinal vein occlusion and macroaneurysms.

BACKGROUND: Macroaneurysms can represent common consequences of branch retinal vein occlusion (BRVO). The aim of the present study is to evaluate the clinical and angiographic aspects of 31 cases of branch retinal vein occlusions (BRVO) in which retinal macroaneurysms developed, in an attempt to analyze their pathogenic features. METHODS: One hundred and sixty-one consecutive patients affected by BRVO were considered. Each patient underwent an opthalmological examination including fluorescein angiography, at an average interval of two months (range: 1-4 months) from the onset of the disease, with a mean follow-up of 43 months (range: 32-56 months). The macroaneurysms were subdivided according to size into small (from 100 to 149 microns), medium (from 150 to 249 microns), and large (greater than 250 microns), and according to origin into arterial, venous, capillary and collateral-associated. RESULTS: Thirty-one patients (19.3%) developed retinal macroaneurysms. The total number of detected macroaneurysms was 51; ten (19.6%) were large, 21 (41.2%) were of medium-size and 20 (39.2%) were small in dimension. Three lesions were of arterial origin, 22 were capillary and 26 were from collateral vessels. In 27 patients (87.1%) the lesions were located outside the macular region, and in 4 patients (12.9%) in the macular region. Patients with retinal macroaneurysms did not show a different prevalence of capillary non-perfusion when compared with others. With regard to the number of retinal venous collaterals patients with macroaneurysms developed fewer than other patients, and the difference was statistically significant (p < 0.001). CONCLUSION: The insufficient number of retinal venous collaterals can be considered the most contributory factor in the development of macroaneurysms secondary to BRVO.

Cyclopean and disconjugate adaptive recovery from post-saccadic drift in strabismic children before and after surgery.

Post-saccadic drift has been analyzed in strabismic children 11-18 yr old, before and after surgery. Before surgery all the subjects had a large multi-component post-saccadic drift. A disconjugate compensation of the drift was not active, but an optimized cyclopean compensation occurred, aimed at minimizing the drift size in both eyes, either with binocular or monocular vision. The drift was directed toward the static offset of the eyes. One week after surgery the drift increased in most cases but the cyclopean compensation still occurred. One week later, a partial disconjugate compensation decreased the drift to levels lower than before surgery. In one subject surgery produced very big three-component drift, exceeding 20 deg. One year after the drift was decreased to < 1 deg. A mathematical model is presented accounting for most of the results.

[Management of congenital nasolacrimal duct obstruction. Timing of probing]. / Trattamento della dacriostenosi congenita. Quando eseguire il sondaggio delle vie lacrimali.

In the management of congenital nasolacrimal duct obstruction (CNDO), there is not a well-established agreement about the proper time for probing. Some authors perform it prior to the first year of life, since after this age the relapse frequency would be very high; others prefer conservative management, since they deny this high frequency. In order to evaluate which one of these two opinions has to be considered more appropriate, the present study retrospectively reviewed the frequency of relapses at the 6-month-mark after surgery in 77 patients (40 males, 37 females) probed for CNDO at the Children's Hospital of Trieste in the 1990-1992 period. In our case-record relapses were found in 7.8% of all patients (8.8% of eyes), while the corresponding percentages were 10.8% of patients (14.3% of eyes) in those probed in the first year of life, 5% of patients (3.8% of eyes) in those probed after this time. These results show no worsening for late probing outcome, with respect to early probing. As a consequence of these findings, it can be recommended that for CNDO it is proper to start with a conservative management, represented by lacrimal sac massage and antibiotic eye drops instillation, if mucopurulent discharge is present, for a 4-6 weeks period. If symptoms do not disappear completely after this period, whether probing is the treatment of choice, possibly after the 6th month of life, or, when parents prefer this option, to resume the medical treatment, since also late probing guarantees a good outcome. The choice for probing is mandatory after second year of life.

Characteristics of horizontal smooth pursuit eye movements to sinusoidal stimulation in children of primary school age.

Previous research about the maturation of the smooth pursuit system has been carried out in newborns and in human infants in the first months of life. A lower gain was found with respect to adults (where gain is close to 1), with frequent saccadic intrusions. On the contrary, no data are available about smooth pursuit response in children. To fill this gap, we analyse in this study the level of maturation reached by children over 7 yr old (the minimum age in which a correct test can be done). Using a cosinusoidal stimulation, the smooth pursuit characteristics (velocity and position gains and phases) evaluated in children are compared to the corresponding parameters in adults. Our data show a clear difference between the two groups, in particular for velocity gain values (which are lower in children), and a larger variability in children. Since the influence of fatigue and prediction appears to be small, we conclude that these differences can be justified both by high level psychological or cognitive factors and incomplete maturation of smooth pursuit system in children.