Peripapillary pachychoroid syndrome treated with dexamethasone implant: A case report.

PURPOSE: To describe a case of peripapillary pachychoroid syndrome (PPS) in a diabetic patient with cystoid macular edema (CME), treated with intravitreal dexamethasone implant (IDI) injection. This report also illustrates the history of the disease after repeated IDI and dexamethasone topical treatment. METHODS: A case report. RESULTS: A 77-year old male patient with PPS and good diabetic control was treated with dexamethasone implant for CME. After an initial morphofunctional improvement associated with a first IDI, the disease relapsed after the second dexamethasone implant injection. This was associated with a significant increase in both intraretinal fluid and choroidal thickness, with subsequent visual acuity (VA) decrease. At this point, a topical dexamethasone treatment was performed and, despite a morphological improvement, VA worsened compared with baseline, likely because of anatomical damage. CONCLUSION: In this report, the importance of the recognition of PPS is underlined and the possible occurrence of a "rebound" effect due to repeated IDI is described.

Heads-up 3D eye surgery: Safety outcomes and technological review after 2 years of day-to-day use.

BACKGROUND: 3D heads-up visualization systems are aimed to improve the surgical experience by providing high-resolution imaging. Objective of our study is to analyze, over a long-time span, the grade of satisfaction and safety of day-to-day 3D surgery compared to standard surgery and to investigate the technical distinctiveness between the heads-up systems currently in use. METHODS: In this retrospective observational case series. we reviewed all surgical records of our ophthalmology-dedicated operatory rooms since the arrival of 3D heads-up viewing system, in November 2017. In particular, we compared the procedural complications of 3D-equipped operatory room (3DR) with the standard microscope operatory room (2DR). Moreover, a satisfaction questionnaire was administered to those surgeons shifting on both rooms to test their preferences on seven specific parameters (comfort, visibility, image quality, depth perception, simplicity of use, maneuverability and teaching potential). RESULTS: 5483 eye surgeries were considered. 2777 (50.6%) were performed in 3DR and 2706 (49.3%) in 2DR. Procedural complication rate was comparable in 3DR and 2DR, also when considering different subtypes of surgery. Twelve surgeons (100% of our surgery team) participated in our satisfaction survey, expressing highest satisfaction score for 3D when applied in retina surgery. For cataract surgery, 3D scored best in all the parameters except for facility in use and depth of field perception. CONCLUSION: Long-term day-to-day use of 3D heads-up visualization systems showed its safety and its outstanding teaching potential in all ophthalmic surgical subtypes, with higher surgeons confidence for retina and cataract surgery.

Covid-19 and acute conjunctivitis: Controversial data from a tertiary refferral Italian center.

PURPOSE: Although acute conjunctivitis has been listed from the beginning as a possible sign of COVID-19, the likelihood of this association remains unclear. The aim of this study was to investigate the relationship between COVID-19 and conjunctivitis. METHODS: In this retrospective, observational study, we recruited all patients with signs and symptoms of acute conjunctivitis seen at the Eye Emergency Department (ED), Turin Eye Hospital, between 01/01/2020 and 12/05/2020 and cross-checked our data with the Piedmont Region online COVID-19 registry in the same period. RESULTS: Among 10,065 patients seen at our ED during the timespan considered, 88 underwent a nasopharyngeal swab (NS) for SARS-CoV-2 detection within 4 weeks before/after our examination. On average, NS was performed -0.72 ± 1.8 weeks before/after eye examination. Of the 77 patients with a negative NS, 26 (33.8%) had a diagnosis of acute conjunctivitis, whereas the remaining 51 (66.2%) had other eye disorders. Among the 11 patients with COVID-19, 7 (63,6%) had a diagnosis of acute conjunctivitis. We found a non-statistically significant increase in NS positivity rate (21.2%) among cases examined at our ED for acute conjunctivitis, compared to the NS positivity rate (7.3%) in patients examined for all other eye conditions (p = 0.092). The Odds Ratio of having a positive NS in patients with acute conjunctivitis was 3.43 (95% I.C. = 0.9-12.8, p = 0.06). Considering online-registry data of Turin population during the same time-span, among 2441 positive NS cases only 27 (1.1%) presented with acute conjunctivitis. CONCLUSION: Our results do not reveal a statistically significant correlation between COVID-19 and acute conjunctivitis. SYNOPSIS: The present study analyzes retrospectively data from a tertiary eye referral center to investigate the relationship between COVID-19 infection and conjunctivitis.

Wide-angle 3D viewing system with valved trocar applied to chandelier-assisted scleral buckling.

INTRODUCTION: Scleral buckling (SB) has been the first technique to repair a retinal detachment (RD) and it is still largely in use. Pars plana vitrectomy (PPV) is currently the most common technique, being more versatile and easier to approach. Here we report on a new SB variant, modified by using some of the latest technological advances borrowed from PPV. METHODS: We retrospectively reviewed all our SB cases from November 2017 to November 2018, all of them performed with a chandelier, mounted on valved trocar, to provide 3D wide-angle viewing. 107 eyes of 107 patients (mean age of 59 ± 8 years, 61 [57%] males) underwent primary uncomplicated RD surgery using this modified SB technique and were enrolled for this study. RESULTS: In this article, the technique is thoroughly described with an online video presentation. Briefly, thanks to valved trocar insertion, it combines the latest breakthroughs in the field of PPV viewing systems with traditional SB surgery. Our first-year data reveal a primary success rate of 94% (101 cases out of 107) at 3 months follow-up. A hidden retinal lesion, undetected at clinical pre-operative evaluation, was found intraoperatively in 12 (8.9%) cases. CONCLUSION: The use of a digital three-dimensional (3D) visualization system, coupled with the positioning of a single 25 gauge valved trocar with chandelier, dramatically simplifies the traditional SB and flattens its learning curve, making this procedure more accessible to young surgeons. In addition, the better visualization capability yields to higher possibility to detect and treat all retinal lesions.

Prevalence of diabetes and diabetic macular edema in patients undergoing senile cataract surgery in Italy: The DIabetes and CATaract study.

BACKGROUND: The purpose of this study is to determine the prevalence of diabetes and diabetic macular edema in patients undergoing senile cataract surgery in Italy. METHODS: It is a prospective, multicenter, cross-sectional study. Thirteen ophthalmic units equally distributed across the Italian territory have been involved in the study. For a period of 3 months, all subjects undergoing phacoemulsification received an Optical Coherence Tompgraphy (OCT) scan and were screened for the anamnestic presence of diabetes. In addition, five selected units collected blood samples from all their patients to measure glycated hemoglobin (HbA1c) levels and detect the presence of occult diabetes (HbA1c > 6.5%). In diabetic patients, levels of retinopathy were measured and diabetic macular edema was considered significant (clinically significant macular edema) when foveal thickness was above 30% of normal levels. RESULTS: A total number of 3657 subjects have been screened. Among them, 20.4% were diabetics. Prevalence of diabetes was significantly higher in males (24.7%) than in females (17%). Levels of HbA1c were tested in a representative sample of 1216 consecutive subjects, and occult diabetes was diagnosed in 4.8% of cases. No significant differences were observed between age groups or different geographic areas. Among diabetic patients, diabetic macular edema of any kind was present in 27.5% (clinically significant macular edema (6.6%)). No significant differences were seen in the prevalence of diabetic macular edema between males and females or between age groups. Among the 745 diabetic patients, no signs of retinopathy were seen in 537 subjects (76.3%), while 101 patients (14.3%) had nonproliferative retinopathy, 13 (1.7%) had nontreated proliferative diabetic retinopathy, and 53 (7.5%) had laser-treated retinopathy. In the entire sample of 3657 subjects, a normal macula was present in 90.9% of cases, diabetic macular edema of any kind in 5.4%, and other maculopathies in 3.4%. CONCLUSION: In this large cohort study on patients undergoing cataract surgery, more than one-fourth were diabetics and more than one-fourth of these had diabetic macular edema. These high prevalences suggest the opportunity to plan an adequate preoperative assessment in all patients in order to reduce the risk of postoperative development or worsening of a sight-threatening complication such as chronic diabetic macular edema.

Heads-up 3D vision system for retinal detachment surgery.

Here we present procedural and safety results from our initial experience using 3D heads-up vitrectomy for retinal detachment surgery. The comparison with our outcomes from previous standard surgery shows how the new 3D system seems safe and effective.

Optical coherence tomography angiography features of chorioretinal folds: a case series.

PURPOSE: To report 3 cases of ocular chorioretinal folds from different etiologies and their aspect with the new imaging technology of optical coherence tomography (OCT) angiography (OCT-A). METHODS: Baseline data, investigational process on etiology, and follow-up data of patients referred for chorioretinal folds to the Medical Retina & Imaging Unit of San Raffaele Hospital in the period January-March 2016 were collected. Multimodal imaging evaluation, comprehensive of infrared, fundus autofluorescence, multicolor, spectral-domain OCT, and OCT-A, was performed on all patients. RESULTS: Four eyes of 3 men, 65, 46, and 50 years of age, showed chorioretinal folds secondary to central serous chorioretinopathy, postoperative hypotony (after deep sclerectomy), and anisometropia with unilateral hyperopia, respectively. In all cases, OCT-A imaging showed a signal reduction in the choriocapillaris layer in correspondence of the folds. Due to this signal reduction, the en face reconstruction of choriocapillaris layer showed, in all cases, a peculiar tigroid aspect. The aspect of the folds at OCT-A remained unchanged during the 3-month follow-up in all patients. CONCLUSIONS: Optical coherence tomography angiography shows a typical linear signal reduction in the choriocapillaris layer in correspondence of the fold with a tigroid pattern. We hypothesize this aspect could be explained by blood flow alteration at the choriocapillaris level in correspondence of the fold.

Optical coherence tomography angiography findings in laser maculopathy.

PURPOSE: Handheld laser pointer thermal injury affects primarily the retinal pigment epithelium (RPE). However, so far no study has reported on the possible effects of laser pointers in the deeper layers, beneath the RPE. Here, we describe the spectral-domain optical coherence tomography angiography findings in the choriocapillaris of a patient with laser maculopathy. METHODS: A 13-year-old boy presented to our department with decreased vision in the left eye 12 hours after having stared at the beam of a laser pointer. RESULTS: Structural optical coherence tomography (OCT) showed 2 focal hyperreflective columns at the fovea extending from the RPE, involving all outer retinal layers, and terminating at the outer plexiform layer. The patient also underwent OCT angiography (OCT-A), which in the choriocapillary segmentation revealed 2 hypointense lesions in correspondence of the focal hyperreflectivities detected on structural OCT. We hypothesize that the OCT-A findings could represent a rarefaction of the choriocapillaris. However, the choriocapillary OCT-A findings could also represent artifacts due to the overlaying hyperreflective lesions. CONCLUSIONS: It is known that the RPE is primarily damaged by the laser injury. Our findings suggest that the thermal injury could involve also the choriocapillaris, and thus not limited to the RPE. Multimodal imaging in laser maculopathy including OCT-A may lead to a better comprehension of the pathogenesis of laser retinal damages.

REPRODUCIBILITY AND RELIABILITY OF OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY FOR FOVEAL AVASCULAR ZONE EVALUATION AND MEASUREMENT IN DIFFERENT SETTINGS.

PURPOSE: Optical coherence tomography angiography (OCTA) allows delineating the foveal avascular zone (FAZ) easily and noninvasively. The present study aims to test reproducibility and reliability of FAZ evaluation by means of OCTA in different settings. METHODS: Twenty-four eyes of 24 normal subjects were investigated using AngioVue OCTA Imaging System. A series of OCTA acquisitions were taken both in basal and in different experimental settings after vasoactive stimuli. Images were evaluated separately by two operators and FAZ area was measured both manually and using the built-in automated measurement tool. RESULTS: No differences for FAZ area were found in the repetition of basal acquisitions, neither in manual nor in automated measurement (0.215 ± 0.06 vs. 0.216 ± 0.07, and 0.268 ± 0.05 vs. 0.264 ± 0.09, first vs. second basal measurement in square millimetres for manual and automated evaluation, P = 0.25 and P = 0.35, respectively). Interoperators correlation was optimal (r = 0.978 [95% CI 0.981-0.976]). No differences were found among the other settings, which included first basal and then repeated (second) in the morning, after flickering light stimulus, after a Bruce treadmill stress test, after 30 minutes dark adaptation, and basal in the evening, neither in automated nor in manual measurements. Automated measurements for nonflow areas provided significantly larger diameters than manual ones. CONCLUSION: AngioVue OCTA Imaging System produces highly reproducible FAZ images with a high interoperators concordance level. Optical coherence tomography angiography capability to detect FAZ area seems not to be influenced by any of the vasoactive stimuli considered in the current study. Nonflow areas seem to be larger when measured automatically than manually.

DYNAMIC AND STATIC VESSEL ANALYSIS IN PATIENTS WITH RETINITIS PIGMENTOSA: A Pilot Study of Vascular Diameters and Functionality.

PURPOSE: To evaluate in vivo the vascular anatomy and functionality of early manifestation retinitis pigmentosa (RP) by means of a dynamic and static vessel analyzer. METHODS: Fourteen patients with early RP and 14 normal subjects were consecutively enrolled in this observational, prospective study. Each patient underwent a complete ophthalmologic examination, including dynamic and static retinal vessel analysis using the Dynamic Vessel Analyzer. RESULTS: The patients with RP and the control group were well matched in age and sex. Patients with RP had a mean best-corrected visual acuity of 20/25 (range: 20/40-20/20). Dynamic vessel analysis performed in patients with RP showed an arterial and venous dilation during flicker stimulation of 5.28 ± 1.7% and 4.07 ± 1.78%, respectively. Only arterial dilation was statistically different compared with control subjects (3.33 ± 0.99%, P = 0.0062). Static retinal vessel analysis in patients with RP showed a decreased mean central retinal artery equivalent (P < 0.001) and central retinal vein equivalent (P < 0.001) compared with control subjects. By contrast, the arterial-to-venous ratio was similar in both groups (RP: 0.79 ± 0.11, control group 0.86 ± 0.04, P = 0.072). CONCLUSION: Our data confirm that retinal arterial and venous narrowing is present at an early stage in patients affected by RP. However, dynamic vessel analysis shows how the retina of patients with RP with no best-corrected visual acuity loss presents an augmented artery dilation response compared with normal subjects and retained neurovascular coupling.

Dynamic functionality and static changes of retinal vessels in diabetic patients treated with intravitreal ranibizumab.

AIMS: To investigate the short-term effects of intravitreal ranibizumab on retinal vessel functionality in patients with diabetic macular edema (DME) by Dynamic Vessel Analyzer (DVA). METHODS: Patients presenting with DME were enrolled in the study. All patients underwent a complete ophthalmic evaluation, including optical coherence tomography and dynamic and static vessel analysis, using the DVA before (baseline), 1 week and 1 month after administration of intravitreal ranibizumab. DME subject were compared with diabetic retinopathy (DR) without DME subjects, and with normal non diabetic subjects (controls) matched for age and sex. RESULTS: A total of 45 eyes of 45 subjects (15 eyes for each group) were included in the analysis. In DME patients, dynamic analysis showed a significant decrease in mean arterial dilation from baseline to 1 week. Mean central retinal artery equivalent (CRAE) of DR patients without DME was significantly different from baseline and week 1 of DME eyes. In healthy control subjects, CRAE was significantly different from CRAE at baseline and 1 week on DME patients, but not significantly different from DR patients without DME. CONCLUSIONS: Using DVA in patients with DME, dynamic analysis showed a significant decrease in mean arterial dilation from baseline to 1 week in DME eyes. A significant reduction in arterial vessels could be demonstrated in DME patients compared to DR patients without DME and controls.

Intravitreal Bevacizumab for Nonsubfoveal Choroidal Neovascularization Associated With Angioid Streaks: 3-Year Follow-up Study.

PURPOSE: To assess the effects of intravitreal bevacizumab injections in the treatment of nonsubfoveal choroidal neovascularization (CNV) associated with angioid streaks (AS) in a 3-year follow-up study. DESIGN: Noncomparative, interventional, prospective case series. METHODS: Eighteen patients (18 eyes) with juxtafoveal/extrafoveal CNV secondary to AS were recruited. All patients underwent a complete ophthalmologic examination, including best-corrected visual acuity (BCVA) measurement on ETDRS chart, optical coherence tomography (OCT), and fluorescein angiography (FA). The protocol treatment included a first injection, followed by repeated injections on the basis of detection of new hemorrhage, any type of fluid on OCT, and/or presence of FA leakage. Primary outcome measures were final mean changes in BCVA and proportion of eyes with 10 ETDRS letters improvement. Secondary outcomes were mean changes of central macular thickness (CMT) and foveal involvement. RESULTS: After a mean BCVA stabilization over the first year, a statistically significant BCVA worsening was registered at the 24-month (72.8 ± 10.0 ETDRS letters, P = .03) and 36-month examinations (65.8 ± 15.0 ETDRS letters, P = .02) in comparison with the 1-year visual outcomes (80.1 ± 5.4 ETDRS letters); lastly, a substantial stabilization in the BCVA was observed at 36 months in comparison with the baseline value (77.9 ± 10.0 ETDRS letters, P = .22). Two eyes (25%) with juxtafoveal CNV and no eye with extrafoveal CNV experienced a 10-letter improvement at the 3-year examination. Mean CMT at baseline was 220 ± 15 µm and 235 ± 66 µm at 36 months (P = 1.00). During the first and second years of follow-up, 5 juxtafoveal CNVs and 3 extrafoveal CNVs showed foveal involvement. CONCLUSIONS: Intravitreal bevacizumab can be effective in the management of nonsubfoveal CNV secondary to AS, although monthly monitoring is required to control CNV recurrence or progression.

Outcomes of intravitreal anti-VEGF therapy in eyes with both neovascular age-related macular degeneration and diabetic retinopathy.

PURPOSE: To investigate the outcomes of intravitreal antivascular endothelial growth factor (VEGF) therapy in eyes with both neovascular age-related macular degeneration (AMD) and diabetic retinopathy (DR). METHODS: Patients from four high-volume referral centres who presented with neovascular AMD and DR, and received intravitreal anti-VEGF therapy, were included. Data retrieved from medical records and multimodal imaging were analysed. RESULTS: Forty-one eyes of 38 patients (21 male, 17 female; mean age 78±8 years) were enrolled. Median follow-up was 28±19 (12-72) months with a mean of 9.2±7.4 intravitreal anti-VEGF injections per eye were administrated. Best-corrected visual acuity (BCVA) was 0.5±0.3 logMAR; it improved significantly at 1 year (0.3±0.3 logMAR; p=0.02) and returned to baseline values at last follow-up visit (0.6±0.4 logMAR; p=0.26). Mean central macular thickness (CMT) significantly decreased from 408±150 µm to 328±104 µm at 1 year (p=0.021) and to 335±127 µm at last follow-up visit (p=0.032). The baseline severity of DR was graded as mild non-proliferative DR (NPDR) in 21 (51%) eyes, moderate NPDR in 14 (34%), severe NPDR in 4 (10%) and inactive proliferative DR in 2 (5%). At last follow-up visit, one eye graded as moderate NPDR improved to mild, one eye graded as severe NPDR improved to mild and one eye graded as severe NPDR was inactivated due to panretinal photocoagulation. CONCLUSIONS: Outcomes analysis of intravitreal anti-VEGF therapy for eyes with both neovascular AMD and DR showed stabilisation of BCVA and reduction of CMT, along with stable or improved DR stage throughout follow-up.