Combined Treatment of Persistent Diabetic Macular Edema with Aflibercept and Triamcinolone Acetonide in Pseudophakic Eyes.

Background and Objectives: The main cause of the vision loss in diabetics is the development of diabetic macular edema, regardless of the stage of diabetic retinopathy. The paper aimed to examine whether the additional intravitreal application of triamcinolone acetonide to continuous anti-vascular endothelial growth factor therapy could improve therapeutic outcomes for pseudophakic eyes with persistent diabetic macular edema. Materials and Methods: twenty-four pseudophakic eyes with refractory diabetic macular edema, that had appeared despite three previously administered intravitreal injections of aflibercept, were divided into two groups (twelve eyes in each group). The first group continued to have aflibercept administered according to a fixed dosing regimen (once in two months). Triamcinolone acetonide 10 mg/0.1 mL (administered once per four months) was included for the second group, i.e., their treatment continued with a combination of aflibercept + triamcinolone acetonide. Results: The reduction in central macular thickness was higher in the eyes treated with combined therapy (aflibercept + triamcinolone acetonide) compared with the use of aflibercept alone during the entire 12-month follow-up period (3rd month p = 0.019; 6th month p = 0.023; 9th month p = 0.027; 12th month p = 0.031). As was evident from the p-values, the differences were statistically significant. No statistically significant difference was recorded for visual acuity: 3rd month p = 0.423; 6th month p = 0.392; 9th month p = 0.413; 12th month p = 0.418. Conclusions: Combined anti-vascular endothelial growth factor and steroid therapy leads to a better anatomical outcome of persistent diabetic macular edema in pseudophakic eyes, but does not lead to a more significant improvement in visual acuity than continuous anti-VEGF therapy alone.

High-frequency deep sclerotomy as adjunctive therapy in open angle glaucoma patients.

INTRODUCTION: Glaucoma is a chronic, progressive disease of the optic nerve that can cause vision loss and blindness. High-frequency deep sclerotomy (HFDS) is a novel ab interno procedure used to lower intraocular pressure (IOP). This study aims at examining hypotensive effects of HFDS in patients with medically uncontrolled primary open-angle glaucoma (POAG). METHODS: 23 patients (23 eyes) participated in this study. They were all affected by primary open-angle glaucoma and used maximum prescribed medical therapy. It is important to note that the target intraocular pressure (IOP) was not detected in any study participant. The target intraocular pressure is the highest IOP value at which no new damages of the optic nerve occur. The procedure was performed with a custom-made, high-frequency dissection probe by applying bipolar current of 500 kHz. Six pockets (1mm deep, 0.3mm high, and 6mm wide) were made ab interno in nasal sclera (through trabecular meshwork and Schlemm's canal). Tobramycin/dexamethasone and pilocarpine eye drops were administered postoperatively for a month. RESULTS: The mean value of the base intraocular pressure had been 25.6mmHg before the procedure. Significant complications were not recorded either during the surgery or in a post-operative follow-up period. The average IOP for our patients reduced by 8.6mmHG (33.6%) after a year. The mean value of the instilled anti-glaucoma eye drops had been 2.78 (SD=0.45) before the HFDS and 0.61 (SD=1.04) at the end of the research. The target IOP was not achieved in five cases (21.7% of our sample). DISCUSSION/CONCLUSION: This study presents the data on our first surgical experience with high-frequency deep sclerotomy that was conducted on 23 patients who had medically-uncontrolled, primary, open-angle glaucoma. The results indicate that HFDS is safe and efficient in reducing IOP.

IS A DECREASED NITRIC OXIDE CONCENTRATION AFTER TRIAMCINOLONE ACETONIDE INTRAVITREAL INJECTION ONE OF THE REASONS FOR INTRAOCULAR PRESSURE RISE?

Diabetic macular edema is the most common cause of vision loss in patients affected by diabetes mellitus. For eyes with persistent retinal thickening despite anti-VEGF therapy, treatment with intravitreal triamcinolone may be considered, especially in pseudophakic eyes. The aim of this study was to examine aqueous humor nitric oxide concentration changes in pseudophakic eyes with persistent diffuse diabetic macular edema after intravitreal injection of triamcinolone acetonide, as well as the potential impact of these changes on the intraocular pressure values. In 10 pseudophakic eyes with persistent diffuse diabetic macular edema, paracentesis of anterior chamber with aspiration of aqueous humor and nitric oxide concentration measurements were done on the day of the intravitreal application of 20 mg triamcinolone acetonide, and after 1, 3, 6 and 9 months. Also, we were recording intraocular pressure values before the intravitreal triamcinolone acetonide injection and during the next 9 months. One month after the intravitreal triamcinolone acetonide injection, we noticed a decrease of nitric oxide concentration (45.37±5.55 µmol/L) by 31.79% compared to the initial values (66.52±7.66 µmol/L). After that, nitric oxide concentrations began to rise slightly, and at the end of the ninth month the mean nitric oxide concentration was similar to that recorded at the beginning of the study. Intraocular pressure values had increasing trend one month after the intravitreal triamcinolone acetonide injection (23.70±4.08 mm Hg) compared to the initial values (16.21±1.55 mm Hg), but after nine months these values returned to normal levels. Decreased concentration of nitric oxide could be one of the reasons for increased intraocular pressure after intravitreal application of triamcinolone acetonide in the treatment of diffuse diabetic macular edema.

THE EFFECT OF PRIMARY ARGON LASER TRABECULOPLASTY ON INTRAOCULAR PRESSURE REDUCTION AND QUALITY OF LIFE IN PATIENTS WITH PSEUDOEXFOLIATION GLAUCOMA.

The aim of the study was to assess the impact of primary argon laser trabeculoplasty (ALT) on intraocular pressure (IOP) lowering and quality of life improvement in patients with pseudoexfoliative glaucoma. Sixty patients with newly diagnosed pseudoexfoliative glaucoma who underwent primary ALT (group 2) or medication therapy (group 1) were followed-up. The effect of ALT on IOP reduction, dry eye development and number of antiglaucoma drugs used was examined. Patients were examined at the beginning of the study and then after 6, 12, and 18 months. A statistically significant difference between IOP values was observed throughout the 18-month follow-up, with the highest significance recorded 6 months after ALT (p=0.009). Twelve months after the start of the study, the TBUT value was 6.0±0.8 s in group 1 and 8.4±0.7 s in group 2. In group 2, the value of Schirmer test was constantly above 10 millimeters. The number of antiglaucoma medications used in group 1 was statistically significantly higher as compared to group 2 throughout the 18-month study period. ALT was found to be better choice for temporary regulation of IOP in patients with pseudoexfoliative glaucoma.

Role of optical coherence tomography in the early detection of macular thinning in rheumatoid arthritis patients with chloroquine retinopathy.

BACKGROUND: Chloroquine and hydroxychloroquine are drugs that are primarily used for the treatment of malaria and are also recommended for treating connective tissue disorders, autoimmune diseases, and some dermatological and inflammatory diseases. Treatment with these drugs has potential risk for the development of retinopathy, clinically characterized by bilateral pigment changes in the macula, as one serious ocular complication. The aim of this research was to evaluate the parafoveal and perifoveal macular retinal thickness, as central foveal thickness in adult patients with rheumatoid arthritis (RA) on chloroquine therapy using optical coherence tomography (OCT). MATERIALS AND METHODS: In this cross-sectional study, 56 RA patients (56 eyes) were included and examined. All patients were treated with chloroquine (tablets resochin or delagil) at a dose of 250 mg/day without treatment with steroids and other immunosuppressive drugs. Patients were divided into two groups, namely, Group I patients - no visible changes in the macula (26 patients) and Group II patients- with visible changes in the macula (30 patients). The central fovea thickness and parafoveal and perifoveal retinal thickness in all quadrants were measured by OCT and compared in both groups. RESULTS: There are a significantly higher number of eyes without thinning of the macula in Group I patients than in Group II (P < 0.001) patients. There are a higher number of patients with recorded parafoveal thinning in Group II patients, especially in the inferior, nasal, and temporal sectors, respectively (P < 0.05). CONCLUSION: Maculopathy is the main side effect of chloroquine therapy in RA patients that can be detected by OCT in the early stages of the macular involvement.

INTRAOCULAR PRESSURE CHANGES AFTER UNEVENTFUL PHACOEMULSIFICATION IN EARLY POSTOPERATIVE PERIOD IN HEALTHY EYES.

The aim was to determine early changes in intraocular pressure (IOP) following uneventful phacoemulsification and intraocular lens (IOL) implantation in healthy eyes. This prospective interventional case series study was conducted at Ophthalmology Department, Kragujevac Clinical Centre, Kragujevac, Serbia. The study included 123 eyes of 123 cataract patients, 66 women and 57 men, age range 50-88 (mean 70.73±7.94) years having undergone phacoemulsification and in-the-bag implantation of a foldable IOL. The patients were treated at Kragujevac Clinical Centre between June 2015 and May 2016. IOP was measured by Goldmann applanation tonometry preoperatively, then 4-6 hours, 18-24 hours and 7 days postoperatively by the same examiner. The mean IOP preoperatively was 15.10±2.68 mm Hg. In three patients, maximum measured IOP was 22 mm Hg. At 4-6 hours postoperatively, the mean IOP was 24.29±7.56 mm Hg (p<0.001), at 18-24 hours it was 18.37±4.80 mm Hg (p<0.001), and 7 days after the surgery the mean IOP was 16.24±2.90 mm Hg (p<0.05). The measured IOP values were statistically significant in all measured times. However, at 4-6 hours and 18-24 hours, the mean IOP value was highly statistically significant (p<0.001). Although 7 days after the surgery IOP normalized, the mean IOP value was statistically significant (p<0.05). In conclusion, our research showed that even eyes with normal preoperative values and uncomplicated phacoemulsification course can show very high IOP values postoperatively, which can cause pain, blurred vision and, rarely, compromise visual function.

Quantitative Analysis of Uveitis Macular Edema in Multiple Sclerosis Patients Receiving Deep Posterior Sub-Tenon Triamcinolone Acetonide Injection.

AIM: We aimed to analyze the effects of adjunctive posterior sub-Tenon capsule triamcinolone acetonide injection in the treatment of intermediate uveitis macular edema in multiple sclerosis patients that could not be controlled by systemic corticosteroid medications and immunomodulators. METHODS: The study included 30 eyes of 25 patients with multiple sclerosis who received a posterior sub-Tenon injection of 40 mg/mL triamcinolone acetonide. Parameters monitored for therapy efficiency were best-corrected visual acuity, intraocular pressure, central foveal thickness (CFT), and fluorescein angiography (FA) scores. RESULTS: Mean best-corrected visual acuity was significantly improved at the control visit 0.15 ± 0.10 versus baseline 0.40 ± 0.20 logMAR (p < 0.05). Six eyes showed intraocular pressure spikes requiring topical antiglaucomatous treatment. Mean CFT and FA scores were significantly decreased versus baseline (CFT: 345 ± 50 µm; FA score: 3.4 ± 1.0) compared with the 12-week control visit (CFT: 219 ± 35 µm; FA score: 1.6 ± 1.1; p < 0.001). CONCLUSION: Posterior sub-Tenon injection of triamcinolone acetonide significantly improved visual acuity and decrease macular edema in patients with intermediate uveitis associated with multiple sclerosis.

The importance of developing atherosclerosis in pseudoexfoliation glaucoma.

Background/Aim: Pseudoexfoliation syndrome (XPS) is an age-related systemic disorder characterized by increased production and accumulation of elastic microfibrillar material in different tissues of the body: skin, connective tissue portions of visceral organs, periphery blood vessels and the eye, as well. The aim of our study was to determine the significance of atherosclerotic changes in the carotid arteries in the development of XFS and pseudoexfoliation glaucoma (XFG). Methods: The study included 120 patients ­ 40 patients per each of the three defined groups: XFS group, XFG group and age- and sex-matched control subjects (control group) without XFG. Blood samples were collected from the patients before cataract surgery. Serum levels of total cholesterol, low-density lipoprotein ­ LDL, high density lipoprotein ­ HDL and triglycerides were analyzed by standard laboratory techniques. Standard ultrasonography of the carotid blood vessels was performed in all the participants. Results: Lipid's profile was disturbed in the patients with XFS and XFG with statistical significance p control group (p < 0.01). Systolic and diastolic pressure was elevated in the patients with XFS and XFG (p < 0.01). Resistance index was increased in the patients with XFG (p < 0.01). Intima-media thickness was prolonged in patients with XFG (p < 0.01). Conclusion: A disturbed lipid profile with elevated resistancy index and intima-media thickness and increased systolic and diastolic pressure were compulsory findings in patients with developed XFG. So, these factors could be considered as risk. It seems to be difficult to inhibit the process of pseudoexfolation production in the whole body, but it appears that with proper therapy (antihypertnesive, cardiotoncs, etc.) and adequate nourishing, the process of XFG development could be interrupted.

Nitric oxide and tumour necrosis factor alpha in the process of pseudoexfoliation glaucoma.

AIM: To establish the role of nitric oxide (NO), ascorbic acid and tumour necrosis factor-α (TNF-α) in the pathogenesis of pseudoexfoliation glaucoma (XFG). METHODS: Our study included 120 patients who were referred for cataract surgery. All patients were divided into four groups according to clinical findings: XFG, early and late pseudoexfoliation syndrome (XFS), and cataract (without pseudoexfoliation). Serum and aqueous humour levels of the ascorbic acid, NO and TNF-α were measured. The concentrations of the ascorbic acid and NO were measured by an appropriate spectrophotometric method. Enzyme-linked immunosorbent assay (ELISA) was used to determine TNF-α level. RESULTS: Aqueous humour concentration of ascorbic acid was significantly lower in patients with late XFS (0.61±0.11 mmol/L) and XFG (0.48±0.15 mmol/L) compared to patients with early XFS (0.9±0.15 mmol/L) and cataract (1.16±0.22 mmol/L), while there was no difference in serum concentration in all examined groups. Aqueous humour concentration of NO was significantly higher in patients with XFG (77.7±11.4 µmol/L) compared to patients with early XFS (50.27±9.34 µmol/L) and cataract (49.77±7.1 µmol/L), while serum concentration was increased in the early stage of XFS (73.26±8.29 µmol/L). Aqueous humour level of proinflammatory cytokine TNF-α was increased in patients with XFS (early 460.04±18.32 pg/mL; late 502.42±53.23 pg/mL) and XFG (510.34±43.07 pg/mL), while there was no difference in serum level in all examined groups of patients. CONCLUSION: Reduced ascorbic acid and elevated NO and inflammation related cytokine TNF-α level in aqueous humour of the patients with developed XFG suggest that oxidative stress induces local inflammation.

Proinflammatory Cytokines Induce XFG Development.

PURPOSE: To reveal the roles of proinflammatory cytokines within the process of pseudoexfoliation (PEX) production. METHODS: Our study included 120 patients referred to cataract surgery (early and late stage of pseudoexfoliation syndrome (XFS), pseudoexfoliation glaucoma (XFG), and control group). Serum and humor levels of cytokines were measured in a sample with high sensitivity enzyme-linked immunosorbent assay (ELISA) kit. RESULTS: Our findings revealed that TNF-α and IL-17, overlooked by IL-6 action in the early stage and in the phase of glaucoma, played the main role in the inflammation activation in the tissue in the early and late stage of XFS and in XFG. CONCLUSIONS: Local conditions cause chronic inflammation in the eye, subsequently activating fibrotic process with fibrotic tissue deposits in the eye.

Evaluation of central corneal thickness in patients with ocular hypertension and primary open-angle glaucoma.

AIM: To determine correlation between central corneal thickness (CCT) and applanation intraocular pressure (IOP) in normal patients with primary open angle glaucoma and patients with ocular hypertension. METHODS: Two-year retrospective study designed to determine correlation between CCT and IOP. Records of 121 patients were included in the study. Inclusion criteria were: IOP higher than 22 mm Hg for a group with ocular hypertension but without functional, morphological damage and progression, diagnosis of glaucoma for a group with open-angle glaucoma and normal ophthalmological results for a control group. Patients who were mono-oculus, patients with secondary glaucoma and who had surgical treatment were excluded. The patients were selectively grouped according to types of glaucoma, by gender and age. The IOP values were measured by Goldman's applanation tonometer, CCT values were determined using ultrasonic pachymeter, in the period from January 2011 to December 2012. RESULTS: Of total 121 subjects, 51 had primary open angle glaucoma (POAG), 40 had ocular hypertension (OHT) and 30 had normal ophthalmological findings (control group). The CCT values in OHT group 529.37+/-25.18 µm were greater than of both POAG, 501.02+/-14.04 µm and control group, 497.37+/-14.90 µm. The IOP values in OHT group were 20.25+/- 3.62 mm Hg, and in POAG group were 18.25+/-2.70 mm Hg, while in the control group they were 13.53+/- 3.62 mm Hg. CONCLUSION: Determination of CCT in patients with glaucoma is crucial, considering its impact on IOP values, which represents a parameter in glaucoma diagnosis, as well as monitoring further progress of ocular hypertension and patients diagnosed with glaucoma.

Tumor of orbit / Tumor orbitário

The cavernous hemangiomas are the most common intra orbital tumors found in adults of the middle age. Although histological benign, they can encroach on intra orbital or the adjacent structures (optic nerve) and be considered anatomically or positional malignant. We present a case report of orbital cavernous hemangioma of right orbit in young women after pregnancy, from Topola near Kragujevac (Central Serbia) with visual compromise and it's by trans-nasal endoscopic surgical management. Our patient was controlled and treated with the symptomatic therapy, topical therapy with artificial tears and surgical treatment. Our patient has optimal visual acuity of affected right eye after surgical treatment of orbital tumor. Surgical treatment of symptomatic orbital cavernous hemangioma is safe and effective, so that the cosmetic results are the important parameter to evaluate the clinical outcome.

Os hemangiomas cavernosos são os tumores intraorbitais mais comuns encontrados em adultos de meia-idade. Embora histológico benigno, eles podem invadir a área orbital ou intraorbital ou ainda as estruturas adjacentes (nervo óptico) e ser considerado anatomicamente ou posicional maligno. Apresentamos um relato de caso de hemangioma cavernoso orbital da órbita direita em mulheres jovens após a gravidez, a partir de Topola perto Kragujevac (Central Sérvia), com comprometimento visual e medicado por tratamento cirúrgico endoscópico transnasal. O paciente foi controlado e tratado com terapia, terapia tópica sintomático de lágrimas artificiais e tratamento cirúrgico. Nosso paciente tem acuidade visual ideal do olho direito afetada após o tratamento cirúrgico de tumor orbital. O tratamento cirúrgico do sintomático hemangioma cavernoso orbital é segura e eficaz, de modo que os resultados cosméticos são o parâmetro importante para avaliar o resultado clínico.

Congenital blindness and visual impairment cause infection or non infection.

CONFLICT OF INTEREST: none declared. INTRODUCTION: Authors are from reference documentation to archive at Organization of Federation of blind and visually impaired in central Serbia (Kragujevac), by retrograde analysis, of 2007-2012, comprehend two groups by etiology-clinical characteristics of congenital blindness and visually impaired, caused infection or non infection example. AIM: to analyze relationship between infectious and non infectious of congenital blindness and visually impaired in our referent region and compare with world references. MATERIAL/METHODS: With 6-years analysis included the most frequency cases of congenital blindness and visually impaired in two groups, according to presence or absence infectious causes. From infectious causes of congenital blindness and visually impaired are included: CMV - infection, congenital rubella syndrome, congenital toxoplasmosis, congenital syphilis and rare mixed syndrome. From non infectious causes are included: retinitis pigmentosa, retinopathy prematurity, primary congenital glaucoma, Leber's congenital amaurosis and rare syndrome. RESULTS: From total number of registered blind and visually impaired - 1308 (100%), over the last 6 years, the registration was 349 (26.68%) with congenital blindness and visually impaired. From recorder with the number of the most common congenital blindness and visually impaired-194 (55.59%) with infections cause, and 155 (44.41%) non infection cause. CONCLUSION: Congenital blindness has shown permanent increase in past 6 years, in group with infectious and with non infectious causes. Congenital blindness and visually impaired of the most common etiology among registered members of our association in Kragujevac is subject of our correlation and global trends mentioned observation of these diseases.