Search

Purpose: To explore the retinal and choroidal thicknesses (RT, CT), as measured using enhanced depth imaging (EDI) optical coherence tomography (OCT, Spectralis) in highly myopic eyes and its relationship with visual function., Materials and Methods: Prospective, case-control, noninterventional clinical study. CT was measured by EDI-OCT in highly myopic eyes (≥6 dpt) without any macular diseases and age-matched control eyes. A complete ophthalmological examination, visual acuity assessment and MP1 microperimetry were obtained., Results: 38 myopic (15 M/23 F, mean age 51 ± 8.9 years) and 21 control eyes (5 M/16 F, mean age 50 ± 5.4 years) were included. The myopic mean refractive error was -13.3 ± 4.9 dpt and axial length 29.2 ± 2.2 mm. The mean best-corrected visual acuity (BCVA) was lower in highly myopic than in control eyes (77.3 ± 9.25 vs. 84.8 ± 0.6 letters, p = 0.0001, respectively) as was the mean retinal sensitivity (MRS; 16.32 ± 2.6 vs. 19.9 ± 0.2 dB, p < 0.0001). While RT was similar between groups (291.5 ± 24.2 vs. 283.6 ± 13.9 µm, p = 0.06, respectively), subfoveal CT was thinner in highly myopic compared to control eyes (114.3 ± 78.5 vs. 272.6 ± 110.2 µm, p < 0.0001). A significant relationship was found between subfoveal CT and MRS (R(2) = 0.22; p = 0.003) and BCVA (R(2) = 0.13; p = 0.027)., Conclusions: Macular function is reduced in highly myopic eyes without any visible macular diseases compared to controls, and a significant proportion of the macular function variability seems to be related to a reduced CT., (© 2014 S. Karger AG, Basel.)

Purpose: To explore functional and morphological retinal changes 6 months after dexamethasone intravitreal implant (DEX implant) for the treatment of macular edema due to central or branch retinal vein occlusion (CRVO, BRVO)., Procedures: In this prospective interventional case series patients underwent a complete ophthalmological examination at baseline and monthly, including best-corrected visual acuity (BCVA), spectral domain-optical coherence tomography and microperimetry. Fluorescein angiography was performed at baseline and at 4 months. All patients were treated with a DEX implant and retreated according to predefined criteria starting from month 4., Results: Sixteen patients (mean age 66 ± 13 years, 14 CRVO, 2 BRVO) were included. At 6 months mean retinal sensitivity improved from 9.7 ± 4.6 to 13.6 ± 5.4 dB (p < 0.0001) while mean BCVA improved from 52.4 ± 16.2 to 66.1 ± 16.6 (p < 0.0001). Mean central retinal thickness decreased from 708.3 ± 151.01 to 362.7 ± 177.4 μm (p < 0.0001); 56.2% of eyes were retreated at month 4., Conclusions: At 6 months DEX implant led to a significant improvement in retinal sensitivity and visual acuity associated with a reduction of retinal thickness in patients with macular edema due to retinal vein occlusion., (© 2014 S. Karger AG, Basel.)

Aim: To evaluate the agreement between fluorescein angiography (FA) and spectral-domain optical coherence tomography (SD-OCT) in detecting myopic choroidal neovascularization (CNV) activity during bevacizumab treatment., Methods: Thirty-four patients with subfoveal myopic CNV were prospectively enrolled. FA and SD-OCT were performed at baseline and at all planned monthly visits. After the first injection, additional treatments were administered following detection of fluid on SD-OCT and/or leakage on FA. κ-Analysis was performed to examine the agreement between FA and SD-OCT., Results: At baseline, FA and SD-OCT agreed in 26/34 cases (κ=0.23); sensitivity and specificity were 77.4 and 66.7%, respectively. Seven eyes presented leakage on FA with no fluid on SD-OCT, 1 case showed intraretinal fluid on SD-OCT and no leakage on FA. At the 1-month examination, specificity and κ-value improved, and 30/34 cases showed complete concordance. At the 3- and 4-month examinations, a discordance was noted in 6 cases. From the 5-month examination on, a correspondence was achieved in at least 30/34 cases and reached a perfect match in 11 sessions., Conclusions: Our study confirms the key role of FA in diagnosing myopic CNV. It seems possible there may be a role for SD-OCT in assisting FA to monitor the myopic CNV activity during anti-vascular endothelial growth factor antibody treatment., (© 2014 S. Karger AG, Basel.)

The aim of this study was to evaluate and compare the effects of photodynamic therapy (PDT) in eyes with subfoveal and juxtafoveal choroidal neovascularization (CNV) secondary to pathological myopia. The study was a single-center, 10-year analysis on 19 eyes. Patients underwent best-corrected visual acuity (BCVA) measurement, slit-lamp examination, ophthalmoscopy and fluorescein angiography. Eyes with subfoveal CNV (7 eyes, 37%) progressively worsened during the 10-year follow-up from 0.68 ± 0.26 to 0.80 ± 0.47 logMAR, while in the eyes with juxtafoveal CNV (12 eyes, 63%) BCVA improved from 0.59 ± 0.42 to 0.33 ± 0.27 logMAR. Prevalence and extension of chorioretinal atrophy (CRA) were greater in eyes with subfoveal compared with juxtafoveal CNV (84 vs. 66%, respectively) and enlargement (10.05 ± 6.7 vs. 3.53 ± 4.7 mm(2), respectively). Our results confirm the limited long-term effectiveness of PDT in myopic subfoveal CNV. Satisfactory results can be achieved in juxtafoveal CNV with a better visual outcome and a minor CRA extension., (© 2014 S. Karger AG, Basel.)

Purpose: To explore functional retinal changes in neovascular AMD patients (nAMD) treated with ranibizumab 0.5 mg combined with photodynamic therapy (PDT) 3 days after the first injection in the long term., Methods: Patients with no prior treatment for nAMD were treated with 3 injections of ranibizumab 0.5 mg 1 month apart and a single session of standard PDT 3 days after the first injection. Best-corrected visual acuity and time-domain OCT at baseline and every 28 ± 2 days were performed; microperimetry at 3, 6, and 12 months and multifocal electroretinogramm (mfERG) at 3 and 12 months were repeated. Fluorescein angiography and vision-related quality-of-life questionnaire were performed at baseline and 12 months., Results: 12/15 nAMD patients completed the 12 months study and received an average of 3.4 ± 0.7 injections. Mean VA changed from 54.67 ± 15.72 to 59.0 ± 24.77 letters (p = 0.371), while mean retinal sensitivity from 5.5 ± 4.8 to 6.6 ± 6.0 dB (p = 0.216). MfERG N1-P1 response amplitude densities (RADs) were significantly different from baseline (p < 0.01) in the central 0°-2.5°, whereas in the peripheral retinal areas (2.5°-20°), not significant (p > 0.01) changes in N1-P1 RADs were detected. The "general vision" VFQ-25 subscale showed a statistically significant improvement at 3 and 12 months., Conclusions: Ranibizumab 0.5 mg combined with standard PDT 3 days after the first injection determines an improvement of mfERG values in the retinal central area in nAMD patients in long-term follow-up.

Dysbindin, the product of the DTNBP1 gene, was identified by yeast two hybrid assay as a binding partner of dystrobrevin, a cytosolic component of the dystrophin protein complex. Although its functional role has not yet been completely elucidated, the finding that dysbindin assembles into the biogenesis of lysosome related organelles complex 1 (BLOC-1) suggests that it participates in intracellular trafficking and biogenesis of organelles and vesicles. Dysbindin is ubiquitous and in brain is expressed primarily in neurons. Variations at the dysbindin gene have been associated with increased risk for schizophrenia. As anomalies in retinal function have been reported in patients suffering from neuropsychiatric disorders, we investigated the expression of dysbindin in the retina. Our results show that differentially regulated dysbindin isoforms are expressed in rat retina during postnatal maturation. Interestingly, we found that dysbindin is mainly localized in Müller cells. The identification of dysbindin in glial cells may open new perspectives for a better understanding of the functional involvement of this protein in visual alterations associated to neuropsychiatric disorders., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Purpose: To investigate the simultaneous association of several psychophysical measures with reading ability in patients with mild and moderate low vision attending rehabilitation services., Methods: Standard measurements of reading ability (Minnesota Reading [MNREAD] charts), visual acuity (Early Treatment of Diabetic Retinopathy Study [ETDRS] charts), contrast sensitivity (Pelli-Robson charts), reading contrast threshold (Reading Explorer [REX] charts), retinal sensitivity, and fixation stability and localization (Micro Perimeter 1 [MP1] fundus perimetry) were obtained in 160 low vision patients with better eye visual acuity ranging from 0.3 to 1.0 logarithm of the minimum angle of resolution and affected by either age-related macular degeneration or diabetic retinopathy., Results: All variables were moderately associated with reading performance measures (MNREAD reading speed and reading acuity and REX reading contrast threshold), as well as among each other. In a structural equation model, REX reading contrast threshold was highly associated with MNREAD reading speed (standardized coefficient, 0.63) and moderately associated with reading acuity (standardized coefficient, -0.30). REX test also mediated the effects of Pelli-Robson contrast sensitivity (standardized coefficient, 0.44), MP1 fixation eccentricity (standardized coefficient, -0.19), and the mean retinal sensitivity (standardized coefficient, 0.23) on reading performance. The MP1 fixation stability was associated with both MNREAD reading acuity (standardized coefficient, -0.24) and MNREAD reading speed (standardized coefficient, 0.23), while ETDRS visual acuity only affected reading acuity (standardized coefficient, 0.44)., Conclusions: Fixation instability and contrast sensitivity loss are key factors limiting reading performance of patients with mild or moderate low vision. REX charts directly assess the impact of text contrast on letter recognition and text navigation and may be a useful aid in reading rehabilitation.

Aim: The purpose of the present work was to evaluate the macular sensitivity of patients with lamellar macular hole (LMH) by means of microperimetry, and to explore the relationships between macular function, LMH anatomical characteristics and vitreous status., Methods: A total of 39 eyes from 37 patients with a diagnosis of LMH and 20 age-matched control subjects were enrolled. All patients underwent a complete ophthalmological examination including visual acuity testing (logMAR) and MP1 microperimetry. LMHs were quantitatively and qualitative characterised by spectral domain optical coherence tomography (OCT) in terms of base and apex diameter, depth, central foveal and perifoveal thickness, splitting location and integrity of outer retina layers. B scan ultrasonography was performed in order to characterise the vitreoretinal relationships., Results: Mean total (17.2 ± 2.2 vs 19.6 ± 0.5 dB, respectively, p<0.0001) and mean central (16.1 ± 3.2 vs 19.2 ± 0.7 dB, p < 0.0001) retinal sensitivity were significantly reduced in LMH eyes in comparison with controls. Best corrected visual acuity (BCVA) (0.15 ± 0.15 vs 0.03 ± 0.06 logMar, p = 0.001) and central retinal thickness (329.05 ± 59.3 vs 265 ± 28.5 μm, p < 0.0001) were significantly worse in LMH eyes in comparison with controls. In our population, mean total and central retinal sensitivity showed a moderately significant relationship with LMH depth (R(2) 0.18, p = 0.006, R(2) 0.14, p = 0.02, respectively). In all, 38% of LMH eyes (15/39) showed focal interruptions of the inner-outer segment junction with lower values of BCVA and macular sensitivity. An incomplete posterior vitreous detachment with vitreopapillary adhesion was found in 48.7% (19/39) of patients with LMH., Conclusions: Eyes with LMH show an impaired macular function, which is partially related to LMH depth and is more pronounced in eyes with outer retinal layers abnormalities.

Purpose: To investigate functional and morphological retinal changes in the long-term follow-up in subjects with type 1 diabetes mellitus (DM1) without any signs of retinal vasculopathy., Methods: Functional testing included Humphrey Matrix perimetry (30-2 threshold program) and white-on-white Humphrey perimetry (HFA, 30-2 SITA standard), while retinal nerve fibre layer (RNFL) thickness was measured by scanning laser polarimetry with variable corneal birefringence compensator., Results: Data from 20 eyes of 20 subjects with DM1 were analysed. No changes of HFA mean deviation (MD: -2.20 ± 3.44 vs. -1.63 ± 2.47; p = 0.14) and pattern standard deviation (PSD: 2.50 ± 1.71 vs. 2.28 ± 1.36; p = 0.31), and Matrix MD (-1.06 ± 3.62 vs. -1.24 ± 2.99; p = 0.65) were found after 5 years. A significant change was found for Matrix PSD between baseline and the end of follow-up (2.76 ± 0.59 vs. 3.1 ± 0.68; p = 0.0078). RNFL parameters were not changed. A significant relationship was found between HbA1c levels and changes from baseline of Matrix PSD (R(2) 0.29, p = 0.02)., Conclusions: Progressive retinal functional impairment could be detected in DM1 subjects by frequency doubling perimetry before the onset of any overt retinal vasculopathy and functional impairment seems to be significantly related to glycaemic control., (Copyright © 2013 S. Karger AG, Basel.)

Purpose: To evaluate the morphologic features of the photoreceptor layer (by spectral-domain optical coherence tomography) and functional parameters in patients with a lamellar macular hole., Design: Prospective, multicenter, observational case series., Methods: Fifty-four patients with lamellar macular hole were enrolled in the study. All patients underwent a complete ophthalmologic examination, including best-corrected visual acuity (BCVA) testing, MP1 microperimetry, and spectral-domain optical coherence tomography. For each patient, 2 experienced masked observers evaluated the integrity of photoreceptor inner segment/outer segment (IS/OS) junction and external limiting membrane (ELM) line., Results: Spectral-domain optical coherence tomography analysis showed complete integrity of the IS/OS junction and ELM line in 40 eyes (group A), partial or complete disruption of the IS/OS junction with an intact ELM line in 8 eyes (group B), and an alteration of both IS/OS junction and ELM line in 6 eyes (group C). Mean BCVA, total retinal sensitivity, and fixation stability were significantly better in groups A and B than in group C (both P < .05, Tukey-Kramer test), whereas there was no significant difference between groups A and B. Mean central retinal sensitivity was significantly different among all 3 groups (all P < .05, Tukey-Kramer test). The grade of integrity of the foveal photoreceptor layer was correlated significantly with mean BCVA (r = -0.57; P < .001), mean central retinal sensitivity (r = 0.52; P < .001), and total retinal sensitivity (r = 0.44; P < .001)., Conclusions: In lamellar macular hole, the morphologic features of the foveal photoreceptor layer consistently are correlated with BCVA and central retinal sensitivity. Preservation of the ELM is related to the maintenance of visual acuity., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Purpose: To explore the interobserver agreement in the diagnosis of retinal angiomatous proliferation (RAP) using fluorescein (FA) and indocyanine green angiographies (ICGA) and to detect which morphologic features of the neovascular lesion are associated with RAP diagnosis., Methods: In this cross-sectional study, consecutive patients with newly diagnosed neovascular age-related macular degeneration (AMD) evaluated in 8 retina centers were considered. The FA and ICGA were obtained in all centers according to a standard protocol, both performed either as a static or as a dynamic examination. All images were graded by 2 observers from different institutions., Results: A total of 201 eyes with neovascular AMD of 155 consecutive patients (mean age 76±8 years) were considered. Overall RAP prevalence was 30% using FA and 26% using ICGA. Patients studied with dynamic angiography were twice as likely to be diagnosed with RAP as those using static angiography. Interobserver agreement for the overall detection of RAP was high using FA (kappa: 0.868; 95% confidence interval [CI]: 0.793-0.944) and very high using ICGA (kappa: 0.905; 95% CI 0.836-0.974). The agreement between the 2 observers tended to be higher for the truncated vessel than for the anastomosis in FA as well as in ICGA, but no comparison yielded statistical significance (p=0.258 and p=0.584, respectively)., Conclusions: The interobserver agreement for RAP detection was very good both using FA and ICGA, but the overall detection of RAP was higher for dynamic strategy compared with static one.

We report the clinical findings and macular function of a patient with Bietti crystalline dystrophy. A 39-year-old woman reported visual loss in both eyes and nyctalopia. A complete ophthalmological evaluation, retromode imaging, SD-OCT acquisition, MP1 microperimetry, and multifocal electroretinogram (mfERG) were performed. Microcrystalline deposits in the cornea and the retina with retinal pigment epithelial atrophy were observed. Retromode imaging revealed visualization of normal large choroidal vessels, cystoid macular edema, and small defined glistening lesions. SD-OCT showed changes in the outer retina with numerous microcrystalline deposits. Microperimetry showed an absolute scotoma involving the perimacular area but sparing of the fovea. In both eyes, mfERG analysis suggests a dysfunction of pre-ganglionic retinal elements detectable in the 20 central retinal degrees. The genetic characterization showed an homozygous mutation c.772C > T[p.Leu258Phe] in exon 6. Retromode imaging and SD-OCT were useful tools to determine the extent and the localization of the crystals. Microperimetry should allow evaluation of the progression of the macular changes.

Retinal neovascularization (RNV) is a critical pathological event and a major cause of blindness. Vascular inflammation and oxidative stress have been shown to play a key role in the induction and progression of RNV. Trans-Chalcone-derived flavonoids have been previously shown to be negative modulators of oxidative stress and inflammatory responses as well as tumor angiogenesis. In this study, we characterized the effects of the flavonoid trans-Chalcone in preventing RNV in a model of ischemic retinopathy. Ischemic retinopathy was induced in neonatal mice subjected to oxygen-induced retinopathy. Trans-Chalcone was administered intra-peritoneum at the dose of 25 mg/kg/day. Vascular density was assessed by morphometric analysis of flat mounted retinas stained with Texas red-Isolectin B4. Western blotting analysis was conducted to determine protein levels of vascular endothelial growth factor (VEGF), inter-cellular adhesion molecule 1 (ICAM-1) and the transcriptional activators' signal transducer and activator of transcription 3 (STAT3) and nuclear factor kappa beta (NF-κB). Treatment with trans-Chalcone significantly inhibited RNV in the ischemic retina, as shown by decreased number of neovascular tufts. Trans-Chalcone also blocked ischemia-induced VEGF and ICAM-1 expression and this effect correlated with inhibition of activated STAT3 and NF-κB. Our results show that trans-Chalcone effectively prevents RNV in the murine retina thus suggesting that Chalcone-derived flavonoids may be beneficial in preventing pathological neovascularization in the ischemic retina., (Published by Elsevier Ltd.)

Purpose: Diabetic macular edema (DME) shows variable clinical characteristics with unpredictable results to local treatment, probably reflecting different phenotypes. The purpose of this study was to evaluate the role of structural and functional macular imaging in the characterization of DME patterns., Methods: One hundred fifty-one eyes of 92 diabetic patients with untreated clinically significant macular edema (CSME) underwent best corrected visual acuity (BCVA) determination (logMAR), slit lamp biomicroscopy; fluorescein angiography; optical coherence tomography (OCT; mean central retinal thickness [CRT], volume, and DME pattern); fundus autofluorescence (FAF; absent or increased [i]FAF, single or multiple spots; iFAF area quantification); and microperimetry. Linear correlation, data agreement and three-way analysis of covariance were used for statistics., Results: Thirty-five (23.2%) eyes had normal FAF; and 116 eyes had iFAF: 48 (31.8%) single-spot iFAF, 68 (45%) multiple-spot iFAF. Retinal sensitivity in areas with iFAF was 11.5±5.3 dB (vs. 15.1±3.9 dB in normal areas, P<0.005). Retinal sensitivity of the central field was 15.1±3.9 dB in normal FAF, 12.4±4.8 dB in single-spot iFAF and 11.4±4.9 dB in multiple-spot iFAF (P<0.05). OCT CRT and volume were not significantly different between the FAF groups. OCT volume correlated to OCT CRT (r=0.68), retinal sensitivity in iFAF (r=-0.50) and BCVA (r=0.42). Cystoid OCT pattern and FA edema patterns correlated with iFAF presence (P<0.0001)., Conclusions: In CSME, FAF correlates better with OCT patterns and central field microperimetry rather than with visual acuity. FAF is a rapid, noninvasive technique that may give new insight into the evaluation of DME. The validity of FAF in the follow-up and treatment outcomes in DME remain to be assessed.

Purpose: To explore the correlation between psychophysical measures of visual function and vision-related quality of life (QOL) in exudative age-related macular degeneration (AMD) and to obtain a new quality of vision index expressed as corrected visual acuity (cVA) that is scaled like visual acuity (VA), but that incorporates the weighted contribution of VA, contrast sensitivity (CS), and reading ability., Methods: Visual acuity, CS, and reading ability were measured in 293 patients with AMD in this multicenter prospective study. Vision-related QOL was quantified by the 25-item National Eye Institute Visual Function Questionnaire (NEI-VFQ-25). The validity of the questionnaire was assessed using Rasch analysis. The relationship between psychophysical tests and NEI-VFQ-25 scores was investigated. A cVA index was developed integrating Rasch-scaled NEI-VFQ-25 score with VA, CS, and reading ability as a tool to be used for evaluating vision-related QOL on the same scale as VA., Results: A total of 27.5% of the variability of VFQ score was found to be explained by VA alone in patients with AMD. The proportion of Rasch-scaled QOL estimate variance explained by cVA was 33.2% as compared to 27.5% explained by VA and 24.5% by CS, which was a statistically significant improvement in both cases (p=0.015 and p<0.001, respectively). The correlation of reading ability with vision-related QOL was largely mediated by VA and CS and therefore it was not retained in the vision index., Conclusions: Visual acuity is poorly correlated with vision-related QOL in patients with AMD. Even though the new cVA index is a new method which better correlates with vision-related QOL, the major components of the individual perception of vision remain unexplained by common psychometric tests.

Purpose: To assess the test-retest variability of central and sectorial macular thickness measurements obtained by Cirrus HD-OCT (Carl Zeiss Meditec, Dublin, CA) in neovascular age-related macular degeneration (nAMD)., Methods: Macular thickness measurements of nine standard ETDRS subfields were obtained and analyzed. The repeatability of macular thickness measurements by Cirrus HD-OCT was assessed by examining the intrasession within subject standard deviation (Sw), coefficient of repeatability (CR), and coefficient of variation (CV), before and after eyes with retinal segmentation errors were excluded., Results: Forty-nine nAMD eyes of 49 consecutive patients were included in the study. The CR for the central macular subfield was 42.4 microm (10.5%) and ranged from 12.1 microm (3.7%) for the outer nasal to 41.8 microm (11.4%) for the inner nasal subfields. In a secondary analysis, eyes affected by erroneous detection of inner and outer retinal boundaries (6/49, 12.24%) were excluded. The revised coefficient of repeatability for the central macular subfield was 26.1 microm (8.1%) and ranged from 10.3 microm (3.8%) for the outer superior to 30.2 microm (8.3%) for the inner nasal subfields., Conclusions: Overall, the test-retest variability of Cirrus HD-OCT is good for the central and sectorial macular subfields, with a low incidence of scan artifacts.

Purpose: The purpose of this study was to assess long-term functional and structural retinal changes in patients with neovascular age-related macular degeneration treated with intravitreal 0.5 mg ranibizumab., Methods: Eighteen patients with neovascular age-related macular degeneration have been evaluated in this retrospective 24-month follow-up study. All patients have been treated with 3 injections of 0.5 mg ranibizumab 1 month apart and retreated according to predefined criteria. At baseline, all patients were subjected to visual acuity, fluorescein angiography, MP1 microperimetry, and Stratus optical coherence tomography. Although visual acuity and optical coherence tomography were repeated 28 +/- 2 days after each injection, MP1 was performed at 6, 12, and 24 months., Results: Seventeen of 18 and 14 of 18 patients completed 12 and 24 months of follow-up, respectively. Mean retinal sensitivity significantly improved from 3.89 +/- 3.0 dB to 7.33 +/- 4.11 dB at 24 months (P = 0.024). Mean visual acuity improved from 48.67 +/- 8.59 to 59.17 +/- 16.45 at 24 months (P = 0.049). Visual acuity improved to >or=15 letters in 33.3% (6 of 18) of patients and <15 letters in 44.4% (8 of 18); 22.2% (4 of 18) of patients lost <15 letters at 24 months. Five of 13 patients (38.5%) with either an instable or relatively instable fixation at baseline showed improvement of fixation stability at 24 months. Central retinal thickness significantly decreased from 310.5 +/- 85.7 to 232.9 +/- 60.1 at 24 months (P = 0.0001)., Conclusion: Intravitreal injections of 0.5 mg ranibizumab determine progressive improvement of retinal sensitivity until 24 months, although visual acuity levels off after 6 months, suggesting that microperimetry may give additional information about macular function not given by visual acuity alone.

Purpose: The purpose of this study was to report functional and morphologic retinal changes after intravitreal injections of 0.5 mg ranibizumab in patients with myopic neovascular membrane (choroidal neovascularization)., Methods: This is a case review of 11 consecutive patients with myopic choroidal neovascularization who received intravitreal injections of ranibizumab at monthly intervals. Serial changes in best-corrected visual acuity, optical coherence tomography, fluorescein angiography, and microperimetry (Nidek MP1, Nidek, Padova, Italy) are presented., Results: Mean baseline best-corrected visual acuity was 59.82 + or - 17.50 Early Treatment Diabetic Retinopathy Study letters. After a follow-up of 36 weeks, mean visual acuity improved to 66.72 + or - 17.3 with a mean change of 6.91 letters. Mean baseline retinal sensitivity was 6.02 + or - 1.9 dB. After 36 weeks, mean sensitivity improved to 8.3 + or - 2.4 dB with a mean change of 2.3 dB. The fixation stability improved from 45.5% to 72.7%. All patients also had complete resolution of subretinal fluid, mean optical coherence tomography central retinal thickness was reduced from 244.64 + or - 39.3 microm to 191.36 + or - 27.3 microm at 36 weeks, and fluorescein angiography at 36 weeks showed absence of leakage in all patients., Conclusion: Intravitreal ranibizumab injections seemed to positively influence retinal functional status in patients with myopic choroidal neovascularization.

Purpose: To evaluate if simple- or multiple-field digital color nonmydriatic (NM) retinal images can replace 7 standard stereoscopic fundus photographs in the screening of diabetic retinopathy (DR)., Design: Prospective, masked, comparative case series., Methods: One hundred and eight eyes of 55 diabetics were studied to determine single lesions and to grade clinical levels of DR and diabetic macular edema (DME) using both 1 and 3 NM digital color retinal images compared with the Early Treatment Diabetic Retinopathy Study (ETDRS) 7 standard 35-mm stereoscopic color fundus photographs (7F-ETDRS). All eyes underwent NM 45-degree field images of 1 central field (1F-NM), NM 45-degree field images of 3 fields (3F-NM), and, after pupil dilatation, 30-degree 7F-ETDRS photography. Images were analyzed by 2 independent, masked retinal specialists (S.V. and E.B.), lesion-by-lesion according to the ETDRS protocol and for clinical severity level of DR and DME according to the international classification of DR., Results: Using 7F-ETDRS as the gold standard, agreement was substantial for grading clinical levels of DR and DME (kappa = 0.69 and kappa = 0.75) vs 3F-NM; moderate for DR level (kappa = 0.56) and substantial for DME (kappa = 0.66) vs 1F-NM; almost perfect for detecting presence or absence of DR (kappa = 0.88) vs both 1F-NM and 3F-NM; and almost perfect for presence or absence of DME (kappa = 0.97) vs 3F-NM and substantial (kappa = 0.75) vs 1F-NM. Sensitivity and specificity for detecting referable levels of DR were 82% and 92%, respectively, for 3F-NM and 71% and 96%, respectively, for 1F-NM., Conclusions: Three color 45-degree NM fundus fields may be an effective tool in a screening setting to determine critical levels of DR and DME for prompt specialist referral. One central 45-degree image is sufficient to determine absence or presence of DR and DME, but not for grading it.

Purpose: To assess functional and structural retinal changes in patients with neovascular age-related macular degeneration treated with intravitreal ranibizumab 0.5 mg., Methods: Eighteen patients with neovascular age-related macular degeneration have been evaluated in this retrospective 24-week follow-up study. All patients were treated with three injections of ranibizumab 0.5 mg, 1 month apart and retreated according to predefined criteria. At baseline, all patients were subjected to visual acuity measurement, fluorescein angiography, microperimetry, and optical coherence tomography stratus. Visual acuity, microperimetry, and optical coherence tomography evaluations were repeated 28 +/- 2 days after each injection., Results: Mean retinal sensitivity significantly improved from 3.89 +/- 3.0 dB at baseline to 6.61 +/- 3.4 dB at 24 weeks (P = 0.044). Mean visual acuity significantly improved from 48.67 +/- 8.58 to 60.72 +/- 16.09 (P = 0.026); visual acuity improved in 44.4% of patients > or =15 letters (24.5 +/- 8.0 letters), and in 38.9% of patients improved <15 letters (6.14 +/- 3.7 letters); 16.7% of patients lost <15 letters (7.3 +/- 2.1 letters). An improvement of fixation stability from baseline was observed in 33.3% of patients. Central macular thickness significantly decreased from 310.5 +/- 85.7 microm to 217.3 +/- 46.8 microm at 24 weeks (P < 0.001)., Conclusions: Although visual acuity and retinal thickness changes seemed to be almost maximum at 4 weeks after intravitreal ranibizumab 0.5 mg, retinal sensitivity as measured by microperimetry showed a trend of progressive improvement till 24 weeks suggesting that microperimetry may give additional information about macular function not given by visual acuity alone.

We describe a case of severe serotonin syndrome. The patient was simultaneously taking the atypical antidepressant olanzapine and a tricyclical antidepressant, clomipramine. Symptoms included altered mental state resulting in coma, myoclonus, hyperreflexia, diaphoresis, diarrhoea, disorientation and fever. After suspension of antidepressant drugs, intensive symptomatic treatment and administration of biperiden and cyproheptadine, the patient's condition improved.

Purpose: To evaluate psychophysical and electrophysiologic responses in eyes with early age-related macular degeneration (AMD) without a decrease in visual acuity and with or without late AMD in the fellow eye., Methods: Fifteen patients (mean age: 67.9 +/- 7.20 years) with early AMD in both eyes (AMD1 group, 15 eyes) and 15 patients (mean age: 71.40 +/- 7.06 years) with early AMD in one eye and late AMD in the fellow eye (AMD2 group, 15 eyes) were enrolled. They were compared to 15 age-similar normal control subjects. LogMAR visual acuity (VA), macular sensitivity by MP-1 microperimetry, and multifocal electroretinograms (mfERG) were assessed in control, AMD1, and AMD2 eyes. mfERG response amplitude density (RAD, nV/deg2) of the N1-P1 component of first order binary kernels was measured., Results: When compared to controls, AMD1 and AMD2 eyes showed a significant (analysis of variance, P < 0.01) decrease in MP-1 microperimetry assessed in the 0-2.5 and 2.5-5 degrees of the macula, significantly correlated (Pearson test, P < 0.01) to the corresponding significant decrease (P < 0.01) in mfERG N1-P1 RADs assessed in the 0-2.5 and 2.5-5 degrees. In AMD1 and AMD2 eyes, VA and mfERG N1-P1 RADs assessed in the 5-20 degrees were similar (P > 0.01) to controls. VA, MP-1, and mfERG values were not significantly different in AMD1 and AMD2 eyes., Conclusion: In eyes with early AMD there is a dysfunction of preganglionic elements in the central 0-5 retinal degrees detectable by mfERG or MP-1 microperimetry. This impairment is not further influenced by the presence of late AMD in the fellow eye.

Purpose: To evaluate the visual and anatomic outcome of photodynamic therapy (PDT) in eyes with nonsubfoveal choroidal neovascularization (CNV) associated with pathologic myopia (PM)., Design: Interventional, noncomparative cases series., Methods: Ninety-seven patients (100 eyes) who were treated with PDT at three centers and followed up for three to 44 months (mean 16.5 months). Outcome measures were visual acuity, lesion size, and the occurrence of subfoveal invasion., Results: Median baseline visual acuity was 20/40(-2) and ranged from 20/20 to 20/160(+2). On average, visual acuity was stable throughout follow-up after a modest increase of about 0.5 lines between three and six months. The probability of losing 3 or more lines was 10% to 15% during the second year. Lesion size (median: 710 microns) slightly decreased after the first PDT and tended to increase later, but not to a statistically significant extent compared with baseline. The probability of developing subfoveal CNV stabilized at 10% in the second year. The mean number of PDTs per individual was 2.9 in the first year and 0.6 in the second., Conclusions: Visual and anatomic outcomes of PDT, in this large group of patients with nonsubfoveal myopic CNV and good visual acuity, suggest that it may halt the progression of the disease in most cases.

We describe the case of a 24 year old woman, affected by haemorrhagic shock due to post-partum uterine atony, who underwent an emergency hysterectomy with persistent postoperative bleeding, successfully treated with recombinant activated factor VII (Novoseven).

We describe a clinical case of a 7 year old girl, affected by peritonitis, septic shock and multiorgan failure, treated successfully with drotrecogin alpha associated with conventional therapy.

Objective: To evaluate the presence of macular holes (MHs) in very highly myopic eyes in the absence of visual symptoms., Design: Retrospective case series., Participants: Three hundred eighty-three eyes from 383 patients (mean age, 51.70+/-12.73 years) affected by very high myopia (between -14 and -32 diopters [D]), with no visual disturbance such as metamorphopsia and with visual acuity (VA) of >0.2 logarithm of the minimum angle of resolution, were considered in the study. They were evaluated at baseline and every 6 months during a mean total period of 30.2+/-0.5 months (range, 28.3-32.1)., Methods: Evaluation of macular morphology by optical coherence tomography (OCT)., Main Outcome Measures: Changes in OCT macular morphology ascribed to the presence of an MH., Results: Macular holes were detected by OCT in 24 of 383 (6.26%) myopic eyes. These MHs were defined as asymptomatic (AMHs). The presence of AMHs was more prevalent (although not significantly when compared with the overall study population) in myopic patients younger than 50 years and with concomitant myopia of >-20 D. Posterior vitreous schisis was the most frequent vitreous modification associated with AMH (18/24 eyes [75.0%]). During follow-up, a decrease in VA was observed in 5 of 24 (20.8%) AMH eyes due to the enlargement of the lesion or to posterior retinal detachment, leading to the development of a symptomatic MH. Greater degree of myopia and younger age were associated with the evolution of the macular disease, consisting of an enlargement of the MH and/or the onset of a macular detachment., Conclusions: A small percentage (6.26%) of highly myopic eyes may develop an MH in the absence of visual symptoms. The absence of symptoms could be related to the localization of the hole in a juxtafoveal area. Its evolution in a symptomatic MH seems to be related to the presence of epiretinal tissue, younger age, and the degree of myopia.

Purpose: To report the use of photodynamic therapy (PDT) for choroidal neovascularization (CNV) in pediatric patients., Methods: Five patients (age range, 7-15 years) who underwent PDT for idiopathic CNV (n = 2) or CNV secondary to macular toxoplasmic scar (n = 3) were included in this study. Follow-up ranged from 12 months to 18 months. PDT was performed according to the standard protocol. We evaluated visual acuity, fluorescein leakage from the CNV, greatest linear dimension of the lesion, and occurrence of ocular or systemic adverse events at baseline and during follow-up., Results: No severe or moderate visual loss occurred in all cases during follow-up. PDT reduced CNV leakage in four cases. No serious ocular or systemic adverse events were recorded. Retinal pigment epithelium atrophic changes were observed around the regressed CNV, but they did not appear to cause visual loss., Conclusions: PDT was safe for pediatric patients, and visual acuity was substantially stable after one or few treatments. Further follow-up is needed to assess if retinal pigment epithelium atrophic changes around the regressed CNV, possibly related to PDT, could affect vision in the long term.

Purpose: To evaluate the effects of photodynamic therapy (PDT) on macular function in myopic subfoveal choroidal neovascularization (CNV)., Methods: Fourteen eyes of 14 patients (mean age, 48.1 +/- 13.3 years) with myopic CNV (myopia ranging from -6.50 to -20 D) were enrolled. In each eye, at baseline and at 15 and 90 days after PDT with verteporfin, logMAR visual acuity (logarithm of the minimum angle of resolution VA), macular sensitivity by scanning laser ophthalmoscope microperimetry, and focal (central 9 x 9 degrees ) ERGs (FERGs) and pattern ERGs (PERGs) were assessed., Results: At 15 days after PDT, myopic CNV eyes showed, in relation to baseline values, a significant (ANOVA, P < 0.01) reduction in the diameter of the lesion that correlated (Pearson test, P < 0.01) with the significant (ANOVA, P < 0.01) increase in FERG and PERG amplitudes, VA, and scanning laser ophthalmoscopy (SLO) microperimetry results obtained from the central 1 degrees to 2 degrees of the macular area (SLO-CM). At 90 days after PDT, myopic CNV eyes showed, in comparison with baseline values, a nonsignificant (ANOVA, P > 0.01) reduction in the diameter of the lesion, a nonsignificant increase in VA and SLO-CM, and a still significant increase in FERG and PERG amplitudes., Conclusions: In myopic CNV eyes, PDT induces an increase, though not significant, in VA and macular sensitivity. These changes may be related to a reduction in the diameter of the lesion, with an improvement in the function of both ganglionic and preganglionic elements of the macular region, as suggested by the improvement in FERG and PERG responses.

Purpose: To evaluate the visual and anatomic outcomes of photodynamic therapy for choroidal neovascularization (CNV) in patients with angioid streaks., Methods: The authors retrospectively evaluated 40 consecutive patients (48 eyes) with visual acuity of 20/200 or greater who were treated at 6 referral centers for CNV associated with angioid streaks. Main outcome measures were visual acuity, greatest linear diameter of the lesion, and, in patients with nonsubfoveal CNV, distance from the foveola., Results: Of 34 eyes with subfoveal CNV, 21 were followed up for at least 12 months (range, 5-33 months). Median visual acuity was 20/50 at baseline and 20/120 at the final examination. The 12-month estimate of the percentage of eyes with vision loss of fewer than 3 lines was 68% (95% confidence interval, 50%-85%) by using survival analysis, whereas eyes with no increase in the greatest linear diameter were 45% (95% confidence interval, 27%-62%). Fourteen eyes had extrafoveal (n = 11) or juxtafoveal (n = 3) CNV, 12 of which were followed up for at least 10 months (range, 4-36 months). Visual acuity was 20/40 or greater in all eyes with extrafoveal lesions at baseline and in 5 of 12 eyes at the last examination, when 3 cases of CNV had become subfoveal. At baseline, visual acuity was low in two eyes with juxtafoveal CNV and nearly normal in the third. It remained substantially stable at the end of follow-up (range, 10-36 months), when two lesions were subfoveal., Conclusions: Most of our patients had good baseline visual function and, thus, were at high risk for losing vision because of the poor prognosis of CNV in angioid streaks. Because most had no or limited vision loss after 1 year, the authors suggest that photodynamic therapy can be used to try to limit or delay visual damage caused by this aggressive disease.

Purpose: To investigate the effects of subfoveal choroidal neovascularizzation (CNV) secondary to age-related macular degeneration (AMD) on macular functional parameters quantified with an automatic fundus perimeter., Methods: 118 eyes of 98 consecutive patients with subfoveal CNV secondary to AMD were evaluated. Best corrected visual acuity (ETDRS charts), fundus photography, and fluorescein angiography were performed. Microperimetry (fundus-related perimetry) was used to quantify macular sensitivity and fixation pattern (location and stability)., Results: Of 118 eyes: 26 (21.9%) had central, 18 (15.1%) poor central and 74 (63.0%) eccentric fixation; 31 (26.0%) had stable, 42 (35.6%) relatively unstable and 45 (38.4%) unstable fixation. In 75 eyes (63.4%) a dense central scotoma was found. Angiographic classification of subfoveal CNV (occult versus classic) was not significantly related to fixation pattern (location: P = 0.274; stability: P = 0.385), and presence of dense scotoma (P = 0.41)., Conclusion: Microperimetric quantification of macular sensitivity and fixation pattern in eyes with subfoveal CNV secondary to AMD offers new data about the impact of visual impairment in these eyes. Moreover, microperimetry improves the functional evaluation of subfoveal CNV in AMD.

Purpose: The Complex Regional Pain Syndrome (CRPS) is a chronic pain state provoked by lesions of the soft tissues or of the bony tissues (type CRPS-I or reflex sympathetic dystrophy-RSD) or by lesions of the nerves (type CRPS-II or causalgia) with vegetative alterations (perspiration, vasomotory alterations) and trophic alterations (bony cutaneous atrophy, alopecia, articular contractures). The pharmacological block of the sympathetic nerves through a peripheral vein is inserted in the multidisciplinary approach that characterizes the therapy of this syndrome., Materials and Methods: A retrospective survey was carried out on a group of 185 patients affected by RDS/CRPS with block of the sympathetic nerves through a peripheral vein with guanethidine. Superior limb: Inflation of the tourniquet till disappearance of the radial wrist. Cannulation of a peripheral vein with Butterfly needle n. 23. Guanethidine 10 mg, lidocaine 20 mg, sodic heparin 500 u.i, NaCl 0.9% 20 ml. Injection in 5 minutes. Permanence of the pneumatic tourniquet inflated above systolic blood pressure for 15 minutes. Deflation slowly. Inferior limb: Inflation of the tourniquet till disappearance of the pedidium wrist. Cannulation of a peripheral vein with Butterfly needle n. 23. Guanethidine 20 mg, lidocaine 40 mg, sodic heparin 1000 u.i, NaCl 0.9% 40 ml. Injection in 5 minutes. Permanence of the pneumatic tourniquet inflated above systolic blood pressure for 15 minutes. Deflation slowly., Results: The first stage (hyperemic) showed the highest incidence of remissions: (83, 33%). Even in the second stage (dystrophic) the answer to the therapy has been fundamentally positive: (53, 68%). In the third stage (atrophic) the results have been more modest: (8, 33%)., Conclusions: The block of sympathetic system with guanethidine is still an important method in the therapy of the CRPS; in fact it is surely less invading than the blocks of the stellate ganglion or of the lumbar sympathetic.

Purpose: To assess the changes in visual acuity and macular sensitivity and the possible evolution into a full-thickness macular hole in patients with macular pseudoholes during a 3-year follow-up period., Methods: Twenty-seven eyes (mean age, 61.0 +/- 8.9 years) with macular pseudoholes were enrolled. They were compared with 16 eyes from 16 age-matched control eyes. In each eye with a macular pseudohole, we assessed the Snellen visual acuity and macular sensitivity by scanning laser ophthalmoscopic central (1-2 degrees of the macula, SLO-CM) and paracentral (annular area from 2-7 degrees from the macula, SLO-PM) microperimetry at the time of diagnosis (baseline condition) and every 6 months for 3 years., Results: Eyes with macular pseudoholes at baseline had a significant (P < 0.05) reduction in visual acuity, SLO-CM, and SLO-PM when compared with control eyes. After 12 months of follow-up, no changes in VA, SLO-CM, or SLO-PM were observed in eyes with macular pseudoholes with respect to the baseline values. After 36 months of follow-up, further significant (P < 0.05) decreases in visual acuity, SLO-CM, and SLO-PM were observed. One third of eyes with macular pseudoholes showed an evolution into a full-thickness macular hole. In these eyes, the lowest SLO-CM had been observed at the baseline condition., Conclusion: This study suggests that in the 36-month follow-up period in eyes with macular pseudoholes, there is the possibility of a worsening trend, leading to the development of a full-thickness macular hole. A useful role of the functional assessment by SLO-CM and SLO-PM can be suggested for the clinical diagnosis and the follow-up of macular pseudoholes.

Background: The purpose of this study was to estimate if and to what extent scanning laser ophthalmoscopy can help in the early diagnosis and follow-up management of the vitreoretinal interface syndrome, which includes disorders such as cellophane maculopathy, pseudomacular hole, macular pucker, and macular hole., Methods: The 35 fellow eyes of 35 patients with vitreoretinal interface syndromes in the first eye underwent scanning laser ophthalmoscopy microperimetry and argon, helium-neon, and infrared scanning laser ophthalmoscopy. Fellow eyes were defined as clinically positive or negative for vitreoretinal interface syndrome. Fellow eyes then were classified based on scanning laser ophthalmoscopy techniques. Patients were observed for an average of 18 months (range, 10-26 months)., Results: Thirty-two of the 35 fellow eyes were classified as clinically negative, and three of the 35 were classified as clinically positive. Fifteen of the 32 clinically negative fellow eyes were redefined as positive on scanning laser ophthalmoscopy. None of the clinically positive eyes proved to be negative on scanning laser ophthalmoscopy. During the average follow-up period (18 months), the condition of five of 18 fellow eyes that were positive on scanning laser ophthalmoscopy worsened. None of the 17 eyes that were negative on scanning laser ophthalmoscopy worsened., Conclusion: Scanning laser ophthalmoscopy can produce beautifully clear images of structures that are otherwise difficult to see and document, such as posterior hyaloid and the inner retinal layers. Despite a relatively limited number of cases and the short duration of the follow-up period, the present study suggests that scanning laser ophthalmoscopy has good sensitivity and specificity for the early diagnosis of vitreoretinal interface syndromes.

Eighty-eight postmenopausal women with metastatic breast cancer, in whom estrogen receptors (ER) were positive or unknown, were treated on a controlled trial to determine the effectiveness of tamoxifen and to assess the therapeutic advantage of sequentially adding low-dose cyclophosphamide-methotrexate-5-fluorouracil (CMF) chemotherapy in tamoxifen responders. Patients with known ER negative status were not studied. After the initial 12-week treatment with tamoxifen alone, 60% of ER positive patients achieved complete or partial response as did 35% in whom ER were unknown. Response status further improved in 18% randomized to continue tamoxifen alone vs 31% in whom CMF was added to tamoxifen. There were no statistically significant differences in time to the development of progressive disease or survival between the ER positive and ER unknown patients or between the tamoxifen and tamoxifen plus CMF groups. We conclude that inability to determine ER status should not prejudice against the use of tamoxifen in postmenopausal patients with advanced breast cancer. No benefit has been demonstrated from the addition of CMF chemotherapy in tamoxifen responders.