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Background: Diabetic papillopathy is a complication of diabetes. It presents with edema, uni or bilateral and vascular alteration of the anterior optic nerve. Often this complication is observed in patients with severe diabetic retinopathy, but is rarely observed in isolated form. Some authors believe that diabetic papillitis is a particular form of non-arteritic anterior ischemic optic neuropathy (NAION). But there is important evidence that confers an inflammatory component to diabetic papillopathy. We report in this work a rare case of isolated acute bilateral diabetic papillopathy developed in a diabetic patient after adding the insulin to the oral hypoglycemic therapy. Case presentation: Male patient, 49-years-old, diabetic type 2, with altered glycemia at follow up, with clinical history of HbA1c 8% to 12% in the last 2 years, on oral hypoglycemic therapy for 10 years. He never had a history of diabetic retinopathy. At the last check-up, this patient presented bilateral papillopathy, without reduction of visual acuity bilaterally. The patient reports he added 10 days before the insulin therapy to the oral hypoglycemic therapy, under medical supervision. Hematochemical and serological tests were requested, which excluded the presence of inflammatory and infectious diseases. The brain magnetic resonance imaging (MRI) with gadolinium excluded the hypothesis of optic neuritis or intracranial hypertension. Cardio-circulatory tests were normal. Fluorescein angiographic examinations and optical coherence tomography (oct) confirmed the bilateral edema and the thickening of optic nerve without other retinal damage. Therefore he was diagnosed with bilateral diabetic papillopathy. Then, diabetologists added pump insulin treatment to the oral hypoglycemic therapy. After 2 months, his blood sugar levels and HbA1C improved and papillopathy regressed. Conclusion: We have reported a rare case of bilateral acute diabetic papillopathy associated with the addition of insulin to the oral hypoglycemic therapy. A randomized control study with diabetic patients, would be useful to verify the possible injuries of the optic nerves during the delicate transition to insulin therapy.

To evaluate the different mechanisms of retinal detachment recurrence after retinectomy for rhegmatogenous retinal detachment (RD) complicated by proliferative vitreoretinopathy (PVR) and to study its outcome and prognosis.Retrospective, multicenter study conducted between January 2009 and November 2016. Retrospective review of 56 patients with recurrent RD (RRD) after a first relaxing retinectomy.The secondary retinal attachment rate was 58.9% (33/56 cases). The various mechanisms of RRD were mainly related to PVR (52/56 cases: 93%). This PVR was anterior in 10 cases (21%), posterior in 31 cases (60%), and combined anterior and posterior in 11 cases (21%). The RRD mechanism was not PVR in 4 of the 56 cases. Some of the RRD mechanisms were specific to retinectomy: fibrosis of the edge of the retinectomy (26 cases: 46.4%), beyond-the-edge proliferation (8 cases: 14.3%), and severe inferior retinal folding (2 cases: 3.6%). In the 2 cases of severe inferior retinal folding, the retina could not be reattached. The anatomical outcome and the mechanism of RRD (anterior PVR, posterior PVR, or combined anterior and posterior PVR) were not correlated (P = 0.12). Visual acuity was significantly better only in patients with complete secondary success, that is, having an attached retina after silicone oil removal: mean preoperative visual acuity was 2.01 logarithm of the minimum angle of resolution versus 1.01 logarithm of the minimum angle of resolution postoperatively (P = 0.019).Proliferative vitreoretinopathy caused most of the recurrences, and the anatomical outcome did not depend on the type of PVR involved. Only complete secondary success (attached retina after silicone oil removal) was accompanied by visual acuity improvement.

PURPOSE To report a case of large full thickness macular hole (MH) as an uncommon complication of an idiopathic retinal vasoproliferative tumor (RPVT) and the successful closure of the full-thickness MH by the inverted internal limiting membrane Flap technique. METHODS A case report. A 40-year-old woman was referred for a progressive and profound visual loss on the right eye. The fundus examination showed a full-thickness MH and the presence of an idiopathic RPVT surrounding by numerous exudates in the inferior temporal of the peripheral retina. In addition, the spectral domain optical coherence tomography imaging confirmed the large size of the full-thickness MH (740 μm-diameter). First, we treated the RPVT using the transconjunctival cryotherapy. Then, we performed the macular surgery including 25 Gauge vitrectomy, inverted internal limiting membrane flap technique, and gas tamponade. RESULTS In the postoperative period, the RPVT remained inactive with no recurrence of the MH or excessive gliosis proliferation on the internal limiting membrane flap area. Moreover, visual acuity rose up from 20/100 (0.2) at 1-month follow-up to 20/40 (0.5) at 6-month follow-up. CONCLUSION In our patient, the full-thickness MH was precisely large and secondary to an RPVT. The treatment of the tumor by transconjunctival cryotherapy had been efficient and the postoperative follow-up after the macular procedure involving the inverted internal limiting membrane flap technique showed the anatomical and functional recovery of the macula.

Background: Despite the high closure rate of large macular hole (LMH) after surgery, visual recovery is often worse than expected. Microperimetric biofeedback can improve visual function in macular pathologies. We evaluated the efficacy of biofeedback on macular function after successful inverted flap technique for LMH. Methods: In this prospective comparative study, 26 patients after LMH surgical closure were enrolled. The whole sample was equally divided into two groups. In Group 1 (trained), patients underwent a double cycle of microperimetric biofeedback, using structured light stimulus plus acoustic tone, in Group 2 (control), patients underwent scheduled visits. We analyzed visual acuity, retinal sensitivity at central 12&deg, (macular sensitivity, MS) and 4&deg, (central macular sensitivity, CMS), and fixation stability over twelve months. Results: Visual acuity improved mainly in the trained group, without any significant differences between the groups (p &gt, 0.05). Only after training did MS significantly improve (p = 0.01). CMS more significantly improved in the trained (p &lt, 0.001) than the control group (p &lt, 0.01) (Group 1 vs. 2, p = 0.004). Only in the trained group did fixation significantly improve (3 months, p &le, 0.03, 12 months, p &le, 0.01). An equality test on matched data confirmed a greater significant improvement of CMS (p &le, 0.02) at all follow-up and fixation (p &le, 0.02) at last follow-up after training. Conclusion: Microperimetric biofeedback consolidates and increases the improvement of retinal sensitivity and fixation gained after successful inverted flap technique.

Marta Zola, Cristina Briamonte, Umberto Lorenzi, Federica Machetta, Federico M Grignolo, Antonio M Fea Ophthalmic Eye Hospital, Department of Surgical Sciences, University of Turin, Italy Purpose: The purpose of this study was to report the functional and anatomical outcomes of a prospective study resulting from repeated dexamethasone intravitreal implants in patients with uveitic refractory macular edema.Methods: Twelve eyes of 9 patients with intermediate and posterior noninfectious inflammatory uveitis complicated with refractory macular edema were regularly reviewed after a dexamethasone intravitreal implant. Patients were examined at baseline, 30, 90, 135, and 180days with best-corrected visual acuity (BCVA), complete slit-lamp examination, intraocular pressure (IOP), optical coherence tomography, and fluorescein angiography. After 6 months of follow-up, eyes were reassessed to receive a second implant. Results: BCVA significantly improved when comparing the baseline values after the first and second implant (16.2 and 25.8 letters, respectively, 9.6 letters improvements, p30 mmHg 30 days after the second implant, treated topically.Conclusion: Repeated dexamethasone intravitreal implants in uveitic patients with refractory macular edema can be used effectively in a clinical setting with an acceptable safety profile. Keywords: uveitis, macular edema, dexamethasone, intavitreal implant

Background Terson syndrome is defined as intraocular hemorrhage associated with intracranial bleeding. This syndrome can occur in the event of intracranial hemorrhage or elevated intracranial pressure. To our knowledge, it has never been associated with chronic myeloid leukemia. A 45-year-old woman suffering from chronic myeloid leukemia was referred to our clinic with Terson syndrome after intracranial bleeding. We followed this patient for a year, performing visual acuity assessment, fundus examination, color retinography, and A-scan and B-scan ultrasonography. At presentation, her best-corrected visual acuity on the right was 20/63 and on the left was 20/320. In the right eye, retinoscopy showed blurring of the optic margins surrounded by retinal and preretinal hemorrhages, preretinal fibrosis of the optic disc along the vascular arcades, and perivascular retinal infiltrates. In the left eye, the optic disc was surrounded by retinal and preretinal hemorrhages, and massive fibrosis with hard exudates and severe preretinal hemorrhage were observed at the posterior pole. Roth spots and many circular hemorrhages were noted at the periphery of the retina. A-scan and B-scan ultrasonography did not show intraocular leukemic infiltration. The clinical picture remained stable over the following 12 months. In this patient, we observed the ophthalmoscopic features of chronic myeloid leukemia, but also coexistence of features typical of Terson syndrome. To our knowledge, no similar cases have been reported previously.

Purpose: To evaluate short-term intraocular pressure (IOP) changes after phacoemulsification in glaucoma and normal patients and the effect of oral acetazolamide (Diamox) to control IOP in these patients. Methods: 120 patients undergoing cataract surgery were included in this prospective multicenter study involving 6 University Eye Clinics: 60 patients with well-controlled primary open-angle glaucoma (POAG) and 60 controls. Half of the study participants received oral acetazolamide, 250 mg, 1 and 6 h after surgery. The treated and untreated groups were matched for age and density of cataract. All patients underwent a standard phacoemulsification procedure and were checked for IOP with Goldmann tonometry in the morning before surgery and then at 3, 6, 21 and 24 h postoperatively by a masked evaluator. Results: The group with POAG showed a significant postsurgical increase in IOP (p < 0.001) at all time points. Six of thirty (20%) untreated POAG patients showed at least 1 IOP reading above 30 mm Hg whereas acetazolamide significantly reduced postoperative IOP at all time points (p < 0.01) and in no case was IOP >30 mm Hg. The control group had high IOP during the first 6 h (p < 0.01), but normal values thereafter. Conclusion: A significant short-term IOP increase may be found after phacoemulsification both in POAG and normal patients; this is not dangerous in normal subjects, but can be potentially dangerous in POAG patients. The use of systemic acetazolamide provided significant control of IOP and could be considered a ‘possible standard’ management of cataract surgery in POAG patients.

Primary open angle glaucoma (PACG) is a major cause of blindness especially in Asia. The pathogenesis of this condition has been widely investigated. Traditionally gonioscopy is the method of choice for the esamination of patients considered to be at risk for angle closure, but it is a rather invasive procedure and it is reported to be primarily used by glaucoma specialists. Recently newer ultrasound and optical methods for the evaluation of the anterior chamber angle have been introduced in the clinical practice, with distinct advantages and disadvantages both compared to each other and to gonioscopy. This review will address the pathogenesis of PACG, the use of gonioscopy and will evaluate the newer methods of angle examination.

Cycloablation is a destructive procedure used to decrease the intra-ocular pressure (IOP) trough the ablation of the ciliary body that produces aqueous humour. Many destructive techniques, including diathermy, cryotherapy, ultrasounds, beta irradiation, and laser photocoagulation have been employed with a wide range of results and side effects. Although all above techniques can effectively destroy the ciliary body, only few of them have been used widely enough to convincingly demonstate their clinical usefulness and gain general acceptance. The ideal method of cyclodestruction should produce clinically useful and predictable reduction of intraocular pressure (IOP), with minimal complications and side effects. (Bartamian & Higginbotham, 2001). Ideally it should have a wide therapeutic window between insufficient and too aggressive treatment intensity, that can result in either insufficient IOP reduction or hypotony/phtisis. Cyclodestructive procedures are usually reserved for cases of glaucoma in eyes with little or no visual potential that proved refractory to medical treatment and outflow surgeries. (Lin, 2008) As an exception to this long established indication, cyclodestructive procedures performed with the 810 nm infrared diode laser transscleral cyclophotocoagulation have been successfully applied also in eyes with refractory glaucoma and good visual potential (Rotchford et al., 2010; Wilensky & Kammer, 2004) supporting an emerging notion that the indications for transscleral laser cyclophotocoagulation should not be limited to eyes with poor visual acuity or potential.