Evaluation of a screening program for diabetic retinopathy in a primary care setting Dodia (Dépistage ophtalmologique du diabète) study

OBJECTIVES

The aim of this observational study was to evaluate the screening for diabetic retinopathy (DR) using eye fundus photography taken by a nonmydriatic camera and transmitted trough the Internet to an ophthalmological reading centre, as compared to a dilated eye examination performed by an ophthalmologist.

METHODS

A total of 456 and 426 diabetic patients were included by two different groups of primary care physicians (PCPs), 358 being screened with the non-mydriatic camera (experimental group) and 320 with dilated eye fundus exam (control group).

RESULTS

The proportion of screened patients for whom PCPs received a screening report within the 6-month follow-up period was 74,1% for the experimental group and 71,5% for the control group. Screening for DR was negative in 77,6% of patients with eye fundus photographs vs 89,6% with dilated eye examination. DR was diagnosed in 62 patients (17,3%) with eye fundus photographs versus 31 with dilated eye examination (10,4%). Referral to an ophthalmologist was required in 59 reports of patients with photographs (16.5%), 23 of them due to high grade DR. Finally, the non-mydriatic camera was found of little inconvenience by patients.

CONCLUSION

The telemedical approach to DR screening proved to be effective in providing primary care practitioners with information about their patient's eye status. This screening method allowed to identify patients requiring prompt referral to the ophthalmologist for further complete eye examination. In conclusion, this study provided successful results of DR screening using fundus photography in primary care patients, and strongly supports the need to further extend this screening program in a larger number of French sites.

Screening for diabetic retinopathy: the first telemedical approach in a primary care setting in France

OBJECTIVES

Diabetic retinopathy (DR) remains a major cause of visual impairment in France, due to insufficient regular annual screening. Fundus photography is a sensitive alternative to ophthalmoscopy for DR screening. The aim of our study was to report the first telemedical approach to this screening in a primary care setting in France.

METHODS

A DR screening centre equipped with a nonmydriatic camera was opened in the 18th district of northern Paris and placed at the disposal of general practitioners (GPs) of the Réseau de Santé Paris Nord (North Paris Health Network). These GPs were invited to send their diabetic patients who had no known DR and had had no fundus examination for more than one year to this screening center. Retinal photographs were taken by an orthoptist without pupillary dilation and sent for grading through the Internet to the Lariboisière Hopital Ophthalmology Department.

RESULTS

During an 18-month period, 912 DR screening examinations were performed in 868 diabetic patients referred to the DR screening center by 240 GPs. Patients' mean +/- SD age was 59.9 +/- 11.1 years. Of these 868 patients, 260 (30%) said they never have had an ophthalmological examination. Diabetic retinopathy was detected in 197 patients (22.7%). The proportion of patients for whom fundus photographs of one or both eyes could not be assessed was 10.1%. 159 patients (18.3%) required referral to an ophthalmologist.

CONCLUSION

Nonmydriatic photography, combined with teletransmission to a reading centre, proved to be a feasible valid method for the detection of DR. This screening method allowed the identification of patients requiring prompt referral to an ophthalmologist for further complete eye examination.

Diagnosis of macular pseudoholes and lamellar macular holes by optical coherence tomography

PURPOSE

To assess the usefulness of optical coherence tomography (OCT) for better differential diagnosis of macular pseudoholes (MPH) and lamellar macular holes (LMH).

DESIGN

Observational case series.

METHODS

setting: Institutional practice. patients: We reviewed the files of 71 eyes of 70 consecutive patients who were diagnosed as having a pseudohole or lamellar hole on OCT examination. All patients referred for suspected pseudohole or lamellar hole on biomicroscopy were evaluated by OCT. main outcome measures: Each eye underwent six radial 3-mm OCT scans centered on the macula, one 6-mm vertical and one 6-mm horizontal scan. Retinal thickness was measured at the foveal center and 750 microm from the center, vertically, and horizontally. The diameter of the macular contour was also measured on vertical and horizontal scans.

RESULTS

In 40 cases, OCT showed a macular profile characteristic of MPH: a steepened foveal pit combined with thickened foveal edges and a small foveal pit diameter. Central foveal thickness was normal or slightly increased (167 +/- 42 microm). Mean perifoveal thickness was greater than normal (363 +/- 65 microm). In 29 other cases corresponding to LMH, OCT showed a profile characterized by a thin irregular foveal floor, split foveal edges, and near-normal perifoveal retinal thickness. Central foveolar thickness was thinner than normal (72 +/- 19 microm). Mean perifoveal thickness was near normal (283 +/- 36). Optical coherence tomography did not allow the classification of the remaining two cases.

CONCLUSIONS

Optical coherence tomography is very useful in distinguishing MPH attributable to epiretinal membrane contraction from LMH because of partial opening of a macular cyst.

Retinal abnormalities in CADASIL: a retrospective study of 18 patients

BACKGROUND

CADASIL is an inherited small vessel disease related to Notch3 gene mutations.

AIM

To report retinal findings in symptomatic CADASIL patients.

METHODS

Assessment of visual acuity (VA), testing of visual fields (VF), funduscopic examination (FE), and fluorescein angiography (FA) were carried out in 18 symptomatic patients.

RESULTS

No visual symptoms were presented by our patients. VA was normal in all. Ophthalmologic abnormalities were found in 8 patients. VF were normal except for a right hemianopia in one subject due to ischemic stroke. FE and FA revealed significant abnormalities in seven other subjects (mean age: 55 years; range: 39-74): nerve fibre loss (n = 4), cotton wool spots (n = 3), sheathed arteries (n = 1), and tortuous arteries (n = 1). Only one patient with both tortuous arteries and nerve fibre loss had multiple vascular risk factors, and another patient with cotton wool spots was a current smoker.

DISCUSSION

FE and FA revealed silent retinal abnormalities in CADASIL patients with nerve fibre loss in 22% and cotton wool spots in 17%. The presence of these abnormal retinal findings does not seem related to the severity of the disorder but may be considered as peripheral markers of this genetic disease.

Heterogeneity of diabetes phenotype in patients with 3243 bp mutation of mitochondrial DNA (Maternally Inherited Diabetes and Deafness or MIDD)

OBJECTIVE

In patients with maternally inherited diabetes and deafness (MIDD), due to 3 243 A > G mutation of mitochondrial DNA (mtDNA), diabetes may present with variable phenotypes.

OBJECTIVE

To ascertain the existence of two distinct phenotypes, MIDD1 and MIDD2, in a series of patients with MIDD.

DESIGN

Multicenter prospective study.

PATIENTS

77 patients with diabetes and the mtDNA 3243 mutation and 139 control patients with type 1 (T1D) or type 2 (T2D) diabetes, matched according to initial presentation of diabetes, age at onset, sex, and duration of diabetes (24 T1D and 115 T2D, including 55 treated with insulin).

MEASUREMENTS

Anthropometric characteristics (height, body weight, body mass index [BMI], sex), family history of diabetes, and characteristics of diabetes (age at onset, treatment, hemoglobin A1c [HbA1c]), extrapancreatic manifestations.

RESULTS

In 13 cases (17%, MIDD1), diabetes presented as insulin-dependent from the onset, with ketoacidosis in 6 cases. In 64 cases (83%, MIDD2), diabetes resembled T2D, and was treated with diet in 12 cases, oral hypoglycemic agents in 21 cases, or insulin in 31 cases. Compared with patients with MIDD2, patients with MIDD1 were characterized by lower age at onset of first manifestation of MIDD (25.4 +/- 9.6 vs 33.7 +/- 13.2 Years, P<0.0005), lower body weight (49.1 +/- 7.4 vs 56.3 +/- 10.9 kg, P<0.0025), lower BMI (18.2 +/- 2.3 vs 20.9 +/- 3.6 kg/m2, P<0.0005), and higher HbA1c levels (9.5 +/- 2.0 vs 7.5 +/- 1.6%, P<0.0005). Frequency of family history of diabetes and of extrapancreatic manifestations was the same in both MIDD subtypes. No difference was found within the MIDD2 subtype when comparing patients treated with or without insulin. Compared with matched controls, patients with MIDD had a lower BMI (MIDD1/T1D 18.2 +/- 2.3 vs 24.0 +/- 3.6 kg/m2 and MIDD2/T2D 20.9 +/- 3.6 vs 30.2 +/- 5.9 kg/m2, P<0.0025). Lastly, male patients with MIDD had a shorter height than controls (MIDD1/T1D: 166.1 +/- 3.2 vs 177.3 +/- 6.6 cm and MIDD2/T2D: 168.4 +/- 7.2 vs 173.6 +/- 6.6 cm P<0.025).

CONCLUSIONS

These results confirm the existence of two different phenotypes in MIDD, MIDD1 and MIDD2, which may be related to the severity of the mitochondrial disease. The role of other genetic and/or environmental factors in the variable phenotype of MIDD remains to be elucidated.

Screening for diabetic retinopathy in France

Ocular complications of diabetes, particularly retinopathy, are the major cause of blindness in the working age population in industrialised nations. Laser photocoagulation has shown definite results in reducing visual morbidity with many more likely to benefit if diagnosed early enough. Institution of an efficient screening programme aimed at detecting patients at risk when they can still be effectively treated has been recognised as an urgent priority worldwide. In France, a signatory to the Saint Vincent's Declaration, an analysis of the national healthcare database reveals a gross inadequacy in the current extent of screening for diabetic retinopathy. The possible causative factors have been analysed and the necessary corrective measures, some of which are already under way, have been discussed. Ideally, screening by ophthalmologists at recommended intervals have been advised by national and professional health care associations. This has not been feasible owing to the lack of organised planning and serious manpower deficit caused by a progressive decline in the number of ophthalmologists. Recently, the need for an efficient, widely-available and user-friendly screening tool has led to the evaluation of multifield fundus photography in real time using digital nonmydriatic camera in comparison with more established methods of detecting diabetic retinopathy. Lastly, the future possibility of involving in France non-ophthalmologists like endocrinologists or general practitioner or non medical profession like orthoptists after proper training to meet the necessary manpower shortage has been addressed. Optimal use of telemedicine along with establishment of preferential reference channels for newly discovered cases of sight-threatening cases of retinopathy are public health priority necessary to give to the screening of diabetic retinopathy its full efficiency.

Intravitreal triamcinolone acetonide for diabetic diffuse macular edema: preliminary results of a prospective controlled trial

OBJECTIVE

To evaluate prospectively the efficacy and safety of 1 intravitreal injection of 4 mg of triamcinolone acetonide for refractory diffuse diabetic macular edema.

DESIGN

Interventional case series.

PARTICIPANTS

Fifteen patients with bilateral diabetic macular edema unresponsive to laser photocoagulation. In all patients, one eye received the injection, and the other served as a control.

INTERVENTION

Intravitreal injection of 4 mg of triamcinolone acetonide under subconjunctival anesthesia.

MAIN OUTCOME MEASURES

The main outcome measure was central macular thickness (CMT) at 1, 3, and 6 months, measured by optical coherence tomography. Secondary outcomes were Early Treatment Diabetic Retinopathy Study (ETDRS) scores, intraocular pressure, and cataract progression.

RESULTS

In this preliminary report, we give the results for 12 patients who had a follow-up of at least 3 months. Seven of them were followed up for 6 months. Before injection, CMT was 509.6+/-143.5 microm (mean +/- standard deviation [SD]) in injected eyes, versus 474.4+/-82.6 microm in control eyes. Four weeks after injection, it was 207.3+/-44.2 microm in injected eyes and 506.7+/-122.4 microm in control eyes (P<0.001, bilateral Wilcoxon test for paired samples), and after 12 weeks, 207+/-96.7 microm and 469.3+/-117.6 microm, respectively (P = 0.005). The difference between the CMTs of injected and control eyes was no longer significant at 24 weeks because of the recurrence of macular edema in 5 of 12 injected eyes. Before triamcinolone injection, the ETDRS score was 47.8+/-13 (mean +/- SD; range, 28-66) in injected eyes, versus 51.9+/-14.6 (range, 31-71) in control eyes. Twelve weeks thereafter, the corresponding values were 52.7+/-10.8 (range, 34-70) and 50.8+/-14.3 (range, 29-69), respectively, and at 24 weeks, 54.7+/-7.6 (range, 47-68) and 50.6+/-18.4 (range, 28-71). At no time was the difference between the ETDRS scores for injected and control eyes significant. In 6 of the 12 injected eyes, intraocular pressure exceeded 25 mmHg, and was controlled by topical medication.

CONCLUSION

Intravitreal injection of triamcinolone effectively reduces macular thickening due to diffuse diabetic macular edema, at least in the short term. Further studies are required to demonstrate that it provides visual benefit.

[The "vessel case flap". About one case in the lower limb]

The authors report an atypical case of lower limb repair in a 69-year-old patient, who presented a closed fracture of the tibia initially fastened with a plate. Skin necrosis developed after osteosynthesis, exposing the plate and the fracture bone. Because of the vascular state of the patient (smoking, arteritis, diabetes), any microsurgical procedure seemed likely to fail. The incisions previously performed contraindicated any form of pedicle flap in the leg area. An original solution was then proposed, involving the long extensor muscle of the great toe pedicled proximally on the anterior tibial artery. After six months of follow-up, healing and bone consolidation have been achieved. The interest of this exceptional technique is considered with respect to therapeutic choices for lower limb repair.

Traumatic lumbosacral dislocation: four cases and review of literature

Diagnosis, physiopathology, and treatments of four patients with traumatic lumbosacral dislocations are described. This is a rare but severe lesion of the lumbosacral junction that usually occurs in patients with multiple trauma. It often is not thought of and the diagnosis may be missed. Evidence of lumbosacral dislocation should be examined and confirmed by computed tomography scans in patients with multiple fractures of transverse lumbar processes, asymmetric lumbosacral joints on frontal images, or slipping of L5 over S1 on lateral images. Treatment consists of reduction of the dislocated and fractured parts, lumbosacral arthrodesis, a posterolateral graft, and posterior instrumentation. Instrumentation may be short, extending from L5 to S1, or long, from L4 to S1, depending on the extension of the lesion. In some cases, reduction can be done intraoperatively, when the L4-S1 instrumentation is inserted, provided L5 transpedicle screws are pulled posteriorly. It usually is preferable to explore the vertebral canal to ensure that there is no disc lesion compressing the dura before proceeding with reduction. Compression of the dura could be avoided with a preoperative magnetic resonance imaging scan on which a lesion of the L5-S1 disc is sought. Additional interbody vertebral arthrodesis should be considered when the L5-S1 disc is affected severely. This lesion should be looked for preoperatively with a magnetic resonance imaging scan and intraoperatively by exploring the canal. This can be done at the time of the posterior surgery or during a second anterior surgical procedure.

Migration of polyethylene debris along well-fixed cemented implants

Implants, consisting of smooth Inox cylinders, were cemented into the lower femur and upper tibia of nine sheep to study the distal migration of polyethylene particles. Some implants had a titanium-bead porous coat at the proximal end. These were of three types: In the first type, the porous coat was covered with hydroxyapatite to obtain a bony seal; the second type was prepared for a polymethylmethacrylate seal; in the third type, the porous zone was surrounded by a 2-mm-thick space to allow the formation of a fibrous seal. Small polyethylene particles were injected into the knees once a week during the third and fourth months after implantation. The animals were euthanized 2 months later. Major longitudinal sections of the implants and the surrounding bone were examined under a polarized light microscope. Birefringent particles were counted at the cement-bone and cement-implant interfaces. Osteolysis was not observed. None of the seals significantly decreased the migration of particles around the cemented part of the implants. Particles were observed in cement fissures and vacuoles. They migrated at both interfaces and in the bone itself. They were visible in marrow spaces between bone trabeculae.

Evaluation of a new non-mydriatic digital camera for detection of diabetic retinopathy

AIMS

To compare the results of fundus photography using a new non-mydriatic digital camera with the results of reference standard of Early Treatment Diabetic Retinopathy Study (ETDRS) retinal photographs, for the detection of diabetic retinopathy (DR).

METHODS

Fundus colour photographs were taken with a Topcon non-mydriatic camera of 147 eyes of 74 diabetic patients, without pupillary dilation (five overlapping fields of 45 degrees; posterior pole, nasal, temporal, superior and inferior). Three retinal specialists classified the photographs in a masked fashion, as showing no DR or mild non-proliferative DR (NPDR) not requiring referral, moderate or more severe NPDR and/or macular oedema, or as non-gradable image requiring referral. ETDRS 35-mm colour slides served as reference images for DR detection.

RESULTS

For moderately severe to severe DR, the sensitivities of detection reported by the three observers were 92, 100 and 92%, respectively, and the specificities, 87, 85, and 88%. For four levels of DR severity (none or mild NPDR, moderate NPDR, severe NPDR and proliferative DR), the percentages of exact agreement between the three observers on the retinopathy grades assigned to the non-mydriatic photographs and to the ETDRS reference slides were 94.6, 93 and 87.6%, respectively (kappa 0.60-0.80). Sixteen eyes of nine patients (11%) were judged ungradable by at least one observer. In a second series of 110 patients, evaluated in the setting of a screening procedure, fewer photographs were ungradable (< 6%).

CONCLUSION

These results suggest that fundus photographs taken by the Topcon TRC-NW6S non-mydriatic camera, without pupillary dilation, are suitable for DR screening.

Treatment of von Hippel-Lindau retinal hemangioblastoma by the vascular endothelial growth factor receptor inhibitor SU5416 is more effective for associated macular edema than for hemangioblastomas

PURPOSE

To test the efficacy of the novel vascular endothelial growth factor (VEGF) receptor inhibitor SU5416, in a case of refractory von Hippel-Lindau (VHL) retinal hemangioblastoma (RHB).

DESIGN

Interventional case report.

METHODS

Patient included in a multicenter phase II trial. A 30-year-old woman presenting with VHL disease and multiple RHB on her only eye, refractory to conventional treatments, had decreased visual acuity due to cystoid macular edema (CME). SU5416 was administered intravenously for 7 months. Best-corrected visual acuity (BCVA) and macular thickness were measured by optical coherence tomography.

RESULTS

Under treatment, the size of the RHB did not change, but CME improved significantly. Best-corrected visual acuity rose from 20/40 to 20/25. However, CME recurred after the end of the treatment.

CONCLUSION

The VEGF receptor inhibitor SU5416 failed to reduce the size of RHB but was very effective for the associated CME.

[Screening for diabetic retinopathy: non-mydriatic retinal photography]

The screening of diabetic retinopathy is still largely insufficient and consequently, its management is often delayed. The various recommendations indicate a fundus examination at diabetes diagnosis and yearly thereafter. In France, this is far to be reached, and this situation is at risk of aggravation with the increasing number of diabetic patients and the decreasing number of ophthalmologists. New efficient tools, as the non-mydriatic cameras and digital photography, may allow a new network organisation for screening of diabetic retinopathy, with local screening sites linked to a centralised ophthalmological reading center where digital images could be transmitted. The various aspects of this screening and possibilities to improve the screening and early management of diabetic retinopathy are discussed in this paper.

[Diabetic retinopathy in children and adolescents]

Diabetic retinopathy rarely occurs before puberty and is never proliferative in prepubescent children. On the opposite, puberty and adolescence are high-risk periods for diabetic retinopathy progression, and call for strict ophthalmologic monitoring. The period between 16 and 18 years of age is particularly critical. Progression towards florid diabetic retinopathy is to be especially feared and should be prevented in the course of adolescence, as this form can be severe and can lead to blindness. Risk factors are probably many, including diabetes duration, difficulties in achieving glycemic control due to increase in insulin requirements, low compliance to treatment, and hormonal changes related to puberty (abnormalities of the growth hormone (GH)/insulin-like growth factor-I (IGF-1) axis). Systematical diabetic retinopathy screening should be performed in adolescents, notably by non-mydriatic fundus photographs. Furthermore, the anticipation of the switch from pediatric to adult structures, together with the careful information and education of parents and children may improve visual prognosis of young diabetic patients, whose life expectancy is high.

[Influence of proximal stem geometry and stem-cement interface characteristics on bone and cement stresses in femoral hip arthroplasty: finite element analysis]

PURPOSE OF THE STUDY

The combined effects of proximal canal filling and stem-cement surface characteristics on stresses in the cement and bone in femoral hip arthrosplasty were investigated by finite element analysis.

MATERIAL AND METHODS

Our finite element study of a femoral implant fitted with a stainless steel stem was based on a set of 4 models with decreasing metaphyseal fill, designed to simulate loading before the occurrence of any deterioration in the cement-bone interface. Thus, the cement was represented fully bonded to the bone. The implant-cement interface was modeling in the bonded and debonded states. First a vertical load was applied to the implant to simulate the conditions of the bearing phase of gait. Second, a rotational load was applied to the implant. Torsional loading tests were found to be satisfactory for studying variations in shape of the proximal portion of femoral implants because they simulate the most critical loading conditions such as stair climbing or chair rising.

RESULTS

With the bonded implant-cement surface, bone stresses were rather distal, whereas they were mainly proximal with the debonded implant-cement interface. Under rotational loading, debonded implants produced less normal tensile and shear stresses in the proximal portion of the cement mantle. In contrast, compressive cement stresses were higher with debonded implants. In the debonded state, the rotational stability of the implant was found to be closely related to the degree of metaphyseal fill.

CONCLUSION

In conclusion, the use of implants with a debonded metal-cement interface and with optimal metaphyseal filling should preserve the cement-bone interface from excessive shear and tensile stresses, while providing good rotational stability.

Persistence of fundus fluorescence after use of indocyanine green for macular surgery

PURPOSE

To investigate the possible persistence and characteristics of infrared fluorescence of the fundus for several months after surgery with intraocular injection of indocyanine green (ICG).

DESIGN

Interventional, noncomparative, prospective case series.

PARTICIPANTS

Seventeen patients operated on in our department with ICG injection into the vitreous cavity, who gave prior informed consent.

METHODS

After standard three-port pars plana vitrectomy and posterior vitreous detachment, 0.1 to 0.2 ml of an ICG solution at a concentration of 2.5 mg/ml was injected through a 5- micro m sterile filter over the posterior pole and left in place for 3 minutes. The stained internal limiting membrane was then peeled off. Patients had postoperative infrared fundus photographs at each consultation in our department. Follow-up ranged from 1 to 7 months. Visual acuity and any unexpected event were also recorded.

MAIN OUTCOME MEASURES

Postoperative infrared fluorescence of the fundus.

RESULTS

The day after surgery, no green ICG staining of the fundus was visible on biomicroscopy. However, infrared photography showed diffuse fluorescence of the fundus. At 1 and 3 postoperative months, infrared fundus photography showed an intensely fluorescent optic nerve disc. In patients with macular hole, the center of the macula also exhibited faint granular fluorescence. At 6 months postoperative or later, only the optic disc remained fluorescent, but the fluorescence was far less intense than at 3 months. Infrared photographs of the fellow eyes exhibited no fluorescence. Visual acuity improved or was unchanged compared with preoperative vision in 16 eyes and decreased by 1 line in 1 eye.

CONCLUSIONS

After intraoperative use of ICG for macular surgery, fluorescence of the optic disc and of the macular center after macular hole surgery persisted for months in all cases. ICG may accumulate in the macular pigment epithelium and optic nerve, raising the problem of the as yet unknown pharmacokinetics of ICG after intravitreous administration and of its long-term safety.

N(carboxymethyl)lysine as a biomarker for microvascular complications in type 2 diabetic patients

AIMS

Hyperglycemia is linked to vascular dysfunction in patients with diabetes mellitus, either directly or through advanced glycation end product (AGE) formation. Experimental evidence has indicated the possible involvement of AGEs in the genesis of vascular complications. We investigated whether serum levels of AGEs and of the glycoxidation compound carboxymethyl-lysine (CML) were increased and correlated with vascular complications in type II diabetes mellitus.

METHODS

Serum levels of AGEs and CML-human serum protein (CML-HSP) were measured by a specific immunoassay in 51 men and 26 women aged 58 +/- 6.1 years (mean +/- SD) who had been treated for type II diabetes mellitus for 11 +/- 8 years, and in a non-diabetic control group consisting of 39 men and 21 women aged 55.5 +/- 7.5 years. Patients with macroalbuminuria or abnormal creatinine clearance were excluded from the study.

RESULTS

The serum levels of AGEs were significantly increased in patients with type II diabetes compared to controls (P<0.001). Blood levels of CML-HSP were significantly increased in diabetic patients compared to normal subjects [35.3 +/- 27.4 and 9.3 +/- 7.2 (mean +/- SD) pmol/mg of protein, respectively; P<0.0001]. In diabetic patients with retinopathy or microalbuminuria (urinary albumin excretion: UAE > 30 mg/24 h), CML-HSP levels were significantly higher (P<0.02), and even more elevated in patients with both complications.

CONCLUSION

In patients with type II diabetes, CML-HSP levels that are at variance with the HbA(1c) index for blood glucose may be a biomarker of glycoxidation, and related to the development of microvascular complications.

Optical coherence tomography for evaluating diabetic macular edema before and after vitrectomy

PURPOSE

To report the use of optical coherence tomography (OCT) for evaluation of diffuse diabetic macular edema (DME) before and after vitrectomy.

DESIGN

Interventional case series.

METHODS

A retrospective study was made of 15 consecutive eyes of 13 patients that had vitrectomy for diffuse DME and OCT preoperatively and postoperatively. In seven eyes of six patients (group 1), vitrectomy was performed because of vitreomacular traction observed on biomicroscopy or OCT. In the other eight eyes of seven patients (group 2), vitrectomy was performed for DME not responsive to laser photocoagulation, with no vitreomacular traction on biomicroscopy or OCT.

RESULTS

Mean +/- standard deviation (SD) follow-up after vitrectomy was 18 +/- 10 months (range, 6 to 33 months). In group 1, mean +/- SD retinal thickness decreased significantly from 661 +/- 181 microm preoperatively to 210 +/- 32 microm at the end of follow-up (P =.018). Median best-corrected visual acuity (BCVA) improved from 20/100 before surgery (range, 20/250 to 20/50) to 20/80 at the end of follow-up (range, 20/250 to 20/25; P =.046). In one eye in group 1, vitreomacular traction was only observed on OCT and not on biomicroscopy. In group 2, mean +/- SD retinal thickness decreased from 522 +/- 103 microm preoperatively to 428 +/- 121 microm at the end of follow-up (P =.2). Median BCVA was 20/100 before vitrectomy (range, 20/320 to 20/63) and 20/200 at the end of follow-up (range, 20/250 to 20/63; P =.78).

CONCLUSIONS

Vitrectomy was beneficial in eyes with diffuse DME combined with vitreomacular traction but not in eyes without traction. Optical coherence tomography allowed diagnosis of subtle vitreomacular traction and provided precise preoperative and postoperative assessments of macular thickness.

Intravitreal triamcinolone for refractory pseudophakic macular edema

PURPOSE

To evaluate the efficacy of intravitreal triamcinolone in refractory pseudophakic cystoid macular edema.

DESIGN

A prospective, interventional case series.

METHODS

Three eyes of three patients with longstanding pseudophakic cystoid macular edema following uncomplicated cataract surgery, refractory to any medication, were treated with 8 mg of intravitreal triamcinolone. All three eyes were evaluated before injection and throughout follow-up with the Early Treatment Diabetic Retinopathy Study's visual acuity chart, fluorescein angiography, and macular mapping using optical coherence tomography.

RESULTS

A month after intravitreal triamcinolone injection, a dramatic decrease in macular thickness was noted by optical coherence tomography in all three eyes (from a mean of 502-233 microm). Mean improvement in visual acuity was 3.7 Snellen lines. Two to 4 months after triamcinolone injection, however, the edema recurred in all cases, to the same degree as before the injection, combined with a decrease in vision. Two eyes underwent a second injection of triamcinolone, and macular thickness decreased, but the edema again recurred 3 months after injection.

CONCLUSION

Intravitreal injection of triamcinolone induces striking regression, within 1 month, of chronic refractory macular edema. This regression appears to be transient, however, even after a second injection.

Hereditary infantile hemiparesis, retinal arteriolar tortuosity, and leukoencephalopathy

BACKGROUND

The main hereditary vascular conditions involving both retinal and cerebral vessels include cerebroretinal vasculopathy, HERNS (hereditary endotheliopathy with retinopathy, nephropathy, and stroke), and hereditary vascular retinopathy; all are linked to the same locus on chromosome 3p21. Hereditary retinal arteriolar tortuosity is a distinct, autosomal dominant condition characterized by retinal arteriolar tortuosity and recurrent retinal hemorrhages. This condition is known to affect only retinal vessels.

METHODS

Clinical and brain MRI investigations of eight members of a three-generation family and extensive biological and systemic vascular investigations within one affected family member were conducted.

RESULTS

Six of eight family members were clinically symptomatic; disorders included infantile hemiparesis (2), migraine with aura (3), and retinal hemorrhage (1). Five individuals had retinal arteriolar tortuosities. A diffuse leukoencephalopathy in association with dilated perivascular spaces was observed in six individuals. Two family members had silent, deep cerebral infarcts as demonstrated on MRI. Genetic linkage analysis strongly suggests that this disorder is not linked to the 3p21 hereditary vascular retinopathy/cerebroretinal vasculopathy/HERNS locus.

CONCLUSIONS

The authors describe a novel hereditary autosomal dominant condition affecting both retinal and cerebral vessels and characterized by infantile hemiparesis, migraine with aura, retinal hemorrhage, retinal arterial tortuosity, and leukoencephalopathy with dilatation of perivascular spaces and microbleeds on brain MRI. Investigation of additional families should help to map the gene and to better categorize the spectrum of hereditary cerebroretinal small vessel diseases.

A contribution of image processing to the diagnosis of diabetic retinopathy--detection of exudates in color fundus images of the human retina

In the framework of computer assisted diagnosis of diabetic retinopathy, a new algorithm for detection of exudates is presented and discussed. The presence of exudates within the macular region is a main hallmark of diabetic macular edema and allows its detection with a high sensitivity. Hence, detection of exudates is an important diagnostic task, in which computer assistance may play a major role. Exudates are found using their high grey level variation, and their contours are determined by means of morphological reconstruction techniques. The detection of the optic disc is indispensable for this approach. We detect the optic disc by means of morphological filtering techniques and the watershed transformation. The algorithm has been tested on a small image data base and compared with the performance of a human grader. As a result, we obtain a mean sensitivity of 92.8% and a mean predictive value of 92.4%. Robustness with respect to changes of the parameters of the algorithm has been evaluated.

Retinal hemangioblastoma in von Hippel-Lindau disease: a clinical and molecular study

PURPOSE

To assess the natural history of retinal manifestations in von Hippel-Lindau (VHL) disease and to study the genotype-phenotype correlation.

METHODS

Data concerning 103 patients with VHL retinal manifestations and 108 patients without VHL retinal manifestations were extracted from the French VHL database. A retrospective study was performed by questionnaire. Patients were classified into three visual morbidity groups. Molecular analysis of the VHL gene was performed in 196 patients.

RESULTS

The mean age of ocular manifestations detection was 24.8 years. In half of the cases, the ocular manifestations revealed the disease. Half of the cases had bilateral involvement. Visual morbidity was significantly associated with the retinal hemangioblastoma count but not with other ocular or general characteristics. One third of the patients were classified in the worst visual morbidity group at the end of follow-up. Mutations were detected in 81% of patients with retinal hemangioblastomas and in 71% of patients without retinal involvement. Using a Poisson model and a marginal approach, the number of hemangioblastomas, age-adjusted, was 2.1 times higher in patients who had a substitution than in patients with a truncation (95% CI, 1.05-4.44; P < 0.05).

CONCLUSIONS

Visual loss remains one of the major complications of VHL disease, confirming the importance of early ophthalmologic screening. Visual morbidity was not related to the type of extraocular manifestation but appeared to be related to the type of germline mutation. However, only further genetic and clinical studies in a larger series of patients will clearly determine the genotype-phenotype relationship.

Macular retinoschisis in highly myopic eyes

PURPOSE

To describe the characteristics and evolution of macular retinoschisis in high myopia observed by optical coherence tomography (OCT).

DESIGN

A consecutive, retrospective, observational case series.

METHODS

Twenty-one highly myopic eyes (mean refractive error, -15.2, range -6 to -25) of 17 patients presenting with the unusual feature of macular thickening without a macular hole and associated with a posterior staphyloma were examined by biomicroscopy and OCT. Ten patients (13 eyes) were followed up for 12 months or more.

RESULTS

On biomicroscopy, the macula of all 21 eyes had a microcystic appearance without macular hole. In all eyes, OCT showed that retinal thickening was mainly due to an extensive hyporeflective space splitting the neuroretina into a thick inner layer and a thin outer layer. We called this condition outer retinoschisis. In six cases, inner splitting, termed inner retinoschisis, was also present. The macular profile exhibited a foveal cyst in 10 eyes, a lamellar hole in six, and a foveal detachment in six. In four of the 21 eyes, a hyperreflective preretinal structure resembling the posterior hyaloid was stretched over the retinoschisis, causing foveal traction. Two of these four eyes subsequently evolved into a full-thickness macular hole.

CONCLUSION

Macular retinoschisis is not uncommon in highly myopic eyes with staphyloma and is better characterized by OCT than by biomicroscopy. Intraretinal splitting occurs in both the outer and inner layers of the retina, leading to the formation of cystoid spaces. In most cases, the condition is fairly stable in terms of visual acuity and retinal thickness and change occurs slowly over time. However, a macular hole may occur when the retinoschisis is associated with tangential traction of the posterior hyaloid.

Combined central retinal arterial and venous obstruction: emergency ophthalmic arterial fibrinolysis

PURPOSE

To investigate the role of urokinase selectively perfused into the ophthalmic artery as an emergency treatment for combined central retinal arterial obstruction (CRAO) and central retinal venous obstruction (CRVO).

MATERIALS AND METHODS

Over a 6-year period, 11 consecutive patients presented with recent combined CRAO and CRVO (< or =72 hours). Urokinase (300,000 IU) was selectively perfused via the femoral artery into the ophthalmic artery for 40 minutes. Evaluation criteria were Snellen visual acuity with best correction, funduscopic results, and retinal arteriovenous transit time assessed over a mean 3.5-year follow-up. Mean vision and retinal perfusion were tested by means of repeated-measures analysis of variance. The correlation between visual improvement and retinal perfusion improvement was evaluated by means of Spearman rank correlation.

RESULTS

Substantial improvement in vision and retinal perfusion was noted in seven of the 11 patients treated. Mean vision improvement was significant (P =.009) within 24-48 hours after fibrinolysis, increased until 1 month after (P =.006), then remained stable throughout the follow-up (P >.10). Visual improvement correlated with retinal perfusion improvement during the period from before fibrinolysis to 24-48 hours after (P =.028). In all patients with improved results, retinal hemorrhages transiently increased. One patient had intravitreal hemorrhage shortly after fibrinolysis.

CONCLUSION

For this uncommon clinical entity, which typically has a poor visual outcome, these results suggest that ophthalmic arterial fibrinolysis may restore retinal perfusion, which leads to rapid substantial visual improvement in many cases of combined CRAO and CRVO, without systemic complications, but it may be responsible for intravitreal hemorrhage.

[Fundus photography for the screening for diabetic retinopathy]

Despite the efficacy of laser photocoagulation to prevent complications of diabetic retinopathy, diabetic retinopathy remains a major cause of visual impairment and blindness in France. This is mainly due to a too late diagnosis of diabetic retinopathy. In an effort to detect diabetic retinopathy at an early stage before visual loss, international and national guidelines for the screening for diabetic retinopathy have been developed, which recommend annual fundus examination for all diabetic patients. In France, a recent survey showed that less than 50% of diabetic patients had had an eye examination during the previous year. With the increasing number of diabetic patients and the decreasing number of ophthalmologists, this situation should not improve by the next 15 years. Fundus photography is a method at least as sensitive as ophthalmoscopy in the screening for diabetic retinopathy. New nonmydriatic cameras and digital photography may allow a network organization of several screening centers around a central ophthalmological reading center where digital images could be transmitted. This organization should improve the screening for diabetic retinopathy, while saving medical time.

Surgical management of epiretinal membrane in young patients

PURPOSE

To report the outcome of epiretinal membrane (ERM) surgery in young patients.

DESIGN

Interventional case series study.

METHOD

A retrospective review of 20 young patients who had undergone vitrectomy and epiretinal membrane removal. All patients had a preoperative examination, including fundus biomicroscopy, red free photographs, and fluorescein angiography.

RESULTS

Nine patients were males and 11 females (age: 7-26 years; mean: 16.3 years). Follow up ranged from 4-96 months (mean: 21.2 months). The 20 patients comprised 13 cases of idiopathic ERM, six cases in which ERM was associated with ocular inflammation and one case of combined hamartoma of the retina and retinal pigment epithelium (RPE). In 13 cases, the ERM was especially white, thick, and opaque, with localized constriction and severe retinal distortion. Final best-corrected visual acuity (VA) was significantly better than preoperatively (20/50 vs. 20/112), (P = 0.0002). Mean improvement in VA was 4.25 lines and 17 patients gained two or more lines. This improvement was better in secondary than idiopathic ERM (6 lines vs. 3.3). During follow up, five cases of recurrence were observed (25%). In another case, postoperative persistent ocular hypertension required filtering surgery.

CONCLUSION

The characteristics of ERM in young patients are quite different in many cases from those in adults in terms of thickness and adherence. Removal of ERM in young patients is feasible and safe although the membrane may focally adhere strongly to retinal vessels. VA usually improves significantly after surgery, but recurrences are more frequent than in adults.

Retinal thickness in healthy and diabetic subjects measured using optical coherence tomography mapping software

PURPOSE

To define the normal retinal thickness in healthy subjects using optical coherence tomography (OCT) mapping software and to assess the ability of OCT to detect early macular thickening in diabetic patients.

METHODS

Six radial scans centered on the fixation point were done on 60 healthy eyes and 70 eyes of 35 diabetic patients without macular edema on biomicroscopy. Retinal thickness was measured automatically with OCT mapping software. Mean retinal thickness was compared in subgroups of healthy patients based on age, sex, and eye, and in the eyes of diabetic patients and healthy subjects. Thickening was diagnosed if mean retinal thickness of an area was greater than the mean thickness + 2SD in the corresponding area in healthy subjects; or if the difference between right and left eye exceeded the mean difference + 2 SD in a given area in healthy subjects.

RESULTS

In healthy subjects, mean retinal thickness in the central macular area 1000 microm in diameter was 170+/-18 microm. There was no significant difference according to age, or left or right eye, but central macular thickness was significantly greater in men than women (p=0.0139). No difference was observed between the eyes of healthy subjects and diabetic patients without macular edema on biomicroscopy, but OCT detected early macular thickening in 12 diabetic eyes.

CONCLUSIONS

In this study average retinal thickness and mean local variations in a normal population were defined using a commercially available mapping software. OCT seems a sensitive tool for detecting early retinal thickening.

Dissociated optic nerve fiber layer appearance of the fundus after idiopathic epiretinal membrane removal

PURPOSE

To report the appearance of the fundus, that is seen frequently after removal of an idiopathic epiretinal membrane and which we refer to as the dissociated optic nerve fiber layer appearance.

DESIGN

Interventional, noncomparative retrospective case series.

PARTICIPANTS

One hundred consecutive patients with an epiretinal membrane who underwent pars plana vitrectomy and epiretinal membrane peeling in one eye.

METHODS

Only patients with an idiopathic epiretinal membrane or a membrane associated with a peripheral retinal tear, but without retinal detachment, were considered for this study. Sixty-one patients met these criteria for one eye. Preoperative and postoperative best-corrected visual acuity and preoperative and postoperative blue filter fundus photographs were reviewed. Histopathologic specimens of epiretinal membranes were available for 14 eyes.

MAIN OUTCOME MEASURES

The postoperative incidence of the dissociated optic nerve fiber layer appearance on blue filter photographs, visual acuity changes, and the presence of internal limiting membrane in epiretinal membrane specimens.

RESULTS

The postoperative incidence of this feature on blue filter fundus photographs was 43%. No difference was found between eyes with or without this feature concerning the average preoperative and postoperative best-corrected visual acuity or the average change in visual acuity. Internal limiting membrane was present in all 14 epiretinal membrane specimens available. Five of these 14 patients concerned exhibited a dissociated optic nerve fiber layer appearance and 9 did not.

CONCLUSIONS

The dissociated optic nerve fiber layer appearance occurred frequently after removal of an epiretinal membrane. As far as we know, this feature has not been previously reported. It consisted of numerous arcuate striae within the posterior pole in the direction of the optic nerve fibers and slightly darker than the surrounding retina. This feature had no functional effect noticeable by the patient and did not preclude good visual recovery. The small number of histologic samples and the impossibility of quantifying the area of internal limiting membrane peeled off did not allow us to supply proof that this feature is due to the extensive peeling of the internal limiting membrane, although this is the most likely hypothesis.

[Ocular complications in diabetes: towards standardizing screening and care]

Diabetic retinopathy remains a major cause of blindness and vision loss in France. Around 2% of diabetic patients become legally blind and 10% have a severe visual handicap. Systematic screening, careful follow-up and treatment of diabetic retinopathy should allow to avoid severe ocular complications. ETDRS (Early Treatment Diabetic Retinopathy Study) brought major information concerning the natural history of diabetic retinopathy and allowed to establish a convenient classification. Laser photocoagulation improves the prognosis of proliferative diabetic retinopathy, and decreases the rate of vision loss due to macular oedema. Diabetic retinopathy may worsen after cataract extraction; therefore close ophthalmological follow-up after surgery is necessary. It has not been proven that glaucoma is more frequent in diabetic patients than in the general population.

[Management of diabetic complications during pregnancy using diabetic retinopathy as an example]

Pregnancy may adversely affect the natural course of diabetic retinopathy (DR). Reported rates of new cases or progression of DR during pregnancy range from 10% to 70%. Regression of some of the nonproliferative vascular changes have been reported after delivery. Several risk factors contribute to the aggravation of DR, such as pregnancy itself, duration of the diabetes, elevated glycohemoglobin level, degree of retinopathy at the beginning of the pregnancy, rapid normalization of blood glucose level. The mechanisms by which pregnancy may alter the course of DR is not elucidated: worsening of DR may be due to modifications of retinal blood flow, or to increase in circulating growth factors levels. Careful ophthalmologic monitoring during pregnancy is required. Fundus examination should be performed before pregnancy or at the beginning of it. In patients with no retinopathy, fundus examination should be performed every three months. In those with diabetic retinopathy, fundus examination should be repeated every month. In eyes with proliferative DR or severe nonproliferative DR before pregnancy or at its beginning, laser photocoagulation should be performed promptly.

Reproducibility of retinal mapping using optical coherence tomography

OBJECTIVE

To assess the reproducibility of retinal thickness measurement using commercially available mapping software of optical coherence tomography (OCT).

METHODS

Six radial scans, 6 mm long and centered on the fixation point, were performed on 10 eyes of 10 healthy volunteers and 10 eyes of 10 diabetic patients with clinically significant macular edema. Retinal thickness was measured automatically using the mapping software of OCT in the 9 macular Early Treatment Diabetic Retinopathy Study areas and in a central area 500 microm in diameter. Measurement reproducibility was tested by means of 3 series of scans performed by 2 different observers on 2 different days. Results were assessed by their repeatability and intraclass correlation coefficients (ICCs).

RESULTS

In healthy subjects, intraobserver, interobserver, and intervisit reproducibility of retinal thickness measurements were excellent, with a repeatability coefficient of less than 7 microm and ICCs of greater than 0.89. In diabetic patients, the repeatability coefficient was less than 21 microm in all areas of the macula except one, with an ICC of greater than 0.98. Relative variations in measurements were small in both healthy and diabetic subjects, with reproducibilities of +/- 5% and +/- 6%, respectively.

CONCLUSION

Retinal mapping software of OCT allows reproducible measurement of retinal thickness in both healthy subjects and diabetic patients with macular edema.

The transcription/replication activity of the polymerase of influenza A viruses is not correlated with the level of proteolysis induced by the PA subunit

The PA subunit of the influenza virus polymerase has been shown to induce degradation of coexpressed proteins, but its role in the replication activity of the polymerase is not fully understood. Here, PA proteins derived from several influenza A viruses were examined at 37 and 33 degrees C for both the level of proteolysis they induced and the efficiency with which they ensured transcription/replication of a viral-like RNA within a polymerase complex reconstituted in vivo from cloned cDNAs. Two mutants of A/Victoria/3/75 PA showed a decreased ability to induce proteolysis as compared to the wild-type PA, but still appeared to be as active as the wild-type protein with respect to the polymerase activity. Furthermore, we observed that the ability of PR8-PA to induce proteolysis was severely impaired at 33 degrees C as compared to 37 degrees C, while the efficiency with which the PR8-derived polymerase complex ensured transcription/replication of the viral-like RNA was similar at both temperatures. Taken together, our observations suggest that the transcription/replication activity of the polymerase of influenza A viruses is not correlated with the level of proteolysis induced by the PA subunit.

Residue 627 of PB2 is a determinant of cold sensitivity in RNA replication of avian influenza viruses

Human influenza A viruses replicate in the upper respiratory tract at a temperature of about 33 degrees C, whereas avian viruses replicate in the intestinal tract at a temperature close to 41 degrees C. In the present study, we analyzed the influence of low temperature (33 degrees C) on RNA replication of avian and human viruses in cultured cells. The kinetics of replication of the NP segment were similar at 33 and 37 degrees C for the human A/Puerto-Rico/8/34 and A/Sydney/5/97 viruses, whereas replication was delayed at 33 degrees C compared to 37 degrees C for the avian A/FPV/Rostock/34 and A/Mallard/NY/6750/78 viruses. Making use of a genetic system for the in vivo reconstitution of functional ribonucleoproteins, we observed that the polymerase complexes derived from avian viruses but not human viruses exhibited cold sensitivity in mammalian cells, which was determined mostly by residue 627 of PB2. Our results suggest that a reduced ability of the polymerase complex of avian viruses to ensure replication of the viral genome at 33 degrees C could contribute to their inability to grow efficiently in humans.

Maternally inherited diabetes and deafness: a multicenter study

BACKGROUND

Maternally inherited diabetes and deafness (MIDD), which is seen in 0.5% to 2.8% of patients with type 2 diabetes mellitus, is related to a point mutation at position 3243 of mitochondrial (mt) DNA. Its clinical description is incomplete.

OBJECTIVE

To study the clinical presentation and complications of diabetes in patients with MIDD and to identify clinical characteristics that may help select diabetic patients for mtDNA mutation screening.

DESIGN

Multicenter prospective descriptive study.

SETTING

16 French departments of internal medicine, diabetes and metabolic diseases, or both.

PATIENTS

54 patients with type 2 diabetes mellitus and the mtDNA 3243 mutation.

MEASUREMENTS

Characteristics of diabetes, metabolic control (glycosylated hemoglobin level), complications of diabetes, and involvement of other organs.

RESULTS

On average, patients with MIDD were young at diabetes onset and presented with a normal or low body mass index. None were obese. Seventy-three percent of probands had a maternal family history of diabetes. Diabetes was non-insulin-dependent at onset in 87% of patients; however, 46% of patients had non-insulin-dependent disease at onset but progressed to insulin therapy after a mean duration of approximately 10 years. Neurosensory hearing loss was present in almost all patients. Eighty-six percent of patients who received an ophthalmologic examination had macular pattern dystrophy (a specific retinal lesion). Forty-three percent of patients had myopathy, 15% had cardiomyopathy, and 18% (9 of 51) had neuropsychiatric symptoms. Although the prevalence of diabetic retinopathy was 8% among patients who received an ophthalmologic examination, lower than expected after a mean 12-year duration of diabetes, prevalence of kidney disease was 28%. This suggests that a specific renal involvement was the result of mitochondrial disease.

CONCLUSIONS

Maternally inherited diabetes and deafness has a specific clinical profile that may help identify diabetic patients for mtDNA testing.

[Central serous chorioretinopathy and systemic steroid therapy]

BACKGROUND

The manifestations of the ocular toxicity of systemic corticosteroids include posterior subcapsular cataracts and glaucoma. We describe 14 cases of serous detachment of the macula due to central serous chorioretinopathy in patients given long-term steroid therapy, which may be another potential ocular side effect of corticosteroid.

CASES REPORT

The 14 (9 men and 5 women) patients were aged from 39 to 55 year old. Their systemic diseases were allergic thrombopenic purpura, optic neuritis, kidney or heart transplant, Churg and Strauss vasculitis, facial palsy, rheumatoid arthritis, systemic lupus and a kidney tumor. None of the patients had hypertension.

RESULTS

Serous detachment occurred between 6 days and 10 years after the start of steroid treatment. The higher the doses, the earlier the onset of ocular disease. All patients were symptomatic, with rapid onset of blurred vision. Serous detachment was bilateral in two cases. The fluorescein angiographic finding was in most cases a single small focal hyperfluorescent leak from the retinal pigment epithelium which appeared early in the angiogram and increased in size and intensity. No diffuse degradation of the retinal pigment epithelium was seen on the fluorescein angiogram. Five patients underwent laser photocoagulation of the leaking area followed by resorption of subretinal fluid. In other patients, the symptoms disappeared as the doses of steroid were reduced.

CONCLUSION

The pathogenesis of central serous chorioretinopathy remains unclear and is controversial. Corticosteroids are known to worsen the prognosis of idiopathic central serous chorioretinopathy, and serous detachment has been reported after renal transplantation. In most of these cases, chorioretinopathy was combined with diffuse leakage from the choriocapillaris. We discuss the relationship between steroid therapy and focal leakage as seen in idiopathic central serous chorioretinopathy. In conclusion, we describe 14 cases of central serous retinopathy whose clinical and fluorescein angiography were fairly typical, without obvious diffuse degradation of the retinal pigment epithelium. All these patients had been given long-term steroid therapy for various diseases.

Foveal pseudocyst as the first step in macular hole formation: a prospective study by optical coherence tomography

OBJECTIVE

To establish the natural history of a series of impending macular holes presenting as foveal pseudocysts using optical coherence tomography (OCT).

DESIGN

In a prospective observational case series, patients exhibiting a foveal pseudocyst on biomicroscopy were examined with OCT and were followed up for 3 to 26 months (mean, 9.4 months)

PARTICIPANTS

Twenty-two eyes of 20 consecutive patients examined for a macular hole in the fellow eye or reporting visual symptoms in only one eye, in whom a foveal pseudocyst was diagnosed on OCT.

METHODS

In all cases, fundus biomicroscopy and OCT findings were compared.

MAIN OUTCOME MEASURES

Biomicroscopic fundoscopy, OCT scans, and visual acuity.

RESULTS

Eight foveal pseudocysts occurred in the fellow eye of an eye with a macular hole, and 14 were diagnosed in patients with unilateral visual symptoms. In four of the 22 eyes, the macula was considered normal on biomicroscopy. In the 18 others, biomicroscopy detected a foveal pseudocyst, radial striae, a yellow spot or ring, or a combination of these findings. No posterior vitreous detachment was seen on biomicroscopy in any of the eyes. On OCT, the cystoid space occupied the inner part of the foveal tissue in the stage 1A impending hole; a stage 1B impending hole corresponded to a cystoid space that extended posteriorly, disrupting the outer retinal layer. During the follow-up period, three pseudocysts evolved into full-thickness macular holes, four turned into lamellar holes, seven resolved completely after detachment of the posterior hyaloid, and eight remained unchanged for a long time.

CONCLUSIONS

Foveal pseudocysts are a specific entity occurring either as a primary ocular involvement or in the fellow eye of an eye with a macular hole. Foveal pseudocysts are the first step of full thickness macular hole formation, but they also may evolve into a lamellar hole, may persist unchanged for months, or may resolve completely. Foveal pseudocyst formation may be the result of the incomplete separation of the vitreous cortex at the foveal center and the particular structure of the foveal Müller cells.

Optical coherence tomography of idiopathic macular epiretinal membranes before and after surgery

PURPOSE

To examine the preoperative and postoperative anatomical features of the macula using optical coherence tomography in patients who underwent surgery for epiretinal membrane and to correlate these features with functional results.

METHODS

In a noncomparative interventional series, 62 eyes of 62 consecutive patients operated on for an idiopathic epiretinal membrane were followed up using a standardized protocol. Preoperative and postoperative examination included best-corrected visual acuity using an Early Treatment Diabetic Retinopathy Study chart, biomicroscopy of the fundus with a contact lens, fundus photography with blue and green filters, fluorescein angiography, and optical coherence tomography.

RESULTS

Median preoperative visual acuity was 20/60 (range, 20/32 to 20/320). Median postoperative visual acuity was 20/40 (range, 20/20 to 20/160). Fifty-one eyes (82%) obtained visual acuity of 20/50 or better. Preoperatively, all eyes had increased macular thickness (mean, 419 +/- 105 microm; range, 265.5 to 689 microm), with disappearance of the foveal pit. An epiretinal membrane was visible on optical coherence tomography scans in 26 cases (42%). Intraretinal cystic spaces were present in the thickened macular tissue in 15 cases but corresponded to cystoid macular edema on fluorescein angiography in only three. Postoperatively, mean macular thickness decreased to 300 +/- 65 microm (range, 185 to 511 microm) but returned to normal in only three eyes. The foveal pit reappeared in 20 eyes. Preoperatively, visual acuity correlated with macular thickness (r = 0.56, P <.0001), but not postoperatively (r = 0.12, P =.37).

CONCLUSION

Macular thickness decreases after epiretinal membrane surgery, but the macular profile rarely returns to normal. However, this does not preclude satisfactory improvement of visual acuity.

Superselective ophthalmic artery fibrinolytic therapy for the treatment of central retinal vein occlusion

AIM

To study the effect of superselective ophthalmic artery fibrinolysis as a treatment for central retinal vein occlusion (CRVO).

METHODS

Retrospective, university based single centre study. The charts of 26 eyes of 26 patients treated were reviewed. Among the 26 patients, there were nine cases of combined artery and vein occlusion, three cases of combined cilioretinal artery and CRVO, and 14 cases of classic CRVO. Complete preoperative and postoperative ophthalmological examination and fluorescein angiography were performed in all cases. The therapeutic procedure comprised the infusion of urokinase through a microcatheter into the ostium of the ophthalmic artery, via a femoral artery approach. The main outcome measure was the improvement in visual acuity 48 hours after the procedure.

RESULTS

Six eyes of six patients exhibited significant improvement in visual acuity immediately after the fibrinolysis procedure. Among them, four had a initial funduscopic appearance suggestive of combined occlusion of the central retinal artery (CRAO) and vein. For these patients, the visual benefit was maintained in the long term. Intravitreal haemorrhage occurred in two patients. There were no extraocular complications linked to the procedure.

CONCLUSIONS

Selective ophthalmic artery infusion of urokinase was followed by improvement in VA in six out of 26 cases of CRVO. Eyes with combined CRAO and CRVO with recent visual loss appeared to be the most responsive. This treatment did not prevent the occurrence of ischaemia in the failure cases. The efficacy of in situ fibrinolysis for treatment of CRVO needs to be further evaluated in a controlled study.

Evaluation of fluorescein-labeled autologous leukocytes for examination of retinal circulation in humans

PURPOSE

Increased leukocyte-endothelium interaction have been suggested as a phenomenon contributing to capillary occlusion and/or rupture of the blood-retina barrier during human retinal vascular diseases. This study was performed to evaluate if fluorescein-labeled autologous leukocytes (FLALs) can be used for examination of leukocyte transit in the human retina.

METHODS

The preparation consisted of human dextran-separated leukocytes mixed with fluorescein. After reinjection in normal subjects and in one diabetic patient, a confocal scanning laser ophthalmoscope was used to visualize them in the retinal circulation. The changes between FLALs and control leukocytes in the expression of leukocytes adhesion molecules CD11b and CD62L were evaluated by flow cytometry.

RESULTS

The circulating FLALs were clearly visible in retinal vessels. The mean (+/- SD) capillaries velocity was 1.43 (+/- 1.3) mm/s in the macula and 1.82 (+/- 1.4) mm/s in the peripapillary area. No leukostasis was detected in the normal subjects, while it was detected in te diabetic patient. Flow cytometry revealed an increase in CD11b and a decrease in CD62L expression of leukocytes after labeling, suggesting that compared to normal leukocytes FLALs are more susceptible to interact with vascular endothelium.

CONCLUSIONS

The use of FLAL is presently the only technique applicable in humans for study of leukocyte transit in the retina. Their preparation is technically simple and unexpensive. Precise measurement of the velocity of leukocytes in small vessels can be obtained. Despite evidence of a certain degree of leukocyte activation after the labeling procedure, no leukostasis was detected in vivo in normal subjects. Potential applications for this technique may include the detection of leukostasis in the human retina during severe forms of diabetes and retinal phlebitis.

Superselective ophthalmic arterial fibrinolysis with urokinase for recent severe central retinal venous occlusion: initial experience

PURPOSE

To investigate the effects of local ophthalmic arterial fibrinolysis on central retinal venous occlusion (CRVO).

MATERIALS AND METHODS

Thirteen patients had recent severe nonischemic CRVO for which no alternative therapy was available. A flow-guide microcatheter was introduced coaxially via the femoral artery into the ophthalmic arterial ostium, and urokinase was perfused for 40 minutes. Vision, funduscopic findings, and retinal perfusion were assessed during 1 year of follow-up.

RESULTS

Five of the 13 patients treated experienced visual improvement (P =.05) and retinal perfusion within 24-48 hours. Vision returned to normal within 24-48 hours in three patients, within 1 week in one patient, and within 1 month in one patient. These five patients exhibited progressive lesion regression within 2-4 weeks at funduscopy. Their clinical course prior to treatment resembled that of combined central retinal arterial occlusion (CRAO) and CRVO, which typically has a poor visual outcome. One patient relapsed 1 month after fibrinolysis. Of the remaining eight patients, one had normal vision at 12 months, and seven had no improvement. No technical complications were observed.

CONCLUSION

Although there was no control group, the short period between fibrinolysis and substantial visual improvement, combined with marked retinal perfusion improvement, suggests that fibrinolysis is beneficial for CRVO, especially for recent CRAO and CRVO.