Topical dorzolamide for treatment of cystoid macular edema in patients with choroideremia

Topical Dorzolamide as Adjunctive Treatment With Intravitreal Bevacizumab in Bilateral Diabetic Macular Edema

BACKGROUND

 Intravitreal injection of anti-vascular endothelial growth factor (VEGF) agents is accepted as the gold standard treatment for center-involving diabetic macular edema (CI-DME). Adjunctive administration of topical dorzolamide may enhance the therapeutic effects of anti-VEGF agents. In this study, we compared the efficacy of topical dorzolamide plus intravitreal injection of bevacizumab (IVB) versus IVB alone in patients with bilateral DME.

METHODS

This prospective, randomized contralateral eye study was carried out in a tertiary referral ophthalmology center, Al-Zahra Eye Hospital, Zahedan, Iran, between April 2021 and April 2022. This study included 50 eyes of 25 patients with bilateral DME. All eyes received three consecutive monthly injections of IVB. For each patient, one eye was randomized to instill dorzolamide eye drops three times a day as an intervention, and the other received artificial tear drops as a placebo. Best-corrected visual acuity (BCVA), central macular thickness (CMT), and intraocular pressure (IOP) were evaluated before starting treatment and then monthly for the first three months.

RESULTS

Among 25 included patients, the average age was 56.64 ± 7.97 years, and 48% were female. BCVA did not improve significantly in any groups (P > 0.05). No significant difference was observed in terms of BCVA between the intervention and control groups (P > 0.05). The present study showed a decrease in CMT in both study groups (P < 0.05). At month 3, the decrease in mean CMT from baseline was significantly higher in eyes receiving topical dorzolamide compared to the control group (-88.92 ± 82.90 vs. -37.64 ± 86.16 µM, respectively; P = 0.037). IOP decreased significantly only in eyes receiving dorzolamide (P < 0.001).

CONCLUSIONS

The results of the present study indicate that adjunctive administration of topical dorzolamide has a beneficial effect on CMT reduction from baseline, but it did not have an additive effect on BCVA improvement compared to IVB monotherapy.

Cystoid macular oedema without leakage in fluorescein angiography: a literature review

Cystoid macular oedema (CMO), which is defined as a macular thickening and cystic changes due to accumulation of fluid, could be asymptomatic and only diagnosed using paraclinical techniques. Fluorescein angiography (FA) and optical coherence tomography (OCT) are useful in detecting CMO in clinical practice. Non-leaking CMO, also known as angiographically silent CMO, is referred to as cases of CMO without leakage in fluorescein angiography. This type of CMO has been reported in some retinal dystrophies, in cases of maculopathy as a side effect of certain drugs, and also in some systemic disorders. The exact mechanism and treatment options for this type of CMO are still not clear. This literature review aims to discuss different causes of non-leaking CMO, proposed mechanisms, and management options. Three sections including drugs, retinal dystrophies, and systemic disorders are discussed in this review.

Carbonic anhydrase inhibitors in the management of macular edema: A review of the literature

Background

Macular edema (ME) is a vision-threatening condition that commonly develops as a consequence of ocular diseases, including age-related macular degeneration, retinal vaso-occlusion of the central retinal vein and its branches, diabetic retinopathy, central serous chorioretinopathy, uveitis, retinitis pigmentosa, pseudophakia, ocular trauma, and drug toxicity. The treatment of ME remains challenging, although steroids and vascular endothelial growth factor inhibitors are available. Cost-effective therapy using a noninvasive administration route is required. This study aimed at reviewing the role of carbonic anhydrase inhibitors (CAIs) in the management of ME.

Methods

A literature search was conducted using PubMed/MEDLINE and Google Scholar for studies from January 2000 to March 2022. The following keywords were used in various combinations: "macular edema", "carbonic anhydrase", "carbonic anhydrase inhibitors", "acetazolamide", "dorzolamide", and "brinzolamide".

Results

Articles with high or medium clinical relevance were selected for this review. We found that multiple studies have demonstrated the relevance and efficacy rates of CAIs in the management of ME. Most published studies focused on acetazolamide and dorzolamide, with nearly all studies reporting therapeutic responses.

Conclusions

ME is the leading cause of vision loss and requires noninvasive and cost-effective pharmacotherapy. With progress in the understanding of ME, particularly the role of carbonic anhydrase as a key driver, CAIs are the focus of research. Further optimization of the choice of CAIs and retinal bioavailability, potentially with nanoparticle formulations, is required to enable the effective management of ME. Further research is warranted to address the therapeutic effects of CAIs in different formulations.

Efficacy of topical dorzolamide 2% in diabetic cystoid macular edema

AIM

To study the effect of topical dorzolamide 2% on macular thickness reduction in diabetic cystoid macular edema (CME).

METHODS

This was a prospective, non-randomized, open study including eyes with diabetic macular edema (DME). All eyes received topical dorzolamide 2% three times daily for one month. Changes in best-corrected visual acuity (BCVA), and central macular thickness (CMT) by optical coherence tomography) were evaluated at 1wk, 1, and 3mo post-treatment.

RESULTS

Ninety-three eyes (84 patients) were included. Mean±SD (logMAR) BCVA improved significantly from 1.08±0.26 pretreatment to 0.66±0.24 at 1mo and 0.87±0.26 at 3mo post-treatment (P<0.001 both). The mean±SD CMT was significantly reduced from 535.27±97.4 µm at baseline to 357.43±125.8 µm at 1mo and 376.23±114.5 µm at 3mo post-treatment (P<0.001 both). No significant ocular or systemic side effects were recorded.

CONCLUSION

Topical dorzolamide 2% results in significant improvement of mean BCVA and reduction of mean CMT at 3mo post-treatment. It can be used as an effective, affordable, and safe therapy for treatment of non-refractory diabetic CME.

Optic Pit Maculopathy: Adjunctive Treatment Using Oral Spironolactone and Topical Dorzolamide

Purpose

There is no consensus for the treatment of optic disc pit maculopathy (ODPM). We describe a case of ODPM refractory to vitrectomy that was successfully treated with systemic spironolactone and topical dorzolamide 2%.

Methods

Case report.

Results

A 27-year-old male was referred for decreased vision in the right eye secondary to macular edema. Fundus examination and optical coherence tomography imaging revealed an optic pit maculopathy with significant macular schisis and intraretinal fluid. After an initial observation period, we performed pars plana vitrectomy with internal limiting membrane peeling, fibrin glue, and gas endotamponade. At the 2 months postoperative follow-up, anatomic and functional outcomes remained unimproved. Oral spironolactone and topical dorzolamide 2% were, therefore, added. Significant reduction in the intraretinal fluid and macular schisis was demonstrated at the last follow-up 2 years postoperative.

Conclusion

The mechanisms underlying optic disc pit maculopathy remain controversial, and treatment guidelines are unclear. To our knowledge, this is the first description of an OPDM treated with a combination systemic mineralocorticoid receptor antagonist and topical carbonic anhydrase inhibitor as adjuvant therapy to vitrectomy with favorable outcomes. We also review the literature and propose mechanisms through which these treatment entities may act.

Autosomal Recessive Bestrophinopathy: Clinical and Genetic Characteristics of Twenty-Four Cases

Background

To describe ocular manifestations, imaging characteristics, and genetic test results of autosomal recessive bestrophinopathy (ARB). The study design is an observational case series.

Methods

Forty-eight eyes of 24 patients diagnosed with ARB underwent complete ophthalmic examinations including refraction, anterior and posterior segment examination, enhanced depth imaging optical coherence tomography (EDI-OCT), fluorescein angiography (FA), electroretinography (ERG), and electrooculography (EOG). Optical coherence tomography angiography (OCTA) and BEST1 gene sequencing were performed in selected patients.

Results

The age at onset was 4–35 years (mean: 18.6 years). The male-to-female ratio was 0.45. All patients were hyperopic, except one with less than one diopter myopia. EOG was abnormal in 18 cases with near-normal ERGs. Six patients did not undergo EOG due to their young age. Eighteen patients (75%) had a thick choroid on EDI-OCT, of which three had advanced angle-closure glaucoma, 15 patients were hyperopic, and eight of them had more than four diopters hyperopia in both eyes. Macular retinoschisis was observed in 46 eyes of 23 patients (95%) with cysts mostly located in the inner nuclear layer (INL) to the outer nuclear layer (ONL). Of the 18 patients who underwent FA, mild peripheral leakage was seen in eight eyes of four patients (22%). Subfoveal choroidal neovascularization (CNV) was seen in three eyes of two patients (6%) that responded well to intravitreal bevacizumab (IVB). Seven mutations of the bestrophin-1 (BEST1) gene were found in this study; however, only two of them (p.Gly34 = and p.Leu319Pro) had been previously reported as the cause of ARB based on ClinVar and other literature studies.

Conclusions

ARB can be presented with a wide spectrum of ocular abnormalities that may not be easily diagnosed. Pachychoroid can occur alongside retinal schisis and may be the underlying cause of angle-closure glaucoma in ARB. Our study also expands the pathogenic mutation spectrum of the BEST1 gene associated with ARB.

Prospective deep phenotyping of choroideremia patients using multimodal structure-function approaches

OBJECTIVE

To investigate the retinal changes in choroideremia (CHM) patients to determine correlations between age, structure and function.

SUBJECTS/METHODS

Twenty-six eyes from 13 male CHM patients were included in this prospective longitudinal study. Participants were divided into <50-year (n = 8) and ≥50-year (n = 5) old groups. Patients were seen at baseline, 6-month, and 1-year visits. Optical coherence tomography (OCT), OCT angiography, and fundus autofluorescence were performed to measure central foveal (CFT) and subfoveal choroidal thickness (SCT), as well as areas of preserved choriocapillaris (CC), ellipsoid zone (EZ), and autofluorescence (PAF). Patients also underwent functional investigations including visual acuity (VA), contrast sensitivity (CS), colour testing, microperimetry, dark adaptometry, and handheld electroretinogram (ERG). Vision-related quality-of-life was assessed by using the NEI-VFQ-25 questionnaire.

RESULTS

Over the 1-year follow-up period, progressive loss was detected in SCT, EZ, CC, PAF, and CFT. Those ≥50-years exhibited more structural and functional defects with SCT, EZ, CC, and PAF showing strong correlation with patient age (rho ≤ -0.47, p ≤ 0.02). CS and VA did not change over the year, but CS was significantly correlated with age (rho = -0.63, p = 0.001). Delayed to unmeasurable dark adaptation, decreased colour discrimination and no detectable ERG activity were observed in all patients. Minimal functional deterioration was observed over one year with a general trend of slower progression in the ≥50-years group.

CONCLUSIONS

Quantitative structural parameters including SCT, CC, EZ, and PAF are most useful for disease monitoring in CHM. Extended follow-up studies are required to determine longitudinal functional changes.

Choroidal Vascularity Features in Patients with Choroideremia and Cystoid Spaces

Cystoid spaces (CSs) are a common retinal finding in choroideremia (CHM) patients. The aim of this study was to analyze the vascular features of the choroid associated with the presence of CSs in patients with confirmed genetic diagnosis of CHM. A total of 33 patients (33 eyes) were enrolled in this retrospective cross-sectional study and divided into two groups based on the presence (17 eyes) or absence (16 eyes) of CSs. Choroidal features were evaluated on spectral-domain optical coherence tomography including subfoveal choroidal thickness (CT), total choroidal area (TCA), luminal choroidal area (LCA), and stromal choroidal area (SCA). The choroidal vascularity index (CVI) was then calculated in all study eyes. All structural choroidal parameters were calculated both on the entire length of the B-scan and in the central subfoveal 1500 μm. The average age was 37.3 ± 11.6 and 31.4 ± 16.7 years (p = 0.25) and mean logMAR best-corrected visual acuity was 0.11 ± 0.20 and 0.20 ± 0.57 (p = 0.54) in the CHM groups with and without CSs, respectively. There were no significant differences in subfoveal CT, and TCA, LCA, SCA, and CVI evaluated on either the entire scan or in the central 1500 μm (all p > 0.05). All choroidal vasculature parameters exhibited no significant differences between CHM eyes with and without CSs. Our results suggest that the choroid may not be involved in the development of CSs in patients with CHM.

Effect of Adjuvant Topical Dorzolamide-Timolol vs Placebo in Neovascular Age-Related Macular Degeneration: A Randomized Clinical Trial

Importance

Some eyes with neovascular age-related macular degeneration (AMD) have persistent exudation despite frequent intravitreal anti-vascular endothelial growth factor (VEGF) injections. Adjuvant therapies that further reduce edema may improve vision outcomes.

Objective

To compare the short-term effect of topical dorzolamide-timolol vs placebo in eyes with neovascular AMD that have persistent exudation following intravitreal anti-VEGF injections.

Design, Setting, and Participants

Randomized placebo-controlled clinical trial with enrollment from March 1, 2017, through October 30, 2018. Multicenter trial at 4 clinical sites in the United States. Sixty-three patients with neovascular AMD who had persistent exudation despite intravitreal anti-VEGF injections at 4-week, 5-week, or 6-week intervals.

Interventions

Patients were randomized to use dorzolamide-timolol or artificial tears for the study duration. They continued to receive the same anti-VEGF drug at the same interval as the 2 visits before enrollment for 3 additional study visits.

Main Outcomes and Measures

The primary outcome measure was change in mean central subfield thickness on optical coherence tomography from baseline to visit 3 (approximately 3 months). Secondary measures included change in mean maximum subretinal fluid height, mean maximum pigment epithelial detachment height, and mean visual acuity (VA).

Results

This trial included 52 patients. All 27 patients (100%) assigned to dorzolamide-timolol and 23 of 25 (92%) assigned to placebo were analyzed for the primary outcome. Mean (SD) age was 78.4 (7) years, and 34 of 50 patients (68%) were women. Mean (SD) injections were 20.5 (14) (range, 4-58) before enrollment. Mean (SD) baseline logMAR VA was 0.361 (0.26) (approximate Snellen equivalent, 20/50). Comparing the dorzolamide-timolol with placebo group from baseline to visit 3, mean (SD) change in central subfield thickness (primary outcome) was -36.6 (54) μm vs 1.7 (52.3) μm (difference, 30.8; 95% CI, 0.3-61.3; P = .04); secondary outcomes: maximum PED height was -39.1 (65) μm vs 1.1 (16) μm (difference, 39.6; 95% CI, 9.6-69.6; P = .01) and change in VA from baseline to visit 3 was -2.3 (5) vs 0.3 (1) letters (difference, 2.6 letters; 95% CI, -1.9 to 7.1 letters; P = .78).

Conclusions and Relevance

These findings suggest use of dorzolamide-timolol in patients with neovascular AMD with persistent exudation resulted in anatomic but not visual acuity improvements compared with placebo at approximately 3 months. Additional clinical trials with longer follow-up and larger sample sizes presumably would be needed to determine the role, if any, of dorzolamide-timolol in neovascular AMD.

Trial Registration

ClinicalTrials.gov Identifier: NCT03034772.

EFFICACY OF ADJUVANT TOPICAL DORZOLAMIDE-TIMOLOL IN PATIENTS WITH NEOVASCULAR AGE-RELATED MACULAR DEGENERATION REFRACTORY TO ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY

PURPOSE

To evaluate the efficacy of adjuvant topical dorzolamide-timolol in patients with neovascular age-related macular degeneration unresponsive to anti-vascular endothelial growth factor therapy.

METHODS

This retrospective, interventional study included 15 patients with neovascular age-related macular degeneration refractory to anti-vascular endothelial growth factor. Patients used topical dorzolamide-timolol twice daily in the neovascular age-related macular degeneration eye and received anti-vascular endothelial growth factor therapy at each visit, with the same fixed interval and agent as before the addition of dorzolamide-timolol. Central macular thickness, maximal subretinal fluid height, and maximal pigment epithelial detachment height were measured at baseline and every visit.

RESULTS

The mean follow-up period was 17.2 ± 5.5 weeks. The mean central macular thickness decreased from 383.5 μm at baseline to 298.3 μm at the final visit (P = 0.041). The mean maximal subretinal fluid height decreased from 105.0 μm at baseline to 58.3 μm at the final visit (P = 0.021). Complete resolution of subretinal fluid was observed in 3 of 11 subretinal fluid-type eyes. There was no significant change in the maximal pigment epithelial detachment height. The mean logarithm of the minimum angle of resolution visual acuity decreased from 0.61 (20/81 Snellen) at baseline to 0.66 (20/91 Snellen) at final visit, which was not significant (P = 0.314). The mean intraocular pressure decreased significantly from 14.9 mmHg at baseline to 12.3 mmHg at the final visit (P = 0.005).

CONCLUSION

The use of adjuvant topical dorzolamide-timolol was effective in decreasing central macular thickness and subretinal fluid in patients with neovascular age-related macular degeneration refractory to continual fixed-interval intravitreal anti-vascular endothelial growth factor therapy, but did not result in functional improvement in this short-term study.

Resolution of optic disc pit-associated macular retinoschisis after topical carbonic anhydrase inhibitor treatment: Report of a case

BACKGROUND

Optic disc pits frequently lead to visual deterioration due to macular retinoschisis or serous retinal detachment. Here, we report a case of optic disc pit-associated macular retinoschisis due to intraretinal fluid accumulation that resolved with improvement in visual acuity after treatment with topical dorzolamide.

CASE DESCRIPTION

A 56-year-old otherwise healthy female with no ocular history presented with 2 weeks of slowly worsening blurry vision in her right eye. Visual acuity was 20/30 in the right eye. Posterior segment examination revealed posterior vitreous detachment, an optic disc pit at 9 o'clock, macular edema and foveoschisis with fluid extending from the optic nerve, and a normal peripheral retina. Optical coherence tomography imaging of the macula showed central subfield thickness of 526 µm. The patient preferred no surgical intervention, so topical dorzolamide 2% three times daily was initiated. Over the next 2 years, the central subfield thickness steadily declined from 526 to 262 µm, and her vision improved to 20/20 with improvement in the macular retinoschisis.

CONCLUSION

Our report presents a case of resolution of optic disc pit-associated macular retinoschisis due to intraretinal fluid accumulation with possible role for dorzolamide as a potential treatment option.

Combination of Intravitreal Bevacizumab and Topical Dorzolamide versus Intravitreal Bevacizumab Alone for Diabetic Macular Edema: A Randomized Contralateral Clinical Trial

Purpose

To evaluate the efficacy of three intravitreal bevacizumab (IVB) injections versus the same combined with 2% of topical dorzolamide in the treatment of diabetic macular edema (DME).

Methods

In this randomized double-masked clinical trial, 32 eyes of 16 treatment-naive patients with bilateral DME were enrolled. The eyes were randomly assigned to receive three monthly injections of IVB (1.25 mg) plus topical dorzolamide 2% twice daily or IVB (1.25 mg) plus topical artificial tear twice daily. Best-corrected visual acuity (BCVA) was the primary outcome of the study followed by the central macular thickness (CMT) and central macular volume (CMV) as the secondary outcomes.

Results

Mean BCVA changes were insignificant in both groups. It changed from 0.21 ± 0.08 logMAR at baseline to 0.23 ± 0.09 (P=0.24) in the combination group and from 0.18 ± 0.09 logMAR to 0.21 ± 0.09 (P=0.11) in the IVB alone group, at 3 months, respectively. Changes in mean CMT and CMV were significant in both groups. However, the difference between the groups was not significant at all the visits. In the study, no major ocular complication or systemic side effects were noted regarding IVB or topical dorzolamide.

Conclusion

This randomized contralateral clinical trial demonstrated that adjuvant topical dorzolamide with IVB injection had no additional effects on IVB in the treatment of DME over a three-month course. This trial is registered with the Iranian Registry of Clinical Trials under the registration code IRCT20131229015975N5.

Optical coherence tomography (OCT) features of cystoid spaces in choroideremia (CHM)

PURPOSE

To investigate the prevalence and features of cystoid spaces (CS) in patients with confirmed genetic diagnosis of choroideremia (CHM) using swept source optical coherence tomography (OCT).

METHODS

We retrospectively reviewed CHM patients examined at the Regional Reference Center for Hereditary Retinal Degenerations at the Eye Clinic in Florence. We took into consideration genetically confirmed CHM patients with ophthalmological and swept source optical coherence tomography (OCT) examinations. The presence/absence and location of cystoid spaces in the retina of each eye were reported.

RESULTS

A total of 42 eyes of 21 CHM patients were included in our series. The average age of the patients was 36.5 ± 20.1 (range, 13-73 years). The average best-corrected visual acuity (BCVA) for all patients was 0.63 ± 1.00 logMar (range, 0-2,80). CS were present in 15 eyes of eight patients (8/21, 38%). In all cases, CS were located in inner nuclear layer (INL); in five eyes of three patients, CS were detected also in ganglion cell layer (GCL). CS appeared as microcistoyd abnormalities and were detected in retinal areas characterized by retinal pigment epithelium (RPE) and outer retinal layers atrophy at the transition zone.

CONCLUSIONS

Cystoid spaces in choroideremia showed peculiar features; they are clusters of small-size extrafoveal degenerative cysts mainly located in inner nuclear layer at the transition zone where outer retinal layers and RPE are severely damaged.

Agents for the prevention and treatment of age-related macular degeneration and macular edema: a literature and patent review

Introduction: Macular degeneration (MD) and macular edema (ME) are ophthalmologic diseases affecting an increasing number of the aging population. Until recently, there were few therapeutic options for both conditions but the last two decades saw important advances. Areas covered: This review summarizes the agents used for the treatment of age-related MD (AMD), which include verteporfin, for photodynamic therapy, and anti-VEGF agents, the aptamer pegaptanib, the monoclonal antibodies (MAbs) ranibizumab (Lucentis®) and bevacizumab (Avastin®) and the fusion protein aflibercept (Eylea®). All these drugs are effective only for the wet form of AMD, whereas for the dry form there is no treatment available. ME is, on the other hand, treated with nonsteroidal anti-inflammatory drugs and carbonic anhydrase (CA) inhibitors. Recently, MAbs such as ranibizumab and bevacizumab were also shown to be effective for the management of the cystoid and diabetic ME. Expert opinion: There are important advances made in the field in the last years but longer-acting anti-VEGF agents or drugs with less ocular side effects are needed. Many such agents are in clinical development.

Efficacy of adjuvant topical timolol-dorzolamide with intravitreal bevacizumab injection in diabetic macular edema: A contralateral eye study

Purpose

To assess the efficacy of adjuvant topical timolol-dorzolamide with intravitreal bevacizumab (IVB) injection on anatomic and functional results in eyes affected with diabetic macular edema (DME).

Methods

In an interventional prospective contralateral pilot eye study at a third level referral academic facility, patients with bilateral DME who were treatment-naive were enrolled. Enrolled patients received a treatment plan of topical timolol-dorzolamide twice daily in the right eye. Three monthly bilateral IVB injections 1.25 mg/0.05 mL were also planned. Baseline central macular thickness (CMT) was measured by spectral-domain optical coherence tomography (SD-OCT), and clinical information such as best corrected visual acuity (BCVA) and intraocular pressure (IOP) were collected at enrollment and one month after the third injection.

Results

Eleven patients (seven females) with DME were included. BCVA and CMT improved in both eyes and IOP decreased in the right eye but did not change in the left eye. In repeated measures ANOVA analysis, the decrease in CMT and improvement in BCVA were significant in the right eye.

Conclusion

Our study suggested that adjuvant topical timolol-dorzolamide in combination with IVB may further reduce central macular thickness in eyes with DME.

EFFECT OF INTRAOCULAR PRESSURE-LOWERING MEDICATIONS ON NEOVASCULAR AGE-RELATED MACULAR DEGENERATION TREATMENT OUTCOMES IN THE COMPARISON OF AGE-RELATED MACULAR DEGENERATION TREATMENT TRIALS

PURPOSE

To evaluate the effect of intraocular pressure-lowering medications on treatment outcomes in the Comparison of AMD Treatments Trials.

METHODS

Secondary analysis of Comparison of AMD Treatments Trials data. Medication logs were reviewed for continuous 2-year use of agents that increased aqueous outflow (Group A: topical prostaglandins) or suppressed aqueous production (Group B: topical beta blockers and carbonic anhydrase inhibitors). Eyes were excluded if mixed-mechanism intraocular pressure-lowering agents or medications from more than one group were taken. Anatomical and vision responses to treatment at years 1, 2, and over the entire 2-year period in each group were compared with controls (no intraocular pressure-lowering medications).

RESULTS

Inclusion criteria were met by 28 Group A patients, 19 Group B patients, and 857 controls. After 2 years, the control group had a mean visual acuity improvement of +6.3 letters from baseline, compared with +3.5 letters in Group A (P = 0.38), and +13.8 letters in Group B (P = 0.052). Mean retinal thickness change from baseline was -54.9 μm in controls, -80.6 μm in Group A (P = 0.26), and -96.8 μm in Group B (P = 0.13). Mean total thickness change from baseline was -163 μm in controls, -180 μm in Group A (P = 0.63), and -238 μm in Group B (P = 0.08). In longitudinal analysis with adjustment by their baseline values, anti-vascular endothelial growth factor treatment drug and regimen, Group B had more visual acuity improvement (difference of 2.6 letters, 95% confidence interval: -3.4-8.5 letters), more reduction in the retinal thickness (-17.9 μm, 95% confidence interval: -36.5 to 0.7 μm), and total thickness from baseline (mean difference of -54.7 μm, 95% confidence interval: -103 to 6.2 μm) compared with the control group.

CONCLUSION

Concurrent aqueous suppressant use during anti-vascular endothelial growth factor therapy for neovascular age-related macular degeneration was associated with a trend toward greater reductions in retinal and total thickness as well as improved visual outcomes over 2 years. A similar effect was not observed to the same extent with agents that increase aqueous outflow. Because of the small sample size and secondary analysis, these findings must be cautiously interpreted and perhaps serve as a basis for future prospective studies.

Quantitative and Qualitative Features of Spectral-Domain Optical Coherence Tomography Provide Prognostic Indicators for Visual Acuity in Patients With Choroideremia

BACKGROUND AND OBJECTIVE

To identify qualitative and quantitative features of spectral-domain optical coherence tomography (SD-OCT) as prognostic indicators of visual acuity (VA) loss in patients with choroideremia (CHM).

PATIENTS AND METHODS

Retrospective study of 57 male patients with CHM. Central foveal thickness (CFT), subfoveal choroidal thickness (SCT), fundus autofluorescence area, and evidence of outer retinal and choroidal degeneration were analyzed by SD-OCT.

RESULTS

Best-corrected VA logMAR at baseline was associated with CFT at baseline (r = -0.47; P < .01), CFT at most recent follow-up (r = -0.27; P < .01), and SCT at baseline (r = -0.31; P < .01). Ellipsoid zone (EZ) rupture was associated with a higher CFT loss (r = 0.33; P < .01) and macular cystic spaces (MCS) with a reduction in VA over time (hazard risk = 0.48; P = .05).

CONCLUSION

Reduced CFT at baseline, EZ rupture, and MCS are poor prognostic indicators for VA outcome. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:711-716.].

Strong topical steroid, NSAID, and carbonic anhydrase inhibitor cocktail for treatment of cystoid macular edema

Purpose

To report the combination cocktail of strong steroid, non-steroidal anti-inflammatory drug (NSAID), and carbonic anhydrase inhibitor drops for treatment of cystoid macular edema.

Methods

This is a retrospective case series of patients with cystoid macular edema managed with a topical combination of strong steroid (difluprednate), NSAID, and carbonic anhydrase inhibitor drops. The patients were followed with optical coherence tomography and fluorescein angiography.

Results

In our six cases, resolution of the cystic edema with improvement in visual acuity was achieved with the use of a combination cocktail of drops. Leakage on fluorescein angiography and cystic edema on optical coherence tomography both responded to treatment with the topical cocktail of drops.

Conclusion

A topical cocktail of strong steroid, NSAID, and carbonic anhydrase inhibitor drops are effective for managing cystoid macular edema. Further studies comparing this combination with more invasive treatments should be undertaken to determine the efficacy of this cocktail over other treatment options.

Characterization of a Case of Pigmentary Retinopathy in Sanfilippo Syndrome Type IIIA Associated with Compound Heterozygous Mutations in the SGSH Gene

PURPOSE

To report longitudinal phenotypic findings in a patient with Sanfilippo syndrome type IIIA, harboring SGSH mutations, one of which is novel.

METHODS

Heparan-N-sulfatidase enzyme function testing in skin fibroblasts and white blood cells and SGSH gene sequencing were obtained. Clinical office examinations, examinations under anesthesia, electroretinogram, spectral domain optical coherence tomography (SD-OCT), and fundus photography were performed over a 5-year period.

RESULTS

Fundus examination revealed a progressive breadcrumb-like pigmentary retinopathy with perifoveal pigmentary involvement. SD-OCT showed loss of normal neuroretinal lamination and cystic macular changes responsive to treatment with carbonic anhydrase inhibitors. Electroretinography exhibited complex characteristics indicative of a generalized retinal rod > cone dysfunction with significant ON > OFF postreceptoral response compromise. Sequencing revealed compound heterozygous mutations in the SGSH gene, the novel c.88G > C (p.A30P) change and a second, previously reported one (c.734G > A, p.R245H).

CONCLUSIONS

We have identified ocular features of a patient with Sanfilippo syndrome type IIIA harboring a novel SGHS mutation that were not previously known to occur in this disease - namely, a progressive retinopathy with distinctive features, cystic macular changes responsive to carbonic anhydrase inhibitors, and complex electroretinographic abnormalities consistent with postreceptoral dysfunction. SD-OCT imaging revealed retinal lamination changes consistent with previously reported histologic studies. Both the SD-OCT and the electroretinogram changes appear attributable to intraretinal deposition of heparan sulfate.

Pathogenic mechanisms and the prospect of gene therapy for choroideremia

INTRODUCTION

Choroideremia is a rare, X-linked disorder recognized by its specific ocular phenotype as a progressive degenerative retinopathy resulting in blindness. New therapeutic approaches, primarily based on genetic mechanisms, have emerged that aim to prevent the progressive vision loss.

AREAS COVERED

This article will review the research that has progressed incrementally over the past two decades from mapping to gene discovery, uncovering the presumed mechanisms triggering the retinopathy to preclinical testing of potential therapies.

EXPERT OPINION

While still in an evaluative phase, the introduction of gene replacement as a potential therapy has been greeted with great enthusiasm by patients, advocacy groups and the medical community.

Synaptic pathology and therapeutic repair in adult retinoschisis mouse by AAV-RS1 transfer

Strategies aimed at invoking synaptic plasticity have therapeutic potential for several neurological conditions. The human retinal synaptic disease X-linked retinoschisis (XLRS) is characterized by impaired visual signal transmission through the retina and progressive visual acuity loss, and mice lacking retinoschisin (RS1) recapitulate human disease. Here, we demonstrate that restoration of RS1 via retina-specific delivery of adeno-associated virus type 8-RS1 (AAV8-RS1) vector rescues molecular pathology at the photoreceptor-depolarizing bipolar cell (photoreceptor-DBC) synapse and restores function in adult Rs1-KO animals. Initial development of the photoreceptor-DBC synapse was normal in the Rs1-KO retina; however, the metabotropic glutamate receptor 6/transient receptor potential melastatin subfamily M member 1-signaling (mGluR6/TRPM1-signaling) cascade was not properly maintained. Specifically, the TRPM1 channel and G proteins Gαo, Gβ5, and RGS11 were progressively lost from postsynaptic DBC dendritic tips, whereas the mGluR6 receptor and RGS7 maintained proper synaptic position. This postsynaptic disruption differed from other murine night-blindness models with an electronegative electroretinogram response, which is also characteristic of murine and human XLRS disease. Upon AAV8-RS1 gene transfer to the retina of adult XLRS mice, TRPM1 and the signaling molecules returned to their proper dendritic tip location, and the DBC resting membrane potential was restored. These findings provide insight into the molecular plasticity of a critical synapse in the visual system and demonstrate potential therapeutic avenues for some diseases involving synaptic pathology.

[Efficacy of dorzolamide in reducing retinal thickness after photocoagulation in diabetic macular oedema]

BACKGROUND

Focal photocoagulation interrupts vascular leakage in diabetic macular edema, and allows the retinal pigment epithelium to withdraw fluid that thickens the retina; this mechanism could be enhanced by dorzolamida, a topical carbonic anhydrase inhibitor.

OBJECTIVE

To determine the efficacy of dorzolamida compared against placebo, in reducing retinal thickness after focal photocoagulation, in eyes with diabetic macular oedema.

MATERIAL AND METHODS

Experimental, comparative, prospective, longitudinal, double blind study in diabetics with focal macular oedema treated with photocoagulation. Treated eyes were randomly assigned three weeks after the procedure to receive dorzolamide (group 1) or placebo (group 2), three times daily during three weeks. Means of visual acuity, center point thickness and macular volume were compared 3 and 6 weeks after photocoagulation within groups (Wilcoxon's t) and between groups (Mann-Whitneys's U).

RESULTS

Sixty-nine eyes form patients aged 58.3 ± 8.3 years; 37 were assigned to group 1 and 42 to group 2. Mean center point thickness changed from 178.4 ± 34μm to 170 ± 29.1μm in group 1 (p = 0.04), and from 179.2 ± 22.4μm to 178.6 ± 20.8μm in group 2 (p = 0.7); mean macular volume changed from 7.63 ± 0.52mm(3) to 7.50 ± 0.50mm(3) in group 1 (p = 0.02) and from 7.82 ± 0.43mm(3) to 7.76 ± 0.42mm(3) in group 2 (p = 0.014).

CONCLUSIONS

The efficacy of dorzolamide was higher than that of placebo, to reduce retinal thickness after focal photocoagulation in diabetics with macular oedema.

Macular retinal detachment associated with intrachoroidal cavitation in myopic patients

PURPOSE

To investigate the clinical characteristics and treatment outcomes of macular retinal detachment (MRD) associated with intrachoroidal cavitation (ICC) in myopic patients.

METHODS

In this retrospective, consecutive, interventional case series, five patients with ICC and associated MRD were enrolled from January 2005 to December 2012. Basic ocular characteristics and clinical appearances of their ICC and MRD were recorded. Individual treatment courses were assessed with fundus photographs and serial optical coherence tomography.

RESULTS

The average age and refraction were 43.8 ± 11.0 years old and -9.37 ± 2.73 diopters, respectively. Initial BCVA ranged from 20/100 to 20/30. Definite communication between the ICC and the subretinal space was noted in one case, suspected curvilinear communication in two cases, and between the peripapillary area and the subretinal space in two cases. Two cases received intravitreal injection of perfluoropropane and peripapillary laser; subretinal fluid (SRF) resolved in one and decreased in the other. One case had SRF reabsorbed after prolonged use of topical carbonic anhydrase inhibitor.

CONCLUSIONS

ICC in high myopic patients may be associated with MRD. There might be communication between the ICC and the subretinal space. Intravitreal injection of an expansile gas may be beneficial, but the best treatment remains undetermined.

Choroideremia associated with choroidal neovascularization treated with intravitreal bevacizumab

Purpose

To report a rare case of central vision loss in a patient with choroideremia.

Patients and methods

A retrospective, interventional case report.

Results

A 13-year-old male with history of choroideremia presented with subacute loss of central acuity in his left eye. Examination and diagnostic testing revealed subretinal fibrosis secondary to a choroidal neovascular membrane (CNVM). A trial of anti-vascular endothelial growth factor (VEGF) therapy with the injection of intravitreal bevacizumab was attempted. Mild improvements in acuity and anatomy were noted.

Conclusion

Choroideremia is a rare hereditary choroidal dystrophy that predominantly affects males in the first and second decades of life. Visual acuity is usually spared until later in life. CNVM is a rare manifestation of choroideremia with only a handful of case reports presented in the literature. This case is unique in that it is the first reported case that received treatment with intravitreal anti-VEGF therapy.

The prevalence of macular cysts in patients with clinical cone-rod dystrophy determined by spectral-domain optical coherence tomography

BACKGROUND

To determine the prevalence of macular cysts in patients with clinical cone-rod dystrophy (CORD) using spectral-domain optical coherence tomography (SD-OCT). If macular cysts could be demonstrated in such patients, they might benefit from treatment with a carbonic anhydrase inhibitor that has been shown to be effective for treating macular cysts in various night-blinding disorders.

MATERIAL AND METHODS

Thirty-six CORD patients underwent a complete ophthalmic examination and an SD-OCT examination using two different systems. The presence of hypo-reflective lacunae was used to determine the presence of macular cysts.

RESULTS

The patients' mean age was 42.9 ± 19.5 years (range 6-71 years). Mean BCVA was 1.09 ± 0.64 logMAR (range no light perception to 20/25 + 2 in the better-seeing eye). All the 72 eyes studied showed a variable degree of retinal thinning, disruption of what has been referred to as the inner segment ellipsoid and outer nuclear layer (ONL) thinning of the macula. None showed evidence of macular cysts on OCT testing.

CONCLUSIONS

Although macular cysts are a common feature of various hereditary night-blinding retinal dystrophies, these were not identified in our cohort of CORD patients.

Topical dorzolamide for macular edema in the early phase after vitrectomy and epiretinal membrane removal

Background

The purpose of this study was to evaluate prospectively the efficacy of a topical carbonic anhydrase inhibitor in macular edema after vitrectomy.

Methods

Forty patients were included, all of whom had undergone vitrectomy combined with phacoemulsification and intraocular lens implantation for epiretinal membrane. Twenty eyes from 40 patients received topical 2% dorzolamide three times a day. The patients were followed up for at least 3 months. In this study, we evaluated the effect of dorzolamide on visual acuity, intraocular pressure, central macular thickness, and aqueous flare.

Results

Mean logarithm of the minimum angle of resolution (logMAR) best-corrected visual acuity preoperatively and 2 weeks, 1 month, and 3 months after surgery was 0.48 ± 0.23, 0.60 ± 0.16, 0.40 ± 0.29, and 0.24 ± 0.32, respectively, in the treatment group, and 0.40 ± 0.09, 0.44 ± 0.12, 0.32 ± 0.10, and 0.16 ± 0.09, respectively, in the control group. No statistically significant difference was observed between the two groups. Mean central macular thickness preoperatively and at 2 weeks and 3 months after surgery was 572.6, 427.2, and 333.4 μm, respectively, in the treatment group, and 571.4, 485.2, and 388.4 μm, respectively, in the control group. Mean aqueous flare preoperatively, and 1 month and 3 months after surgery was 8.6, 34.2, and 23.5 photon counts per millisecond (pc/ms), respectively, in the treatment group, and 9.7, 24.7, and 23.4 pc/ms, respectively, in the control group. No statistically significant differences were observed between data from the two groups. However, statistically significant (P < 0.05) differences in mean central macular thickness at 1 month and mean aqueous flare at 2 weeks after surgery were found between the treatment group (358.8 μm, 36.8 pc/ms) and the control group (467.8 μm, 64.0 pc/ms). Differences in mean intraocular pressure preoperatively and at 2 weeks, 1 month, and 3 months after surgery were not statistically significant between the two groups. Intraocular pressure never exceeded 21 mmHg.

Conclusion

Topical dorzolamide significantly reduced mean central macular thickness at 1 month and mean aqueous flare at 2 weeks after surgery for epiretinal membrane compared with controls. Although further investigation of more cases and longer follow-up are needed, this study suggests that topical dorzolamide can be efficacious in reducing macular edema in the early phase after vitrectomy via its anti-inflammatory effect.

Topical dorzolamide treatment of macular cysts in the enhanced S-cone syndrome patient

Purpose

The purpose of the study was to evaluate the efficacy of a topical form of a carbonic anhydrase inhibitor (dorzolamide) on the foveal function and thickness in the eye of a patient with enhanced S-cone syndrome (ESCS) associated with macular cysts.

Methods

Twenty-eight-year-old Polish man with ESCS and macular cysts appearance in the right eye was treated 3 times daily with 2.0 % dorzolamide drops for the period time equal to 6 months. Monthly controls included: best corrected distance visual acuity (BCDVA-logMAR), foveal thickness (optical coherence tomography, OCT) and foveal function (multi-focal electroretinography, mfERG).

Results

Before treatment, BCDVA in the right eye was equal to 0.26 logMAR, improved to 0.1 logMAR during the first 3 months and remained stable for the next 3 months. After 6 months, foveal thickness decreased (from 482 to 224 μm) and foveal function improved (the amplitude of P1-wave density increased from 34.8 to 107.3 nV/deg²) and was between the ranges of normal values. Implicit time of P1-wave remained prolonged.

Conclusions

The results of our short-term study suggest potential efficacy of topical dorzolamide treatment in ESCS patients with macular cysts.

Autosomal recessive bestrophinopathy: differential diagnosis and treatment options

OBJECTIVE

To describe the clinical and genetic characteristics of patients with autosomal recessive bestrophinopathy (ARB).

DESIGN

Retrospective case series.

PARTICIPANTS

Ten patients with ARB from 7 different families.

METHODS

All patients underwent a complete ophthalmic examination, including dilated fundus examination, fundus photography, and fluorescein angiography (FA). In all probands, fundus autofluorescence (FAF) imaging, spectral-domain optical coherence tomography (OCT), full-field electroretinography (ERG), electro-oculography (EOG), and Goldmann perimetry were performed. In selected patients, multifocal ERG was performed. Blood samples were obtained to analyze the BEST1 gene for biallelic mutations that confirmed the diagnosis of ARB.

MAIN OUTCOME MEASURES

Age at onset; visual acuity; fundus appearance; characteristics on FA, FAF, OCT, full-field ERG, and EOG; BEST1 gene mutations; and genotype-phenotype correlation.

RESULTS

The age at onset varied widely, from 2 to 54 years. A spectrum of fundus abnormalities was observed, such as multifocal yellowish subretinal deposits, subretinal fibrous scars, and cystoid intraretinal fluid collections in the macula. All ARB patients were hyperopic, and some had shallow anterior chamber angles that predisposed them to angle-closure glaucoma. The EOG results were abnormal in all patients. The full-field ERG results were abnormal in 8 ARB patients, whereas 2 patients demonstrated normal cone and rod responses on full-field ERG. Nine ARB patients carried biallelic mutations in the BEST1 gene, and in 1 patient with a characteristic ARB phenotype, only 1 mutation could be identified. Seven different mutations were detected, including 4 novel mutations.

CONCLUSIONS

Autosomal recessive bestrophinopathy is a recognizable phenotype caused by autosomal recessively inherited mutations in the BEST1 gene. A differential diagnosis with other conditions can be made on the basis of marked autofluorescence changes in combination with an absent light rise on the EOG that outweighs the full-field ERG abnormalities, which point to the BEST1-related hereditary nature of the disease. A number of currently available therapeutic options should be considered in ARB, a disease that seems to be a suitable candidate for future gene therapy.

Comparison between MP-1 and Humphrey visual field defects in glaucoma and retinitis pigmentosa

PURPOSE

To compare MP-1 microperimeter and Humphrey Field Analyzer (HFA) defects, in patients with retinitis pigmentosa (RP), a disease primarily affecting the photoreceptors, and in patients with glaucoma, a disease primarily affecting postreceptoral ganglion cells, and to analyze the similarities and differences between the results.

METHODS

Eleven patients (11 eyes) with RP and 10 patients (10 eyes) with primary open-angle glaucoma (OAG) underwent MP-1 and HFA visual field testing (10-2 pattern). All tested eyes had defects encroaching within 10° of fixation. MP-1 total deviation (TD) probability defects, derived from a previously collected normative database of 50 subjects, were compared to HFA TD defects and to the local defect map of the MP-1. Test duration was compared between instruments.

RESULTS

In RP patients, MP-1 scotomata were deeper and wider than HFA defects; however in OAG, the opposite was observed. Examination duration in both patient groups was 12 to 14 min for the MP-1 and 6 min for the HFA. The MP-1 local defect map tended to overestimate defects compared to the MP-1 TD analysis.

CONCLUSIONS

The differences in results between the MP-1 and HFA for the two groups of patients with RP and OAG can be attributed to the different adaptation levels and to the dynamic range of test lights available for the two instruments. The clinician should also be aware of the possible consequences of the differences in the method of derivation of normative data for the two instruments, as this may affect the interpretation of visual field results.

Relationship between retinal layer thickness and the visual field in early age-related macular degeneration

PURPOSE

To quantify and compare the structural and functional changes in subjects with early age-related macular degeneration (AMD), using spectral-domain optical coherence tomography (SD-OCT) and microperimetry.

METHODS

Twenty-one eyes of 21 subjects with early AMD were examined. MP-1 10-2 visual fields (VFs) and SD-OCT line and detail volume scans were acquired. The thicknesses of the outer segment (OS; distance between inner segment ellipsoid band and upper retinal pigment epithelium [RPE] border) and RPE layers and elevation of the RPE from Bruch's membrane were measured using a computer-aided manual segmentation technique. Thickness values were compared with those for 15 controls, and values at locations with VF total deviation defects were compared with values at nondefect locations at equivalent eccentricities.

RESULTS

Sixteen of 21 eyes with AMD had VF defects. Compared with controls, line scans showed significant thinning of the OS layer (P = 0.006) and thickening and elevation of the RPE (P = 0.037, P = 0.002). The OS layer was significantly thinner in locations with VF defects compared with locations without defects (P = 0.003). There was a negligible difference between the retinal layer thickness values of the 5 eyes without VF defects and the values of normal controls.

CONCLUSIONS

In early AMD, when VF defects were present, there was significant thinning of the OS layer and thickening and elevation of the RPE. OS layer thinning was significantly associated with decreased visual sensitivity, consistent with known photoreceptor loss in early AMD. For AMD subjects without VF defects, thickness values were normal. The results highlight the clinical utility of both SD-OCT retinal layer quantification and VF testing in early AMD.