Anterior segment neovascularization in diabetic retinopathy: a masquerade

Ocular Ischemic Syndrome and the Role of Carotid Artery Revascularization

BACKGROUND

Ocular ischemic syndrome (OIS) is a rare presentation of atherosclerotic carotid artery stenosis that can result in permanent visual loss. This severely disabling syndrome remains under diagnosed and undertreated due to lack of awareness; especially since it requires expedited multidisciplinary care. The relevance of early diagnosis and treatment is increasing due to an increasing prevalence of cerebrovascular disease.

METHODS

The long-term visual and cerebrovascular outcomes following intervention for nonarteritic OIS, remain poorly described and were the objective of this concise review. We conducted a PubMed search to include all English language publications (cohort studies and case reports) between 2002 and 2023.

RESULTS

A total of 33 studies (479 patients) report the outcomes of treatment of OIS with carotid endarterectomy (CEA, 304 patients, 19 studies), and carotid artery stenting (CAS, 175 patients, 14 studies). Visual outcomes were improved or did not worsen in 447 patients (93.3%). No periprocedural stroke was reported. Worsening visual symptoms were rare (35 patients, 7.3%); they occurred in the immediate postoperative period secondary to ocular hypoperfusion (3 patients) and in the late postoperative period due to progression of systemic atherosclerotic disease. Symptomatic recurrence due to recurrent stenosis after CEA was reported in 1 patient (0.21%); this was managed successfully with CAS. None of these studies report the results of transcarotid artery revascularization, the long-term operative outcome or stroke rate.

CONCLUSIONS

OIS remains to be an underdiagnosed condition. Early diagnosis and prompt treatment are crucial in reversal or stabilization of OIS symptoms. An expedited multidisciplinary approach between vascular surgery and ophthalmology services is necessary to facilitate timely treatment and optimize outcome. If diagnosed early, both CEA and CAS have been associated with visual improvement and prevention of progressive visual loss.

Comparison of corneal endothelial cell changes after phacoemulsification between type 2 diabetic and nondiabetic patients

The aim of this study is to compare the endothelial cell density (ECD) and morphology between diabetic mellitus (DM) and nondiabetic patients at 1 year after phacoemulsification in operated eyes and nonoperated eyes.Evaluation was performed in 28 patients (56 eyes) with type 2 diabetes and 37 patients (74 eyes) without diabetes who underwent 1-year interval cataract surgery. Using a noncontact specular microscope and Scheimpflug rotating camera, corneal parameters were analyzed before and 1 year after surgery. Subgroups analysis was performed based on a disease duration 10 years and HbA1c concentration 7% and Pearson correlation analysis was performed.The mean change in ECD at 1 year after surgery was 13.28% in the DM group and 11.40% in the control group. In the fellow nonoperated eyes, the mean change was 4.47% and 3.63% in the DM and control groups, respectively. There was no significant difference in postoperative ECD, coefficient of variance, hexagonality, and central corneal thickness between 2 groups. In the subgroup analysis, the long disease duration DM group (≥10 years) had a significantly greater ECD loss than the control and short disease duration DM groups (<10 years). Blood urea nitrogen (BUN) showed a significant correlation with postoperative ECD change (r = -0.474, P = .011).The diabetic group with a longer disease duration showed significantly greater ECD decrease compared to the nondiabetic group and BUN correlated with ECD changes after phacoemulsification. Postoperative ECD loss may be high if the disease duration is long or if the BUN level is high.

Active-fluidics-based torsional phacoemulsification in diabetic eyes: A prospective interventional study

Purpose

To compare the outcomes of active-fluidics based torsional phacoemulsification in diabetics and nondiabetics using a balanced tip.

Methods

Two hundred and forty-eight patients undergoing senile cataract surgery using torsional phacoemulsification on an active-fluidics-based platform from December 2016 to August 2017 were included in this prospective, nonrandomized, interventional cohort study; of the 248 patients, 54 were controlled diabetics and 194 were nondiabetics. Intraoperative parameters such as cumulative dissipated energy (CDE), total ultrasound time, torsion usage time, torsion amplitude, aspiration time, and fluid usage were documented and compared. Endothelial cell loss (ECL) and central corneal thickness (CCT) were evaluated at 1 month postoperatively.

Results

Diabetics and nondiabetics did not differ in CDE, total ultrasound time, torsion amplitude, aspiration time, fluid usage, endothelial cell count, and CCT. ECL on Day 1 (10.2 ± 8.0%) and Day 30 (11.05 ± 8.3%) were significantly higher in diabetics (P = 0.025 and P = 0.045, respectively). There was an increase in CCT on Day 1 (P = 0.018), which settled by Day 30. Grade 4 cataracts in diabetics had significantly higher CCT at Day 1 (P = 0.032) and Day 30 (P = 0.007). In the diabetic subgroup, Grades 3 and 4 cataracts required lower CDE (P < 0.001) and Grade 4 cataracts showed higher ECL than others till 1 month of follow-up (P < 0.05).

Conclusion

Intraoperative and postoperative parameters after torsional phacoemulsification are comparable in diabetics and nondiabetics. Endothelial changes and pachymetry may be related to the grade of cataract in diabetics.

Clinical Features of Ocular Ischemic Syndrome and Risk Factors for Neovascular Glaucoma

Purpose

We aimed to examine the clinical features and prognosis of ocular ischemic syndrome and to investigate the risk factors for the development of neovascular glaucoma (NVG).

Methods

The medical records from 25 patients (25 eyes) who were diagnosed with ocular ischemic syndrome were retrospectively analyzed. We recorded the length of time between symptom onset and diagnosis, visual acuity, intraocular pressure, clinical findings of the anterior and posterior segments of the eye, fluorescein angiography, systemic diseases, smoking history, and the extent of any ipsilateral carotid artery stenosis. The risk factors for NVG in patients with ocular ischemic syndrome were investigated.

Results

The mean age was 67.9 ± 12.5 years, and 21 men and 4 women were included in this study. At initial examination, the mean logarithm of the minimum angle of resolution (logMAR) was 2.02 ± 1.26, and the mean intraocular pressure was 21.0 ± 10.3 mmHg. Among 25 eyes of the 25 patients, NVG occurred in 17 eyes after a mean period of 12.6 ± 14.0 months. The length of time between symptom onset and diagnosis (p = 0.025) and the extent of ipsilateral carotid artery stenosis (p = 0.032) were identified as significant risk factors for NVG. At the final follow-up, the mean logMAR visual acuity was 3.13 ± 1.24, showing a poor prognosis regardless of whether NVG occurred.

Conclusions

Overall, the prognosis for ocular ischemic syndrome is very poor. The risk of NVG increases with the length of time between symptom onset and diagnosis, as well as with the severity of ipsilateral carotid artery stenosis.