Enhancing Diabetic Macular Edema Treatment Outcomes: Exploring the ESASO Classification and Structural OCT Biomarkers

INTRODUCTION

This study assessed the European School of Advanced Studies in Ophthalmology (ESASO) classification's prognostic value for diabetic macular edema (DME) in predicting intravitreal therapy outcomes.

METHODS

In this retrospective, multicenter study, patients aged > 50 years with type 1 or 2 diabetes and DME received intravitreal antivascular endothelial growth factor (anti-VEGF) agents (ranibizumab, bevacizumab, and aflibercept) or steroids (dexamethasone). The primary outcome was visual acuity (VA) change post-treatment, termed as functional response, measured 4-6 weeks post-third anti-VEGF or 12-16 weeks post-steroid injection, stratified by initial DME stage.

RESULTS

Of the 560 eyes studied (62% male, mean age 66.7 years), 31% were classified as stage 1 (early), 50% stage 2 (advanced), 17% stage 3 (severe), and 2% stage 4 (atrophic). Visual acuity (VA; decimal) improved by 0.12-0.15 decimals in stages 1-2 but only 0.03 decimal in stage 3 (all p < 0.0001) and 0.01 in stage 4 (p = 0.38). Even in eyes with low baseline VA ≤ 0.3, improvements were significant only in stages 1 and 2 (0.12 and 0.17 decimals, respectively). Central subfield thickness (CST) improvement was greatest in stage 3 (-229 µm, 37.6%, p < 0.0001), but uncorrelated with VA gains, unlike stages 1 and 2 (respectively: -142 µm, 27.4%; - 5 µm, 12%; both p < 0.0001). Stage 4 showed no significant CST change. Baseline disorganization of retinal inner layers and focal damage of the ellipsoid zone/external limiting membrane did not influence VA improvement in stages 1 and 2. Treatment patterns varied, with 61% receiving anti-VEGF and 39% dexamethasone, influenced by DME stage, with no significant differences between therapeutic agents.

CONCLUSION

The ESASO classification, which views the retina as a neurovascular unit and integrates multiple biomarkers, surpasses single biomarkers in predicting visual outcomes. Significant functional improvement occurred only in stages 1 and 2, suggesting reversible damage, whereas stages 3 and 4 likely reflect irreversible damage.

ESASO classification relevance in the diagnosis and evolution in diabetic macular edema patients after dexamethasone implant treatment

PURPOSE

To assess the clinical relevance of The European School for Advanced Studies in Ophthalmology (ESASO) classification in patients with diabetic macular edema (DME) after their first dexamethasone implant (DEXI) treatment.

METHODS

Retrospective real-world study conducted on consecutive DME patients who underwent DEXI treatment and were controlled at month-2. Subjects were initially classified according to the ESASO classification stages. The outcomes were anatomical biomarkers with spectral-domain optical coherence tomography (SD-OCT) and best-corrected visual acuity (BCVA).

RESULTS

A total of 128 patients were classified according to ESASO classification stages as early (7; 5.5%), advanced (100; 78.1%), and severe (21; 16.4%). At baseline, there were significant differences between stages in BCVA, central macular thickness (CMT), and tomography anatomical biomarkers (p < 0.05). Initial BCVA (logMAR) was 0.33 ± 0.10, 0.58 ± 0.34, and 0.71 ± 0.35 in the early, advanced, and severe stages, respectively (p < 0.05). At month-2, BCVA was 0.17 ± 0.15, 0.46 ± 0.29, and 0.69 ± 0.27 in those classified as early, advanced, and severe stages, respectively. At month-2, DME was resolved or improved in 6 (85.7%), 60 (60%), and 12 (60%) patients classified as early, advanced, and severe stages, respectively.

CONCLUSIONS

There was a good correlation between BCVA and ESASO classification stages. Patients in the severe stage did not achieve visual acuity improvement over the study period.

Worsening of early DME after cataract surgery. The DICAT II Study report #2

PURPOSE

To analyse the long anatomical and functional outcome of a subgroup of the DICAT II study cohort, consisting of 26 patients undergoing cataract surgery and withdrawn from the study for a clinically significant worsening of early diabetic macular edema (DME).

MATERIALS

Patients who underwent cataract surgery and withdrawn from the DICAT II study for a clinically significant worsening of early DME with at least 12 months follow-up after the dropout. The study population was divided into two groups according to the clinical evaluation at one-year follow-up: ongoing treatment patients for DME (Treatment group, TG) and patients no longer treated (Non Treatment group, NTG).

RESULTS

Central foveal thickness (CFT) at baseline and dropout time were higher in TG than in the NTG, with a statistically significant difference (p < 0.05). In addition, TG patients reported a higher levels of glycated hemoglobin at time baseline compared to NTG patients (7.81 ± 1.15 vs 7.02 ± 0.56; p = 0.048). The linear regression analysis demonstrated a statistically significant relationship between the visual acuity and the ongoing treatment group at one-year follow-up (p = 0.042).

CONCLUSION

The study provides parameters to be considered when assessing the risk of developing persistent DME after cataract surgery in diabetic patients. In particular, CFT at baseline and dropout time have been reported to be an effective and predictable OCT biomarkers when evaluating DME progression. During the evaluation of the systemic disease, similar results were found for the glycated hemoglobin at baseline.

Validation of Esaso Classification of Diabetic Maculopathy

PURPOSE

To test reliability and reproducibility of ESASO morphologic OCT-based classification of diabetic maculopathy (DM).

METHODS

This is a multi-center cross-sectional study including a coordination center (CC) and 18 participating centers (PCs). After instruction on the correct use of ESASO Classification, the validation process was carried out in two consecutive stages. In the first retrospective phase, we evaluated the concordance between PCs and CC in the staging of OCT images collected during PCs' daily activity (608 images). In a second prospective phase, we analyzed the inter-observer agreement of staging assigned by each PCs to OCT images selected by the CC (22 images).

RESULTS

The overall concordance achieved in the retrospective phase was 89.8% (Kappa = 0.83 (95% CI: 0.78-0.87); p<0.0001). In 99.5% of cases, concordance did not differ by more than one stage. In the prospective phase, PCs reached an inter-operator agreement of 93.0% (Krippendorff's Alpha = 0.953, 95% CI: 0.929-0.977, p<0.0001). Any discrepancy among the 22 images was within one stage.

CONCLUSION

The results achieved in this study confirm that ESASO OCT-based Classification can be considered as an easy and reproducible method to stage DM during clinical practice. A diffused use of a common and validated method to describe the progression of retinal damage in DM may offer several clinical and scientific advantages.

From diagnosis to prognosis: A paradigm shift for multimodal imaging in assessing diabetic macular edema

Diabetic macular edema (DME) is one of the leading causes of visual impairment in patients with diabetes. Multimodal imaging (MMI) has allowed a shift from DME diagnosis to prognosis. Although there are no accepted guidelines, MMI may also lead to treatment customization. Several study groups have tried to identify structural biomarkers that can predict treatment response and long-term visual prognosis. The purpose of this editorial is to review currently proposed optical coherence tomography (OCT) and optical coherence tomography angiography (OCT-A) biomarkers.

The effect of pars plana vitrectomy with internal limiting membrane peeling on the durability of the intravitreal dexamethasone implant in the treatment of diabetic macular edema

Purpose

To evaluate the influence of pars plana vitrectomy with internal limiting membrane peeling on recurrence time of diabetic macular edema in eyes under treatment with dexamethasone intravitreal implant injections.

Material and methods

Twelve pseudophakic eyes of 12 patients with non-proliferative diabetic retinopathy and non-tractional diabetic macular edema were included. All eyes had already been treated with two or more dexamethasone intravitreal implant injections evidencing a recurrence time of three months or less (early recurrence). At baseline, they underwent pars plana vitrectomy with internal limiting membrane peeling, ending with dexamethasone intravitreal implant injection. Patients were then followed-up monthly, treated with a second injection at the first recurrence, and followed up to the second recurrence. Measurements of best corrected visual acuity, intraocular pressure, and central foveal thickness by spectral-domain optical coherence tomography were performed at each follow-up examination.

Results

Vitrectomized eyes showed a significant extension of recurrence time of diabetic macular edema, and specifically from 3.4 (3.2–3.7) to 6.5 (5.7–8.2) months after the first injection, and to 7.0 (5.7–8.2) months (p < 0.01) after the second injection (p < 0.01).

Conclusions and importance

Pars plana vitrectomy with internal limiting membrane peeling seems not to influence functional and anatomical results in eyes under treatment with dexamethasone intravitreal implant injections for diabetic macular edema, but appears to significantly extend the benefit of the drug.

Early DMO: a predictor of poor outcomes following cataract surgery in diabetic patients. The DICAT-II study

BACKGROUND

The prospective DIabetes and CATaract Study II (DICAT II) was performed to characterise the risks of cataract surgery to the retinae of patients with early diabetic macular oedema (E-DMO).

METHODS

DICAT II was a prospective, comparative, multicentre, observational study involving six Italian clinics. Patients were aged ≥55 years, had type 1 or 2 diabetes with spectral-domain optical coherence tomography evidence of ESASO classification Early DMO. Group 1 eyes (78 eyes, 78 patients) underwent phacoemulsification-based cataract surgery. Group 2 eyes (65 eyes, 65 patients) had E-DMO and either clear media or had undergone uncomplicated cataract surgery ≥1 year previously. Central subfield thickness (CST) and best-corrected visual acuity (BCVA) were assessed in both groups.

RESULTS

The negative impact of surgery on CST was evident after the first postoperative week; CST peaked during the first month, then rapidly decreased. CST worsening ≥10 µm was observed in 63/78 eyes (80.7%) and 29/65 eyes (44.6%) in Groups 1 and 2, respectively (p < 0.0001). CST worsening of ≥50 µm was observed in 51 eyes (65.4%) and 10 eyes (15.4%) in Groups 1 and 2, respectively (p < 0.0001). Mean CST worsening was lower in Group 2 than in Group 1 (38.6 ± 30.4 µm vs 85.5 ± 55.3 µm, p < 0.0001) with a lower BCVA loss (-2.6 ± 3.5 letters vs -8.2 ± 6.2 letters, p < 0.0001). Higher glycaemic levels and HBA1c levels were significantly associated with the risk of >50 μm CST worsening in eyes from both groups.

CONCLUSION

Early DMO is associated with poorer outcomes after cataract surgery and requires close pre- and postoperative monitoring.

Intravitreal dexamethasone implant one month before versus concomitant with cataract surgery in patients with diabetic macular oedema: the dexcat study

PURPOSE

To report clinical outcomes of two different timings of intravitreal dexamethasone (DEX) implant administration for prevention of diabetic macular oedema (DME) worsening following cataract surgery.

METHODS

This multicentre, retrospective study included patients with DME who received an intravitreal DEX implant 1 month before cataract surgery, 'precataract DEX' group, or at the time of cataract surgery, 'concomitant treatments' group. Inclusion criteria were a follow-up ≥3 months and ophthalmological examination with optical coherence tomography (OCT) imaging at baseline (cataract surgery) and throughout follow-up. Anatomical improvement was considered to be a decrease in OCT central subfield (CSF) thickness ≥20% compared to baseline. The primary outcomes were anatomical and functional results at 3 months.

RESULTS

Two hundred twenty-one patients were included: 136 in the 'precataract DEX' group and 85 in the 'concomitant treatments' group. At 3 months, a reduction of CSF thickness ≥ 20% was found in 7.3% of eyes in the 'precataract DEX group' and in 83.7% of eyes in the 'concomitant treatments' group (p < 0.001), with mean CSF thickness lower in the latter group (371 ± 52 µm versus 325 ± 57 µm, p < 0.001). At 3 months, mean best-corrected visual acuity had improved from baseline in both groups (p < 0.001), with no difference between groups (p = 0. 20). No serious systemic adverse events were reported.

CONCLUSION

Both approaches prevented a worsening of DME, showing a comparable visual outcome. Dexamethasone (DEX) implant given at the same time as cataract surgery provided a better anatomical outcome.

Dexamethasone implants in patients with diabetic macular edema undergoing cataract surgery: Italian expert panel consensus statements

PURPOSE

Intravitreal corticosteroid implants based on sustained-release dexamethasone provide effective retinal delivery of drug for around 6 months for the treatment of diabetic macular edema (DME). As current recommendations on the management of patients with DME undergoing cataract surgery are limited, this article aims to highlight issues and provide guidance on the use of dexamethasone intravitreal implants (DEX-DDS) in patients with DME undergoing cataract surgery, based on the consensus findings of a panel of Italian experts.

METHODS

The panel developed a survey regarding the use of DEX-DDS in patients with DME undergoing cataract surgery, following a comprehensive literature search. The results of the survey were discussed at an experts' meeting in September 2018, with a structured approach to determining consensus. The routine management of patients with DME undergoing cataract surgery was also developed for use as a basis of discussion to highlight current issues.

RESULTS

Eight consensus statements are presented, along with key issues that highlight controversial/outstanding issues in the use of DEX-DDS in DME patients with cataracts.

CONCLUSION

The consensus statements can help provide practical guidance for clinicians in daily practice on the rationale, patient diagnosis and selection, and optimal management of patients with DME undergoing cataract surgery.

Diabetes and diabetic retinopathy in patients undergoing cataract surgery: a prevalence study-DiCat study report #2

PURPOSE

To report on the prevalence of diabetes, diabetic macula oedema (DME) and retinopathy and their respective grading in a large cohort of patients undergoing cataract surgery.

METHODS

Data on previous diagnosis of diabetes, fasting glucose, glycated haemoglobin, presence and type of retinopathy and other maculopathy of 3657 patients over 55 years of age undergoing cataract surgery in 13 centres scattered throughout Italy were analysed.

RESULTS

A total of 20.4% of patients were known diabetics and 27.9% of diabetics showed signs of retinopathy. Haemoglobin A1C was higher than 48 mmol/L (6.5%) in 32% of diabetics and 2.4% non-diabetics. Fasting blood glucose level was higher than 120 mg/dL in 4.3% non-diabetics and 50% diabetics. Duration of diabetes did not significantly correlate with either fasting glucose or glycated haemoglobin, while higher grades of diabetic retinopathy were significantly more prevalent as duration of disease increased. DME was present in almost 40% of diabetics and 22% of patients showed non-diabetic maculopathy.

DISCUSSION

Diabetic retinopathy and DME worsen after cataract extraction thus complicating long-term prognosis and requiring expensive injective therapy. Since unknown diabetics represent 2-4% of the many million cataract candidates and even known diabetics show poor metabolic control and high rates of DME, preoperative medical testing and accurate retinopathy screening may prove both ethically necessary and cost-effective.

An optical coherence tomography-based grading of diabetic maculopathy proposed by an international expert panel: The European School for Advanced Studies in Ophthalmology classification

AIMS

To present an authoritative, universal, easy-to-use morphologic classification of diabetic maculopathy based on spectral domain optical coherence tomography.

METHODS

The first draft of the project was developed based on previously published classifications and a literature search regarding the spectral domain optical coherence tomography quantitative and qualitative features of diabetic maculopathy. This draft was sent to an international panel of retina experts for a first revision. The panel met at the European School for Advanced Studies in Ophthalmology headquarters in Lugano, Switzerland, and elaborated the final document.

RESULTS

Seven tomographic qualitative and quantitative features are taken into account and scored according to a grading protocol termed TCED-HFV, which includes foveal thickness (T), corresponding to either central subfoveal thickness or macular volume, intraretinal cysts (C), the ellipsoid zone (EZ) and/or external limiting membrane (ELM) status (E), presence of disorganization of the inner retinal layers (D), number of hyperreflective foci (H), subfoveal fluid (F), and vitreoretinal relationship (V). Four different stages of the disease, that is, early diabetic maculopathy, advanced diabetic maculopathy, severe diabetic maculopathy, and atrophic maculopathy, are based on the first four variables, namely the T, C, E, and D. The different stages reflect progressive severity of the disease.

CONCLUSION

A novel grading system of diabetic maculopathy is hereby proposed. The classification is aimed at providing a simple, direct, objective tool to classify diabetic maculopathy (irrespective to the treatment status) even for non-retinal experts and can be used for therapeutic and prognostic purposes, as well as for correct evaluation and reproducibility of clinical investigations.

Prevalence of diabetes and diabetic macular edema in patients undergoing senile cataract surgery in Italy: The DIabetes and CATaract study

BACKGROUND

The purpose of this study is to determine the prevalence of diabetes and diabetic macular edema in patients undergoing senile cataract surgery in Italy.

METHODS

It is a prospective, multicenter, cross-sectional study. Thirteen ophthalmic units equally distributed across the Italian territory have been involved in the study. For a period of 3 months, all subjects undergoing phacoemulsification received an Optical Coherence Tompgraphy (OCT) scan and were screened for the anamnestic presence of diabetes. In addition, five selected units collected blood samples from all their patients to measure glycated hemoglobin (HbA1c) levels and detect the presence of occult diabetes (HbA1c > 6.5%). In diabetic patients, levels of retinopathy were measured and diabetic macular edema was considered significant (clinically significant macular edema) when foveal thickness was above 30% of normal levels.

RESULTS

A total number of 3657 subjects have been screened. Among them, 20.4% were diabetics. Prevalence of diabetes was significantly higher in males (24.7%) than in females (17%). Levels of HbA1c were tested in a representative sample of 1216 consecutive subjects, and occult diabetes was diagnosed in 4.8% of cases. No significant differences were observed between age groups or different geographic areas. Among diabetic patients, diabetic macular edema of any kind was present in 27.5% (clinically significant macular edema (6.6%)). No significant differences were seen in the prevalence of diabetic macular edema between males and females or between age groups. Among the 745 diabetic patients, no signs of retinopathy were seen in 537 subjects (76.3%), while 101 patients (14.3%) had nonproliferative retinopathy, 13 (1.7%) had nontreated proliferative diabetic retinopathy, and 53 (7.5%) had laser-treated retinopathy. In the entire sample of 3657 subjects, a normal macula was present in 90.9% of cases, diabetic macular edema of any kind in 5.4%, and other maculopathies in 3.4%.

CONCLUSION

In this large cohort study on patients undergoing cataract surgery, more than one-fourth were diabetics and more than one-fourth of these had diabetic macular edema. These high prevalences suggest the opportunity to plan an adequate preoperative assessment in all patients in order to reduce the risk of postoperative development or worsening of a sight-threatening complication such as chronic diabetic macular edema.

Novel Artificial Tears Containing Cross-Linked Hyaluronic Acid: An In Vitro Re-Epithelialization Study

Dry eye syndrome is a common disease which can damage the corneal epithelium. It is treated with eye drops to stimulate tear production and hydrate the corneal surface. The most prescribed artificial tear remedies contain hyaluronic acid (HA), which enhances epithelial wound healing, improving tissue health. To the best of our knowledge, only a few recent studies have investigated cross-linked HA (HA-CL) in eye drops for human applications. This work consists in an in vitro evaluation of the re-epithelialization ability of two different preparations containing a recently synthetized HA cross-linked with urea: 0.02% (w/v) HA-CL (solution 1, S1), and 0.4% (w/v) HA-CL (solution 2, S2). The study was conducted on both 2D human corneal cells (HCEpiC) and 3D reconstructed tissues of human corneal epithelium (HCE). Viability by 3(4,5-dimethylthiazol-2)2,5-diphenyltetrazolium bromide (MTT) test, pro-inflammatory cytokine release (interleukin-8, IL-8) by ELISA, and morphology by hematoxylin and eosin (HE) staining were evaluated. In addition, to understand the molecular basis of the re-epithelialization properties, cyclin D1 levels were assessed by western blot. The results showed no cellular toxicity, a slight decrease in IL-8 release, and restoration of epithelium integrity when the wounded 3D model was treated with S1 and S2. In parallel, cyclin D1 levels increased in cells treated with both S1 and S2.

Morphologic Criteria of Lesion Activity in Neovascular Age-Related Macular Degeneration: A Consensus Article

Intravitreal antivascular endothelial growth factor drugs represent the current standard of care for neovascular age-related macular degeneration (nAMD). Individualized treatment regimens aim at obtaining the same visual benefits of monthly injections with a reduced number of injections and follow-up visits, and, consequently, of treatment burden. The target of these strategies is to timely recognize lesion recurrence, even before visual deterioration. Early detection of lesion activity is critical to ensure that clinical outcomes are not compromised by inappropriate delays in treatment, but questions remain on how to effectively monitor the choroidal neovascularization (CNV) activity. To assess the persistence/recurrence of lesion activity in patients undergoing treatment for nAMD, an expert panel developed a decision algorithm based on the morphological features of CNV. After evaluating all current retinal imaging techniques, the panel identified optical coherent tomography as the most reliable tool to ascertain lesion activity when funduscopy is not obvious.

Diode laser, vitrectomy and intravitreal triamcinolone. A comparative study for the treatment of diffuse non tractional diabetic macular edema

PURPOSE

To determine the effectiveness and safety of diode laser, pars plana vitrectomy (PPV) with gas tamponade, and intravitreal triamcinolone (IVT) as possible treatments for diffuse diabetic macular edema (dDME). To determine whether the new macular edema Classification previously proposed by some of the authors may help as a guide in the choice of treatment.

METHODS

A retrospective, comparative study of 169 eyes with dDME that underwent treatment. The eyes divided into 3 groups: in the PPV Group, 59 eyes received PPV with gas tamponade; in the DIODE Group, 53 eyes received a laser grid; in the IVT Group, 57 eyes received an intravitreal injection of 4 mg of triamcinolone acetonide. The follow up ranged from 6 to 24 months. The eyes were classified according to the new DME Classification based on OCT.

MAIN OUTCOMES

Change in foveal thickness as determined by Optical Coherence Tomography (OCT); change in visual acuity; intra and postoperative complications.

RESULTS

Mean visual acuity (VA) improved at 3 months with every treatment. At one year only eyes which underwent PPV still had better VA than the pre-op value, while eyes which underwent IVT and laser treatment showed regression. PPV show the greater percentage of eyes which gain 3 or more lines of VA at one year (17%). Mean foveal thickness improved at 3 months with every treatment. Only the eyes into the PPV Group showed relatively low foveal thickness at one year. Better final VA and foveal thickness were obtained if preop VA is > or = 0.3 and if earlier stages of DME were treated according to the new DME Classification. PPV was the treatment which offered the most stable results with at one year or longer. Similar results were observed into the PPV Groups as a whole and into a subgroup of eyes with preoperative PVD. No complications were encountered with laser diode treatment. Long term complications into the IVT Group were elevated IOP (8%), retinal detachment (3.5%) and posterior cataract (15%). Long term complications into the PPV Group were retinal detachment (3.4%) and cataract (90%).

CONCLUSIONS

Diode laser, PPV with gas tamponade and IVT are effective alternative treatments to decrease foveal thickness and improve visual acuity in eyes with DME. However while the results of PPV are stable in the long term follow-up, diode laser and IVT do not offer stable results. Complications may be severe with PPV and IVT. It is necessary to carefully select cases which would benefit from these types of treatments. The authors think that the OCT Classification may serve as a guide for the choice of treatment.

OCT in the monitoring of visual recovery after uneventful retinal detachment surgery

The aim is to describe 5 cases of unexplained visual impairment after uneventful episcleral surgery associated with submacular lesions occurring post-operatively (bleb-like syndrome). The 5 cases were followed with biomicroscopy and OCT for up to 6 months. At biomicroscopy the 5 eyes presented no visible abnormalities or a yellow subfoveal dot. OCT demonstrated the presence of isolated or multiple subfoveal or submacular blebs. Some cases experienced partial or total slow spontaneous resolution, while other blebs remained stable for months or slightly enlarged. In conclusion, OCT can play an important role in the follow up of patients with unexplained visual impairment after episcleral surgery and diagnose the presence of small subfoveal shallow retinal detachments persistent for months after surgery. We think that OCT should be routinely considered in the follow-up of these patients.

Vitrectomy for Myopic Traction Maculopathy

OBJECTIVE

To describe the results of vitrectomy in highly myopic eyes affected by a form of posterior vitreous traction termed myopic traction maculopathy (MTM).

METHODS

In this retrospective case series, 24 highly myopic eyes with MTM underwent vitrectomy and release of vitreoretinal traction without final fluid/gas exchange. Nine eyes (37.5%) received a combined phacovitrectomy. Mean patient age was 58 years, mean refractive error was -16.8 dioptric spherical equivalent, and preoperative visual acuity ranged from 20/400 to 20/32 (mean, 20/80). Mean follow-up was 29.6 months.

RESULTS

Twenty-three (95.8%) of 24 eyes had complete and stable resolution of MTM after a mean of 4.4 months. Mean visual improvement was 2.5 Snellen lines (range, 0 to 6 lines). Five eyes (20.8%), despite achieving complete retinal flattening, developed a macular hole that did not progress to macular detachment during follow-up.

CONCLUSIONS

Vitrectomy without fluid/gas exchange leads to stable resolution of MTM and good visual improvement. Posterior retinal detachment probably precedes macular hole formation in highly myopic eyes.

Diabetic macular edema: an OCT-based classification

PURPOSE

More than ten years after ETDRS, Optical Coherence Tomography (OCT) greatly enhanced our ability to detect macular thickening and has brought new insights on the morphology of edema and on the presence of vitreal traction. In this study we propose a new classification of macular edema based on OCT findings to better catalogue and follow this complex clinical entity.

METHODS

Since January 2000 we analysed with OCT 2 (Zeiss Inc.) more than one thousand and two hundred eyes with DME.

RESULTS

The classification takes into account five parameters: retinal thickness, diffusion, volume, morphology and presence of vitreous traction. Standard figures and numerical values for every parameter are given.

CONCLUSION

Although ETDRS guidelines for laser treatment of DME still remain the only proven therapy for this condition, many other strategies are now on trial, and the vast majority of authors use OCT as the best indicator of therapeutic benefit. The amount of information given by OCT demonstrates that macular edema is a complex clinical entity with various morphology and gravity, and disclaimed the limitations of a simple "clinical" definition. As in many other examples such as macular holes and choroidal neovascularization, a uniform and precise definition of macular edema would increase the possibility to compare and judge the result of different therapeutic strategies. Aim of this classification is to implement the ETDRS clinical definition of DME with the precise and useful data given by OCT to better diagnose, catalogue and follow macular edema.

Cataracts associated with posterior segment surgery

Although cataract is widely described among the complications of vitrectomy, the precise relationship between vitrectomy and the development of lens opacity is not completely understood. This article presents an extensive literature review and the authors' personal experience with this complication.

Role of OCT in the diagnosis and follow up of diabetic macular edema

The aim is to present, along with a brief literature review, the results of OCT scan in eyes with diabetic macular edema (DME), as well as examples of the utility of OCT for different therapeutic approaches. One-hundred and thirty-six eyes with diabetic retinopathy were analyzed with OCT to explore the different patterns of DME. Some eyes with DME were studied with OCT pre and postoperatively to determine the efficacy of photocoagulation and vitrectomy to restore a normal macular profile. Sixty-eight eyes with a central foveal thickness of 200 mu or more were considered "edematous". Three different patterns of DME were recognized and analyzed: macular thickening, cystoid macular edema and shallow retinal detachment. The change in macular profile and internal retinal structure after laser or surgical treatment are well visible with OCT. OCT contributes in understanding the anatomy of DME and the intraretinal damage and seems to be the technique of choice for the follow-up of macular edema. We think that this tool should always be used in monitoring the effect of therapies in future studies.

Relationships between vitreoretinal and refractive surgery

OBJECTIVE

To describe retinal complications after posterior chamber phakic intraocular lens (PCPIOL) implantation and refractive surgery complications after scleral buckling surgery.

DESIGN

Retrospective, noncomparative, small case series.

PARTICIPANTS

Four patients in whom retinal detachment developed after PCPIOL implantation and two patients with previously placed encircling scleral buckles in whom corneal steepening developed after laser in situ keratomileusis (LASIK).

INTERVENTION

The four patients with retinal detachment after PCPIOL implantation underwent vitreoretinal surgery. One of the two patients in whom corneal steepening developed after LASIK underwent buckle removal.

MAIN OUTCOME MEASURES

The main parameters evaluated were vitreoretinal findings, corneal topography, and pachymetry.

RESULTS

Retinal attachment was achieved for all patients. Mean postoperative best-corrected visual acuity (BCVA) was 20/30. One patient lost one line of BCVA. One patient with corneal steepening achieved partial corneal flattening after buckle removal.

CONCLUSIONS

Vitreous base stimulation related to PCPIOL implantation and manipulation during LASIK may trigger retinal complications. Laser in situ keratomileusis in patients with previously placed scleral buckles may result in unexpected corneal steepening.

Vitrectomy for refractory diabetic macular edema

Diabetic macular edema may occur or worsen as a consequence of vitreomacular traction in some eyes. The precise role of the posterior hyaloid in the pathogenesis of diabetic maculopathy remains unclear. The determination of which eyes might benefit from vitrectomy is the most challenging aspect in the treatment of this condition. Fluorescein angiography, B-scan untrasonography, and optical coherence tomography may be helpful in this regard. Most often, vitreous surgery is performed when diabetic macular edema persists despite multiple laser treatments. All reports published to date regarding vitrectomy for diabetic macular edema are uncontrolled and nonrandomized patient series. Visual improvement after vitrectomy is related to the duration of edema, as well as the extent of intraretinal lipid and vascular nonperfusion.

Association of xerophthalmia, flecked retina, and pseudotumor cerebri caused by hypovitaminosis A

PURPOSE

To report an unusual case of hypovitaminosis A with bilateral papilledema and flecked retina that regressed after restoration of vitamin A deficiency.

METHOD

Case report. A 27-year-old woman had undergone a biliopancreatic bypass for obesity in 1990. In 1995, she presented with bilateral xerophthalmia, bilateral papilledema, and bilateral flecked retina.

RESULTS

Laboratory tests demonstrated low serum levels of vitamin A (0.8 micromol/l) and vitamin E (8.54 micromol/l). Xerophthalmia, papilledema, and flecked retina disappeared after restoration of normal vitamin A blood levels.

CONCLUSION

Hypovitaminosis A after biliopancreatic bypass for obesity may be associated with xerophthalmia, pseudotumor cerebri, and flecked retina.

Hereditary hyperferritinemia-cataract syndrome caused by a 29-base pair deletion in the iron responsive element of ferritin L-subunit gene

Iron availability regulates ferritin synthesis posttranscriptionally by the interaction between iron-regulatory proteins (IRPs) and an iron responsive element (IRE), a stem-loop sequence located on the 5' untranslated region of ferritin mRNA. IRPs recognize IREs as a sequence/structure motif, blocking ferritin translation. Recently, we and others independently described families with a combination of hyperferritinemia (serum L-ferritin > or = 1,000 microg/L, without iron overload) and congenital bilateral cataract, transmitted as an autosomal-dominant trait. The molecular basis were two distinct point mutations in the highly conserved CAGUG(X) hexaloop of L-ferritin IRE on chromosome 19. A new three-generation family with a similar phenotype and a unique genotype is here reported. DNA amplification by polymerase chain reaction and sequence analysis showed a 29-base pair deletion in the L-ferritin IRE, involving the whole 5' sequence essential to the base pairing of the IRE stem. This deletion is predicted to cause the disruption of IRE stem-loop secondary structure and the nearly complete abolition of the negative control of ferritin synthesis by IRE/IRP binding. Hereditary Hyperferritinemia-Cataract Syndrome (HHCS) appears as a new genetic disorder with a unique phenotype associated with at least four different mutations in the L-ferritin IRE. Hematologists should take into account HHCS in the differential diagnosis of unexplained hyperferritinemia.

Clinicopathologic correlation of localized retinal pigment epithelium debridement

PURPOSE

To characterize changes in the retina, retinal pigment epithelium (RPE), and choriocapillaris with fluorescein angiography (FA) and histology after hydraulic or abrasive RPE debridement in 26 domestic short-haired cats.

METHODS

Hydraulic debridement was produced by injecting balanced salt solution forcefully into the subretinal space. For abrasive debridement, RPE were removed with a silicone-tipped cannula after creating a localized retinal detachment. The FAs were performed after surgery, and tissue was prepared for light microscopy (LM) and scanning electron microscopy (SEM).

RESULTS

Sixty-seven blebs were examined by FA 1 hour after surgery, and RPE debridement was confirmed by SEM or LM in 15 blebs from 10 animals. Hyperfluorescence and variable central fluorescein leakage were seen 1 week after surgery in 52 of 53 blebs (which includes all 27 blebs from the 1-week timepoint and 26 of 29 blebs from the 4-week timepoint that were studied by FA 1 week after surgery). Choriocapillary filling delays were seen in no hydraulic debridements, but in 11 of 14 abrasive blebs, especially in areas showing leakage late in the angiogram. In 1 of 13 hydraulic and 12 of 14 abrasive debridements, areas of late dye leakage had no RPE with outer retinal degeneration. At the 4-week timepoint, 1 of 17 hydraulic and 10 of 12 abrasive debridements had foci of delayed or absent choriocapillary perfusion by FA, with degenerated outer retina, no RPE, and choriocapillary atrophy by histologic analysis.

CONCLUSIONS

Abrasive debridement is more commonly associated with abnormal FAs and with incomplete RPE repopulation, choriocapillaris atrophy, and outer retinal degeneration than is hydraulic debridement. This clinicopathologic study may give insight into FA interpretation after choroidal neovascular membrane removal in human patients.

Effect of inflammation on intraocular penetration of intravenous ofloxacin in albino rabbits

The effect of inflammation on the intraocular penetration of ofloxacin was studied in 20 albino rabbits (New Zealand White). Inflammation was induced in the left eye by inoculation of a suspension of 10(9) CFU of heat-killed Staphyloccus epidermidis per 0.1 ml of saline solution (0.9%) in the midvitreous cavity. The other eye was kept as a control. Twenty-four hours following inoculation, ofloxacin was administered in the marginal ear vein at a dose of 15 mg/kg over 20 min with an infusion pump. Animals were sacrificed at different times up to 24 h following drug administration. Ofloxacin levels were determined in aqueous humor, vitreous humor, and serum by a bioassay. Inflammation was scored on the basis of perilimbal and corneal reactions and vitreoretinal statuses. Inflammation had a relevant effect on intraocular penetration of ofloxacin, with levels in the ocular fluids of the inflamed eye markedly exceeding the ones of the control eye. In the uninflamed eye, the levels were rapidly decaying below assay sensitivity and were no longer detectable at approximately 5 h following drug administration while they were still detectable in both ocular fluids of the inflamed eye at 24 h. Ofloxacin levels in the ocular fluids of the inflamed eye were superior to the MIC for several of the bacteria which commonly cause endophthalmitis, including Staphylococcus epidermidis, Staphylococcus aureus, most members of the family Enterobacteriaceae, Haemophilus influenzae, and strains of Pseudomonas aeruginosa.

[Do radiologists develop perceptual learning contrast sensitivity?]

A slight difference in brightness between objects close to each other and with no clear-cut outlines separating them can be recognized by the visual function called contrast sensitivity. This function is particularly developed in the radiologist, whose task is to analyze images in many shades of grey and with no clear-cut outlines, due to kinetic and radiogeometrical shading. Assuming that professional habit might develop this function, the authors compared contrast sensitivity in a group of 26 radiologists with contrast sensitivity in a control group (30 non-radiologists). The Vistech VTCS 6500 test was chosen for the task because of its practicality and reliability. The test consists in the recognition of the orientation of 5 series of alternate bright and dark lines differencing in thickness and contrast. The results obtained in the two groups were studied and compared with the statistical test of the analysis of variance, the T-test by Student and the U-test by Mann-Whitney. Contrast sensitivity was surprisingly higher in the radiologists group, in 4 of 5 series of images with bright and dark lines, than in controls and the difference was statistically significant: p < 0.001 with the test and the U-test. A deviation standard increase in contrast sensitivity was found also in radiologists with short-term professional activity (a few years). To explain these results, two hypotheses one suggested by the authors: radiologists pay greater attention to image details, because of their profession; perceptual learning--that is an improvement in the image-research cortical function--might occur, because of constant training. In the radiologist to conclude repeated stimulation of research capabilities in low-contrast images is thought to improve the efficiency of this cortical function.

Skin substitutes in the treatment of deep partial skin thickness burns in children: clinical experience and long-term results

This report describes the use of skin substitutes in the treatment of deep partial skin thickness burns in childhood. These are lesions that, if treated inadequately, can result in severe scarring. However, if treated appropriately, they can heal without any sequelae, which is obviously crucial for aesthetic and psychological reasons. This review contains children admitted to the authors' Burn Unit over a 5-year period (1984-88) with deep partial skin thickness lesions which were treated with synthetic and/or biosynthetic skin substitutes and without surgical procedures. This group of children has been compared with another group hospitalized for burns of the same depth and treated with conventional closed wound management. First, short-term results are presented, highlighting healing time, followed by the long-term results from an aesthetic and functional viewpoint.

Injection therapy with triamcinolone hexacetonide in the treatment of burn scars in infancy: results of 44 cases

In many cases deep second degree and third degree burns cause severe scarring. The authors have reported here their experience of the treatment of hypertrophic scarring from burns carried out on 44 children with intralesional injections of a long-acting cortico-steroid (Triamcinolone hexacetonide) using the jet spray technique.