Non-invasive Respiratory Support and Severe Retinopathy of Prematurity

The authors describe two premature infants who developed stage 3, zone I retinopathy of prematurity (ROP) with plus disease in both eyes, despite limited exposure to supra-ambient oxygen. Both infants received noninvasive respiratory support for several weeks. Both cases are notable because the ROP was more posterior and aggressive than is typical for the gestational ages or birth weights. These cases are insufficient to make definitive conclusions regarding the factors that cause ROP. Further investigation is required to determine if there is an association between the use of non-invasive respiratory support, even in the absence of supra-ambient oxygen, and severe ROP development. [J Pediatr Ophthalmol Strabismus. 2016;53:e47-e50.].

Intravitreal bevacizumab versus ranibizumab for the treatment of retinal angiomatous proliferation

PURPOSE

To evaluate the effects of intravitreal bevacizumab and ranibizumab treatments in retinal angiomatous proliferation (RAP).

METHODS

Fifty patients affected by RAP were randomly assigned either to intravitreal bevacizumab injection (IVBI) or intravitreal ranibizumab injection (IVRI). After a loading phase including three consecutive monthly injections, the retreatment was administered in cases of persistent RAP. The primary outcome measures were the mean changes in BCVA between the two treatment groups, and the proportion of eyes gaining 1 and 3 lines at the end of the follow-up. Secondary outcomes included central macular thickness (CMT) changes and progression to more advanced stages of RAP.

RESULTS

Fifty patients affected by stage 1 and 2 RAP were recruited. Twenty-six and 24 patients received IVBI and IVRI, respectively. At the baseline, mean best corrected visual acuity (BCVA) values were 0.59 ± 0.21 (LogMAR ± SD, approximately corresponding to 20/80 Snellen Equivalent-SE) in IVBI group and 0.66 ± 0.33 (approximately 20/90 SE) in IVRI group with no statistical difference. At 12-month examination, both groups showed a statistically significant improvement in the BCVA, with a final mean value of 0.43 ± 0.24 (approximately 20/54 SE) in IVBI group and 0.50 ± 0.32 (approximately 20/63 SE) in the IVRI group. A BCVA gain of 1 and 3 lines was registered in 20 and 8 eyes, respectively, in the IVBI group. Similarly, 17 and 7 eyes showed an improvement of 1 or 3 lines, respectively, in the IVRI group. The CMT reduced significantly from baseline to 12-month examination in both groups. A lower proportion of eyes with complete pigment epithelium detachment resolution was noted in the IVBI group than in the IVRI group (40% versus 90%).

CONCLUSIONS

Our study shows that both IVBI and IVRI are equally effective in improving the BCVA over a 1-year follow-up in eyes affected by stage 1 and 2 RAP.

Identifying subtypes of patients with neovascular age-related macular degeneration by genotypic and cardiovascular risk characteristics

BACKGROUND

One of the challenges in the interpretation of studies showing associations between environmental and genotypic data with disease outcomes such as neovascular age-related macular degeneration (AMD) is understanding the phenotypic heterogeneity within a patient population with regard to any risk factor associated with the condition. This is critical when considering the potential therapeutic response of patients to any drug developed to treat the condition. In the present study, we identify patient subtypes or clusters which could represent several different targets for treatment development, based on genetic pathways in AMD and cardiovascular pathology.

METHODS

We identified a sample of patients with neovascular AMD, that in previous studies had been shown to be at elevated risk for the disease through environmental factors such as cigarette smoking and genetic variants including the complement factor H gene (CFH) on chromosome 1q25 and variants in the ARMS2/HtrA serine peptidase 1 (HTRA1) gene(s) on chromosome 10q26. We conducted a multivariate segmentation analysis of 253 of these patients utilizing available epidemiologic and genetic data.

RESULTS

In a multivariate model, cigarette smoking failed to differentiate subtypes of patients. However, four meaningfully distinct clusters of patients were identified that were most strongly differentiated by their cardiovascular health status (histories of hypercholesterolemia and hypertension), and the alleles of ARMS2/HTRA1 rs1049331.

CONCLUSIONS

These results have significant personalized medicine implications for drug developers attempting to determine the effective size of the treatable neovascular AMD population. Patient subtypes or clusters may represent different targets for therapeutic development based on genetic pathways in AMD and cardiovascular pathology, and treatments developed that may elevate CV risk, may be ill advised for certain of the clusters identified.

New classification system-based visual outcome in Eales' disease

PURPOSE

A retrospective tertiary care center-based study was undertaken to evaluate the visual outcome in Eales' disease, based on a new classification system, for the first time.

MATERIALS AND METHODS

One hundred and fifty-nine consecutive cases of Eales' disease were included. All the eyes were staged according to the new classification: Stage 1: periphlebitis of small (1a) and large (1b) caliber vessels with superficial retinal hemorrhages; Stage 2a: capillary non-perfusion, 2b: neovascularization elsewhere/of the disc; Stage 3a: fibrovascular proliferation, 3b: vitreous hemorrhage; Stage 4a: traction/combined rhegmatogenous retinal detachment and 4b: rubeosis iridis, neovascular glaucoma, complicated cataract and optic atrophy. Visual acuity was graded as: Grade I 20/20 or better; Grade II 20/30 to 20/40; Grade III 20/60 to 20/120 and Grade IV 20/200 or worse. All the cases were managed by medical therapy, photocoagulation and/or vitreoretinal surgery. Visual acuity was converted into decimal scale, denoting 20/20=1 and 20/800=0.01. Paired t-test / Wilcoxon signed-rank tests were used for statistical analysis.

RESULTS

Vitreous hemorrhage was the commonest presenting feature (49.32%). Cases with Stages 1 to 3 and 4a and 4b achieved final visual acuity ranging from 20/15 to 20/40; 20/80 to 20/400 and 20/200 to 20/400, respectively. Statistically significant improvement in visual acuities was observed in all the stages of the disease except Stages 1a and 4b.

CONCLUSION

Significant improvement in visual acuities was observed in the majority of stages of Eales' disease following treatment. This study adds further to the little available evidences of treatment effects in literature and may have effect on patient care and health policy in Eales' disease.

Subtype lesions of neovascular age-related macular degeneration in Chinese patients

PURPOSE

To identify the subtype frequency and clinical features of neovascular age-related macular degeneration (AMD) in Chinese patients.

METHODS

From January 2003 to August 2006, we investigated prospectively 155 newly diagnosed patients with presumed neovascular AMD. Fundus fluorescein angiography (FFA) and indocyanine green angiography (ICGA) were performed in both eyes of all patients. Subtype frequency and clinical features were recorded according to their angiograms.

RESULTS

Three subtypes of lesion were noted, which were polypoidal choroidal vasculopathy (PCV), retinal angiomatous proliferation (RAP) and mixed lesions. Of the 155 patients, 105 (67.7%) had choroidal neovascularization (CNV) of the typical type seen in AMD, 38 (24.5%) had PCV and seven (4.5%) had RAP. In five (3.2%) additional cases, mixed lesions were noted. In 38 cases (47 eyes) with PCV, the rates of subfoveal, juxtafoveal and extrafoveal lesion were respectively 29.8% (14 eyes), 8.5% (four eyes), and 61.7% (29 eyes), compared with 75.6%, 14.6% and 9.8% for CNV lesion (P < 0.01). The percentage of subfoveal lesion in PCV group was significantly lower than that in the CNV group (P < 0.01). The location of the RAP lesion was subfoveal in two (28.6%) eyes, juxtafoveal in three (42.9%) eyes and extrafoveal in two (28.6%) eyes. The five eyes with mixed lesions were all PCV coexisting with CNV at the same eye, and in all of the five cases, CNV was subfoveal while PCV was extrafoveal.

CONCLUSIONS

In this hospital-based study, PCV accounts for 24.5% of neovascular AMD and is the most common subtype, RAP is less frequent (4.5%), and mixed lesions are much less common in Chinese patients. PCV is least likely to involve the fovea in neovascular AMD.

Visual acuity change after intravitreal bevacizumab for exudative age-related macular degeneration in relation to subfoveal membrane type

PURPOSE

To examine an association between the subfoveal neovascular membrane type and visual acuity change after intravitreal bevacizumab injection for exudative age-related macular degeneration (AMD).

METHODS

We carried out a clinical, retrospective, interventional case-series study including 66 consecutive patients (67 eyes) with exudative AMD who received an intravitreal injection of 1.5 mg bevacizumab. Study subgroups included the occult type without or with minimally classic subfoveal neovascularization (n = 28 eyes, 42%), predominantly or purely classic subfoveal neovascularization (n = 22 eyes, 33%), and eyes with retinal pigment epithelium detachment (n = 17 eyes, 25%). Follow-up was >or= 2 months.

RESULTS

The maximal visual acuity (VA) gain (mean +/- standard deviation - 0.07 +/- 0.30 logMAR, 0.5 +/- 2.9 Snellen lines; p = 0.87), and VA gain at 1 month (p = 0.10), 2 months (p = 0.77) and 3 months (p = 0.35) after the injection did not vary significantly between the three study subgroups. Correspondingly, a multivariate analysis did not reveal a statistically significant (p = 0.57) influence of subfoveal lesion type on gain in VA.

CONCLUSIONS

Visual improvement after intravitreal bevacizumab does not differ markedly between various types of subfoveal neovascularization in AMD.

A new staging system for idiopathic retinal periphlebitis

PURPOSE

To develop and standardize a universally acceptable new staging system for idiopathic retinal periphlebitis (Eales disease).

METHODS

A new staging system was established and standardized based on standard terminology and features. Idiopathic retinal periphlebitis was classified as peripheral and central types. Peripheral disease consisted of four stages. Stage 1 is periphlebitis of small (1a) and large (1b) caliber vessels with superficial retinal hemorrhages. Stage 2a denotes capillary nonperfusion and 2b neovascularization elsewhere/of the disc. Stage 3a is classified as fibrovascular proliferation and 3b vitreous hemorrhage. Stage 4a is traction/combined rhegmatogenous retinal detachment whereas 4b is rubeosis iridis, neovascular glaucoma, complicated cataract, and optic atrophy. A total of 253 cases of idiopathic retinal periphlebitis (mean age, 24.7 +/- 4.7 years, all male) presenting at this tertiary care center were classified prospectively according to the new staging system, by two independent observers (interobserver correlation = 0.7).

RESULTS

The new staging system was consistent, simple, and easy to recall. Peripheral and central types of idiopathic retinal periphlebitis were found in 94.07% and 5.93% of cases, respectively. The new staging system also defined the severity of the disease. Vitreous hemorrhage was found to be the commonest presenting feature (51.68%), whereas traction/combined rhegmatogenous detachment was found in 5.88% of cases.

CONCLUSIONS

The new staging system is useful in classifying and assessing the severity of disease. Management strategy can also be defined according to the stage of the disease. It is designed to promote the use of standard assessment with applications to clinical management and research.

Subretinal organization in stage 5 retinopathy of prematurity

BACKGROUND

The subretinal organization (SRO) seen in patients who undergo vitrectomy for stage 5 retinopathy of prematurity has not previously been characterized. We report our observations of SRO and correlate its development with previous laser and cryotreatment for neovascular disease.

METHODS

We surveyed data from 426 eyes in a retrospective chart review of 263 patients that underwent open-sky vitrectomy for stage 5 retinopathy of prematurity.

RESULTS

Of 426 eyes evaluated, 130 eyes received laser, cryo, or a combination of both treatments. In 44 eyes (10.3%), SRO was observed and considered the cause of incomplete retinal attachment. Three forms of SRO were identified: subretinal bands (63.6%), subretinal plaques (15.9%), and diffuse SRO (18.2%). One patient had both a band and a plaque. SRO developed in 24 eyes after cryotreatment, 3 after laser, and 2 after combination cryo and laser treatment. Fewer untreated eyes than cryotreatment eyes developed SRO (15 of 296 eyes, 5.1%; ( P=0.0001). Eyes without laser or cryotreatment had a 5.1% frequency of developing SRO.

CONCLUSION

Subretinal organization, a previously uncharacterized entity in retinopathy of prematurity, was most frequently identified in the form of subretinal band formation. SRO was identified in 10.3% of all stage 5 eyes evaluated, and was associated with incomplete retinal reattachment in all cases.

[Pigment epithelial detachments in age-related macular degeneration -- classification, differentiation and prognosis]

BACKGROUND

A pigment epithelial detachment (PED) is an exudative manifestation of late age-related macular degeneration (AMD). Its long-term unfavourable prognosis is influenced by the association of a neovascular membrane. Seemingly identical PEDs in ophthalmoscopy can be further differentiated by fluorescein and indocyanine green angiography. The purpose of this prospective follow-up study was to determine the most reliable angiographic classification to distinguish PEDs in AMD and to evaluate their outcome.

MATERIAL AND METHODS

73 eyes of 68 patients with a PED in AMD were examined with simultaneous angiography with fluorescein and indocyanine green. 34 eyes were additionally scanned by retinatomography. Fluorescein angiographic classification comprises 4 types: 1. early hyperfluorescent type, 2. late hyperfluorescent type, 3. drusen type, 4. irregular fluorescent type. Indocyanine green angiographic classification consists of the following three groups: 1. angiographically no vascularisation, 2. associated choroidal neovascularisation, 3. associated polypoidal choroidal vasculopathy.

RESULTS

Both classifications show statistically significant correlation with visual acuity (fluorescein classification: P = 0.0112, ICG-classification: P = 0.0004) and area of the PEDs (fluorescein classification: P = 0.0002, ICG-classification: P < 0.0001). ICG-classification additionally is significantly associated with the volume (P = 0.0008). Both classifications correlate (P = 0.0001). Factors influencing visual acuity are: age (P = 0.0044), associated neovascular membrane (P = 0.0004), area (P < 0.0001), volume (P = 0.0077) and height (P < 0.0001).

CONCLUSIONS

PEDs in AMD can best be classified by indocyanine green angiography on the basis of an associated prognostically important neovascular membrane, which can only be further distinguished into choroidal neovascularisation or polypoidal choroidal vasculopathy by indocyanine green angiography. Statistical analysis shows qualitatively and quantitatively more significant results for the indocyanine green angiographic classification.

Subclassification of preproliferative diabetic retinopathy and glycemic control: relationship between mean hemoglobin A1C value and development of proliferative diabetic retinopathy

PURPOSE

We evaluated the relationship between long-term glycemic control and the proportion of patients developing proliferative diabetic retinopathy (PDR) among cases with mild type preproliferative diabetic retinopathy (PPDR).

METHODS

The relationship was evaluated between the mean hemoglobin A1C (HbA1C) value during a period of at least 2 years and the proportion of patients developing PDR among cases with mild type PPDR, based on our previously proposed subclassification.

RESULTS

During follow-up, 27% of the total PPDR cases developed PDR. The mean HbA1C value in those patients who had developed PDR was 9.4% and was significantly higher than the 7.6% in those who had not developed PDR. The proportion developing PDR was 48% of the cases with a mean HbA1C value of 8.6% or more. By comparison, the proportion developing PDR was 8% among those with a mean HbA1C value below 8.6%. The proportion developing PDR was estimated to approximately double with each 1% increase in the mean HbA1C value. The cumulative occurrence rates of PDR at 2, 5, and 10 years were estimated to be 5%, 28%, and 60% in cases with a mean HbA1C value of 8.6% or more, and 0%, 7%, and 14% in those with a mean HbA1C value below 8.6%, respectively.

CONCLUSION

Stricter systemic and ophthalmological control is indicated for cases with a mean HbA1C value exceeding 8.6%.

Neovascularization grading methods in a rat model of retinopathy of prematurity

PURPOSE

The method of counting cell nuclei above the internal limiting membrane in histologic sections is considered the standard when quantifying neovascularization (NV) in rodent oxygen-induced retinopathy (OIR). An alternative, more rapid method of counting clock hours in flatmounted adenosine diphosphatase (ADPase)-stained rat retinas is analogous to clinically scoring retinopathy of prematurity (ROP). In the present study, the validity of counting clock hours was evaluated by a direct comparison of these techniques. The intereye correlation of NV score and retinal vascular area were also studied.

METHODS

Newborn Sprague-Dawley rats were exposed to cycles of O2 (80-10%) for 7 days, followed by 5 days of room air recovery. Preretinal NV was quantified by three masked observers counting clock hours in flatmounted ADPase-stained retinas of both eyes. Retinal vascular and total retinal areas were calculated using computer-assisted analysis. Representative retinas that had been scored positive (n = 10) and negative (n = 3) for NV and room air control retinas (n = 3) were embedded in paraffin. Each entire peripheral retinal quadrant was serially sectioned at 6 microm and stained with hematoxylin and eosin. Nuclei above the internal limiting membrane were then counted in a masked manner. The total number of nuclei counted per retina was defined as the nucleus count (704-938 sections per retina; 12,900 sections). Correlations were evaluated using Spearman rank coefficients.

RESULTS

The nucleus count was 0 to 44 in room air control retinas, 0 to 40 in negative OIR retinas, and 250 to 5634 in positive OIR retinas. The nucleus count was highly correlated with the clock hour score (r(s) = 0.95, P = 0.0001). For the paired retinas, there was a significant correlation between right and left eyes in the severity of NV (clock hours; r(s) = 0.76, P = 0.0001) and the ratio of retinal vascular area to total retinal area (r(s) = 0.81, P = 0.0001).

CONCLUSIONS

The more rapid method of counting clock hours in flatmounted ADPase-stained retinas is valid for quantifying NV in rat models of ROP. Incidence and severity of NV and vascularized areas were similar between left and right eyes, which permits the use of paired retinas for complementary research techniques.

[Value of optical coherence tomography in diagnosis of age-related macular degeneration. Correlation of fluorescein angiography and OCT findings]

BACKGROUND

Age-related macular degeneration (AMD) is the leading cause of blindness in industrialized countries. In this study, we used optical coherence tomography for evaluation of patients with AMD.

METHODS

Optical coherence tomography imaging is analogous to ultrasound, except that reflected light instead of sound is used. The analysis of the reflected light is processed with the technique of low-coherence interferometry. In this study, 33 patients with different stages of AMD were examined with optical coherence tomography. The classification of AMD was according to the guidelines as proposed by the "International ARM Epidemiological Study group".

RESULTS

With this method we were able to identify drusen, alteration of the retinal pigment epithelium, and secondary retinal changes. Other structures such as basal laminar (linear) deposits could not be identified with this method. Choroidal neovascularization was evident in the tomogram. Classic choroidal neovascular membranes presented with well-defined boundaries on optical coherence tomography and occult choroidal neovascular membranes had a less delineable structure with optical coherence tomography.

CONCLUSION

Optical coherence tomography cannot replace conventional diagnostic techniques. This method provides no additional information in patients with non-exsudative AMD. In patients with choroidal neovascular membranes secondary to AMD optical coherence tomography may be able to characterize the relation of the membrane to the retinal pigment epithelium and imaging may be possible through hemorrhage. The interpretation of the optical coherence tomogram needs further studies including clinicopathologic correlation.

[Histological characterization and classification of surgically excised choroid neovascular membranes]

PURPOSE

This study was undertaken in order to histologically characterize surgically-excised choroidal neovascular membranes and to correlate theses histologic findings with the fundus and fluorescein angiographic appearance.

MATERIAL AND METHODS

Surgically-excised subfoveal choroidal neovascular membranes submitted in the time period from November 1994 to July 1996 were included in this study. The membranes were processed and evaluated by light and transmission electron microscopy. Some membranes were oriented by the surgeon and marked on their inner surface with India ink and the configurations of these membranes were recorded and correlated with the fundus and fluorescein angiographic features.

RESULTS

Sixty-two choroidal neovascular membranes were available for this study. In 74% age-related macular degeneration was the underlying disease. Retinal pigment epithelium and endothelial lined vascular channels were present in over 87.5% of cases. Basal laminar (linear) deposit was only present in membranes excised from patients with age-related macular degeneration. In six cases with Gass Type II choroidal neovascular membranes the histologic-clinical-fluorescein angiographic correlation showed well-defined (classic) neovascular membranes according to the criteria of the Macular Photocoagulation Study. Two membranes were not surrounded by retinal pigment epithelium and were classified as Type IIa membranes. Four membranes were surrounded by retinal pigment epithelium and classified as Type IIb membranes.

CONCLUSIONS

Choroidal neovascular membranes represent a stereotypic, non-specific wound repair response to a specific stimulus. Retinal pigment epithelium may proliferate around and attempt to wall off choroidal neovascular membranes. We propose a new classification of surgically-excised choroidal neovascular membranes as Types I, IIa, and IIb.

[Pattern dystrophies and intrafamilial phenotypic variation]

BACKGROUND

Transmitted in an autosomal dominant fashion, the pattern dystrophies involve the retinal pigment epithelium and the external macular retina and are usually divided into four different entities. However, a progression from one form to another is possible, various forms may coexist in the same patient and a combination of different entities may be present in the same family.

CASE REPORTS

Two families (4 cases) are described, in which a butterfly dystrophy coexist with a vitelliform dystrophy or with a central atrophy. Whereas the vitelliform dystrophy is usually characterised by a unique centromacular lesion, a case of multiple lesions is described. The possible association with a neovascular membrane is also presented.

CONCLUSION

The coexistence of various forms of pattern dystrophies in a same family suggests a variable expression of a same genetic disorder. The presence of a centromacular atrophy in one patient demonstrates also that the spectrum of the disease is not limited to the four classic entities.

[Peripheral neovascularization of the retina in diabetic retinopathy: fluorescein angiography classification and results of panretinal laser treatment]

The prospective study reported here was based on 105 diabetic eyes with "new vessels elsewhere" (NVE), treated exclusively by panretinal laser application and followed up for 2.5 to 4 years. Fundus angiography was performed before treatment. The eyes were then classified in four categories according to the extent and location of capillary nonperfusion responsible for the NVE, namely 1) generalized ischemia (Type A); 2) extensive midperipheral ischemia (Type B); 3) moderate midperipheral ischemia (Type C); and 4) peripheral ischemia (Type D). Analysis of the neovascularization distribution pattern showed that NVE alone existed only in Type D, whereas in the other three types the neovascularization was present either only in the retina or in both the retina and the optic disk. This mixed vascularization was 100% in Type A, 71% in Type B, 31% in Type C, and nonexistent in Type D. Statistical analysis revealed a significant correlation between the type of ischemia and the location of the new vessels. The therapeutic results 3-4 months, 1 year, and 2.5-4 years after intervention showed a significant trend toward an increase in the number of eyes with recurrences when moving from Type D to Type A. This means that the prognosis of NVE after panretinal laser coagulation depends mainly on the type of retinal ischemia. The poorest prognosis is that for generalized ischemia (Type A), followed in descending order by Types B, C, and D. The critical period for increased recurrence in cases which initially responded positively to treatment is primarily in the first 3-4 months following the intervention.