Intravitreal Pegaptanib in Ischemic CRVO Refractory Exudative Macular Detachment

Abstract Recent literature data reported evidence of the visual and/or anatomical benefits of all clinically available anti-VEGF drugs for the treatment of macular edema (ME) following Central Retinal Vein Occlusion (CRVO), up to 1-year followup. There are no randomized clinical trial data on anti-VEGF agents in ischemic CRVO-ME and the use of anti-VEGF agents to treat this condition. A 73-year old caucasian man, with a medical history of diabetes and systemic hypertension and an ophthalmic history of ischemic CRVO with cystoid macular edema was referred to our division on January 2011. The ophthalmic examination showed in right eye a visual acuity of 20/2000, a C2N1 cataract and an exudative macular detachment. On February 2011, a 0.5mg ranibizumab intravitreal injection (Lucentis®, Novartis, Basel, Switzerland) was carried out in the right eye. 15 and 25 days later the OCT showed no changes. On March 2011, we performed a 0.3mg pegaptanib sodium intravitreal injection (Macugen, Eyetech Pharmaceuticals, Inc. and Pfizer Inc, New York, NY) in the right eye and 15 days later the fluorescein angiography and the OCT examination showed reabsorption of subretinal fluid, complete disappearing of macular detachment and normalization of foveal profile, with a thickness of 240 μm and visual acuity of 20/400. Three months later, foveal profile and visual acuity were unchanged. In our refractory ischemic CRVO-ME patient, pegaptanib sodium showed prompt clinical response. In some cases, even if it is selective for the VEGF165 isoform only, pegaptanib sodium could represent a further possibility in such a therapeutic challenge

Attualità e future prospettive terapeutiche

La ricerca di base e clinica sul glaucoma costituisce oggi uno dei principali campi di impegno scientifico del mondo oftalmologico. E questo dipende da svariati fattori, quali la cronicità di una patologia seconda causa di cecità nel mondo, con il conseguente onere sociale che ne deriva; il progressivo invecchiamento anagrafico delle aree occidentali con incremento di prevalenza del glaucoma primario ad angolo aperto (POAG) o chiuso (PACG); i recenti successi terapeutici in campo chirurgico e soprattutto medico, che negli ultimi 25 anni hanno creato un circolo virtuoso in termini di impiego di uomini e di risorse. C’è da aggiungere che man mano che la generazione del “baby boom” post-bellico invecchia, si incrementerà la richiesta di un trattamento che preservi la visione, senza intaccare il godimento di attività sociali e ricreative che è oggi tipico anche dell’età avanzata. I tentativi di ridurre in modo sostanziale il deficit visivo e la cecità da glaucoma necessiteranno di una diagnostica sempre più aggressiva, in modo da rendere coscienti della propria condizione un maggior numero di pazienti. Inoltre è necessario un più attento trattamento di POAG e PACG che possa includere le acquisizioni derivanti dalla ricerca corrente. A causa delle conseguenze della cecità sulla salute e sull’economia, il fardello di POAG e POCG ricade non solo sui pazienti e i loro medici ma anche, come detto, sulla società. Pertanto le strategie di controllo della malattia devono andare oltre il semplice input al medico di base per uno screening sistematico, avvalendosi di più ampie campagne di informazione pubblica che possano sottolineare la necessità di un periodico esame dell’occhio, specialmente tra coloro con storia familiare o altri fattori di rischio per il glaucoma. Le metodiche per la diagnosi precoce e per il followup della malattia sono sempre più raffinate e promettenti per il futuro, come le sezioni precedenti di questo volume hanno evidenziato. Una loro trattazione prospettica renderebbe troppo ampio questo capitolo, che pertanto si incentrerà sulle problematiche future terapeutiche, mediche e chirurgiche

Pharmacologic pupil dilation as a predictive test for the risk for intraoperative floppy-iris syndrome

PURPOSE: To evaluate the effect of α1-adrenergic receptor antagonists (α1-ARAs) on pupil diameter and determine whether the diameter predicts intraoperative floppy-iris syndrome (IFIS). SETTING: Ophthalmology Section, Palermo University, Palermo, Italy. DESIGN: Prospective cohort study. METHODS: Male outpatients taking tamsulosin, α(1)-ARAs, or no α(1)-ARAs having phacoemulsification were recruited. Pupils were measured 1 month preoperatively, immediately preoperatively, and postoperatively under mesopic low (0.4 lux) and high (4.0 lux) illumination after pharmacologic dilation. The IFIS severity was graded. RESULTS: Each group comprised 50 patients. Pharmacologic dilation in both α(1)-ARA groups was statistically significantly less than in the no α1-ARA group 1 month preoperatively, immediately before surgery, and postoperatively (P=.001, P<.0005, and P<.0005, respectively). The IFIS incidence differed significantly between the tamsulosin and other α(1)-ARA groups and the no α1-ARA group (P<.0005 and P=.017, respectively) and between the tamsulosin group and the other α1-ARA group (P=.027). On regression analysis, the hazard ratio for overall IFIS incidence was 3.8 in the other α(1)-ARA group (P=.012) and 10.1 in the tamsulosin group (P<.0005). Pupil size was inversely related to IFIS incidence and severity (P<.0005). A dilated pupil of 7.0 mm or smaller had 73% sensitivity and 95% specificity for predicting IFIS (P=.0001). CONCLUSIONS: Pupil dilation was inhibited by α(1)-ARAs, in particular tamsulosin. For a pupil 7.0 mm or smaller, the risk for IFIS existed regardless of α(1)-ARAs treatment, which surgeons should take into consideration

Working-Age Cataract Patients: Visual Results, Reading Performance, and Quality of Life with Three Diffractive Multifocal Intraocular Lenses

Abstract PURPOSE: To compare the visual outcomes, reading performance, and quality of life (QoL) of working-age cataractous patients bilaterally implanted with 3 different diffractive multifocal intraocular lenses (MIOLs). DESIGN: Two-center, randomized, prospective, double-masked study. PARTICIPANTS: Sixty-three consecutive patients (126 eyes) seen at Ophthalmology Section, Palermo and Florence University, Italy, randomized to receive the ReSTOR SN6AD3 (Alcon Laboratories, Inc, Irvine, CA) (20 patients, group A), ReSTOR SN6AD1 (Alcon Laboratories, Inc) (21 patients, group B), or TECNIS ZMA00 (Abbott Medical Optics, Santa Ana, CA) (22 patients, group C) MIOL. INTERVENTION: Phacoemulsification. MAIN OUTCOME MEASURES: One-year follow-up differences among the 3 MIOL groups in visual acuity, reading performance by MNREAD (Minnesota Laboratory for Low-Vision Research, University of Minnesota, Minneapolis, MN) reading acuity (RA), critical print size (CPS), and maximum reading speed (MRS) under mesopic and photopic conditions. SECONDARY OUTCOME MEASURES: Photopic and mesopic contrast sensitivity (CS) by Pelli-Robson test and patient satisfaction by National Eye Institute Refractive Error Quality of Life Instrument-42 (NEI RQL-42) questionnaire. RESULTS: Mean photopic uncorrected near visual acuity (UNVA), distance-corrected near visual acuity (DCNVA), and corrected near visual acuity (CNVA) did not differ among groups, with a preferred reading distance greater in group B (P&lt; 0.0005). Photopic distance-corrected intermediate visual acuity (DCIVA) was best in group B (P = 0.001) and better in group C than in group A. Mesopic UNVA and DCNVA were worse in groups A and B compared with group C (P&lt; 0.0005 in both cases), with better DCNVA in group B than in group A (P = 0.031). Mesopic uncorrected intermediate visual acuity (UIVA) and DCIVA were worst in group A, with better results in group C (P&lt; 0.0005 and P = 0.001, respectively). Mesopic MNREAD RA was better in group C (P = 0.02), and mesopic MRS was higher in groups B and C than in group A (P = 0.002). The QoL scores by the NEI RQL-42 test exhibited no differences among groups in 9 over 13 scales. "Near vision" (P = 0.005), "symptoms" (P = 0.001), and "satisfaction with correction" scale scores (P = 0.030) were lowest in group A, and "appearance" scale score was lowest in group B (P = 0.045). CONCLUSIONS: Newer-generation aspheric diffractive MIOLs, especially low-add hybrid apodized or full diffractive, are highly suited for working-age cataractous patients in terms of visual outcomes, reading performance, and QoL. Intrinsic optical differences, such as optimization for computer or dim-light working, or night driving, could be useful tools to customize the IOL in each single case

Day care cataract surgery in Central and Southern Italy: a multicentric survey

surgical techniques and costs are generally lower than those involved in ordinary hospitalization. Cataract surgery serves as a proxy indicator of the trend towards day surgery hospitalization in Italy and, therefore, of regional variability in health-care delivery and cost. The aim of this study was to update the diffusion of cataract day surgery through various surgical ophthalmological centers in central and southern Italy during 2005. Methods: A two-stage stratified cluster sampling method was used to draw a sample of Cataract Surgery Unit from Ophthalmic Units of central and southern Italy. A questionnaire was sent to 25 cataract surgery centers in nine health districts that represented the range of establishments (public, private, accredited or otherwise) in which cataract surgery is performed. Data were collected on numbers of procedures performed in 2005, hospital admission type, time from the onset of cataract day surgery, surgical procedure, and presence of other surgical centers. Results: The response rate was 42% (10 surveys), resulting in at least one completed questionnaire for each of these 9 districts. There is a positive trend towards day surgery hospitalization in all surgical centers. The percentage of patients treated as outpatients during 2005 varied from 50–60% (Avellino, Naples, Campobasso), to 80–90% (Rome, Bari), up to 90–100% (Catania, Palermo, Siracusa and Trapani), with an increasing trend in all the centers studied. Few differences were found in surgical procedures, and these were statistically insignificant. Conclusion: Our results confirm a positive trend towards day surgery in place of hospital inpatient admission for cataract surgery. This trend is expected to close the existing regional gap in Italy. Increased efficiency is an overriding need for the National Health Service in order to improve the rationalization of resources

Flogosi post-trapianto di cornea

Il Trapianto di Cornea, o Cheratoplastica, che prevede la sostituzione sub-totale della cornea mediante un innesto circolare di tessuto omologo (lembo), rappresenta la procedura d’elezione per il trattamento di diverse patologie corneali congenite o acquisite. Se ne discutono tutti i determinanti e le prospettive

Bilateral Ultrathin Descemet's Stripping Automated Endothelial Keratoplasty vs. Bilateral Penetrating Keratoplasty in Fuchs' Dystrophy: Corneal Higher-Order Aberrations, Contrast Sensitivity and Quality of Life

Background and Objectives: The objective of this paper is to compare the visual outcomes and quality of life (QoL) after bilateral ultrathin Descemet's stripping automated endothelial keratoplasty (UT-DSAEK) with bilateral penetrating keratoplasty (PK) for Fuchs' endothelial dystrophy (FED). Materials and Methods: Retrospective comparative cohort study, including 11 patients with FED who underwent bilateral PK and 13 patients with FED who underwent bilateral UT-DSAEK. All patients were already pseudophakic or had undergone a combined cataract procedure. The main outcomes were corrected distance visual acuity (CDVA) corneal higher-order aberrations (HOAs), contrast sensitivity (CS) and quality of life (QoL). Results: The mean follow-up after the second eye surgery was 32.5 ± 10.2 months in PK and 19.6 ± 8.6 months in UT-DSAEK patients. The CDVA in the UT-DSAEK group was significantly better than in the PK one (0.18 ± 0.07 vs. 0.35 ± 0.16 logMAR, p &lt; 0.0001). The mean anterior corneal total HOAs of the central 5 mm were significantly lower in UT-DSAEK eyes than in PK eyes (0.438 ± 0.078 and 1.282 ± 0.330 respectively, p &lt; 0.0001), whilst the mean posterior total HOAs did not differ between groups (0.196 ± 0.056 and 0.231 ± 0.089 , respectively, p = 0.253). The CS was lower at 0.75 and 1.5 cycles/degree in P the K group when compared to the DSAEK one (p = 0.008 and 0.005, respectively). The QoL scores by the NEI RQL-42 test exhibited better values in DSAEK patients in 9 out of 13 scales. Conclusion: Our study confirms that UT-DSAEK provides a better visual function in terms of CDVA and CS, together with lower HOAs, when compared to PK. Hence, the vision-related QoL, binocularly evaluated by the NEI RQL-42 items, indicates a higher satisfaction in UT-DSAEK eyes

A note on preconditioning weighted linear least squares, with consequences for weakly-constrained variational data assimilation

The effect of preconditioning linear weighted least-squares using an approximation of the model matrix is analyzed, showing the interplay of the eigenstructures of both the model and weighting matrices. A small example is given illustrating the resulting potential inefficiency of such preconditioners. Consequences of these results in the context of the weakly-constrained 4D-Var data assimilation problem are finally discussed.Comment: 10 pages, 2 figure

The chimeric ALT-vastus lateralis free flap in reconstruction of advanced BRONJ of the maxilla.

Introduction Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is a dangerous complication of bisphosphonates, a class of pharmaceutical agents used in numerous bone disor- ders. No gold standard therapy exists, but recent literature suggests that, in advanced stages, the best results are achieved with aggressive debridement. In this paper, we report our experience of treatment of stage 3 BRONJ of the maxilla with extensive surgical debridement and reconstruction with a chimeric ALT-Vastus lateralis flap. Methods Five selected patients with stage 3 BRONJ underwent partial maxillectomy with dis- ease-free margins followed by immediate reconstruction with a chimeric ALT-Vastus lateralis free flap. Results Only two patients experienced minor complications. All other patients healed unevent- fully within two weeks and donor site morbidity was minimal. Conclusions Our data suggest that aggressive debridement and reconstruction with a chimeric ALT -Vastus lateralis flap is an effective option for the treatment of stage III BRONJ of the maxilla