Treatment chronic macular edema in Vogt-Koyanagi Harada syndrome with dexamethasone intravitreal implant: description of three case

Purpose: To report our experience with dexamethasone intravitreal implant (Ozurdex, DEX implant) in the chronic cystic macular edema (ME )with Vogt-Koyanagi-Harada (VKH) Syndrome. Method: A retrospective chart review of three patients with (VKH) treated with sustained-release dexamethasone 0.7 mg intravitreal implant was performed.Complete ophthalmic examination included: best corrected visual acuity; ocular tonometry, were also evaluated signs of inflammatory activity of the anterior segment with biomicroscopy slit-lamp, and posterior segment with fundus biomiocrosopy, fundus photography and fluorescein angiography; measurement of macular morphology and thickness, optical with coherence tomography; and tolerability of the implant. Mean follow-up time post-injection was 6 months. All three eyes received 1Ozurdex implants during the follow-up period. The duration of effect of the implant was 4 to 6 months. No serious ocular or systemic adverse events were noted during the follow-up period. Results: In all three eyes, were observed a remarkable decrease ME, in angiographic and OCT , following placement intravitreal DEX implant Conclusions: The DEX implant 0.7 mg may be an effective treatment option for reduction ME in VGT, met the primary efficacy endpoint for improvement in visual acuity (VA) and safety profile was also acceptabl

Fast glycorrhachia and cerebrospinal fluid protein as predictors of sensory block in anesthesia with subarachnoid Ropivacaine

BACKGROUND: Identify if glycorrhachia and cerebrospinal fluid protein could influence the time of sensory block to T10, the duration and the metameric block's level, after a standard dose of Ropivacaine. METHODS: 80 patients, ASA I - III undergoing to transurethral prostate resection with spinal anesthesia in a prospected open study were recruited. A 0.2 ml liquor's sample was taken; glycorrhachia, by glycemic stix and CSF protein, by urinary stix, were got, before Ropivacaine 0.5% 15 mg injection (0.10 - 0.15 mlsec). After anti-trendelemburg, with 30 ° tilting for 15 min, the onset of sensory block to T10, the maximum metameric level to 15' and the time of sensory block were reported. The data collection were analyzed using the software language R. RESULTS: A significant correlation liquor specific weigh preoperative glycemia (0.749), liquoral specific weigh glycorrhachia (rho = 0.751; R2 = 0.564; P 0.05) and specific weigh CSF protein (rho = 0.684; R2 = 0.468; P 0.05) were reported. Inverse relation CSF weightsensory block level (rho -0.789, P 0.05, R2 0.621) was evidenced. Inverse relation onset time to T10 glycorrhachia (84%) and cephalic block glycorrhachia (76%) were found. Inverse correlation onset time to T 10 CSF protein and cephalic block proteinorrachia was respectively 84% and 67%. A rho of 0.712 with R2 of 51% BMI onset to T10 and rho of 0.681 with R2 of 51% BMI maximum cephalic block with P 0.05 were reported. CONCLUSIONS: The predictability of a iso-hypobaric local anesthetic could reduce the risk of procedure failure and adverse events by further cephalic spread

Ropivacaine vs tetracaine in topical anesthesia for intravitreal injection

Aim: The object of the study was to evaluate the long term efficacy and safety of ropivacaine 0,5% vs tetracaine 0,5% for topical anesthesia in intravitreal injection of dexamethasone in patients with diabetic macular edema (DME) and anti-vascular endothelial growth factor (VEGF) therapy. Methods: Thirty-seven patients were enrolled in the study. Intravitreal anti-vascular endothelial growth factor (VEGF) and Dexamethasone were placed in DME patients. Intravitreal administration determines appropriate and long-lasting drug's concentration without systemic side effects. Topical anesthesia under ropivacaine 0,5% vs tetracaine 0,5% was performed. Results: Intravitreal injection without any supplemental anesthesia and sedation was realized. Patients reported mild pain (recorded by a 0 to 10 scale) during the procedure with optimal operative result. Conclusions: Topical anesthesia with ropivacaine and tetracaine is safe and effective in intravitreal injection. The long-lasting anesthesia secured low pain during this limited but unpleasant procedure

Neurovisual training (TRIGRAM) in young patients with visual-perceptive dyslexia

Dyslexia is a language-based learning disability. Although this condition is characterized by anatomical malformation of the brain, it seems that the typical reading pattern of dyslexic may be also related to more complex sensory deficits. Among them, visual- perceptive deficits have been described in a subtype of dyslexia, called visual-perceptive dyslexia. The distinctive feature of a patient suffering from visual-perceptive dyslexia form is marked by effortlessly recognize the characteristics of each individual stimulus. The Tetra protocol is a visual-perceptual evaluation protocol that was introduced for the diagnostic phase and the rehabilitation of visual-perceptive dyslexia. The diagnostic tests include: the eidomorphometry test, designed to evaluate the perception of spatial relationships; the contrast sensitivity threshold test, especially at low spatial frequencies; and the REPORT TEST words, to assess the speed and the reading efficiency. In addition, the rehabilitation phase is carried out with the visual neuro-enhancement program TRIGRAM, a visual training proposal designed to reduce the lateral masking phenomenon in visual-perceptive dyslexic. Thus, in this study we used the diagnostic tests of TETRA® Protocol to determine presence of visual-perceptual abnormalities in children with dyslexia. Proven time the presence of these visual-perceptual alterations, the patients were also subjected to the rehabilitation sessions of TRIGRAM, in order to investigate whether this visual training may improve the pattern of reading. At the end of the program (t1) and after three months (t2), the same subjects underwent the same diagnostic tests of TETRA® Protocol to evaluate and confirm the results obtained during rehabilitation program. The results showed a significant increase in contrast sensitivity at low and high spatial frequencies. Moreover, the same improvements in the visual system's ability to discriminate the contours of an object within the field of view, have been maintained three months after the end of treatment. We also observed a significant improvement in the perception of spatial relationships, with reduction of SRA value. In conclusion, this study demonstrates that the visual rehabilitation training (TRIGRAM) is able to improve the perception of spatial relationships, and increase contrast sensitivity in young patients affected by "visual dyslexia". Nonetheless, these data need to be confirmed in larger cohort of subjects in order to establish whether these effects can also increase lexical ability (increased reading speed and reduce errors during the lexical task)

Six months follow up of a single intravitreal injection of ocriplasmin for symptomatic vitreomacular adhesion

Purpose: To evaluate the efficacy and the safety of the enzymatic vitreolysis with a single intravitreal injection of ocriplasmin 125 μg across a group of patients with symptomatic vitreomacular adhesion (sVMA) during 6 months follow up. Design: A randomized, placebo-controlled, double-masked, 6-month follow up study. Participants: A total of 28 patients (12 M / 16F) (19 receiving ocriplasmin; 9 receiving placebo), mean aged 71 years old, diagnosed with sVMA, VMT, FTMH e ERM by optical coherence tomography. Methods: A single intravitreal injection of ocriplasmin 125 μg or placebo. Primary endpoint was sVMA resolution or FTMH closure. Secondary endpoint included the integrity of the external membrane and the inner and outer segments of the photoreceptor interface using OCT. The evaluation was carried out at baseline and during 6 months after intravitreal injection of ocriplasmin or placebo. Results: After a 6 months follow-up period, the rate of VMA resolution was 42.1% in the Ocriplasmin group vs the 22% in the placebo group. FTMH closure rate was 50% in the Ocriplasmin group vs 0% in the placebo group. The best results were optained within 28 days from the treatment. No case of uveitis, endophthalmitis, retinal tears, retinal detachment or bleeding during followup were reported. One patient reported floaters and transitional photopsias. Conclusions: The study confirmed the efficacy and safety of Ocriplasmin injection for patients with VMT, including when associated with full-thickness macular holes during six months follow up. Long term studies are certainly needed to confirm these results

Management of anterior chamber dislocation of a dexamethasone intravitreal implant: a case report

Background Ozurdex is a 700 mcg dexamethasone intravitreal implant, approved for the management of macular edema secondary to retinal vein occlusion, and other related pathoglogiesAnterior chamber dislocation of Ozurdex represents an uncommon complication of the intravitreal injection, which can be managed by repositioning the implant into the vitreous cavity. We describe the case of a successful repositioning of an Ozurdex implant by mobilization and subsequent balanced saline solution injection in the anterior chamber. Case presentation An 83-year-old white woman presented to our Emergency Unit complaining of pain and vision loss in herright eye lasting a week. Her anamnesis revealed a history of persistent cystoid macular edema after phacoemulsification with scleral-fixated posterior chamber intraocular lens implantation, recently treated with an intravitreal Ozurdex implant. She also took a long-distance flight 2 days after the injection. An anterior segment examination showed corneal edema and the rod implant adherent to corneal endothelium. To avoid corneal decompensation, we opted for a implant repositioning. Under topical anesthesia, a 30-gauge needle was introduced through a limbar incisionto mobilize the dislocated rod. Balanced saline solution was injected, with a successful repositioning of the implant into the vitreous cavity. Topical 5 % hypertonic saline solution and 0.2 % betamethasone associated with 0.5 % chloramphenicol drops were administered four times a day. To prevent redislocation of the Ozurdex implant, she was instructed to avoid prone position, any kind of physical effort, and not to undertake long-distance flights during the first postoperative week. One week after surgery, an anterior segment examination showed an improvement of corneal edema. Funduscopy showed that the Ozurdex implant was settled into the vitreous cavity. Conclusions Anterior chamber dislocation of Ozurdex from the vitreous cavity is rare. In our patient, in addition to the posterior capsule tearing, the long-distance flight could have contributed to implant dislocation. Repositioning of the implant is necessary to avoid endothelial decompensation. It can be carried out by using saline balanced solution with the same efficacy as other surgical procedures reported in the literature. A possible disadvantage of this procedure could be implant migration

Comparison between “early” or “late” intravitreal injection of dexamethasone implant in branch (BRVO) or central (CRVO) retinal vein occlusion: six months follow-up

AIM: The aim of this study was to compare early and late injections of intravitreal dexamethasone implant in patients affected by central retinal vein occlusion (CRVO) or branch retinal vein occlusion (BRVO) with a six-months follow-up. We assessed whether an earlier treatment start (within seven days from diagnosis) could be more beneficial than a delayed (or late) treatment start (after seven days). MATERIALS AND METHODS: The study included 81 patients (81 eyes) affected by retinal vein occlusion. Best corrected visual acuity was assessed through Early Treatment Diabetic Retinopathy Study (ETDRS) while central macular thickness (CMT) was measured by spectral-domain optical coherence tomography. RESULTS: Both types of patients had a positive therapeutic response to dexamethasone, with an increase in visual acuity (ETDRS) and CMT reduction. CRVO patients were characterized by lower ETDRS values at baseline and at the end of the follow-up as compared to BRVO. CRVO patients showed higher CMT values at baseline, after three and six months from injection. No significant differences in therapeutic response to dexamethasone were observed between patients treated early or late, regardless of RVO type. CONCLUSIONS: This study demonstrates that the therapeutic properties of dexamethasone implant are not significantly influenced by an early or late treatment start in patients affected by BRVO and CRVO, although its therapeutic efficacy seems greater in the former type

Glycosaminoglycans in the human cornea: age-related changes

Abstract AIM: To investigate possible age-related changes in glycosaminoglycans (GAGs) in the human cornea. The substances today called GAGs were previously referred to as mucopolysaccharides. METHODS: Samples of human cornea were taken from 12 younger (age 21 ± 1.2) and 12 older (age 72 ± 1.6) male subjects. Samples were weighed, homogenized, and used for biochemical and molecular analyses. All the quantitative results were statistically analyzed. RESULTS: The human cornea appears to undergo age-related changes, as evidenced by our biochemical and molecular results. The total GAG and hyaluronic acid counts were significantly higher in the younger subjects than in the older subjects. The sulfated heavy GAGs, such as chondroitin, dermatan, keratan, and heparan sulfate, were lower in the younger subjects than in the older subjects. DISCUSSION: GAGs of the human cornea undergo numerous age-related changes. Their quantity is significantly altered in the elderly in comparison with younger subjects. GAGs play an important role in age-related diseases of the human cornea

An eighteen-month follow-up study on the effects of intravitreal dexamethasone implant in diabetic macular edema refractory to anti-VEGF therapy

Abstract AIM: To evaluate the long-term efficacy and safety of dexamethasone implants in subjects affected by diabetic macular edema (DME) resistant to anti-vascular endothelial growth factor (VEGF) therapy. METHODS: Thirty-two DME patients were enrolled. A 700 microgram slow release Intravitreal Dexamethasone Implant (Ozurdex®) was placed in the vitreous cavity. All patients were followed for 18mo. Best-corrected visual acuity (BCVA) measured with Early Treatment Diabetic Retinopathy Study (ETDRS) and central macular thickness (CMT) exams were carried out at baseline (T0) and after 1 (T1), 3 (T3), 4 (T4), 6 (T6), 9 (T9), 12 (T12), 15 (T15), and 18mo (T18) post injection. RESULTS: Repeated measures ANOVA showed an effect of treatment on ETDRS (P<0.0001). Post hoc analyses revealed that ETDRS values were significantly increased at T1, T3, T4, T9, and T15 (P<0.001) as compared to baseline value (T0). At T6, T12, and T18, ETDRS values were still statistically higher than baseline (P<0.001 vs T0). However, at these time points, we observed a trend to return to baseline conditions. ANOVA also showed an effect of treatment (P<0.0001). CMT decreased significantly at T1, T3, T4, T9, and T15 (P<0.001). At T6 (P<0.01), T12 and T18 (P<0.001) CMT was also significantly lower than T0 although a trend to return to the baseline conditions was also observed. CONCLUSION: Our findings demonstrate that Intravitreal Dexamethasone Implant is a good option to improve BCVA and CMT in DME patients resistant to anti-VEGF therapy. Our data also show that the use of drugs administered directly into the vitreous allows achieving appropriate and long-lasting concentration at the site of disease without systemic side effects

Glaucoma and cigarette smoking: a review of narrative reviews

Background: Glaucoma is an optic neuropathy associated with visual field changes for which high intra-ocular pressure is a major risk factor. Emerging research indicates that modifiable factors, among which the cigarette smoke, besides IOP may be associated with the presence of glaucoma. Objective: The objective of the study was to perform a review of narrative reviews to examine on the relationship between cigarette smoking and glaucoma. Methods: The results of all narrative reviews in the scientific literature about glaucoma and tobacco smoking were analyzed. A quality assessment was performed according to an easy and convenient tool for the quality assessment of narrative reviews for systematic reviews (International Narrative Systematic assessment) the INSA tool. Literature searches were performed using PubMed. Results: 20 studies about relation between glaucoma and smoke were collected, no restriction language was applied. 15 of these studies have been excluded. We selected among them 5 reviews. With the INSA tool we measured the quality of the 5 selected narrative reviews. Studies that had a highest score with the INSA tool were two: A. Coleman et al. “Risk Factors for Glaucoma Needing More Attention” and R. Salowe et al. “Primary Open-Angle Glaucoma in Individuals of African Descent: A Review of Risk Factors”. Conclusion: The narrative reviews analyzed underline that there is no definitive association between cigarette smoking