Treatment of Submacular Haemorrhage in Patients with Neovascular Age Related Macular Degeneration

To evaluate the efficacy of the pneumatic displacement of the submacular haemorrhage combined with the intravitreal injection of the tissue plasminogen activator. We present a retrospective clinical case series of nine eyes of nine patients that were treated with the intravitreal injection of the tissue plasminogen activator and expansile gas for the submacular haemorrhage due to the age related macular degeneration. We evaluated visual acuities and complications. Selected patients were additionally treated with the intravitreal bevacizumab injections after the procedure. Mean postoperative followup was 19 weeks. Four (4/9) eyes (44%) received additional treatment with the intravitreal bevacizumab during the postoperative period. Statistical analysis was performed using the Student’s paired t-test. The mean visual acuity was 1.77 logMAR preoperatively and 1.06 logMAR postoperatively. After the surgery, 4 or more Snellen lines were gained in 7/9 eyes (78%). The improvement of the visual acuity postoperatively was statistically significant (p = 0.002). In 2/9 eyes (22%) the visual acuity did not get better after the procedure. We observed no complications during the follow up period. In our case series, pneumatic displacement of the submacular haemorrhage with the use of the intravitreal tissue plasminogen activator (with or without additional bevacizumab treatment in the selected cases) turned out to be an effective and safe method leading to the improvement of the visual acuity in the majority of cases. To maximise the treatment success, prompt referral to the retinal surgeon is imperative

Entoptični pojavi, fotopsije in fosfeni

Entoptični pojavi v medicini pomenijo zaznavanje struktur in vidnih pojavov v lastnem očesu ob izpolnjenih določenih pogojih osvetlitve ali dražljaja. Ker teh pogojev v vsakdanjih normalnih razmerah ni, ne povzročajo zaznave optične slike. Entoptični pojavi so lahko povezani z lastnostmi optičnih medijev ali s strukturnimi in fiziološkimi lastnostmi mrežnice ter vidne poti. Entoptični pojavi, ki so povezani z lastnostmi optičnih medijev, nastanejo zaradi refraktivnih ali difraktivnih vzrokov. Skupna lastnost vseh entoptičnih pojavov je, da je njihovo dojemanje subjektivno in odvisno od preiskovančeve pozornosti ter sodelovanja. Entoptični pojavi se razlikujejo od optičnih iluzij, ki nimajo osnove v resničnem okolju. Posebna skupina vidnih pojavov so fotopsije in fosfeni. Fotopsija je subjektivno zaznavanje svetlobe brez dejanskega fotonskega ali svetlobnega dražljaja in se pojavlja v obliki strukturiranih slik oz. geometričnih vzorcev ali kot enostavne ponavljajoče se slike. Fosfeni so fotopsije, ki jih bolniki zaznavajo kot nestrukturirane statične ali premikajoče se svetlobne vzorce različnih barv, bliske svetlobe, iskre ali t.i. cik-cakaste črte. Fotopsije v večji meri nastajajo v očesu, redkeje v centralnem živčnem sistemu, ali pa so znak sistemskih okvar, zato je ob njihovem pojavu potreben natančen pregled

Rezultati vitrektomije pri bolnikih z regmatogenim odstopom mrežnice

Izhodišča: Ovrednotili smo anatomski in funkcionalni izid zdravljenja kompleksnega regmatogenega odstopa mrežnice z vitrektomijo pars plana (PPV). Metode: V retrospektivno raziskavo smo vključili 88 oči 88 bolnikov, ki so bili zaradi kompleksnega regmatogenega odstopa mrežnice zdravljeni s PPV. Določili smo anatomski uspeh in funkcionalni izid na podlagi korigirane vidne ostrine (VO) v celotni skupini bolnikov in v skupinah glede na status očesne leče, rumene pege in prisotnosti proliferativne vitreoretinopatije (PVR) stopnje ≥ C1. Z optično koherenčno tomografijo (OCT) rumene pege smo vsaj 6 mesecev po PPV ovrednotili prisotnost prekinitev elipsoidne cone, cistoidnega makularnega edema (CME), epiretinalne membrane (ERM) ali makularne luknje. Rezultati: Anatomski uspeh je bil po primarni PPV 93,2 %. Končni anatomski uspeh je bil dosežen pri vseh 88 bolnikih (100 %). Korigirana VO se je statistično značilno izboljšala iz VO 1,7 ± 1,2 SD logMAR pred operacijo na VO 0,6 ± 0,7 SD logMAR po operaciji (p=0,01). Med skupinama bolnikov je glede na prisotnost PVR izstopal slabši anatomski izid v skupini s PVR stopnje ≥ C1 (89,7 %). Korigirana VO se je po operaciji izboljšala pri vseh skupinah bolnikov, vendar po analizi glede na skupine statistično značilno le v skupini fakih (p=0,019), z odstopom rumene pege, (p=0,016) in s prisotnim PVR stopnje ≥ C1 (p=0,028). Končna VO je bila boljša v skupini psevdofakih (0,75 ± 1,06), v skupini bolnikov z ležečo rumeno pego (0,78 ± 1,30) in pri bolnikih brez PVR (0,80 ± 1,15 logMAR). Analiza OCT rumene pege po operaciji je pokazala prisotnost prekinitev elipsoidne cone v 39 %, CME v 15 %, ERM v 2 % in makularne luknje v 2 %. Primerjava spremenljivk OCT glede na skupine na podlagi statusa očesne leče, rumene pege in prisotnosti PVR stopnje ≥ C1 je pokazala največji delež prekinitev elipsoidne cone v skupini oči s prisotnim PVR stopnje ≥ C1 (58,6 %). Zaključek: Ugotovili smo visoko stopnjo anatomske in funkcionalne uspešnosti zdravljenja kompleksnega regmatogenega odstopa mrežnice z vitrektomijo. Funkcionalni izid je bil boljši pri bolnikih z umetno znotrajočesno lečo, pri bolnikih z ležečo rumeno pego in pri bolnikih brez PVR. Največji delež bolnikov s prekinjeno elipsoidno cono je bil v skupini bolnikov s predoperativno PVR

Anatomical success rate of pars plana vitrectomy for treatment of complex rhegmatogenous retinal detachment

BACKGROUND: Pars plana vitrectomy (PPV) is preferred surgical procedure for the management of complex rhegmatogenous retinal detachment (RRD). The purpose of this study was to evaluate the anatomical results of primary PPV for the treatment of primary complex RRD and to determine the influence of lens status, tamponading agent, preoperative proliferative vitreoretinopathy (PVR) and axial length (AL) of the eye upon the anatomical outcome. METHODS: A retrospective consecutive chart analysis was performed on 117 eyes from 117 patients with complex RRD managed with PPV. Fifty-nine eyes were phakic and 58 pseudophakic eyes. All patients had a minimum follow-up period of 12 months. Eyes were classified into groups using independent variables (first classification based upon lens status and tamponade used, second classification based upon lens and PVR status and third classification based upon AL of the eye). The groups were compared for anatomical outcomes (dependent variables) using nonparametric- or, in case of normally distributed data, parametric- statistical tests. RESULTS: Retinal reattachment rate in phakic eyes was 94.9% compared to 93.1% in pseudophakic, with no statistically significant difference between the two. The overall retinal reattachment rate with single surgery was 94.0%. Final reattachment rate was 97.4%. In case of established PVR >/= C1, the reattachment rate was not statistically different (92.6%) from eyes with no PVR (91.1%) irrespective of lens status. A statistically significant difference was found between redetachment rates only between phakic eyes with gas tamponade compared to silicon oil (SO) (p = 0.001). Reattachment rate proved to be similar in both AL groups ( 24 mm). CONCLUSIONS: High anatomical success rate of primary vitrectomy for complex RRD with either gas or SO tamponade was achieved in phakic as well as pseudophakic eyes irrespective of AL of the eye

Clinical and molecular markers in retinal detachment: From hyperreflective points to stem cells and inflammation

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Association of growth factors and cytokines gene polymorphism with proliferative vitreoretinopathy

Proliferativna vitreoretinopatija (PVR) predstavlja rast membran na površini mrežnice ter med mrežnico in steklovino pri bolnikih z regmatogenim odstopom mrežnice. Je najbolj pogost razlog za neuspeh pri zdravljenju bolnikov z odstopom mrežnice. Zaradi PVR imajo ti bolniki tudi slabši funkcionalni izid zdravljenja. Klinične raziskave kažejo, da kljub uspešnemu anatomskem zdravljenju bolniki nepojasnjeno izgubljajo tako centralni kot tudi periferni vid. Zaradi prizadetosti centralnega dela mrežnice, rumene pege, se poslabšata tako vidna ostrina kot tudi barvni vid. Zaradi okvare ostalih delov mrežnice imajo ti bolniki začasne ali trajne izpade vidnega polja. Številni dejavniki na celični in molekularni ravni so odgovorni za poslabšanje vida pri teh bolnikih. Morfološke analize rumene pege, narejene s pomočjo optične koherenčne tomografije (OCT), so pokazale, da je osip notranjih in zunanjih segmentov fovealnih fotoreceptorjev značilen pojav pri bolnikih s slabo vidno funkcijo po odstopu mrežnice. Zadnja desetletja so bile objavljene številne raziskave, ki nakazujejo na vpletenost rastnih dejavnikov in citokinov v patogenezi PVR. Skupaj s hipotezo rastnih dejavnikov se je porodilo vprašanje o vplivu genetskih dejavnikov na proces celjenja ran in na pojav PVR. Določanje genetskih determinant v povezavi s PVR se je pričelo v zadnjih desetih letih. V do sedaj objavljenih raziskavah je že bila dokazana povezava med posameznimi polimorfizmi enega nukleotida v genih TGFB1, SMAD7, p53, MDM2 in TNF in PVR, ki pa je ozko omejena samo na nekaj evropskih populacij. V naši raziskavi smo se osredotočili na klinične in genetske dejavnike PVR. Vrednotili smo funkcionalne plati rehabilitacije vidne funkcije bolnikov kot tudi morfološke spremembe, ki vplivajo na končni izid kirurškega zdravljenja. Poleg funkcionalnih preiskav, kot so vidna ostrina, barvni vid in vidno polje, smo v naši raziskavi analizirali tudi s pomočjo OCT pridobljene morfološke parametre: centralno debelino mrežnice (CRT) in skupno prostornino rumene pege (TMV). Analizirali smo vidno ostrino, barvni vid, vidno polje, stopnjo PVR, število operacij, očesni tlak, CRT in TMV za vse bolnike skupaj in za vsako skupino posebej. Pri vseh bolnikih, vključenih v raziskavo, smo ugotavljali, ali stopnja PVR vpliva na končno vidno ostrino. Analizirali smo, ali je barvni vid povezan s končno vidno ostrino. Prav tako smo pod drobnogled vzeli vprašanje o morebitni povezavi CRT in TMV z vidno ostrino in barvnim vidom, saj številna poročila kažejo, da so subklinične morfološke spremembe v rumeni pegi pomemben dejavnik za funkcionalno rehabilitacijo bolnikov po odstopu mrežnice. V raziskavo smo vključili 191 bolnikov z odstopom mrežnice, ki smo jih razdelili v 2 skupini: 113 bolnikov, pri katerih se je pojavila PVR (PVR skupina), in 78 bolnikov brez PVR (kontrolna skupina). Bolniki iz PVR skupine so imeli slabšo povprečno preoperativno vidno ostrino (0,13) v primerjavi s kontrolno skupino (0,28). Statistično pomembna razlika med skupinami je bila tudi glede postoperativne vidne ostrine. Povprečna postoperativna vidna ostrina bolnikov s PVR je bila slabša kot pri ostalih bolnikih z odstopom mrežnice. Zaradi relativno omejenega števila preiskovancev smo za genetsko analizo in v namen doseganja praga za ugotavljanje statistično značilnih povezav raziskavo za posamezne gene razširili na 261 primerov. Naša raziskava je pokazala statistično pomembne razlike v porazdelitvi genotipov med bolniki s PVR in kontrolnimi bolniki pri SNP-jih znotraj ali v bližini genov IL6, TGFB1 in IL10. V tej raziskavi nismo ugotovili povezanosti med SNP-ji znotraj ali v bližini genov za CCL2, FGF2, IL1A, IL2, JAK3, LTA, p53, PDGFRA, SMAD7, in TNF ter PVR, s čimer nismo potrdili do sedaj dognanih povezav med SNP-ji in PVR. Primerjali smo tudi razporeditev genotipov med kontrolno skupino 96 slovenskih krvodajalcev in bolnikov iz PVR skupine pri 4 SNP-jih v genih IL1A, IL2, LTA ter TNF.Proliferative vitreoretinopathy (PVR) is defined as the growth and contraction of cellular membranes within the vitreous cavity and on both retinal surfaces in patients with the rhegmatogenous retinal detachment (RRD). It is the major complication following the retinal detachment surgery and also a leading cause of failure in the management of RRD. Numerous clinical studies have shown that despite the successful anatomical treatment of RRD these patients inexplicably lose both central as well as peripheral vision. The structural changes of the central part of the retina, the macula lutea, consequently lead to the deterioration of both the visual acuity and the color vision. Due to involvement of other parts of retina, these patients have a temporary or permanent visual field loss. Numerous factors on the cellular and molecular levels are responsible for the vision impairment in these patients. Morphological analysis of macula lutea using optical coherence tomography (OCT) showed the characteristic drop-out of internal and external segments of foveal photoreceptors in patients with poor visual function after treatment. In recent years the question whether genetic factors are those who play a key role in the PVR development has become topical. Together with the “growth factors hypothesis” there arises the question about the effect of genetic factors on the wound healing process and on the development of the PVR. Results of genetic research published during the last decade have shown a strong association between the genetic profile in genes for TGFB1, SMAD7, TNF locus, MDM2, and p53 with the development of the PVR in some of European populations. The aim of our study was to enlighten the PVR from the clinical as well as from the genetic point of view. We evaluated functional aspects of visual function rehabilitation in patients with PVR as well as morphological retinal changes that have an impact on the final outcome of surgical treatment. In addition to the functional tests such as the visual acuity, color vision and visual field in our study we also analyzed the morphological OCT parameters: the central retinal thickness (CRT) and the total macular volume (TMV). We analyzed the visual acuity, color vision, visual field, PVR stage, number of surgeries required in patients with and without the PVR, intraocular pressure, CRT and TMV for all patients and for each group separately. In all patients included in the study we tried to find whether the PVR stage has an impact on the final visual acuity. We also analyzed if the color vision correlates with the final visual acuity. Questions whether the CRT and the TMV are correlated to the postoperative visual acuity and color vision were also taken into consideration, as many reports suggest that the subclinical morphological changes in the macula lutea are an important factor determining functional rehabilitation of patients with RRD. We genotyped SNPs in genes of CCL2, FGF2, IL1A, IL2, IL6, IL10, JAK3, LTA, SMAD7, p53, TGFB1, TNF and PDGFRA. Due to the relatively small sample size and for the purpose of achieving the threshold for the detection of statistically significant associations for some of the genes we expanded the research to 261 cases. Our study showed a statistically significant difference of TGFB1 SNP rs1800471, IL6 SNP rs1800795, and IL10 SNP rs1800871 between Slovenian patients with and without PVR. Contrary to findings of other study groups, in this study we did not find a statistically significant association between the PVR and the SNPs of genes for CCL2, FGF2, IL1A, IL2, JAK3, LTA, p53, PDGFRA, SMAD7, and TNF. We also compared the distribution of genotypes in 96 Slovenian blood donors and in patients from the PVR group at 4 SNPs in genes of IL1A, IL2, LTA and TNF. The comparison showed that the distribution of genotypes for the IL1A SNP rs17561 and TNF SNP rs1800629 significantly differs between the groups

Dysphotopsias or Unwanted Visual Phenomena after Cataract Surgery

Dysphotopsias are unwanted visual phenomena that occur after cataract surgery. They represent some of the most common reasons for patient dissatisfaction after uncomplicated surgery for cataract phacoemulsification with in-the-bag intraocular lens (IOL) implantation. Depending on the form of the optical phenomenon and the effect it poses on vision, dysphotopsias are divided into positive and negative type. Positive dysphotopsias are usually described by patients as glare, light streaks, starbursts, light arcs, rings, haloes, or flashes of light. Negative dysphotopsias are manifested as an arc-shaped shadow or line usually located in the temporal part of the visual field, similar to a temporal scotoma. In addition to their different clinical manifestations, positive and negative dysphotopsia also have different risk factors. Even though up to 67% of patients may experience positive dysphotopsia immediately after surgery, only 2.2% of the cases have persistent symptoms up to a year postoperatively. Surgical intervention may be indicated in 0.07% of cases. The incidence of negative dysphotopsias is up to 26% of all patients; however, by one year postoperatively, the symptoms usually persist in 0.13 to 3% of patients. For both types of dysphotopsia, preoperative patients’ education, accurate preoperative diagnostics, and use of an appropriate IOL design and material is mandatory. Despite all these measures, dysphotopsias may occur, and when noninvasive measures fail to improve symptoms, a surgical approach may be considered