Management della retinopatia diabetica e dell'edema maculare diabetico: linee guida "Euretina 2017"

Si prevede che la malattia diabetica con tutte le sue complicanze avrà un forte aumento di incidenza con un grosso impatto socioeconomico nei prossimi decenni in tutto il mondo. Pertanto ben si comprende l'importanza di individuare attraverso una fine diagnostica quanto più precocemente la comparsa dei sintomi diabetici, migliorare lo stile di vita ed impostare cure efficienti. Riportiamo la serie di raccomandazioni EURETINA 2017, dei maggiori esperti in Europa per la gestione della malattia diabetica e delle complicanze della retina. Per combattere questa "pestilenza" occorre un team medico preparato. Il trattamento laser è stato considerato sino a non molto tempo fa il Gold standard della retinopatia diabetica e dell'edema diabetico (RD e EMD). Recenti studi hanno dimostrato, invece, che si possono raggiungere risultati migliori mediante l'iniezione diretta di farmaci nella cavità vitreale. In particolare è emerso terapia di prima linea, molecole in grado di inibire il fattore di crescita endoteliale vascolare (anti VEGF) mentre non è più raccomandata la fotocoagulazione laser per il trattamento del DME. Nell'ambito delle molecole farmacologiche gli steroidi hanno mantenuto un ruolo nella gestione del DME cronicamente persistente.

New therapies in common ocular surface disorders

Lacrimal dysfunction syndrome (LDS) and meibomian gland dysfunction (MGD) are common pathologies of the ocular surface both characterized by quantitative and/or qualitative tear film changings. They may result in symptoms of eye irritation, clinically apparent inflammation and ocular surface disease. Recent researches about the chronic inflammatory nature of dry eye, revealed the possibility to develop new treatments for LDS like new immunological drugs. MGD, alone or if it occurs contemporary to LDS, can be treated with a thermal pulsation system, a useful tool to alleviate symptoms.

Botulinum toxin treatment in glaucomatous patients: a pilot study

PURPOSE

The purpose was to evaluate the efficacy of the treatment of iatrogenic entropion (IE), in patients affected by primary open angle glaucoma (POAG), by botulinum toxin injections (BTI).

PATIENTS AND METHODS

20 patients of the "Glaucoma Center" of the Hospital "Umberto I" (Rome) were examined. These patients had POAG and used prostaglandin analogues (PA). Mean age was 75.5 years old (range 68-83); they had been suffering from PAOG since 10 years and were not affected by other relevant systemic diseases. One to three BTI were made into the lower orbicularis muscle using a 0.3 G needle (0.025 to 0.05 units for each injection site).

RESULTS

The results were particularly significant in 18 out of 20 patients. Two patients showed slight improvements. A rating scale ranging from 0 to 6 points (0 corresponded to 'no effect' and 6 to the 'complete' resolution of the entropion) was used to evaluate the goals of the treatment. The average rating was 5.37 points.

CONCLUSIONS

The entropion due to glaucoma therapy with PA can be successfully treated with BTI in the orbicularis muscle, despite offering temporary therapeutic effects.

[Stabilometric analysis in patients affected by maculopathy]

OBJECTIVES

The walk is strictly influenced by vision, that's essential for the position of the body in the space during the walk cycle and the postural control. The quality of life related to the vision is widely highlighted in literature: for example Brown et al. in 2005 underlined the comparison from DMLE and chronic ills, like HIV, angina, dialysis, advanced prostate tumor, stroke, and heart attack. Peripheral low vision appeared the most crippling aspect to the walk, but in recent years a lot of studies stressed the walk difficulty in patients with central low vision.

MATERIALS AND METHODS

Our study has been carried out in partnership between Ophtalmic Department and Physiatrist Department. Its aim was to evaluate static posture in patients affected by maculopathy. We picked out subjects affected by maculopathy with central low vision due to a variety of causes but with preserved peripheral vision.

RESULTS

Test trials had the purpose to investigate different aspects of static posture, in subjects affected by central low vision. It was related to risk of falling and faulty postures, that are pathologically in a long term.

CONCLUSIONS

Our study claimed that in stabilometric analysis the differences between patients affected by maculopathy and control group aren't statistically significant.

Forskolin and rutin prevent intraocular pressure spikes after Nd:YAG laser iridotomy

AIM

the purpose of this research was to evaluate whether an oral treatment with an association of forskolin and rutin can blunt the intraocular pressure (IOP) spikes and avoid the damage that may occur after laser iridotomy.

METHODS

Ten patients underwent bilateral Neodymium:YAG (Nd:YAG) laser iridotomy (Visulas YAG III Laser, Zeiss), for the prevention of primary closed-angle glaucoma. IOP was measured in subjects before and after 7 days of pretreatment with placebo or forskolin and rutin by Goldman applanation tonometry. The IOP was measured before surgery and after surgery at 30-60-120 minutes, and 4-7 days.

RESULTS

Analysis of variance indicated a significant increase of the postoperative values in patients receiving treatment with placebo (p < 0.001), but not in those who received treatment with the forskolin and rutin association. T test analysis confirmed that IOP still remained significantly elevated 7 days after laser intervention in placebo treated patients, whereas it stayed within normal values in forskolin/rutin treated patients.

CONCLUSION

Forskolin and rutin can blunt the increase of IOP that occurs after Nd-YAG laser iridotomy. This can avoid serious risk to the optic nerve of the patients under laser treatment for iridotomy.

Idiopathic juxtafoveal retinal telangiectasis and retinal macroaneurysm treated with indocyanine green dye-enhanced photocoagulation

This case report presents the use of indocyanine green dye-enhanced photocoagulation (ICG-DEP) for the treatment of idiopathic juxtafoveal retinal telangiectasis and a retinal macroaneurysm. A 35-year-old male with 20/20 vision had been followed for 5 years for a retinal macroaneurysm with retinal telangiectasis outside the macular area. He then presented with a recently decreased vision in his right. He had macular edema with a new area of idiopathic juxtafoveal retinal telangiectasis. After 4 focal argon laser treatments, angiographic closure of the lesions was not obtained and the retinal edema remained. After 3 sessions of ICG-DEP, the lesions were closed and the edema absorbed. The 810 nm infrared laser with ICG-DEP should be considered for the treatment of idiopathic juxtafoveal retinal telangiectasis and retinal macroaneurysms. In this case the procedure appears to be safe and well tolerated. It may allow for more direct energy absorption than that of the argon laser to these types of retinal lesions with better tissue closure.

Pneumotrabeculoplasty as treatment for primary open angle glaucoma: critical review of the literature

PURPOSE

To evaluate with criticism the available evidence shown in the literature about the efficacy of pneumotrabeculoplasty (PNT) as a treatment for primary open angle glaucoma.

MATERIALS AND METHODS

PNT is a recent non-surgical and noninvasive technique to safely reduce the intraocular pressure (IOP) in eyes suffering from ocular hypertension or primary open angle glaucoma. The technique consists in the application on the ocular surface of a disposable suction ring that induces a temporary trabecular meshwork stretching, increasing outflow of aqueous humor in the Schlemm's canal. In our study, we compared the results on the efficacy and safety of this treatment published to date in the literature.

RESULTS

During follow-up, Authors have observed significant reductions in IOP in about 70% of treated eyes. The first treatment consists in 3 applications at day 0, 7 and 90, repeatable every 90 days. Immediately after suction ring application there is a significant elevation of IOP, however, of short duration and without demonstrable visual field worsening. Side effects observed are of little clinical significance and spontaneously resolving in a short time.

CONCLUSIONS

The PNT is a safe and effective technique to reduce IOP in patients with ocular hypertension or open-angle glaucoma. It is repeatable, but can not replace drug treatment in patients already receiving topical therapy for glaucoma; however, it has proven effectiveness in maintaining an IOP target over time if accompanied with only a single topical drug, favoring a reduction of antiglaucoma drugs in polytherapy and increasing the compliance with treatment.

Henoch-Schönlein purpura in a patient with bowel bypass syndrome

Henoch-Schönlein purpura (HSP) is a common vasculitis being characterized by the classic tetrad of nonthrombocytopenic palpable purpura, arthritis or arthralgias, gastrointestinal and renal involvement. Antigen-antibody (IgA) complexes activate the alternative complement pathway, resulting in inflammation and small vessels vasculitis. We present the case of a 53 years old Italian woman with HSP who was previously hospitalized for purpura skin lesions of the lower legs and diarrhea; a skin biopsy showed a leukocytoclastic vasculitis with perivascular accumulation of neutrophils and mononuclear cells. She was treated with immunosuppressive therapy. After 8 months she was hospitalized again for a recurrent episode of purpura skin lesions of the lower legs. At age 49 she was affected by obesity (BMI = 41.6 Kg/m2), treated via a bilio-pancreatic diversion that led, within a year, to a BMI reduction (25 Kg/m2). We suppose that bariatric surgery played a role on the development of autoimmune phenomena and that the formation of immunecomplexes is secondary to the excess of intestinal bacterial antigens. A cyclic therapy with Paromomicine 500 mg twice daily and Metronidazole 250 mg twice daily was performed with a clear up of the clinical picture. In medical literature are described numerous complications which include arthritis, erythema nodosum-like lesions, eruptions and other skin manifestations in patients who have undergone jejunocolic bypass. This case report describes for the first time the presence of HSP in a patient with bowel bypass syndrome and it is also able to demonstrate the relationship between the intestinal bacterial overgrowth and the systemic autoimmune system.

The combination latanoprost-timolol versus twice daily 0.50% timolol administration either associated or not with latanoprost: efficacy and tolerability in the primary open-angle glaucoma

AIMS

To evaluate the ocular hypotensive effects and tolerability of the once daily fixed combination latanoprost-timolol versus twice daily 0.50% timolol associated or not with once daily latanoprost in patients suffering from Primary Open-Angle Glaucoma (POAG).

METHODS

We compared the effects of such a combination with those of 0.50% timolol alone twice daily in a group of 24 patients and with the effects of timolol 0.50% twice daily associated with once daily latanoprost in a second group of 20 patients with a follow-up of 24 months.

RESULTS

In the first group of patients after one month the Intraocular Pressure (IOP) was reduced from a mean of 19.93 to a 17.04 mmHg. This reduction remained stable with a mean value of 17.00 mmHg at the third month, of 16.49 mmHg at the sixth month, of 17.04 at the twelfth month, 16.00 at the eighteenth month, and of 15.86 mmHg in the twenty-fourth month. In the second group there was a statistically significant reduction from 19.4 to 16.84 mmHg after one month. This reduction remained constant with mean values of 16.47 at the sixth month, of 16.20 at the twelfth month and of 16.00 mmHg at the twentyfourth month of treatment.

CONCLUSIONS

The once daily latanoprost-timolol combination was shown to furtherly reduce the Intraocular Pressure (IOP) (p=0.001) and to maintain under control the intraocular pressure for the observation period (24 months). Both topical and systemic side-effects were scarse and tolerability was good.

Oral administration of an association of forskolin, rutin and vitamins B1 and B2 potentiates the hypotonising effects of pharmacological treatments in POAG patients

BACKGROUND/AIMS

Control of intraocular pressure is still the main strategy to treat glaucoma patients. Forskolin has already shown an ability to control intraocular pressure after topic administration, whereas rutin is known to improve ocular blood fl ow. Therefore, aim of this pilot study has been to observe whether administration of an association of oral forskolin and rutin to POAG patients under different regimens of medical therapy may contribute to their effects, further decreasing IOP values.

MATERIALS AND METHODS

Forskolin (a natural compound present in the crude extract of the plant Coleus Forskohlii) and rutin are the main ingredients of a food supplement commercially available in Italy. In an open label pilot study, 16 patients with POAG under treatment with different topical drugs and with stable IOP were given additional treatment with the food supplement for 40 days, and their IOP values measured at enrolment, at the end of treatment and 40 days after treatment interruption.

RESULTS

Further addition of forskolin and rutin to topical association treatments resulted in a further decrease of IOP by roughly 20% of the initial value. The effect was reversible upon suspension of the treatment.

CONCLUSIONS

These data show for the fi rst time that forskolin and rutin given through the oral route appear to reach the ocular district, where they can act in synergy with topical pharmacological treatments, and contribute to the control of intraocular pressure.

Pilot study to evaluate the efficacy and safety of pneumatic trabeculoplasty in glaucoma and ocular hypertension

PURPOSE

Following laser-assisted in situ keratomileusis (LASIK), intraocular pressure (IOP) is measurably lower in a significant number of cases. It has been proposed that the decrease in IOP may be a real event. Prior trials have evaluated pneumatic trabeculoplasty (PNT) in combination with concomitant glaucoma medications. The aim of this study was to determine the efficacy and the safety of PNT alone to lower IOP in patients with primary open angle glaucoma (POAG) or ocular hypertension (OH).

METHODS AND RESULTS

A total of 37 subjects with POAG or OH were enrolled in a prospective, open-label, fellow-eye, multicenter trial to determine the IOP lowering effects of PNT. All subjects underwent ophthalmologic examinations and IOP measurements and were washed out from all glaucoma medications prior to the start of the study. The trial was intrapatient controlled for the first 30 days, with one eye receiving PNT at days 0 and 7 and the fellow eye serving as the control. The second eye was treated with PNT at day 30. The patients were followed for 120 days, with the first eye receiving an additional PNT treatment at days 90 and 97. Two analyses-an intent to treat analysis in which the last IOP measurement for patients dropped from the study was carried forward and an analysis including only those patients who completed the trial-were performed. Of the 37 patients enrolled, 27 (73%) completed the study. For the intent to treat analysis the baseline mean IOP was 24.7+/-1.9 mmHg for eye 1 and 23.6+/-2.3 mmHg for eye 2 and the difference was statistically significant (p<0.05). Using this analysis the differences between eye 1 mean IOP at days 1, 7, 14, and 60 and the baseline mean IOP were statistically significant (p<0.05). The differences between eye 2 mean IOP and the baseline mean IOP were statistically significant (p<0.05) at all time points except day 14 and day 30. The greater mean IOP reductions from the baseline mean IOP for eye 1 were at study day 1 (-16,1%), day 14 (-9%), and day 60 (-8.9%). For eye 2 they were at day 60 (-8.7%) and at day 120 (-9.1%). For the analysis that included only those subjects who completed the trial the decrease in eye 1 mean IOP from baseline was statistically significant (p<0.05) at all time points. The decrease in eye 2 mean IOP from baseline was statistically significant at all time points except day 30. Using this analysis the greater mean IOP reductions from the baseline mean IOP for eye 1 were at study day 1 (-19%), day 14 (-15.7%), day 37 (-16.3%), day 60 (-20.0%), day 90 (-18.1%), day 97 (-16.8%), and day 120 (-15.8%). For eye 2 greater mean IOP reductions from baseline mean IOP were seen on day 37 (-13.0%), day 60 (-16.7%), day 90 (-15.5%), day 97 (-14.5%), and day 120 (-7.2%). No statistically significant differences were found in mean IOP reduction between the two eyes treated. A total of 34 patients (92%) showed adverse effects: conjunctival hyperemia in 26 (70.3%) and conjunctival hemorrhage in 14 (37.8%).

CONCLUSIONS

This pilot study of PNT showed a potentially good IOP lowering effect on glaucoma and hypertensive patients. Additional studies would help to better define the types of patients who respond to PNT and to identify risk factors that may lead to treatment failure.