Current Treatments and Innovations in Diabetic Retinopathy and Diabetic Macular Edema

Diabetic retinopathy (DR) is one of the leading causes of blindness worldwide. Multiple treatment options have been used over time to attempt to modify the natural progression of the disease in both proliferative diabetic retinopathy (PDR) and diabetic macular edema (DME). These two retinal complications are the result of microvascular occlusions and vascular hyperpermeability and are considered one of the leading causes of irreversible blindness in patients of working age. It is now well demonstrated that PDR and DME are associated with increased levels of inflammatory and pro-angiogenic factors in the ocular compartment. To date, laser photocoagulation, vascular endothelial growth factor (VEGF) inhibitors, and corticosteroids have demonstrated efficacy in their treatment in large randomized controlled trials and in real-life observational studies. This manuscript aims to provide a comprehensive review of current treatments, including the main drugs used in diabetic pathologic manifestations, as well as new therapeutic alternatives, such as extended-release intraocular devices.

Spontaneous closure of an idiopathic macular hole after epiretinal membrane development

Purpose

To report non-operative closure of an idiopathic full thickness macular hole (FTMH) spontaneous secondary to the development of a macular epiretinal membrane (ERM).

Observations

A 68-year-old woman, with no relevant medical history, and a 6-month history of decreased visual acuity in her right eye was diagnosed to have an idiopathic FTMH. The patient refused surgery and the FTMH was followed-up for seven years. The spectral domain optical coherent tomography follow-up showed the evolution of the FTMH and its spontaneous closure after development of an ERM. In the presence of an ERM with vitreo-papillary detachment, it is possible that the centripetal forces involved helped bring together the edges of the macular hole resulting in a possible spontaneous closure. Additionally and separately, the presence of an ERM may act as scaffolding for Muller cell migration and consequent macular hole closure.

Conclusions and importance

Development of an ERM was followed by non-operative FTMH closure in this specific case. It is important to note, that this is an extraordinary situation in which the patient had a favorable anatomical evolution despite having rejected conventional surgical intervention. Studies aimed at determining the mechanisms and situations in which these cases occur could provide answers that help us make more appropriate decisions. To our knowledge, the present case is the first in the literature to report a spontaneous closure of a FTMH secondary to the appearance and progression of a previously non-existent ERM.

Sudden branch macular artery avulsion during internal limiting membrane peeling for idiopathic macular hole: A case report

INTRODUCTION AND IMPORTANCE

Macular Holes (MH) are variable thickness openings of the retina that develop in the fovea. This case presents a branch macular artery avulsion during internal limiting membrane (ILM) peeling for idiopathic macular hole management in an adult patient. The proper management of this complication along with the preventive measures is mentioned.

CASE PRESENTATION

A 65-year-old woman developed a branch macular artery avulsion during ILM peeling for MH. After cataract extraction by phacoemulsification with intraocular lens implantation and pars plana vitrectomy, during ILM peeling, a multifocal bleeding along a macular artery was noted indicating its avulsion. The intraocular pressure was raised to control hemorrhage, blood remnants were passively aspirated and ILM peeling was kindly completed under adequate visualization.

CLINICAL DISCUSSION

Branch macular artery avulsion is a potential complication even for experienced surgeons. Proper management of this complication involves the increase of intraocular pressure for hemostasia. If hemostasia and proper visualization are achieved, the surgery could be completed, and if it is not the case, the ILM peeling could be completed in a second procedure. This complication might be avoided by initiating the ILM peeling away from the macular vessels.

CONCLUSION

Branch macular artery avulsion is an intraoperative complication that might be avoided by initiating the ILM peeling away from the macular vessels.

Double-bellied medial rectus muscle in a patient with Down syndrome and congenital esotropia

A 13-year-old male with Down syndrome, pseudophakic secondary to congenital cataract presented with esotropia. During bilateral medial rectus recession, a unilateral two-bellied right medial rectus was identified and recessed successfully with complete resolution of the deviation. Clinicians facing a two-bellied medial rectus can consider continuing with their surgical plan.

Resolution of giant ocular surface squamous neoplasia with topical 5-fuorouracil 1

An 82-year-old man presented with a left eye elevated single ocular surface squamous neoplasia. The tumor involved 360° of limbus, three quadrants of cornea and conjunctiva; this was compatible with the diagnosis of giant ocular surface squamous neoplasia. Topical 5-fluorouracil 1% was planned four times daily for 1 week followed by 3 weeks off-treatment. Patient inadvertently continued 5-fluorouracil, four times daily for 4 weeks, presenting with clinical resolution of the ocular surface squamous neoplasia and subtotal corneal epithelial defect associated with 5-fluorouracil toxicity. One month later, we observed a transparent cornea and no signs of toxicity. Total tumor resolution was observed for at least 6 months of follow-up.

Anatomical Changes of Full-Thickness Macular Hole Documented by Microscope-Integrated Spectral-Domain Optical Coherence Tomography

BACKGROUND AND OBJECTIVE

To evaluate anatomical changes of idiopathic macular hole (MH) after internal limiting membrane removal and after passive suction at the hole's borders using microscope-integrated intraoperative optical coherence tomography (iOCT).

PATIENTS AND METHODS

Five eyes of five subjects with full-thickness idiopathic MH underwent phacoemulsification, intraocular lens implantation, pars plana vitrectomy, and internal limiting membrane (ILM) removal. iOCT was performed after ILM removal and after passive suction at the hole's borders.

RESULTS

iOCT showed decreased MH diameter after ILM removal in all cases. Passive suction achieved complete apposition of borders. All cases presented successful postsurgical closure.

CONCLUSIONS

iOCT provides anatomical information during MH surgery that may impact surgical decision-making by allowing a real-time evaluation of structures. iOCT with preservative-free triamcinolone acetonide enhanced ILM visualization. Its use is superior to iOCT alone for the identification of vitreomacular interface structures. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e105-e111.].

Long-term visual and anatomic outcomes after photodynamic therapy for symptomatic circumscribed choroidal hemangioma

Circumscribed choroidal hemangiomas (CCHs) are relatively rare. We report the response of a symptomatic CCH to photodynamic therapy (PDT). A 70-year-old male presented with blurred vision of the left eye (OS). Best-corrected visual acuity (BCVA) was 20/60 right eye and 20/160 OS. Biomicroscopy revealed bilateral cataracts. Diagnosis of CCH was made fundoscopically for OS and confirmed with optical coherence tomography (OCT). One session of PDT with individualized parameters was administered. After 2 months, anatomical improvement was evidenced with OCT and BCVA was 20/60. After cataract surgery, his BCVA was of 20/25 and remained stable. PDT showed excellent anatomic and visual results after a 2-year follow-up.

Minimally Invasive Surgery for the Removal of Posterior Intraocular Foreign Bodies

This is a prospective clinical assay that included six patients who were diagnosed with penetrating corneal injury, traumatic cataract, and posterior segment intraocular foreign body (IOFB). Following anterior segment repair and extraction of traumatic cataract by clear cornea phacoemulsification, a standard 25-gauge transconjunctival pars plana vitrectomy was performed to find and release the IOFB. With active suction using a 25-gauge silicone tipped cannula, the foreign body was retrieved and safely placed in the anterior chamber. After stabilization of the anterior chamber with viscoelastic injection, IOFB extraction through the main phaco incision was easily performed, followed by placement of an intraocular lens. Of the six patients, 66.6% showed a significant improvement of visual acuity. No complications associated directly with the surgical procedure occurred. Our surgical technique is a safe alternative for handling and removing a posterior IOFB. There was no need for a scleral incision.

Morning Glory Disc Anomaly, A Report of a Successfully Treated Case of Functional Amblyopia

Morning Glory Disc Anomaly (MGDA) is a congenital malformation of the optic nerve characterized by the presence of a funnel-shaped macropapilla with neuroglial remnants in its center surrounded by an elevated and pigmented chorioretinal ring. Its incidence is rare and no gender predisposition has been found. Associated conditions like strabismus lead to an early diagnosis. We report the case of a 3.8-year-old boy with amblyopia of the right eye (count fingers 0.3 meters) due to MGDA. Correction of the refractive error with glasses, along with occlusive therapy resulted in a visual acuity of 20/100 after a five-year follow up. The presence of amblyopia in these cases demands an early management oriented to improve the visual acuity. Every patient with an anatomical malformation diagnosed during the period of sensory maturation should be treated with occlusive therapy and followed on a regular basis to diagnose associated conditions such as retinal detachment. We recommend occlusive therapy in every patient diagnosed with MGDA or in any patient with unilateral or asymmetric structural abnormalities that could lead to amblyopia. This 5-year case follow-up provides additional evidence of the importance of treatment during the period of amblyopia reversibility.

Olfactomedin-like 3 (OLFML3) gene expression in baboon and human ocular tissues: cornea, lens, uvea, and retina

BACKGROUND

Olfactomedin-like is a family of polyfunctional polymeric glycoproteins. This family has at least four members. One member of this family is OLFML3, which is preferentially expressed in placenta but is also detected in other adult tissues including the liver and heart. However, its orthologous rat gene is expressed in the iris, sclera, trabecular meshwork, retina, and optic nerve.

METHODS

OLFML3 messenger amplification was performed by RT-PCR from human and baboon ocular tissues. The products were cloned and sequenced.

RESULTS

We report OLFML3 expression in human and baboon eye. The full coding DNA sequence has 1221 bp, from which an open reading frame of 406 amino acid was obtained. The baboon OLFML3 gene nucleotidic sequence has 98% and amino acidic 99% similarity with humans.

CONCLUSIONS

OLFML3 gene expression in human and baboon ocular tissues and its high similarity make the baboon a powerful model to deduce the physiological and/or metabolic function of this protein in the eye.