Three-Year Outcomes of Wet Age-Related Macular Degeneration Treatment in Polish Therapeutic Programs

Background and Objectives: Wet age-related macular degeneration (wAMD) is a chronic, progressive disease of the central part of the retina. Standard treatment for wAMD consists of multiple intravitreal injections of anti-vascular endothelial growth factor drugs. The study goal was to evaluate the three-year effectiveness of wAMD treatment with aflibercept and ranibizumab as part of the therapeutic program in routine clinical practice. Materials and Methods: 1430 patients (possessing 1430 wAMD eyes) with median age of 78.0 years (71.0, 83.0) were enrolled in a non-randomized, retrospective, observational, multicenter study; 804 (56.2%) eyes were treatment-naïve. Therapy was carried out in accordance with the guidelines of the treatment program (the fixed or pro re nata regimen). Results: After the first year of treatment, there was a gain of 2.03 (12.15) letters; after the second, 0.94 (13.72) (p ˂ 0.001); and after the third, 0.17 (14.05) (p ˂ 0.001). There was a significant reduction in the central retinal thickness. In the first year, the patients received 7.00 (5.00, 8.00) injections. In the following years, a significantly lower number of injections (4.00 (2.00, 5.00)) was administered. After the first year, there was a significant difference in the distribution of the best corrected visual acuity according to the Early Treatment Diabetic Retinopathy Study protocol, with more frequent values in the ranges > 35 ≤ 70 for this parameter and > 70 letters in the treatment naïve eye subgroup. After the first year, central retinal thickness in treatment-naïve eyes was significantly reduced. Conclusions: Regular treatment of wet age-related macular degeneration as part of the treatment program achieves functional stabilization and significant morphological improvement over a long-term, three-year follow-up, with significantly fewer injections needed after the first year of treatment.

One-year outcomes of the Polish treatment program for the wet form of age-related macular degeneration using intravitreal therapy

PURPOSE

To report 12-month outcomes of a Polish National Treatment Program using aflibercept and ranibizumab in eyes with wet, age-related macular degeneration in routine clinical practice.

MATERIAL AND METHODS

This was a non-randomized, retrospective, observational multicenter study. Anonymous data contained in the electronic Therapeutic Program Monitoring System were utilized in this study.

RESULTS

The study population consisted of 2828 eyes from 2718 patients. The median age was 76.0 [70.0, 81.0] years; 61.7% were female. Best corrected visual acuity increased from 58.86 [50.05, 69.95] letters to 65.1 [50.1, 73.9] letters (p < 0.001). The median change in best corrected visual acuity was 0.0 [-4.0, 12.2] letters: 2.9 [-2.9, 15.1] letters for treatment-naïve eyes and 0.0 [-4.0, 8.8] letters for those continuing treatment (p < 0.001). The median central retinal thickness was significantly reduced from 341.0 [281.0, 422.0] to 275.0 [221.0, 344.0] μm (p < 0.001). The median number of visits was 9.0 [8.0, 9.0]. The median number of injections was 7.0 [6.0, 8.0]: 8.0 [7.0, 8.0] for treatment-naïve eyes and 6.0 [5.0, 7.0] for those continuing treatment (p < 0.001).

CONCLUSION

Eyes treated as part of the Polish therapeutic program gained functional stability and morphological improvement. Treatment-naïve eyes showed the greatest functional benefit.

Effect of Phacoemulsification on Visual Acuity and Macular Morphology in Patients with Wet Age-Related Macular Degeneration

Background

This article discusses the effectiveness of phacoemulsification cataract surgery with intraocular lens implantation in patients with wet age-related macular degeneration in the inactive phase of the disease.

Material/Methods

Forty-nine patients (50 eyes) aged 78.94±5.54 years, previously treated with intravitreal injections of anti-vascular endothelial growth factor agents, were qualified for a prospective, randomized 12-month study. The participants were divided into 2 groups. Group I consisted of 25 patients (25 eyes) who were subjected to phacoemulsification cataract surgery. Group II consisted of 24 patients (25 eyes) who were not subjected to phacoemulsification cataract surgery despite having a lens opacity of grade II or higher according to the Lens Opacities Classification System.

Results

After 12 months of follow-up, patients in group I gained on average 8.04 letters (p<0.001). Furthermore, 20% of the eyes had a significant improvement in best corrected visual acuity of ≥15 Early Treatment of Diabetic Retinopathy Study Chart letters. Patients in group II lost on average 1.96 letters (p>0.05). No significant differences between central retinal thickness values in either group (p>0.05) were noted. The mean number of intravitreal injections of anti-vascular endothelial growth factor agents during the study was 2.64±1.98 in group I and 2.92±2.40 in group II (p>0.05).

Conclusions

Phacoemulsification performed in eyes with wet age-related macular degeneration during the inactive phase of the disease significantly improves visual acuity. In addition, it does not significantly influence the frequency of intravitreal injections of anti-vascular endothelial growth factor agents or disease activity.

Triple therapy: Phaco-vitrectomy with ILM peeling, retinal endophotocoagulation, and intraoperative use of bevacizumab for diffuse diabetic macular edema

BACKGROUND

The aim of this study was to evaluate the visual acuity and structural outcomes of combined phacovitrectomy with ILM peeling, retinal endophotocoagulation and use of bevacizumab in patients with diffuse diabetic macular edema (DDME).

MATERIAL/METHODS

In this prospective, nonrandomized, interventional study we included 29 eyes of 26 patients with DDME. The best-corrected visual acuity (BCVA) and central retinal thickness and volume (CRT and CRV) were recorded at 4, 8, 12, and 16 months after surgery.

RESULTS

The mean preoperative BCVA was 0.74±0.36 logMAR (0.3-1.5) and improved finally to 0.4±0.24 logMAR (-0.1-1.0) p=0.000006. The mean preoperative CRT in the 1mm zone was 516±184 microm (256-950) and decreased postoperatively at the last control to 237±75 microm (117-489) p=0.000003. The mean preoperative CRV in the 1mm zone was 0.39±0.14 microL (0.19-0.74) and decreased postoperatively at the last control to 0.17±0.06 microL (0.09-0.36) p=0.000003. The mean preoperative CRT in the 6 mm zone was 407±105 microm (279-640) and decreased postoperatively at the last control to 282±40 µm (212-380) p=0.000004. The mean preoperative CRV in the 6 mm zone was 11.4±2.9 microL (7.85-17.93) and decreased postoperatively at the last control to 7.92±1.0 microL (5.62-10.97) p=0.000003. The 23 (79.3%) eyes showed improvement in BCVA ≥0.2 logMAR, 5 (17.2%) eyes improvement or stabilization of BCVA and 1(3.5%) eye deterioration. Preoperative BCVA was a positive factor for prognosis of BCVA at 12th month follow-up (b=0.42; p=0.006), while the negative factors were: previous panretinal photocoagulation (b=-0.24; p=0.04), presence of vitreomacular traction (b=-0.29; p=0.02) and preoperative CRT in the 1000 microm zone (b=-0.24; p=0.07). A greater visual acuity improvement occurred in eyes with worse baseline visual acuity (b=-1.01; p=0.00001). The presentation of vitreomacular traction (b=-0.38; p=0.02), previous panretinal photocoagulation (b=-0.31, p=0.04) and greater preoperative CRT in the 1000 µm zone (b=-0.31; p=0.07) were negative factors for visual improvement.

CONCLUSIONS

This combined treatment resulted in improvement or stabilization of BCVA and decrease of CRT and CRV. Larger comparative studies are necessary to establish the real impact of this therapeutic approach.

Retinal pigment epithelial tears following ranibizumab therapy for fibrovascular retinal pigment epithelial detachment due to occult age-related macular degeneration

BACKGROUND

The aim of this paper is to report the incidence of retinal pigment epithelial (RPE) tears in patients treated with ranibizumab for subfoveal fibrovascular retinal pigment epithelial detachment (FVPED) due to occult age-related macular degeneration (AMD).

MATERIAL/METHODS

Thirty patients were treated according to the following schedule: saturation phase, further treatment was based on activity of the degeneration process. Visual acuity (VA), optical coherence tomography (OCT) and fluorescein angiography (FA) parameters were evaluated and compared.

RESULTS

Patients had a mean improvement of +4.7 ± 8.1 letters at month 12. The mean number of needed injections was 6.8 ± 1.8 (range, 3 to 9). RPE tears in fovea occurred in 8 cases (27% of all patients). Analysis of variance revealed significant upper mean values of ETDRS letters for the subgroup without RPE tears. Mean values of PED height were significant upper for RPE tears without baseline. Statistical analysis revealed that in the subgroup without RPE tears mean values of VA significantly differed in succeeding periods compare to baseline (P<0.001). Visual improvement or stabilization was observed in 90.9% of patients without RPE tears (significant improvement of 15 or more letters in 22.7% - 5/22) and in 87.5% of patients with RPE tears (significant improvement was not observed). Baseline leakage parameters, lesion and leakage parameters at month 12 were significantly higher in patients with RPE tears. The chi-square test revealed statistically significant associations between RPE tears and subretinal fluid in OCT (P<0.05) at month 12.

CONCLUSIONS

In eyes with FVPED and RPE tears treated with ranibizumab, stabilization of visual acuity without significant improvement is predictable. One of the risk factors common to RPE tears may be baseline leakage parameters and pretreatment distorted RPE contour in OCT. During ranibizumab therapy in eyes with RPE tears, upper parameters of FVPED height may occur without significant differences in fovea and macula volume compare to eyes without RPE tears.

Severe decrease in visual acuity with choroidal hypoperfusion after photodynamic therapy

Background

Photodynamic therapy (PDT) is considered a selective method of treatment which works in areas of choroidal neovascularization (CNV); however, there are reports of choroidal hypoperfusion after PDT. This paper presents a clinical case of choroidal circulation disturbances caused by PDT, accompanied by CNV progression.

Case Report

The patient, a 75-year-old woman, was qualified for PDT in the right eye – first treatment due to progression of occult CNV. Best corrected visual acuity (BCVA) in the right eye at baseline was +0.3 logMAR. After PDT, a rapid decrease in visual acuity to +0.7 logMAR in the right eye was observed, central choroidal hypoperfusion in fluorescein angiography (FA) with subretinal fluid appeared and, as a consequence, progression of neovascular age-related macular degeneration (AMD). After stabilizing the local state through conservative therapy, a decision was made to treat the right eye with intravitreal injections of vascular endothelial growth factor (VEGF) inhibitor. During a 12-month period of observation, 7 doses of ranibizumab were administered. A regression in activity of wet AMD was observed, with visual acuity of +0.6 logMAR.

Conclusions

Choroidal circulation disturbance after PDT is possible and has to be taken into account. Sporadically, it can lead to an acute decrease in visual acuity and local state. After stabilization of AF and optical coherence tomography imaging, further treatment of neovascular AMD with intravitreal injections of anti-VEGF agents should be considered.

[Azithromycin in prophylaxis of intravitreal injections in patients with wet age-related macular degeneration]

Endophthalmitis is one of the most dangerous complications after intravitreous drug injection. Preparing a patient to the injection general and topical endophtalmitis development risk factors should be eliminated. Antibiotic injection prophylaxis is still an important issue.

PURPOSE

This research has to evaluate effectiveness and tolerance of Azithromycin (Azyter, Thea), in injection as an antibiotic prophylaxis in patients suffering from age-related macular degeneration (AMD).

MATERIAL AND METHODS

The study was conducted in Ophtalmology Department (Medical Military Institute, Warsaw, Poland), in the group of 52 patients, who underwent 52 intraocular injections of anti-VEGF because of AMD. Topical Azithromycin had been administrated twice a day to both eyes in 2 days before injection. On the third day injection was performed in aseptic conditions. One drop of Azithromycin had been administrated to each eye directly before injection and one drop after the procedure. At that moment antibiotic prophylaxis was terminated.

RESULTS

Topical tolerance and effectiveness were evaluated. In 2 cases (3.8%) intensive allergic reaction was reported (significant conjuctives oedema, itch, bloodshot), what caused change of antibiotic. In 5 cases (9%) light bloodshot was reported. 12 patients (23%) reported light or moderate foreign body sensation and in 2 cases (3.8%) the sensation was significant. No reaction of ophthalmic inflammation was reported 5 days after injection, moreover foreign body sensation and bloodshot were absent. 30 patients (57%) were satisfied with new and simplier scheme of antibiotic injection prophylaxis (twice a day for 3 days).

CONCLUSIONS

Azithromycin is a comfortable alternative for other topical antibiotics, especially in repetitive procedures like anti-VEGF injections. High Azithromycin concentration in tissues, tear film, and on the ophthalmic surface, protects injection site and inhibits growth of primary and mutual bacterial colonies. Short-term exposition to Azithromycin decrases risk of drug resistance development.

[Combined pharmacological-surgical treatment in exudative age-related macular degeneration]

PURPOSE

The aim of this paper is to present the early phase of treating exudative age-releted macular degeneration (AMD)--coexisting witch vitreoretinal pathology--with combined pharmacological-surgical therapy.

MATERIAL AND METHODS

Our observation is based on one clinical case of combined therapy: pars planavitrectomy (PPV) and one intravitrealranibizumab injection. Observation is being carried on larger patient group according to the treatment scheme presented In this paper.

RESULTS

In this case described combined pharmacological-surgical therapy allowed a significant improvement in visual acuity and closure of choroidal neovascularization (CNV), leakage confirmed by fluorescein angiography (FA) and optical coherence tomography (AMD). The treatment is being continued--another ranibizumab injection according to PRONTO study reinjection criteria.

CONCLUSIONS

The pathomechanism of exudative AMD and coexistance of vitreoretinal pathology implications confirm reasonability of combined therapy.Due to actual clinical studies: the pharmacological -surgical treatment reduces the number of required intravitreal anti-VEGF agents injections. To confirm this observation we need to perform large randomised clinical studies.

Future possibilities in glaucoma therapy

Glaucoma is a group of eye diseases causing irreversible optic nerve damage. This review presents 4 elements of future glaucoma treatment strategies: baroprotection, vasoprotection, neuroprotection and gene therapy. New baroprotection includes compounds that alter the actin cytoskeleton (rho-kinase inhibitors, latrunculin, cytochalasin), new drugs that enhance aqueous outflow via the trabecular meshwork (statins, steroid antagonists) and via the uveoscleral route (EP2 agonists, 5-HT2 agonists), as well as new classes of components that suppress aqueous humor formation (cannabinoids). Vasoprotection includes blocking reperfusion injury (NOS-2 inhibitors, endothelin blockers, MMP-9 inhibitors). Concerning neuroprotection antiamyloids antibodies, erythropoietin and caspase inhibitors are discussed. Gene therapy may target various effectors: the trabecular meshwork (cytoskeleton regulatory proteins, miocyllin, MMPs), the ciliary body epithelium (genes modifying aqueous humor production, neuropeptides), the ciliary body cells (MMPs, genes of local PGs biosynthesis, ciliary muscle relaxants), the retinal ganglion cells (neurotrophin genes, anti-apoptotic genes), Müller cells (neurotrophins, GLAST) and conjunctiva (gene of chloramphenicol acetyltransferase, inhibitor p21). Experimental studies on the graft mesenchymal stem cells and mature retinal cells to replace the dead retinal ganglion cells are advanced. Immunotherapy, offering a vaccination, providing protection against loss of retinal ganglion cells, has been investigated.

Safety of ranibizumab therapy in wet AMD and the role of vascular endothelial growth factors in physiological angiogenesis

Vascular endothelial growth factor - A (VEGF-A), is a major factor implicated in choroidal neovascularisation (CNV) and therefore a target for therapeutic agents in wet age related macular degeneration (AMD). Ranibiuzumab (Lucentis) blocks all active isoforms of VEGF-A and the products of their degradation. It penetrates through all layers of the retina in order to reach the target tissue. It is quickly removed from the system and it is characterised by low level of immunogenicity. The essence of angiogenesis is formation of new vessels by branching and expansion of already existing ones. Angiogenesis is an important physiological process that takes place during the healing of wounds, reconstruction of hypoxic injury and reproduction. However some diseases such as cancer, arthritis, diabetes and neovascular AMD are associated with persistent unregulated angiogenesis. There is an important question whether binding vascular-endothelial growth factors in wet AMD therapies using ranibizumab is correlated with the increase of the incidence of systematic adverse effects (AEs), such as cardiovascular episodes or thrombosis. The aim of this article is to present ranibizumab as a safe drug in treating wet AMD patients. Even though the concentration of Lucentis administered in a dose of 0.3 or 0.5 mg into the vitreous body in the organism is very low, the incidence of AEs during the anti-VEGF therapy was traced. In MARINA and ANCHOR studies, occurrence of possible AEs was observed. No statistically significant differences were shown in the AEs frequency between the patients treated with ranibizumab and the control group, and in correlation with the general population of patients suffering from wet AMD.

Optical coherence tomography in imaging of macular diseases

OCT (opitcal coherence tomography), is a diagnostic method that enables the analysis of the retinal structures by means of high-resolution tomographic cross-sections of the retina. Whereas fluorescein and indocyanine angiography allow visualization of the retinal epithelium layer and chorioretinal vessels, OCT may help in diagnosing and monitoring the condition of many internal retinal layers. Ultrasound B-mode examinations have a resolution of about 150 microm while OCT provides a resolution of 10 microm. OCT makes it possible to detect and measure morphological changes, retinal thickness, retinal volume, thickness of retinal nerve fiber layer and various parameters of the optic disc. We use OCT in the analysis of the retinal structures in various pathologies such as macular holes and pseudo-holes, epiretinal membranes, macular edemas of various origins, including vasooclusive disease and diabetic macular edema, lesions of vitreoretinal interface and vitreoretinal traction, serous and hemorrhagic detachments of the retina and of pigment epithelium, age related macular degeneration, diabetic retinopathy, glaucoma. OCT is an examination that is fast, sensitive, reproducible, non-invasive, non-contact and easy to perform and interpret for a retinologist. The aim of this article is to present OCT principles and techniques as well as OCT interpretation and images of most common retinal diseases: age related macular degeneration--dry and wet form, retinal angiomatous proliferation (RAP), central serous chorioretinopathy, epiretinal membranes, macular holes, diabetic retinopathy.

[Combined surgical and pharmacological treatment of diabetic maculopathy]

There are at least three avenues of investigation that support the theoretical value of vitrectomy for the treatment of DME, based on (1) vitrectomy with ILM peeling for the relief of traction on the macula, (2) vitrectomy to improve oxygenation of the macula leading to decreased vascular permeability with subsequent resolution or decrease in DME, and (3) ILM peeling to remove a part of the Müller cell endfeet and the horizontal gliosis. Visual improvement could be due to the induction of a higher overexpression of GFAP at the Müller cells level. It is likely that the proliferation of GFAP-stained gliofibrils, observed in these cells, preserves the blood-retinal barrier, reinforces architectural cohesion, and opposes the installation of the edema. In addition, the search for a specific pharmacological treatment is ongoing on the basis of new findings regarding the involvement of cytokines and growth factors in the formation of macular edema. Vascular endothelial growth factor (VEGF), inhibitors are currently being investigated in clinical studies. However, endogenous VEGF is required for visual function. Growing body evidence indicates that VEGF acts also on nonvascular cells, it plays survival role on Müller cells and photoreceptors. Therefore anti-VEGF therapies should be administered with caution.

Müller glial cells--the mediators of vascular disorders with vitreomacular interface pathology in diabetic maculopathy

The key to identifying the type of diabetic maculopathy is determining the status of posterior vitreous adhesion. In the pathological state, the breakdown of the internal and external blood-retina barrier is evident, however the mechanism is usually complex. The common denominator for these disorders are Müller glial cells, which mediate in maintaining the blood-retina barrier by linking the vessels, neurons and the vitreous in anatomical network and into functional dependence. The breakdown of the blood-retina barrier results in proliferation of Müller cells. Molecular changes in these cells increase endothelial barrier properties, but also induce pathological processes on the vitreo-retinal junction, resulting in increased adhesiveness of the collagen fibers of vitreous to retinal internal limiting membrane. The ability of Müller cells to reactive gliosis is influenced by the healthy functioning of the retinal pigment epithelium, which is a source of trophic factors necessary for appropriate Müller cells morphogenesis. Vitrectomy with the removal of ILM eliminates the vitreofoveal interface pathology, additionally provoking reactive gliosis within the macula. Intraoperative use of anti-VEGF supports short-term tightness of the blood-retina barrier in the perioperative neuralgic period. In the future, supplying astrocytes may be a strategy that will allow not only the inhibition of pathological neovascularization but also the restoration of the physiological network of capillaries in avascular retina areas. The delivery of recombinant PEDF allows for the recovery of Müller cells, and thus creates the conditions favourable for the survival of nerve cells in loss of retinal homeostasis.

Combined therapy in exudative age-related macular degeneration

PURPOSE

Therapeutic options in active exudative age-related macular degeneration (AMD) are following means used to destroy the choroidal neovascularization (CNV) lesion: laser photocoagulation, radiotherapy, transpupillary thermotherapy, photodynamic therapy (POT) or removal of neovascular membrane through vitreoretinal surgery. Another possibility is to suppress the development of neovasculanization through intravitreal administration of anti-VEGF agents: ranibizumab, bevacizumab (off-label), sodium pegaptanib or steroids (off-label). The aim of this paper is to present the early phase of treating exudative AMO with combined therapy: photodynamic therapy with intravitreal ranibizumab injection.

MATERIAL AND METHODS

Our observation is based on three clinical cases. Observations are being carried out on larger patient groups according to the treatment scheme presented in this paper.

RESULTS

In the three cases described one POT procedure and the saturation phase of three ranibizumab injections allowed a significant improvement in visual acuity and closure of CNV leakage confirmed by fluorescein angiography (FA) and optical coherence tomography (OCT). Treatment is being continued according to AMO activity: next POT in case of leakage in FA, another ranibizumab injection according to PRONTO study reinjection criteria.

CONCLUSIONS

The pathomechanism of exudative AMB confirms reasonability of combined treatment. Considering the stages of neovascularization in exudative AMO. VEGF inhibition combined with POT has a synergistic action and increases the effectiveness of both therapies alone. L.arge clinical studies (FOCUS) show that combined therapy reduces the number or required POT procedures. In combined therapy modification of POT parameters should be considered: reduction of energy and laser exposure time.

Atypical peripapillary location of choroidal neovascularization--case reports

Choroidal neovascularization (CNV) is one of the main reasons for sight loss in adults. CNV located at the border of the optic disc or adherent atrophy is described as peripapillary choroidal neovascularisation (PPCNV). The aim of the work is to present a course of changes and the effects of treatment with intravitreal ranibizumab injections for peripapillary subretinal neovascularization, its consequences and accompanying other CNV foci in two patients. The diagnosis and monitoring of the therapeutic effects were based on the results of fluorescein angiography and OCT. In a 53-year-old female patient three injections of ranibizumab at a dose of 0.05 mg were administered according to a saturation regimen. Visual improvement of 5 lines on an ETDRS board (25 letters) was obtained, as well as withdrawal of the subretinal fluid from the area of the macula in OCT and limitation of the peripapillary exudate visible in 12 months follow-up angiography. In a 70-year-old female patient bilateral development of symmetric peripapillary CNV foci was observed accompanied by a occult CNV focus in the left eye macula. Spontaneous CNV limitation without macular lesions was visible in the right eye. Intravitreal ranibizumab injections were given into the left eye. A 12 months follow-up revealed vision stabilisation in both eyes at the baseline level.

CONCLUSIONS

Intravitreal injections can be used in the treatment of atypical extramacular CNV, responsible for secondary damage to the fovea. Ranibizumab, a non-selective VEGF-A inhibitor, allows the elimination of changes in the central retina, closure or significant limitation of the exudates and vision improvement. Spontaneous limitation of lesions may also be frequently expected in the eyes with peripapillary CNV foci.

[Risk factors in age-related macular degeneration and glaucoma--own observations]

PURPOSE

To assess the differences between the prevalence of risk factors in patients with age- related macular degeneration (AMD), with glaucoma and with both diseases.

MATERIAL AND METHODS

The study included 255 patients, 156 F/99 M, in age 30 to 92 years, mean age 70.9 years. They were divided into 3 groups: AMD Group (83 patients, 46 F/37 M, mean age 71.5), Glaucoma Group (34 patients, 17 F/17 M, mean age 67.1) and AMD + Glaucoma Group (138 patients, 93 F/45 M, mean age 70.9). In all groups age, sex, family history of AMD and glaucoma, hypertension, hypotension, hypercholesterolemia, diabetes, coronary heart disease, vasospasm (cold hands), migraine, heart failure and stroke in anamnesis, smoking, type of diet (high or low fat intake, high or low vitamin intake), UV exposition, cataract surgery in anamnesis, bright-coloured iris, disc hemorrhages and peripapillary atrophy were determined, and compared between them. T-student test, ANOVA, Bonferoni, Kruskall-Wallis and chi-square tests and logistic analysis (likelihood ratio chi-square) were used for statistical analysis.

RESULTS

Family history of glaucoma were higher in the Glaucoma Group (odds ratio OR 9.0 p = 0.004) than in the AMD Group (odds ratio OR 9.0 p = 0.004) and than in the AMD + Glaucoma Group (OR 3.01 p = 0.001). Disc hemorrhages were higher in the Glaucoma Group (OR 13.0 p = 0.020) than in the AMD Group (OR 13.0 p = 0.020). High fat intake in diet were lower in the Glaucoma Group as compared to the AMD Group (OR 0.5 p = 0.03). Cholesterol high level and UV exposition were lower in the Glaucoma Group than in the AMD + Glaucoma Group (OR 0.278 p = 0.020 and OR 0.23 p = 0.040 respectively). Coronary heart disease and peripapillary atrophy were lower in the AMD Group as compared to the AMD + Glaucoma Group (OR 0.43 p = 0.004 and OR 0.5 p = 0.040).

CONCLUSIONS

The study has found that high fat intake in diet was higher in the patients with AMD and family history of glaucoma, and disc hemorrhages were higher in the patients with glaucoma. The following risk factors: high level of cholesterol, UV exposition, coronary heart disease and peripapillary atrophy, were higher in the patients with co-existing both diseases.

[Anty-VEGF therapy in the treatment of myopic macular choroidal neovascularization--cases report]

PURPOSE

Myopia is the second most frequent cause of CNV after AMD. Since the introduction verteporfin photodynamic therapy and anti-angiogenic drugs into clinical practice, major changes occurred in the treatment of subfoveal exudative maculopathy associated with myopia.The aim of the paper is to present the effect of intravitreal injections ranibizumab (Lucentis) for myopic choroidal neovascularization.

MATERIAL AND METHODS

The study included two patients (25 and 55 years old women) with high myopia. Diagnosis and monitoring of the treatment were based on fluorescein angiography and optical coherence tomography.

RESULTS

In 55-years old woman after two injections central retinal leakage decreased in fluorescein angiography and optical coherence tomography and visual acuity improved of two lines (10 letters). After 9 months follow-up in 25 years old woman's after three injections of Lucentis, visual acuity improved of three lines on ETDRS chart (15 letters). The leakage in fluorescein angiography was closed.

CONCLUSIONS

Intravitreal injections therapy of ranibizumab may be a therapeutic option for CNV associated with myopia. It causes chance for decreased central retinal thickness and increased visual acuity, particularly in view of the young patients. One must take note of the other illness associated with CNV in myopic eyes like as epiretinal membranes or vitreoretinal tractions.

Humans cannot consciously generate random numbers sequences: Polemic study

It is widely believed, that randomness exists in Nature. In fact such an assumption underlies many scientific theories and is embedded in the foundations of quantum mechanics. Assuming that this hypothesis is valid one can use natural phenomena, like radioactive decay, to generate random numbers. Today, computers are capable of generating the so-called pseudorandom numbers. Such series of numbers are only seemingly random (bias in the randomness quality can be observed). Question whether people can produce random numbers, has been investigated by many scientists in the recent years. The paper "Humans can consciously generate random numbers sequences..." published recently in Medical Hypotheses made claims that were in many ways contrary to state of art; it also stated far-reaching hypotheses. So, we decided to repeat the experiments reported, with special care being taken of proper laboratory procedures. Here, we present the results and discuss possible implications in computer and other sciences.

[Diagnostic difficulties of advanced forms of exudative AMD]

Advanced forms of exudative AMD often form diagnostic difficulties and need to be differentiated with other proliferative diseases of the posterior pole. The necessary diagnostic examinations in theses cases are fluorescein and indocyanine green angiography, and nuclear magnetic resonance (MR) of the eye balls. Angiogenesis in the degenerative changes of the retina results in similar degree of enhancement in MR as in melanomas and metastases. The aim of this presentation is to discuss and compare the images of advanced forms of exudative AMD in images from fluorescein angiography, ultrasound, and especially MR based on clinical cases.

CONCLUSIONS

Despite being a very sensitive method due to its high tissues differentiation MR does not allow to define degenerative and proliferative changes in small foci.

[Photodynamic therapy for treatment choroidal neovascularization in angioid streaks--case report]

The aim of this paper is to present the effects of photodynamic therapy for treatment of bilateral macular choroidal neovascularization in angioid streaks during 16 months period. 50 years old man has one PDT in the right eye and three in the left eye. In the left eye conversion from choroidal neovascular membrane (CNV) to a fibrous disciform lesion following photodynamic therapy, was observed. In the right eye vision decreased from 1.0 to 0.2, but the leakage was minimal and stabilization of CNV size after the progression was noted.

[Effect of local abnormalities and systemic disorders on phacotrabeculectomy and the post-operative period]

The aim is to present that local abnormalities of eyes chronically treated for glaucoma and cardiovascular, metabolic disorders may influence the course of phacotrabeculectomy and post-operative period.

MATERIAL AND METHODS

The research covered 68 patients. In 89 eyes phacoemulsification of cataract connected with Cairns-type trabeculectomy and implantation of lens prosthesis has been performed. The patients were divided into two groups: I group - 37 patients, 45 surgeries. All patients were chronically treated for arterial hypertension and other cardiovascular disorders. 7 patients had non-insulin-dependent type II diabetes mellitus without diabetic retinopathy. II group - 31 patients without cardiovascular and metabolic disorders, 44 surgeries. Stromal atrophy and posterior synechiae were recognized as local abnormalities (12 eyes in I group and 18 eyes in II group). They were released during phacotrabeculectomy.

RESULTS

In post-operative period, higher coefficients of complications such as hematoceles or blood in the anterior chamber were shown in both groups, more incidents of fibrinous reaction in I group and exudate in the anterior chamber after release of posterior synechiae in II group. Statistically significant difference at p=0,016 was observed only in comparison of the incidence of complications after release of choroid-lens synechiae in I group, in comparison to II group, where synechiae were not released. Choroidal detachment was observed in 8 eyes of I group and in 1 eye of II group. Anterior chamber reconstructed in 3 eyes of I group and 1 of II group was noted. In one case of booth groups, drainage of the suprachoroid space were performed. The study didn't show statistically significant differences in the frequency of fibrinous reaction or inflammatory exudates in 9 eyes of diabetic patients, in comparison to other patients of I group.

CONCLUSIONS

Additional procedures, especially releasing of posterior synechiae are correlated with most often early complications as hematoceles, hyphema in anterior chamber, exudate or fibrinous reaction. Cardiovascular disorders are associated with non stability of choroidal circulation, that with post-operative hypotony may correlated with choroidal detachment. In patient with non-insulin-dependent type II diabetes mellitus without diabetic retinopathy, fibrinous reaction or inflammatory exudate, clinical symptoms of blood-aqueous humor barrier damage were not observed in every case.

[Therapy of the wet form of age-related macular disease: the present state and perspectives]

Age-related macular disease (ARMD) is affecting the central part of the retina. ARMD has two major forms: the dry type and the wet type. Although wet type comprises only 15% of ARMD, it is responsible for 90% of severe visual impairment in all ARMD cases. The problem is effective treatment of ARMD, above all its wet type. Laser therapy, retina surgery, TTT and local radiotherapy did not give expected results. The aim of this article is to present modern trends of wet type ARMD therapy, including pharmacotherapy and photodynamic therapy (PDT) in relation to pathobiology of choroidal neovascularization (CNV). The goals of pharmacotherapy were discussed in support, that choroidal neovascularization is a dynamic evolution, which includes initiation, active inflammation and non active involution. Cellular mechanisms of photodynamic therapy were presented. It is necessary to accentuate that in the future it can be a combination between PDT and pharmacotherapy, which inhibits early stage mediators of all types CNV and limits inflammation attendant CNV. These therapeutic approaches ere more likely succeed and included wide spectrum of wet ARMD pathogenesis. The clinical studies show that may be soon we will treat wet form of ARMD using angiostatic steroids, anti-VEGF monoclonal antibodies and anti-VEGF aptamers.

[Monitoring of blood pressure during phacotrabeculectomy]

PURPOSE

To evaluate systolic and diastolic blood pressure during phacotrabeculectomy performed under regional anaesthesia with retrobulbar block and intravenous analgosedation with midazolam and fentanyl.

MATERIAL AND METHODS

68 patients were involved into the study: I Group: 37 patients with chronic cardiovascular and metabolic diseases: 22 women and 15 men (45 operations), mean aged 72.02 years, mean weight 73.4 kg, II Group: 31 patients without additional diseases: 20 women and 11 men (44 operations), mean aged 70 years, mean weight 68.9 kg. Systolic and diastolic arterial blood pressure was recorded at 5-minute intervals throughout the intraoperative period and anesthetist intervened medically when necessary.

RESULTS

In I Group statistically significant mean systolic BP decrease was observed in 5 and 20 minutes after injection of midazolam and fentanyl and mean diastolic BP decrease was observed in 5 and 15 minutes after analgosedation. In II Group statistically significant mean systolic BP decrease was noted in 5 minutes and mean diastolic BP decrease in 5 and 35 minutes. During phacotrabeculectomy mean systolic and diastolic BP was statistically higher in I group. In I group 12 patients and in II group 4 patients required additional antihypertensive drug.

CONCLUSIONS

Regional anaesthesia with retrobulbar block and intravenous analgosedation provides hemodynamic stability. Patients with cardiovascular and metabolic diseases required acute observation during phacotrabeculectomy.

[Physiological basis of visual acuity measurement]

The paper presents information about types of acuity tasks, visual acuity limitations and contrast sensitivity function. Measurements of resolution acuity may be interpreted as estimates of spatial density of the mosaic of photoreceptors and ganglion cells of the living human eye. Physiological basis such as Raleigh's criteria, sampling theory and filtering theory of visual resolution are described.

[Surgery for involutional ectropion--case report]

In this paper authors described methods of surgery in involutional ectropion, surgical anatomy and changes in the lower eyelid due to aging. The surgical treatment of advanced involutional ectropion and its results is presented.

[Retina transplantation in exudative form of age-related macular degeneration]

The paper presents different techniques of macular translocation in exudative form of AMD, including particularly retinal detachment followed by retinotomy, limited macular translocation with chorioscleral infolding and outfolding by scleral imbrication.