Aflibercept monotherapy versus aflibercept with targeted retinal laser to peripheral retinal ischemia for diabetic macular oedema (LADAMO)

OBJECTIVE

We tested the hypothesis that targeted retinal laser photocoagulation (TPRP) to peripheral retinal ischaemia reduces the overall burden of aflibercept injections when treating diabetic macular oedema (DMO) over a 24-month period.

METHODS

Prospective, double-masked, multicentre, randomised controlled trial in Australia comparing aflibercept monotherapy, following a treat-and-extend protocol, or combination therapy of aflibercept and TPRP for DMO. The aflibercept monotherapy group received placebo laser. The primary outcome measure was the mean number of intravitreal aflibercept injections for each group at 24 months. Secondary outcome included: mean change in central macular thickness (CMT) and vision at trial completion, the proportion of eyes whose DMO resolved and the mean injection treatment interval. Ocular and systemic adverse events were recorded.

RESULTS

We enrolled 48 eyes of 47 patients; 27 eyes were randomised to combination therapy (aflibercept and TPRP) and 21 to aflibercept monotherapy. Thirty-two eyes (67%) completed the 2-year study. The number of intravitreal treatments given were similar for combination therapy (10.5 (SD 5.8) and monotherapy (11.8 (SD5.6)) (P = 0.44). The mean visual improvement (+4.0 (-1.8, 9.8) and +7.8 (2.6, 12.9) letters, P = 0.32), mean decrease in CMT (-154 (-222,-87) µm and -152 (-218,-86) µm, P = 0.96), proportion of eyes with CMT < 300 µm (48% and 67%; P = 0.50) and safety outcomes were similar in both the combination and monotherapy treatment groups (respectively).

CONCLUSIONS

Laser to areas of ischaemic peripheral retina does not reduce the burden of intravitreal aflibercept injections when treating diabetic macular oedema.

Acute effects of caffeine and glucose intake on retinal vessel calibres in healthy volunteers

PURPOSE

To evaluate the acute effects of caffeine and glucose intake on retinal vascular calibre of healthy adults.

METHODS

This prospective crossover study was conducted at the Centre for Eye Research Australia (Melbourne, Australia). Standardized doses of 300 mg caffeine (approximately 3 cups coffee), 30 g glucose or 300 ml of water, were each given to 19 healthy subjects on separate days. Retinal photographs and blood pressure measurements were taken at baseline, 30-, 60- and 120-min after ingestion of each solution. Central retinal artery and vein equivalents (CRAE, CRVE) and the arterio-venule ratio were measured using computer-assisted software. The mean retinal vascular calibre measurements were compared between pre- and post-ingestion images.

RESULTS

After caffeine intake, significant reductions were observed in mean CRAE of - 9.3 μm, - 10.4 μm and - 8.5 μm and CRVE of - 16.9 μm, - 18.7 μm and - 16.1 μm at 30-, 60- and 120-min after intake when compared with baseline (p ≤ 0.002 for all; paired t test). No significant changes were observed in mean retinal vascular calibre measurements after intake of either glucose or water when compared to baseline (p ≥ 0.072 for all). When controlling for baseline characteristics and blood pressure measurements, only caffeine intake had a significant effect on reducing both CRAE and CRVE at all time points post ingestion (p ≤ 0.003 for all, multiple linear regression model).

CONCLUSION

Caffeine is associated with an acute vasoconstrictive effect on retinal arterioles and venules in healthy subjects. Factors other than blood pressure-induced autoregulation play a significant role in caffeine-associated retinal vasoconstriction.

Response to correspondence from Koerner and colleagues concerning our paper entitled: The effect of diluting povidone-iodine on bacterial growth associated with speech

Clinicians adopt varying strategies for antisepsis with PI, which to this day remains efficient, economical and effective. Clinicians should prudently consider effective PI application, and we thank Koerner and Grzybowski for encouraging debate and raising the profile of this issue.

Diabetic retinopathy progression 6 months post-cataract surgery with intravitreous bevacizumab vs triamcinolone: A secondary analysis of the DiMECAT trial

IMPORTANCE

Diabetic retinopathy (DR) may progress following cataract surgery due to surgery-induced inflammation. The effect of intravitreal bevacizumab (BVB) and triamcinolone acetonide (TCA), which have differing anti-inflammatory properties, on DR progression following cataract surgery has not been reported.

BACKGROUND

To report the progression of DR in diabetic patients undergoing cataract extraction treated with intravitreal BVB or TCA during the surgery.

DESIGN

Post hoc analysis of 6-month data from a prospective, randomized, double-masked clinical trial.

PARTICIPANTS

Diabetic patients with clinically significant cataract and fovea involving diabetic macular oedema (DME), or a recent history of DME.

METHODS

Participants were randomly allocated 1:1 to receive intravitreal BVB 1.25 mg or TCA 4 mg during and post-cataract surgery as needed. The rate of DR progression between groups was compared.

MAIN OUTCOME MEASURES

DR progression.

RESULTS

There were 61 eyes included. Patients receiving BVB were older than those receiving TCA (70.2 vs 64.3 years; P < .05). Three participants (10.7%) in the BVB and three (9.09%) in the TCA group had a one-step progression, while none in BVB and only one (3%) in the TCA group demonstrated two-step DR progression. In the majority of these patients, DR progression was from mild to moderate non-proliferative diabetic retinopathy.

CONCLUSION AND RELEVANCE

In this study, BVB and TCA groups had a similar, and lower rate of DR progression compared to previous studies where no adjunctive treatment was administered, suggesting that patients with DME may benefit from either intraoperative intravitreous BVB or TCA injection to reduce the risk of DR progression following cataract surgery.

The association between intravitreal ranibizumab therapy and serum cytokine concentrations in patients with diabetic macular edema

Aim

To investigate the association between intravitreal ranibizumab therapy and serum cytokine concentrations in patients with diabetic macular edema (DME).

Methods

Twenty-five patients with center-involved DME were recruited prospectively. Serum samples were collected from the patients before and 4 weeks after two ranibizumab injections. The levels of 32 cytokines at these two time points were assessed using a multiplex array assay.

Results

Following two ranibizumab injections, there was a statistically significant decrease in the median [interquartile range] levels of Interleukin 1-1beta (IL-1β) from 5.56 [3.6, 8.75] to 2.33 [1.51, 2.89], Interleukin 13 (IL-13) from 4.30 [1.84, 18.55] to 0.38 [0.38, 0.78], granulocyte-colony stimulating factor (G-CSF) from 64.65 [42.9, 108] to 37.8 [27.3, 46.37], Interferon gamma (IFN-γ) from 241 [103.33, 753.4] to 94.4626 [42.04, 118.58], Interferon gamma-induced protein 10 (IP-10) from 234.68 [144.16, 285.98] to 158.73 [94.71, 198.64], Macrophage Inflammatory Protein-1 alpha (MIP-1α) from 3.65 [2.62, 11.02] to 1.41 [0.94, 1.88], and Tumor necrosis factor- alpha (TNF-α) from 131.09 [100.68,28 240.27] to 45.19 [24.04, 68.55]. There was a statistically significant increase in the levels of Interleukin 9 (IL-9) from 0.76 [0.76, 7.03] to 19.67 [5.36 27.76], Macrophage Inflammatory Protein-1 beta (MIP-1β) from 0.28 [0.28, 30 0.28] to 6.79 [I3.74, 14.16], Vascular endothelial growth factor (VEGF) from 2.55 [2.55, 2.55] to 25.24 [14.51, 41.73], and soluble vascular endothelial growth factor -1 (sVEGFR-1) from 333.92 [204.99, 440.43] to 500.12 [38.7, 786.91]. A Bonferroni-corrected p value of 0.00156 was considered statistically significant.

Conclusions

In patients with DME, intravitreal ranibizumab therapy appears to influence the serum levels of a range of cytokines. After two injections, intravitreal ranibizumab therapy appears to be associated with a significant decrease in inflammatory mediators and a rise in VEGF and sVEGFR1.

The effect of diluting povidone-iodine on bacterial growth associated with speech

Background

Povidone-Iodine (PI) may be diluted when used as an antiseptic prior to an intravitreal injection in an attempt to decrease patient discomfort. This study aims to investigate the effect of diluting povidone-iodine (PI) on bacterial growth from bacterial droplet dispersal associated with speech.

Methods

Participants read a standardised script for 5 min over a blood agar plate positioned at 20 cm in a simulated position of an intravitreal injection procedure. The blood agar plates were subject to a randomised pre-application of 1% PI; 2.5% PI; 5% PI and no pre-application (control). The plates were incubated at 37 °C for 72 h and the number of Colony Forming Units (CFUs) was determined. CFUs were summarised as median and interquartile range (IQR). Wilcoxon rank sum test was used to assess pairwise comparisons of the various PI concentrations to the control group. Any trend across PI concentration was assessed using Kendall’s tau rank correlation.

Results

Twenty-one subjects participated. Control plates had a median growth of 25 CFUs (interquartile range [IQR]:15–40), 1% PI plates had a median growth of 30 CFUs (IQR:15–82), 2.5% PI had a median growth of 18 CFUs (IQR:10–32) and 5% PI had a median growth of 2 CFUs (IQR:0–5). There was significantly less bacterial growth with 5% PI compared to control (P < 0.001). Bacterial growth at 2.5% PI and 1% PI did not differ significantly from control. There was a statistically significant trend for decreasing colony count as PI concentration increased (P < 0.001).

Conclusions

PI concentrations less than 5% are not effective at reducing bacterial growth from bacterial droplet dispersal associated with speech. When using PI for pre-injection antisepsis, concentrations below 5% should be avoided.

Mapping standard ophthalmic outcome sets to metrics currently reported in eight eye hospitals

Background

To determine alignment of proposed international standard outcomes sets for ophthalmic conditions to metrics currently reported by eye hospitals.

Methods

Mixed methods comparative benchmark study, including eight eye hospitals in Australia, India, Singapore, Sweden, U.K., and U.S. All are major international tertiary care and training centers in ophthalmology. Main outcome measure is consistency of ophthalmic outcomes measures reported.

Results

International agreed standard outcomes (ICHOM) sets are available for cataract surgery (10 metrics) and macular degeneration (7 metrics). The eight hospitals reported 22 different metrics for cataract surgery and 2 for macular degeneration, which showed only limited overlap with the proposed ICHOM metrics. None of the hospitals reported patient reported visual functioning or vision-related quality of life outcomes measures (PROMs). Three hospitals (38%) reported rates for uncomplicated cataract surgeries only. There was marked variation in how and at what point postoperatively visual outcomes following cataract, cornea, glaucoma, strabismus and oculoplastics procedures were reported. Seven (87.5%) measured post-operative infections and four (50%) measured 30 day unplanned reoperation rates.

Conclusions

Outcomes reporting for ophthalmic conditions currently widely varies across hospitals internationally and does not include patient-reported outcomes. Reaching consensus on measures and consistency in data collection will allow meaningful comparisons and provide an evidence base enabling improved sharing of “best practices” to improve eye care globally. Implementation of international standards is still a major challenge and practice-based knowledge on measures should be one of the inputs of the international standardization process.

Electronic supplementary material

The online version of this article (doi: 10.1186/s12886-017-0667-0) contains supplementary material, which is available to authorized users.

Predictors of visual outcome and the role of early vitrectomy in streptococcal endophthalmitis

IMPORTANCE

Streptococcal endophthalmitis has devastating sequelae. This study aims to identify factors which may be targeted to optimize patient outcomes.

BACKGROUND

This study investigated characteristics influencing visual outcomes and the role of early vitrectomy.

DESIGN

Retrospective observational case series of consecutive patients was conducted.

PARTICIPANTS

All patients with a culture-positive diagnosis of streptococcal endophthalmitis treated at a tertiary ophthalmology referral centre between July 1997 and February 2012 were included.

METHODS

Patient records were reviewed and data collected on their presentation, examination, microbiology results, procedures and final outcome.

MAIN OUTCOME MEASURES

Visual acuity (VA) and enucleation/evisceration were measured.

RESULTS

Of the 101 patients, 35.6% presented with a VA of hand movements and 42.6% with light perception (LP). Final VA was poor (6/60 or worse) in 77.6% and 24.7% were enucleated/eviscerated. Presenting VA of LP or worse (P = 0.008), no view of fundus (P = 0.001), large number of organisms (P < 0.001), recognition of Streptococcus on Gram stain (P = 0.010), heavy growth on culture (P < 0.001) and more intravitreal injections (P = 0.038) were significantly associated with poor visual outcome (6/60 or worse). Presenting VA of LP or worse (P = 0.042) and non-viridans Streptococcus species (P = 0.002) were significantly associated with enucleation/evisceration. Fifteen patients (14.9%) had early vitrectomy within 48 h which was not associated with poor final VA or removal of the eye (P = 1.000).

CONCLUSIONS AND RELEVANCE

Early vitrectomy did not influence visual outcome in this cohort. Microbiology results were useful in predicting poor outcomes, and may allow clinicians to make early treatment decisions and provide prognostic information for patients.

Patents on Endophytic Fungi

BACKGROUND

Endophytic fungi are taxonomically and ecologically heterogeneous group of organisms, mainly belonging to the Ascomycotina and Deuteromycotina. Endophytes usually produce the enzymes necessary for the colonization of plant tissues. Endophytes are able to utilize components of plant cells without disturbing host metabolism, which is confirmed by isozyme analysis and studies on substrate utilization. The patents related to enzymes and metabolites produced by endophytic fungi are associated with their ecological significance. Application of metabolites and growth promoting factors produced from endophytic fungi, in the pharmaceutical and agricultural industries, is now well established. The patents on secretion of extracellular enzymes in vitro by endophytic fungi needed for cell wall degradation, support the hypothesis that fungal endophytes represent a group of organisms specialized to live within plant tissue.

OBJECTIVE

This review presents the patents granted on different aspects of endophytic fungi for the last 11 years. This expresses the scenario and impact of these patents regarding significance in human society.

CONCLUSION

In the last few years, research and inventions regarding the different aspects of endophytic fungi beneficial for host plant as well as for human beings have been carried out, which is supported by the increasing number of patents granted on endophytic fungi.

Change in the collateral and accessory collateral ligament lengths of the proximal interphalangeal joint using cadaveric model three-dimensional laser scanning

The purpose of this study was to assess the lengths of the index and middle finger proximal interphalangeal joint ligaments and determine the relative changes in the collateral and accessory collateral ligament lengths at 0°, 45° and 90° flexion. We generated three-dimensional scans of 16 finger (eight index and eight middle) proximal interphalangeal joints to assess relative changes in ligament length. Significant changes were found between 45°-90° and 0°-90° for the ulnar collateral ligament of the index finger and both collateral ligaments of the middle finger between 45°-90° and 0°-90°. No significant changes in length were found for the radial collateral ligament of the index finger or the accessory collateral ligaments of the index and middle fingers. Overall, it was found that the collateral ligament length changed significantly, but there was no significant change in the accessory collateral ligaments.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Assessment of Bt trait purity in different generations of transgenic cottons

Adequate expression of Bt (Bacillus thuringiensis) toxins and purity of seeds of Bt-transgenic cottons are important for controlling bollworms, and thereby increasing the cotton productivity. Therefore, we examined the variability in expression of Bt toxin proteins in the seeds and in leaves of different cotton (Gossypium hirsutum (L.) hybrids (JKCH 226, JKCH 1947, JKCH Durga, JKCH Ishwar, JKCH Varun KDCHH 441 and KDCHH 621) expressing Bt toxins in F₁ and F₂ generations, using bioassays against the cotton bollworm, Helicoverpa armigera (Hübner), and the lateral flow strip (LFS) test. Toxicity of Bt toxin proteins in the seeds of Bt-transgenic cottons to H. armigera correlated with their toxicity in the leaves in one- toxin Bt cotton hybrids. The Bt-F₁ and Bt-F₂ seeds of JKCH 1947 were more toxic to H. armigera than those of JKCH Varun seeds. The seeds and leaves of F₁s showed greater toxicity than the F2 seeds or leaves of one-toxin (cry1Ac) Bt cotton hybrids. However, no significant differences were observed for the two-toxin (cry1Ac and cry2Ab) hybrid, KDCHH 621. Toxicity of leaves to H. armigera increased with crop age, until 112 days after seedling emergence. The Bt trait purity in F₁ seeds of four two-toxin Bt cotton hybrids ranged from 86.7 to 100%. The present study emphasizes the necessity of 95% Bt trait purity in seeds of transgenic cotton for sustainable crop production.

Recent patents on flavonoids

Flavonoids are substances which are widely distributed in the plant kingdom. They occur in considerable quantities in common food products, spices and beverages. Interest of researchers has been greatly enhanced towards therapeutic potential of flavonoids in last some years. This review summarizes important patents pertaining to recent biotechnological techniques applied for the production, analysis of biosynthetic pathways, effects and applications of different flavonoids. For systematic studies investigations which have been published in the form of patents, are classified in different sectors like biosynthesis, medical application, antimicrobial activity, alteration of flower color, industrial application, cosmetics, food and plant tissue culture. A number of activities have been observed in each sector with vast area of research on flavonoids.

Variants in the VEGFA gene and treatment outcome after anti-VEGF treatment for neovascular age-related macular degeneration

PURPOSE

To determine the association of genetic variants of the VEGFA gene with outcome of anti-vascular endothelial growth factor (VEGF) treatment in neovascular age-related macular degeneration (AMD).

DESIGN

A prospective cohort study.

PARTICIPANTS

We included 201 consecutive patients receiving anti-VEGF injections for neovascular AMD.

METHODS

Patients were followed over 12 months. They were treated with 3 initial monthly ranibizumab or bevacizumab injections. Thereafter, the decision to retreat was made by clinicians at each follow-up visit on the basis of retreatment criteria. Seven tagged single nucleotide polymorphisms (tSNPs) in the VEGFA gene were selected and examined. Multivariate data analysis was used to determine the role of each tSNP in treatment outcome.

MAIN OUTCOME MEASURES

The influence of selected VEGFA tSNPs on visual acuity (VA) outcome at 6 months.

RESULTS

Mean baseline VA was 51±17 Early Treatment Diabetic Retinopathy Study (ETDRS) letter scores. Overall, the mean change in VA from baseline was +6.5±12, +4.4±13.4, and +2.3±14.6 letters at 3, 6, and 12 months, respectively. The tSNP rs3025000 was the only SNP significantly associated (P<1 × 10(-4)) with visual outcome at 6 months with multiple correction. The presence of the T allele (TC or TT genotypes) at this tSNP predicted a better outcome of +7 letters at 6 months compared with the CC genotype. In a subgroup analysis, presence of the T allele predicted a significantly higher chance of the patients belonging to the responder group (gain of ≥5 letters from baseline) after 3, 6, and 12 months treatment (odds ratio, 2.7, 3.5, and 2.4; 95% confidence interval, 1.46-5.07, 1.82-6.71, and 1.27-4.57, respectively) than any other outcome group.

CONCLUSIONS

Pharmacogenetic association with anti-VEGF treatments may influence the visual outcomes in neovascular AMD. In patients with the T allele in tSNP rs3025000, there was a significantly better visual outcome at 6 months and a greater chance of the patients belonging to the responder group with anti-VEGF treatment at 3, 6, and 12 months. The VA outcomes of patients harboring the T allele at SNP rs3025000 were comparable with those of the pivotal clinical trials but with fewer injections, making the treatment perhaps more cost effective in certain subgroups of patients.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Do topical ophthalmic corticosteroids suppress the hypothalmic-pituitary-adrenal axis in post-penetrating keratoplasty patients?

PURPOSE

To establish whether hypothalmic-pituitary-adrenal axis suppression is possible secondary to long-term topical ophthalmic corticosteroid use in patients who have undergone penetrating keratoplasty (PKP).

METHODS

Patients who had undergone a PKP and had been using corticosteroid-based eye drops continuously for more than 6 months, with no history of concomitant steroid (oral, inhaled, or cutaneous) use, were included within the study. A low-dose short Synacthen (LDSST) test was performed in each patient followed later by a short Synacthen test (SST). The mean SST and LDSST after 30 min were calculated along with their corresponding 95% confidence intervals (CIs). Correlation between both baseline SST and baseline LDSST with duration of treatment was determined using Spearman's correlation.

RESULTS

In all, 20 patients were included within the study. The mean duration treatment was 28.2 months (range 11-96 months). All patients had normal baseline cortisol levels in both SST and LDSST tests. The mean 30 min SST was 753.8 nmol/l (95%CI: 696.6 nmol/l, 811.0 nmol/l) and no patients displayed inadequate adrenal response. The mean 30 min LDSST was 709.8 nmol/l (95%CI: 665.1 nmol/l, 754.5 nmol/l) and only one patient had an inadequate adrenal response. There was no correlation between baseline SST or LDSST and duration of treatment.

CONCLUSIONS

This study found no evidence that patients using continuous long-term corticosteroid eye drops after PKP experienced inadequate adrenal response. We did not find any evidence of a negative correlation between length of treatment and SST or LDSST measurements at baseline.

Iron regulation in tuberculosis research: promise and challenges

Tuberculosis is a major global health challenge and is far from being controlled. Development of resistance to currently available drugs due to the successful adaptation of the pathogen has been a major contributing factor for its control failure. Presently, there is an immense interest in identification of pathways, unique to the intracellular environment that could be utilized for the development of new and better drugs. In this sequence, targeting essential functions of Mycobacterium tuberculosis has emerged as a reliable strategy for containing the spread of the disease by this organism. The fact that iron has been known to be the key player required for its survival and ability to spread infection, the organism must carefully balance iron acquisition with iron uptake for its infectivity. Conversely, this iron homeostatic process could be disrupted to interfere with the survival and replication of this bacterium in host. Urgency to develop such an approach has been further strengthened with the worldwide recrudescence of tuberculosis especially in the developing nations of the world. In the current review, we have focused on the recent developments in targeting the essential functions of mycobacterium especially interfering in its iron homeostatic process. The relevance of iron for mycobacterial virulence, the intracellular survival and the immense potential of targeting iron-sulfur (Fe-S) cluster containing proteins in tuberculosis drug discovery has been discussed.

Anatomical and visual outcome of retinal angiomatous proliferation treated with photodynamic therapy and intravitreal triamcinolone

PURPOSE

To evaluate the efficacy and safety of photodynamic therapy (PDT) with verteporfin combined with intravitreal triamcinolone (TA) in retinal angiomatous proliferation (RAP).

DESIGN

Retrospective, consecutive, noncomparative case series.

METHODS

Patients newly diagnosed with RAP underwent indocyanine green angiography (ICGA)-guided PDT with verteporfin, immediately followed by intravitreal TA. Complete ocular examination, fluorescein angiography (FA), ICGA, and optical coherence tomography (OCT) were performed at baseline and follow-up visits every three months.

RESULTS

Seventeen eyes of seventeen patients underwent this simultaneous combined treatment. All patients had 12 months of follow-up. Complete resolution of angiographic leakage was achieved in 83% at 12 months. Visual acuity improved in 35%, and was stable in 47%. Eleven patients developed recurrent leakage after six to 12 months, which settled completely after repeat combined treatment.

CONCLUSIONS

This simultaneous combined treatment in patients with RAP was effective in reducing or eliminating retinal edema, regression of neovascularization, and stabilizing or improving visual acuity.

Short-term effects of focal argon laser treatment in diabetic maculopathy as demonstrated by optical coherence tomography

PURPOSE

To assess the short-term effects of argon laser on retinal thickening as demonstrated by optical coherence tomography (OCT).

METHODS

A prospectively collected consecutive series of patients undergoing routine focal argon laser treatment for sight-threatening diabetic maculopathy had bilateral OCT performed before laser treatment and 1 hour, 24 hours, and 2 weeks after treatment. The main outcome measure was change in retinal thickness in the region of laser treatment.

RESULTS

Forty-six eyes were analyzed. There was a small increase in retinal thickness in the treated area 1 hour after laser treatment, with a mean change from before laser treatment of +2.6 microm (95% confidence interval [CI], +0.2 to + 5.0). However, there was a larger change 24 hours after treatment of +39.0 microm (95% CI, +31.6 to + 46.4) and a significant decrease 2 weeks after treatment of -14.6 microm (95% CI, -21.6 to -7.7) from before laser treatment values.

CONCLUSION

Focal argon laser treatment remains the first-line treatment for sight-threatening diabetic maculopathy. This study shows that in the short-term, areas of retinal thickening worsen before settling in response to argon laser treatment as demonstrated by OCT.

Acute Optic Neuropathy in Patients with Behçet’s Disease

Although acute optic neuropathy has been rarely reported in patients with Behçet's disease, a detailed description of its clinical course is lacking. We report in detail the course of acute optic neuropathy in two patients with Behçet's disease. Our experience suggests that it can be bilateral, can affect both eyes simultaneously, and can be recurrent. The severity of the visual loss and its recovery can be very variable even in the same patient. Early recognition of this entity and treatment with high-dose systemic corticosteroids may limit the degree of permanent visual loss. However, the optimal treatment has not been established.

Correlation of optical coherence tomography and fundus fluorescein angiography following photodynamic therapy for choroidal neovascular membranes

AIMS

To assess the correlation between optical coherence tomography (OCT) and leakage on fundus fluorescein angiography (FFA) following photodynamic therapy (PDT) with verteporfin for choroidal neovascularisation (CNV).

METHODS

Retrospective comparative observational case series of patients who were treated with PDT for CNV from one centre. All patients had 3 monthly FFA and OCT following initial PDT to assess if further treatment was required. A pair of FFA and OCT images from the same visit at a random follow up date were taken from each patient's series and assessed separately by different observers. The presence of pigment epithelial detachment, subretinal fluid, vitreomacular traction, intraretinal fluid, absence of foveal depression, and the retinal thickness on OCT were correlated with presence of leaks on FFA.

RESULTS

A total of 121 eyes of 121 patients were included. The presence of subretinal fluid, gross cystoid macular oedema, sponge-like retinal thickening and retinal thickness of more than 350 mum on OCT correlated well with leak on FFA (p value <0.01). The likelihood ratios were 3.0, 5.7, 2.7, and 3.6, respectively. The presence of a solitary foveal cyst did not correlate well with leaks on FFA.

CONCLUSIONS

The presence of subretinal fluid, intraretinal fluid in the form of gross cystoid macular oedema, or sponge-like retinal thickening, or a retinal thickness more than 350 mum correlates with leaks on FFA and so suggests the need for repeat PDT.

Effect of Posterior Juxtascleral Triamcinolone Acetonide on Choroidal Neovascular Growth after Photodynamic Therapy with Verteporfin

OBJECTIVE

To assess if posterior juxtascleral application of 40 mg triamcinolone acetonide (TA), given at the same time as initial photodynamic therapy (PDT) for predominantly classic choroidal neovascularization (CNV) related to age-related macular degeneration affects lesion growth at 3 and 6 months.

DESIGN

Comparative (nonrandomized) interventional study.

PARTICIPANTS

The study group consists of 38 eyes of 38 patients. The control group consists of 73 eyes of 73 patients.

METHODS

Comparison of 2 consecutive case series collected at different times. The study group had a posterior juxtascleral TA with their initial PDT treatment. The controls were treated with PDT alone. All patients were reviewed at 1, 3, and 6 months.

MAIN OUTCOME MEASURES

Change in total lesion size; secondary outcomes: area of leak, best-corrected visual acuity, number of treatments, and intraocular pressure.

RESULTS

There was significantly less growth of total lesion at 3 months (mean difference = 2.47 mm2; 95% confidence interval (CI): +1.22 to +3.72 mm2; P = 0.0002) and 6 months (mean difference = 2.88 mm2; 95% CI: +0.61 to +5.15 mm2; P = 0.0134) in patients given TA with PDT compared with PDT alone. There was also a significantly smaller residual area of leak at 3 months in the study group (mean difference = 1.07 mm2; 95% CI: +0.16 to +1.97 mm2; P = 0.02). At 6 months, the residual area of leak between the 2 groups became comparable (mean difference = 0.13 mm2; 95% CI = -1.59 to +1.33 mm2; P = 0.86). Mean number of letters lost on the logarithm of the minimum angle of resolution chart at 6 months was 9.1 letters (standard error of the mean [SEM] = 2.21) in the study group compared with 12.4 letters (SEM = 1.91) in the control group (P = 0.30). At 6 months, 10 of 36 eyes (27.8%) in the study group showed > or =15 letters loss, compared with 29 of 73 eyes (39.7%) in the control group. Intraocular pressure was raised in 4 of 38 eyes (10.5%). Fewer retreatments were required in the TA with PDT group (2.03 compared with 2.47 [P = 0.006]).

CONCLUSIONS

Posterior juxtascleral placement of TA with PDT at baseline significantly reduces CNV growth at 3 and 6 months. Fewer retreatments were required. Visual outcome may be improved, although we did not show a statistically significant improvement with this sample size. A larger, randomized trial with longer follow-up is justified.

Correlation of optical coherence tomography, with or without additional colour fundus photography, with stereo fundus fluorescein angiography in diagnosing choroidal neovascular membranes

AIMS

To assess the diagnostic accuracy of optical coherence tomography (OCT), with/without colour fundus photographs, in predicting fundus fluorescein angiography (FFA) findings in patients suspected of having choroidal neovascularisation (CNV).

METHODS

A consecutive series of patients suspected of having CNV underwent OCT and stereo FFA images, which were assigned a diagnosis by two masked observers, one examining OCT alone and then OCT plus stereo colour photographs, and one examining FFA alone. The main outcome measures were the diagnostic accuracy of OCT (with/without colour photos) in predicting the presence of CNV and secondly the characteristics of the CNV compared to the FFA findings.

RESULTS

131 eyes of 118 patients were analysed. The sensitivity and specificity of OCT for detecting new potentially treatable CNV lesions compared to FFA was 96.4%, and 66.0%, respectively. For OCT with stereo images the sensitivity was 94.0% and specificity 89.4%. For detecting CNV with a classic component the sensitivity and specificity of OCT alone was 78.6% and 82.7%. With stereo colour images the sensitivity was 82.1% and specificity 89.3%.

CONCLUSION

OCT is good at detecting the presence of CNV in patients suspected of having new CNV. However, it is less accurate at identifying the exact components of CNV. OCT cannot at present replace FFA in accurately diagnosing CNV components. However, this imaging method may have a role as a screening tool to help prioritise FFA requests.

Unusual cause of visual symptoms after bilateral laser in situ keratomileusis

We present a case involving a serious systemic cause of visual symptoms after successful bilateral laser in situ keratomileusis. There were no signs in the anterior segment to explain the visual symptoms. Ancillary tests and investigations confirmed a pituitary tumor, which was removed. We recommend comprehensive ophthalmological examination and full investigation of symptoms in all patients before and after laser treatment.

RAPD analysis of herbicide-resistant Brasilian rice lines produced via mutagenesis

Over the last two decades, mutational techniques have become one of the most important tools available to progressive rice- breeding programs. In a mutation-breeding program initiated in 1999 at the Instituto Agronômico of Campinas, SP, Brazil, a rice line, IAC103, was selected for mutational studies with gamma radiation and ethyl methyl sulfonate mutagenesis, with the aim of developing a herbicide-resistant crop. After mutagenesis, surviving plants were exposed to glufosinate to check for herbicide resistance, which was examined up to the second generation. A detailed RAPD analysis was made of the resistant plants. Eighty Operon technology primers were tested and 10 were selected for a detailed study of RAPD markers that could tag herbicide resistance genes. Resistant and susceptible lines produced variation in the RAPD patterns and certain bands were found only in certain lines. These results suggest genetic ligation that will be confirmed through a genetic segregation study.

Transformation system of Beauveria bassiana and Metarhizium anisopliae using nitrate reductase gene of Aspergillus nidulans

An heterologous transformation system for entomopathogenic fungi B. bassiana and M. anisopliae was developed based on the use of A. nidulans nitrate reductase gene (niaD). B. bassiana and M. anisopliae niaD stable mutants were selected by treatment of protoplast with ethane methane sulphonate (EMS) and regenerated on chlorate medium. The cloned gene was capable of transforming B. bassiana and M. anisopliae at a frequency of 5.8 to 20 transformants per microg of DNA. Most of them were mitotically stable.

An improved cementing technique for revision hip surgery after peri-prosthetic fractures

Replacement of the femoral component by a long-stemmed implant is one possible solution to the management of periprosthetic femoral shaft fractures. A problem often encountered, due to the extensive disruption of the femoral canal, is difficulty in achieving adequate cement pressurisation. We have overcome this by applying a split 60 ml syringe sleeve around the femoral shaft and holding it in position with clamps. This method has been used on five patients of mean age 87.7 (range 82-94) years with fractures that occurred at an average of 7.2 (range 4-17) years after the primary hip surgery. Two of the five patients achieved independent mobility and all of the patients were sufficiently independent to be discharged from the acute orthopaedic unit. We hope this cheap, effective method of supporting the bone fragments, maintaining alignment and achieving an acceptable level of pressurisation will lead to a decrease in the inevitable morbidity and mortality associated with a problem which as a result of an ageing population is likely to become increasingly common.

Pure small cell carcinoma of the prostate

Pure small cell carcinoma of the prostate is a rare anaplastic tumour. This report presents the clinicopathological findings of two patients presenting with this disease. Immunohistochemistry was positive for protein gene product 9.5, neurone specific enolase and calcitonin. Staining was negative for prostate specific antigen and prostate acid phosphatase. androgen ablation has no place in the management of this lesion and patients with this disease should be managed as if they have a neuroendocrine tumour.