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Background Diabetic papillopathy is a rare diagnosis of exclusion characterized by unilateral or bilateral optic disc edema with variable degrees of visual loss. Although the visual prognosis has been generally reported as favorable, the presence of severe disc edema associated with macular edema prompts the need for treatment. We present a specific and unreported therapeutic approach consisting of intravitreal aflibercept and subtenon triamcinolone acetonide injections in two patients with evidence of diabetic papillopathy and macular edema. Case presentation In the first case, a 60-year-old Caucasian woman affected by type II diabetes mellitus presented with fundoscopic evidence of sequential bilateral optic disc edema associated with acute severe visual loss in both eyes. The second patient, a diabetic 57-year-old Caucasian male, presented with sudden painless visual loss in his left eye. Multimodal imaging and systemic findings correlated towards an infrequent diagnosis of diabetic papillopathy. In a period of 5–7 weeks after treatment, both patients experienced almost full visual and anatomical recovery. A steady situation was observed at 12 months of follow-up. Conclusions Both our cases displayed a severe grade of optic disc edema, which was optimally reversed with intravitreal aflibercept and subtenon triamcinolone acetonide leading to a relatively rapid and safe improvement in visual acuity.

Uveitis is an important cause of blindness worldwide. Its reported incidence in the United States ranges from 17 per 100,000 to 24 per 100,000 people per year, and its prevalence ranges from 38 per 100,000 to 204 per 100,000 people per year. Uveitis may be associated with autoimmune inflammatory or infectious conditions. Some of the severe sequela that are associated with chronic uveitides include retinal and ciliary body (CB) detachment with consequent ocular hypotony and phthisis bulbi. In the principle of ultrasonography (USG), the depth of the tissue structures is determined by directly measuring the time delay of the returning ultrasound signal. Most ophthalmologists are familiar with B-scan USG techniques; however, the employment of high frequency ultrasound bio-microscopy (UBM), which is based on high frequency transducers incorporated into a B-mode clinical scanner, allows for the achievement of high-resolution images, useful in distinguishing subtle changes in the anatomy and pathology of structures like the retroiridal face, CB, and pars plana (PP), which are not precisely accessible by routine USG. This technology has a tissue depth penetration of approximately 3–6 mm and can visualize structures through opaque media, unlike optical coherence tomography (OCT). The addition of UBM in the armamentarium of diagnostic methods in the evaluation of uveitis patients, has yielded the level of clinical information considerably towards a definitive diagnosis and therapeutic efficiency. Inflammatory involvement of the iris, ciliary sulcus, CB and PP are among the main conditions in which the employment of UBM is highly recommended.

Objectives: Despite being approved and effective, steroids, and especially dexamethasone intravitreal implants, still have a poorly-defined role in management of diabetic macular edema. In order to overcome some of the limitations in current recommendations, a group of experts met to define consensus on some of the most controversial issues on the use of dexamethasone intravitreal implants in daily management of diabetic macular edema. Methods: A Delphi-based approach was utilized to develop clinically relevant statements applicable to routine treatment settings. A Steering Committee composed of four experts formulated 30 relevant statements, which were voted upon by a panel of 40 ophthalmologists/retinal specialists from across Italy. Results: Dexamethasone intravitreal implants were considered to be a valid first-line alternative to treatment with an anti–vascular endothelial growth factor agent and should be the first choice in pseudophakic and vitrectomized patients. A Pro Re Nata regimen was felt to be appropriate for retreatment with dexamethasone intravitreal implants while a 6-month waiting period was not considered suitable. Among steroid treatments, dexamethasone intravitreal implants were considered to have the best ocular tolerability. In patients with persistent macular edema after the loading-phase treatment with an anti–vascular endothelial growth factor, consensus was reached that clinicians should consider switching therapy to dexamethasone intravitreal implants. Moreover, dexamethasone intravitreal implants can reduce the treatment burden for individuals who are not able to cope with the more intensive treatment regimen required by anti–vascular endothelial growth factor therapy. Conclusions: While further studies are needed, this survey provides some key recommendations for clinicians treating diabetic macular edema that may be useful when choosing dexamethasone intravitreal implants in daily practice.

Purpose To describe clinical findings in patients with acute exudative polymorphous vitelliform maculopathy (AEPVM). Design Retrospective, observational, multicenter case series review. Participants Consecutive patients diagnosed with idiopathic AEPVM. Methods Review of clinical charts, multimodal imaging, electrophysiologic findings, and genetic findings in previously unpublished patients and review of the literature. Main Outcome Measures Clinical features of idiopathic AEPVM and differential diagnosis. Results Eighteen patients (age range, 21–74 years) with typical features of AEPVM, including initial localized, serous detachments followed by the development of characteristic yellow-white deposits in the vitelliform space. Over time, this hyperautofluorescent material gravitated within the larger lesions, resulting in typical curvilinear deposits characteristic of later stages. Symptoms and clinical findings lasted from weeks to several years. Some patients showed previously undescribed features such as fluorescein-negative intraretinal cystic changes, choroidal neovascularization, serous retinal elevations mimicking retinal folds, increased choroidal thickness, lack of rapid visual recovery, and recurrence years after complete resolution of initial manifestations. Conclusions Acute exudative polymorphous vitelliform maculopathy can present with a more variable natural course than previously described. Paraneoplastic retinopathy and autosomal recessive bestrophinopathy closely resemble AEPVM, necessitating medical and hereditary evaluation to exclude these clinical possibilities. This series of patients with AEPVM expands the clinical spectrum of the disorder, including demographics, clinical manifestations, imaging features, natural course, and visual prognosis.

Purpose: Demyelinizing neurological disease is a rare complication after treatment with tumor necrosis factor (TNF)α antagonists. We report on a case of multiple sclerosis after TNFα antagonist treatment and discuss its differential diagnosis. Methods: This is an observational case study. Results: A 48-year-old male was referred to Ophthalmology in January 2015 for an absolute scotoma in the superior quadrant of the visual field in his right eye. Visual acuity was 20/50 in the right eye and 20/20 in the left. Fundus examination was unremarkable bilaterally. Spectral domain optical coherence tomography revealed a normal macular retina structure. Visual field examination revealed a superior hemianopsia in the right eye. Head magnetic resonance imaging showed findings compatible with optic neuritis. The visual evoked potentials confirmed the presence of optic neuritis. The patient had been under therapy with adalimumab since January 2014, for Crohn’s disease. Suspension of adalimumab was recommended, and it was substituted with tapered deltacortene, from 1 mg/kg/day. After 1 month, the scotoma was resolved completely. Conclusions: TNFα antagonists can provide benefit to patients with inflammatory autoimmune diseases. However, they can also be associated with severe adverse effects. Therefore, adequate attention should be paid to neurological abnormalities in patients treated with TNFα antagonists.

Non-infectious uveitis can be a potentially sight threatening disease. Very recently, therapeutic strategies have turned towards a new methodology, which includes biologic agents. The introduction of biologic drugs has started a Copernican revolution in ophthalmology: biologic therapies represent a revolutionary option for those patients who present non-responder, sight threatening uveitis. The availability of these therapies has improved the uveitis outcome. The present review shows the most relevant medical literature on biologic agents in ophthalmology, such as tumor necrosis factor blockers, anti-interleukins and other related biologics. Several papers reported the efficacy of biologic agents in a large number of refractory uveitides, which suggest a promising role of biologic drugs for selected cases. On the other hand, the medical literature does not have consistent numbers yet, which hopefully will validate the promising preliminary results. Biologic agents are not only promising drugs for the treatment of nonresponder uveitis, but also they show an apparently favourable safety profile, although several topics remain unsolved: it is still not clear when commencing the treatment, which agent to choose, and the length of biologic therapy. Moreover, the high costs and the still not clear safety profile have very often limited their use only for severe, non-responder uveitis in highly specialized uveitis centres.

Dome-shaped macula (DSM) is characterized by an inward convexity of the macula in myopic eyes, as visualized on optical coherence tomography (OCT). Serous retinal detachment (SRD) is a common complication of DSM, leading to a deterioration of visual acuity, in association with retinal pigment epithelium (RPE) atrophic changes. Many different therapeutic approaches to SRD secondary to DSM have been attempted, with variable results. We report our experience (11 treatment-naïve patients) with a combined new treatment approach, using half-fluence and half-dose photodynamic therapy (PDT) followed by subthreshold 577 nm micropulse laser treatment (STLT), for SRD related to DSM after a 6-month follow-up. Central foveal thickness was significantly decreased at the end of the follow-up. SRD diminished in all cases, and 5 eyes (45.4 %) registered complete resolution at the end of the 6-month follow-up, while 6 eyes (54.5 %) experienced two lines of improvement in BCVA at the end of the follow-up. No case showed postoperative complications. Therefore, this represents the first study evaluating the visual and anatomical outcomes of a safe and effective combined treatment of SRD in DSM.

The authors report a multimodal imaging analysis of a case of acute syphilitic posterior placoid chorioretinitis (ASPPC) occurring in a 51-year-old man. Best-corrected visual acuity (BCVA) was 0.5 and 0.8 in the right and left eyes, respectively. The authors performed spectral-domain optical coherence tomography, fundus autofluorescence, fluorescein angiography, and indocyanine green angiography. All of the examinations were suggestive of the diagnosis of ASPPC, a rare manifestation of syphilis that has distinctive anatomical characteristics that are detectable early on with multimodal imaging. Moreover, serological tests were positive for syphilis infection, so the patient received intravenous penicillin G for 14 days. Final BCVA was 1.0 in the right eye and 0.9 in the left eye. [ Ophthalmic Surg Lasers Imaging Retina . 2019;50:e179–e184.]

Aim The aim of this study is to evaluate long-term efficacy of intravitreal injections of aflibercept as primary treatment for subfoveal/juxtafoveal myopic choroidal neovascularisation (CNV). Methods Thirty-eight treatment-naive eyes of thirty-eight patients with subfoveal/juxtafoveal myopic CNV received initial intravitreal aflibercept injections and were followed for at least 18 months. Aflibercept was applied again for persistent or recurrent CNV, as required. Statistical analysis was carried out using SPSS. Results Mean patient age was 45.8 years, and mean eye refractive error was −7.79 D. For the total patient group (n=38 eyes), mean logMAR best-corrected visual acuity (BCVA) significantly improved from 0.69 at baseline to 0.15 at 18 months (P

Purpose: To compare the clinical outcomes and the rate of complications of 27-gauge transconjunctival nonvitrectomizing vitreous surgery (NVS) and of 25-gauge transconjunctival sutureless vitrectomy surgery for idiopathic epiretinal membrane removal. Methods: In this prospective randomized study, 83 phakic eyes of 83 consecutive patients with an idiopathic epiretinal membrane were randomized to receive 27-gauge NVS (NVS-group) or 25-gauge vitrectomy (Standard-group). Main outcome measures were best-corrected visual acuity, central retinal thickness, nuclear density units' changes, and rate of complications. Results: Thirty-nine eyes of the Standard-group and 40 of the NVS-group were considered in final analysis. Mean best-corrected visual acuity improved significantly in both groups, with a significant better result at 12 months in NVS-group (P 0.039; t-test). Central retinal thickness decreased significantly in both groups (P < 0.001, Tukey test), without significant difference between the two groups at any time point. At 12 months, nuclear density increased significantly in the Standard-group (analysis of variance, P < 0.001), and it did not change in the NVS-group (analysis of variance, P 0.537). Epiretinal membrane recurred in 5.1% of eyes in the Standard-group and in 7.5% of eyes in the NVS-group (Fisher's exact test, P 1.000). Conclusion: The 27-gauge NVS is an effective surgical procedure in eyes with epiretinal membrane and it induces less progression of nuclear sclerosis than 25-gauge vitrectomy.

BACKGROUND AND OBJECTIVE: To study the role of photodynamic therapy (PDT) as a therapeutic modality in myopic patients with dome-shaped macula (DSM) associated with foveal serous retinal detachment (SRD). PATIENTS AND METHODS: Retrospective interventional case series. The medical records of 10 consecutive myopic patients (10 eyes) with DSM associated with subfoveal SRD and treated with PDT were reviewed. Visual gain and loss were considered as increasing or decreasing of two or more lines of best corrected visual acuity (BCVA), respectively, and eyes with fluid resolution were deemed responsive to PDT. RESULTS: All eyes underwent several PDT treatments, with a median of three and a median follow-up time of 15.5 months. At final follow-up, six eyes (60%) showed complete resolution of the foveal SRD. The baseline hypocyanescent macular area observed during late indocyanine green angiography (ICGA) frames was significantly lower in the group of patients who responded to PDT and had an increase of at least two Snellen lines in BCVA ( P = .01). CONCLUSION: Data suggest that myopic eyes associated with DSM and foveal SRD may be responsive to PDT, showing total resolution of fluid accumulation and positive BCVA changes if baseline ICGA findings show evidence of a limited hypocyanescent macular area. [ Ophthalmic Surg Lasers Imaging Retina. 2015;46:217–223.]

Age-related macular degeneration (AMD) is still referred to as the leading cause of severe and irreversible visual loss world-wide. Advances in medical research have identified vascular endothelial growth factor (VEGF) as an important pathophysiological player in neovascular AMD and intraocular inhibition of VEGF as one of the most efficient therapies. Anti-VEGFs currently used to treat AMD included a monoclonal antibody (bevacizumab), an antibody fragments (ranibizumab), a fusion protein (aflibercept), and an aptamer (pegaptanib). The wide introduction of anti-VEGF therapy has led to an improvement in the prognosis of patients affected by AMD, with a consequent effects on the burden of care due to highly priced drugs, increasing patient numbers, and long-term disease chronicity. Aim of this review is to present an overview of available therapeutic strategies in AMD in term of clinical efficacy and economic sustainability.

We report an atypical presentation of Antiphospholipid syndrome (APS) with concomitant subhyaloid hemorrhage, engorged and tortuous retinal veins, intraretinal hemorrhages, and cotton wool spots in a 38-year-old female. Medical treatment was preferred to any invasive treatment. The subhyaloid hemorrhage resolved spontaneously and the patient recovered a visual acuity of 20/20 in her right eye 3 months after the initial episode. A prompt diagnosis of this condition is fundamental to consider a systemic treatment to avoid any further thrombosis.

The ocular involvement in psoriasis is not a completely well-known problem. The ophthalmologic involvement occurs in about 10 % of patients, particularly in case of arthropathic or pustular psoriasis. Ocular lesions are more common in males, and they often occur during psoriasis exacerbations. Our study aimed to assess the prevalence and type of ocular involvement in psoriasis, by a comparison between psoriasis and healthy subjects, and if/how a 12-week long systemic immunosuppressive therapy is able to modify them. This study involved thirty-two psoriatic patients and thirty-two healthy subjects. Dermatological evaluation was done using Psoriasis Area and Severity Index, Physician Global Assessment, and Dermatology Life Quality Index (PASI, PGA, and DLQI score). Ophthalmological evaluation included ocular surface involvement (Schirmer, Jones, break-up time--BUT, DR-1 camera), retinal pathologies, and ocular surface disease index. Laboratory investigations including the C-reactive protein (CRP) of all the patients were performed. At baseline, the values of Schirmer, Jones, and BUT tests in the patient group were significantly lower compared to controls; moreover, conjunctival hyperemia was more frequent in psoriatic patients than in healthy subjects. Ocular involvement was more prominent in the subset of psoriatic patients with sebo-psoriasis than in general psoriatic population. A statistically significant correlation was found in sebo-psoriasis between PASI and Schirmer, between PASI and Jones, and between PASI and BUT. On the other hand, the results obtained from DR1 camera showed statistically significant difference between psoriatic and sebo-psoriatic patients at the end of the follow-up. After 12 weeks of treatment, the mean values of PASI, PGA, DLQI, CRP, and BUT showed significant changes in psoriatic patients. Our findings suggest a high rate of ocular involvement in psoriatic patients, emphasizing the need of performing periodic ophthalmological examinations in order to avoid underestimating eye diseases and to allow early diagnosis and treatment of patients.

Purpose: To investigate, with spectral-domain optical coherence tomography, if the preoperative status of the retinal pigment epithelium (RPE) affects the postoperative foveal morphology and visual outcomes in eyes with surgically closed macular holes (MHs). Methods: In 52 eyes with surgically closed MHs, preoperative RPE morphology was evaluated and graded based on the measurement of the largest hyperreflective protrusions above the RPE line. Foveal microstructural features and best-corrected visual acuity (BCVA) were evaluated 12 months after surgery. Results: At 12 months, a significant correlation was found between postoperative degree of integrity of the photoreceptors with preoperative RPE morphology, and base diameter of the hole (p = 0.003 and p = 0.028, respectively); mean BCVA at 12 months in eyes with diffuse RPE alteration was significantly lower than in eyes with small or no RPE alteration (p < 0.05). Conclusions: Preoperative RPE integrity may be indicative of good photoreceptor restoration and visual recovery in patients with surgically closed MHs.

Purpose To assess anatomic and visual outcomes of ocriplasmin use for symptomatic vitreomacular adhesion (VMA). Design Retrospective chart review. Methods Macula Society members were surveyed online to collect data on ocriplasmin for symptomatic VMA. Clinical and optical coherence tomography data were collected using standardized data entry forms. Results There were 208 patients (208 eyes) with symptomatic VMA followed at least 3 weeks after receiving ocriplasmin. At baseline, VMA was focal (

To report a case of bilateral acute macular neuroretinopathy (AMN) occurring in a 32-year-old woman, analyzed using the multimodal imaging technique. A 32-year-old Caucasian woman presented with 20 days history of acute onset of blurred vision in the right eye. The best-corrected visual acuity (BCVA) was 0.8 and 1.0 in the right and left eyes, respectively. She reported a lower urinary tract infection associated with fever, 7 days before the onset of the ocular symptoms. Serological tests demonstrated the presence of IgM specific for cytomegalovirus (CMV), while all the other laboratory tests were negative. SD-OCT exhibited the disruption of the inner segment–outer segment junction, associated with hyper-reflectivity of a thickened outer plexiform layer overlying such area associated with thinning of the outer nuclear layer. The patient was diagnosed with AMN and received a corticosteroid treatment. During all the follow-up, OCT features did not change, although BCVA improved. Four months after the first visit, we found also in the left eye a subfoveal IS/OS disruption but differently from the right eye, in which the abnormalities persisted during all the follow-up visits, in the left one they disappeared only after a month. The IgM specific for the CMV remained positive during the whole follow-up. To our knowledge, this is the first patient reported with a diagnosis of AMN associated with persisting presence of IgM specific for CMV.

Purpose The aim of this study was to compare the efficiency and safety of ultrahigh-speed cut rate 25-gauge system and standard cut rate 25-gauge vitrectomy system. Methods In this single-center, prospective randomized study, all consecutive eyes that underwent 25-gauge vitrectomy at the Eye Clinic of the University of Ancona from September 2014 to November 2014 were randomized to receive 25-gauge vitrectomy with 7,500 cuts per minute (cpm) probes (7,500 Group) or 25-gauge vitrectomy with 5,000 cpm probes (Standard Group). Exclusion criteria were previously vitrectomized eye, trauma cases, retinal detachment with proliferative vitreoretinopathy, and endophthalmitis. Main outcome measure was core vitrectomy duration. Secondary outcome was the incidence of iatrogenic retinal breaks and other complications related to surgery. Results Overall, 62 eyes were enrolled; 31 eyes received 25-gauge 7,500 cpm vitrectomy and 31 eyes received 25-gauge 5,000 cpm vitrectomy. The duration of core vitrectomy was significantly lower in the 7,500 Group (P = 0.030, t-test for independent samples). Mean ± standard deviation core vitrectomy time was 161.32 ± 39.10 seconds in the 7,500 Group and 184.10 ± 41.69 seconds in the Standard Group. The observed difference in mean core vitrectomy duration between subjects treated with 7,500 cpm probes and those in the Standard Group was equal -22 seconds (95% confidence interval: -43.3 to -2.2). There was no difference in the incidence of iatrogenic breaks between the 2 groups, and there were no other complications over a 3-month follow-up period. Conclusion The 25-gauge 7,500 cpm vitrectomy is an effective and safe surgical procedure, and it can significantly reduce core vitrectomy time in eyes undergoing vitreoretinal surgery.

To study the functional recovery of a patient with cerebrovascular injury using combined functional magnetic resonance imaging (fMRI) and diffusion tensor imaging (DTI). A 24-year-old woman with left hemianopsia underwent fMRI and DTI in a 1.5-tesla machine both in the acute phase and 1 month after an ischaemic stroke involving the right calcarine cortex. Acute-phase fMRI demonstrated that peripheral left visual field stimulation did not activate the right primary visual cortex, whereas stimulation 1 month later activated the visual cortex bilaterally. Analysis of acute-phase DTI data disclosed that a reduction of fractional anisotropy in the right optic radiation had almost resolved after 1 month. Fibre direction was normal at either time point. fMRI and DTI can demonstrate functional damage and recovery in patients with neuro-ophthalmological lesions.

Goldenhar syndrome is a rare clinical disturbance with a wide range of clinical manifestations. We report on a 6-year-old male with peculiar retinal presentation of Goldenhar syndrome. The patient was referred to Ophthalmology for central scotoma in the left eye, where visual acuity was 20/100. Fundus examination was unremarkable, except for yellowish material in the central macula. SD-OCT revealed interruption of the external limiting membrane and inner and outer segment junctions, with disorganized material in the vitelliform space and subretinal fluid. Six months later, fundus and SD-OCT examinations were unchanged without treatment, but visual acuity in the left eye had improved to 20/50. Five years later, he had similar clinical manifestations in the right eye. He was started on systemic steroids. After 15 days, his visual acuity improved to 20/20 and subretinal fluid and yellowish material in the vitelliform space disappeared. Goldenhar syndrome has variable presentation, including vitelliform maculopathy.

BEST1 (VMD2) is a gene located on the long arm of chromosome 11 (11q12.3) that encodes for the 585 amino acid transmembrane protein bestrophin 1, located on the basolateral aspect of retinal pigment epithelial (RPE) cells.1 The exact function of bestrophin 1 is still not unequivocally characterized, but it is linked to transepithelial chloride flow possibly by controlling Ca2+ channels in the RPE.1–3 Mutations in BEST1 therefore affect RPE metabolism, and by consequence outer retinal function with which the RPE is intimately associated. Over 200 mutations in BEST1 have been identified and published.1,3,4 Mutations are associated with Best vitelliform macular dystrophy (VMD, MIM 153700), adult-onset vitelliform macular dystrophy (MIM 608161), retinitis pigmentosa 50 (RP50, MIM 613194), and autosomal dominant vitreoretinochoroidopathy (MIM 193220). These diseases are all caused by autosomal dominant mutations. Recently, a phenotype caused by autosomal recessive mutations in BEST1 was described: autosomal recessive bestrophinopathy (ARB, OMIM 611809). Autosomal recessive bestrophinopathy is a rare ocular disease. It was defined by Burgess et al1 in 2008, although the same condition with compound heterozygous mutations in VMD2 had been described 2 years earlier.5 It results from biallelic mutations in BEST1 and is characterized by a multifocal vitelliform dystrophy with subretinal fluid. An association with hypermetropia and angle closure has been described.1 Herein, we review the clinical features and mutation analysis of four families with ARB.

To investigate the effect of aflibercept in a rare case of choroidal neovascularization (CNV) secondary to choroidal osteoma (CO) and refractory to ranibizumab and bevacizumab. A 45-year-old male with CO-related CNV in his left eye received prior two intravitreal 1.25 mg bevacizumab injections and three intravitreal 0.5 mg ranibizumab injections without visual and anatomic improvement. Best-corrected visual acuity assessment, ophthalmic examination, fundus photography, and optical coherence tomography (OCT) were performed. Switching to intravitreal injection of 2.0 mg aflibercept was performed. After three loading doses of intravitreal aflibercept, visual acuity of the left eye improved from 20/50 to 20/32. Resolution of the persistent subfoveal fluid and reduction of retinal hemorrhage were confirmed according to ophthalmoscopy and OCT findings. No serious adverse events were observed. The treatment effect persisted during a 10-month follow-up period. In choroidal osteoma, switching to intravitreal aflibercept injection may be an effective therapeutic option for treatment of CNV refractory to ranibizumab and bevacizumab.

The aim of to test efficacy and safety of Echinacea purpurea (echinacea) extract in the control of low-grade uveitis.Fifty-one (51) patients with low-grade, steroid dependent, autoimmune uveitis were recruited; posterior uveitis was excluded. The start therapy was represented by topical desamethazone for anterior uveitis and oral prednisone, rapidly tapered, for anterior uveitis with inflammatory scores equal to +2 and in all cases of intermediate uveitis. Best-corrected visual acuity (BCVA) decrease or improvement was defined as a reduction or increase of 2 or more letters seen from the initial BCVA; ETDRS chart was used. Thirty-two (32) patients (21 with anterior uveitis and 11 with intermediate uveitis) received Echinacea (150 mg twice/day) as add-on therapy, whereas 20 patients (10 with anterior uveitis and 9 with intermediate uveitis) were treated with the conventional steroid therapy alone.Thirty-one (31) patients showed anterior uveitis and 20 intermediate uveitis. The follow-up duration was 9 months. At the last follow-up, 19/21 patients with anterior uveitis and 9/11 with intermediate uveitis treated with echinacea presented uveitis settled, with a steroid-off time of 209 and 146 days, respectively. BCVA was stable or improved in 19/21 of anterior uveitis and 9/11 of intermediate uveitis. No adverse reactions supposed to be resulting from commercial-grade echinacea were recorded. Patients who did not receive echinacea required a longer treatment period with steroids with a steroid-off time of 121 and 87 days.Systemic echinacea appears safe and effective in the control of low-grade autoimmune idiopathic uveitis.

To report a case of overlapping choriocapillaritis that initially presented as multifocal choroiditis (MFC) but later showed features compatible with acute zonal occult outer retinopathy (AZOOR) resistant to standard immunosuppression that responded only to adalimumad therapy. A 41-year-old patient presented with multiple small, discrete yellow-whitish spots in both eyes, compatible with MFC. A few weeks later, despite treatment with sub-Tenon and systemic corticosteroids, a choroidal neovascularization occurred in the right eye. The patient was treated with intravitreal anti-vascular endothelial growth factor. After 2 months, reduced visual acuity, photopsia and visual field defect in the left eye occurred. Spectral domain optical coherence tomography revealed photoreceptor outer segment defects common to all choriocapillaritis. The additional finding of an annular scotoma and a 360° ring on indocyanine green angiography led us to make the diagnosis of presumed AZOOR. Despite the combination of several immunosuppressive agents leading to temporary control of the disease, the patient experienced a further worsening. At that point, adalimumab was introduced, which led to an obvious improvement. This case supports the hypothesis that two different entities of the so-called AZOOR complex can be possible in the same eye, even asynchronously. In our case, anti-tumor necrosis factor alpha monoclonal antibody therapy represented a valid treatment option in a patient unresponsive to traditional immunosuppressive treatments.

Purpose: To evaluate the incidence rates of iatrogenic retinal breaks in eyes that underwent 25-gauge vitrectomy under air compared with 25-gauge standard vitrectomy for idiopathic macular holes or idiopathic epiretinal membranes. Methods: In this retrospective, comparative interventional study, 435 eyes were enrolled. In all patients after core vitrectomy and epiretinal/inner limiting membrane peeling, complete vitrectomy of the base was performed, respectively under air (air group) or under fluid infusion (standard group). Results: The number of eyes with iatrogenic retinal breaks was significantly lower in the air group than in standard group (4/197 and 16/238, 2% and 7%, respectively; P = 0.035). A postoperative retinal detachment developed in 2 eyes (1%) in the standard group, and in no eyes of the air group (0%). Factors related to the occurrence of retinal breaks were surgically induced posterior vitreous detachment (P = 0.006), standard vitrectomy (P = 0.023), and surgery for macular hole (P = 0.030). Conclusion: The 25-gauge vitrectomy under air is associated with a lower incidence rate of retinal breaks compared with the standard 25-gauge vitrectomy.

Purpose: To evaluate the anatomic and functional outcomes and the rate of complications of a novel pars plana vitrectomy approach (airbag vitrectomy), with 25-gauge vitrectomy performed under air infusion, in the treatment of primary pseudophakic rhegmatogenous retinal detachment (PsRD). Methods: Prospective, noncomparative, interventional case series. One hundred forty-one eyes of 141 consecutive patients with primary PsRD uncomplicated by severe proliferative vitreoretinopathy (grade A or B). All patients underwent primary 25-gauge vitrectomy under continuous infusion of air, laser retinopexy of retinal breaks, and air or gas tamponade. Eyes with minimum follow-up of 6 months were evaluated. The Main Outcome Measures were primary anatomical success rate, defined as retinal reattachment at final follow-up after a single operation without additional surgery, visual outcome and rate of complications. Results: At 6 months the retina was reattached successfully after a single surgery in 98% of eyes (138/141). In 3 eyes (2%) retinal detachment recurred during the follow-up period, caused by proliferative vitreoretinopathy in 2 eyes and by new retinal breaks in 1 eye. After surgery, best corrected visual acuity improved significantly (P 21 mmHg), detected in 10 eyes (7%) on postoperative day 1. Conclusions: Primary 25-gauge airbag vitrectomy provides a high anatomic and functional success in eyes with PsRD and is associated with a low rate of complications.

A rare case of juxtapapillary retinal capillary hemangioma (JRCH) with tractional macular detachment that was managed successfully with minimally invasive 25-gauge vitreoretinal surgery, followed by two sessions of half-fluence photodynamic treatment (PDT) with good visual outcome, is presented. A 13-year-old female patient had progressive deterioration of the vision of her right eye due to the presence of tractional macular detachment associated with JRCH in von Hippel-Lindau (VHL) disease. A 25-gauge sutureless vitreoretinal surgery was successfully performed. Two months following surgery, the JRCH was treated with two sessions of half-fluence PDT at an interval of 4 months. Visual acuity improved from a preoperative level of 20/50 to 20/25 24 months postoperatively. Resolution of the tractional macular detachment, reduction of papillomacular area fluid, and reduction in size of the JRCH were observed during the follow-up period. No serious adverse events were observed. Small-gauge vitreoretinal surgery followed by PDT can be effective and safe in relieving tractional macular detachment and recovering useful visual acuity in JRCH in VHL disease.

Purpose To evaluate intravitreal aflibercept for treatment of macular edema secondary to central retinal vein occlusion (CRVO). Design Randomized, double-masked, phase 3 study. Methods A total of 177 patients with macular edema secondary to CRVO were randomized to receive 2 mg intravitreal aflibercept (n = 106) or sham (n = 71) every 4 weeks for 20 weeks. From weeks 24 to 48, patients were monitored every 4 weeks; the former group received intravitreal aflibercept as needed (PRN), and the sham group received sham. From weeks 52 to 76, patients were monitored every 8 weeks, and both groups received intravitreal aflibercept PRN. The primary endpoint (proportion of patients who gained ≥15 letters) was at week 24. This study reports exploratory outcomes at week 76. Results The proportion of patients who gained ≥15 letters in the intravitreal aflibercept and sham groups was 60.2% vs 22.1% at week 24 (patients discontinued before week 24 were considered nonresponders; P P P .001). Mean μm change from baseline central retinal thickness was −448.6 vs −169.3 at week 24 ( P P P = .1122). Over 76 weeks, the most common ocular serious adverse event in the intravitreal aflibercept group was macular edema (3.8%). Conclusions The visual and anatomic improvements seen after fixed, monthly dosing at week 24 were largely maintained when treatment intervals were extended. Patients with macular edema following CRVO benefited from early treatment with intravitreal aflibercept.

* BACKGROUND AND OBJECTIVE: To assess the role of optical coherence tomography (OCT) in the evaluation and follow-up after vitrectomy for diabetic macular edema. * MATERIALS AND METHODS: The 18 eyes of 12 patients affected by presumed diabetic vitreousinduced macular edema underwent biomicroscopy with a Goldmann contact lens, fluorescein angiography, and OCT. * RESULTS: OCT revealed two patterns of edema. The first group (15 eyes) was characterized by widespread thickening of the neurosensory retina with an increased nonhomogeneous reflectivity of the inner retinal layers; cystoid-like spaces of absent or reduced reflectivity in the neurosensory retina were also present. In the second group (3 eyes), a cystoid macular edema with a dome-shaped foveal profile because of a markedly increased retinal thickness in the foveal region was observed. The disappearance of the physiologic foveal profile was always seen. Biomicroscopy revealed an increased reflex of the inner limiting membrane in the first group and minimal alterations in the second one. Four patients (7 eyes) underwent vitrectomy with posterior hyaloid removal. In 5 eyes, the patients experienced a visual improvement greater than two Snellen lines. The restoration of the normal foveal profile and the reduction of the retinal thickness on the OCT were evident in all cases one month after surgery. * CONCLUSION: OCT appears to be a useful tool in the diagnosis and management of diabetic macular edema and in the monitoring of the morphological changes after vitrectomy. [Ophthalmic Surg Lasers 2000;31:187-191]

Purpose: To study the findings of optical coherence tomography (OCT) in retinal pigment epithelial (RPE) tears. Methods: Sixteen eyes of 16 consecutive patients with age-related macular degeneration complicated by RPE tear were studied using OCT. Fluorescein angiography also was performed. Thirteen eyes were at the acute stage and three eyes were at the scarring stage, still with a recognizable tear. Results: Optical coherence tomography identified an RPE detachment (PED) with focal interruption of the RPE in all cases. Optical coherence tomography always highlighted a peculiar non-dome-shaped profile of the serous PED, as opposed to that of the PED not complicated by an RPE tear. A very intense hyperreflectivity was observed in the OCT scans performed through the retracted RPE. A deep hyperreflectivity under the line corresponding to the RPE was evident in the area of the bare choroid. No choroidal neovascularization could be visualized using OCT, either at the acute or at the scarring stages. Conclusions: Optical coherence tomography, a noncontact, noninvasive imaging technique, may be a useful tool, complementary to fluorescein angiography, in the clinical assessment of RPE tears.

AIM—To evaluate the optical coherence tomographic characteristics of choroidal neovascularisation (CNV) in age related macular degeneration (AMD) and in idiopathic and inflammatory CNV. The use of this technique in the selection of patients for surgery is discussed. METHODS—Ocular coherence tomography (OCT), fluorescein, and indocyanine green angiography were performed in 23 patients affected by AMD complicated by well defined CNV and in 10 patients affected by inflammatory or idiopathic CNV. The neovascular membrane was surgically removed in five age related CNVs, two inflammatory choroidopathies, and two idiopathic CNVs. RESULTS—In inflammatory and idiopathic CNV, the OCT displayed a neovascularisation on the retinal pigment epithelium (RPE). In three cases the CNV was excised with an improvement of visual acuity equal to or greater than two Snellen lines; in a fourth case, the visual acuity after surgery was unchanged. In the cases of AMD the OCT fell into three different patterns: (A) CNV above the RPE (five cases); (B) focal, irregular thickening of the retinal pigment epithelial band (12 cases); (C) CNV above and below the RPE (six cases). The five pattern A CNV patients underwent the surgical excision of the neovascularisation. In four cases the visual acuity improved by two or more Snellen lines; in the fifth case the visual acuity remained unchanged. CONCLUSIONS—The authors suggest that the surgical removal of early age related CNV could be performed in those cases where the OCT shows a neovascular membrane on the RPE, as in idiopathic and inflammatory CNVs. Keywords: age related macular degeneration; choroidal neovascularisation; optical coherence tomography; vitreoretinal surgery

Purpose: The purpose of the study is to determine indocyanine green (ICG) angiographic characteristics of patients with multifocal choroiditis (MC) and to identify features that may assist in the differentiation of MC from other ocular inflammatory diseases. Methods: After complete ophthalmologic examination, fluorescein angiography and ICG angiography were performed in a series of 14 patients with MC. The ICG findings were then correlated with the clinical and fluorescein angiographic appearance of these patients to determine specific characteristics and distinguishing features of the entity. These findings then were compared with those of angiographic patterns observed in patients with ocular histoplasmosis syndrome to determine whether differentiating features could be identified. Results: Fourteen (50%) of the 28 eyes were found to have large hypofluorescent spots in the posterior pole on ICG angiography, which, in most cases, did not correspond to clinically or fluorescein angiographically detectable lesions. Seventeen (61%) had smaller hypofluorescent lesions (approximately 50 µm in size) in the posterior pole on the ICG study. In seven eyes exhibiting enlarged blind spots on visual field testing, ICG angiography showed confluent hypofluorescence surrounding the optic nerve. The ICG angiogram was found useful in evaluating the natural course in two patients with MC as well as a response to oral prednisone therapy in four others. The ICG angiographic findings differed from those seen in patients with ocular histoplasmosis. Conclusions: Indocyanine green angiography can provide information that is not detectable by clinical or fluorescein angiographic examination in patients with MC. This information may prove useful in differentiating this condition from the ocular histoplasmosis syndrome, provide a better understanding of the natural course and progression of the disease, and provide a potential adjunct in the clinical evaluation of patients undergoing therapeutic regimens for active inflammatory lesions.

Inflammation of uveal tract can be divided into: anterior, intermediate, posterior, and panuveitis. Uveitis can be a sight-threatening disease. The commonest ocular symptoms are: blurred vision, ocular pain, photophobia and floaters, depending on the type of uveitis. The onset of uveitis can be either acute or insidious, involving one or both eyes. Posterior uveitis is usually associated with vitritis. Anterior chamber cells and flare should be graded according to standardized uveitis nomenclature (SUN) working group. Binocular indirect ophthalmoscopy (BIO) score is used to grade vitreous involvement. Vitreous changes may comprehend: vitreous hemorrhage, vitreous strands, and vitreous traction. A further classification of posterior uveitis depends on the primary site of inflammation, which can identify: retinitis, choroiditis, retinochoroiditis, and chorioretinitis. Posterior pole uveal involvement can be: focal, multifocal, and placoid. Retinal vasculitis can be associated with several sub-types of posterior uveitis. Uveitis can present several complications such as, anterior and posterior synechiae, which can lead to uveitic glaucoma, cystoid macular oedema, retinal and choroidal neovascularizations, and retinal ischemia.

Inflammatory Choroidal Neovascularization (CNV) can be one of the most severe sequela in patients with uveitis. The outcome of subfoveal inflammatory CNV is poor if untreated: several procedures have been considered, even though there is lack of guidelines. On the other hand, the better knowledge of CNV pathophysiology may suggest a suitable treatment strategy. The combination of steroids and immunosuppression represents an important aspect of inflammatory CNV treatment. This ensures suitable control of inflammation as well as the reduction concomitant steroids dose. Neverthless there are cases which do not show a fully satisfactory response. Recently, the role of intravitreal anti-Vascular Endothelial Growth Factor (VEGF) has become primary in the treatment of neovascularizations. At this time, the combination of anti-VEGF drugs and immunesuppressives seems to be the best option for the management of inflammatory CNV. In summary, CNV secondary to uveitis is a severe sequela, which can lead to significant visual impairment. Although no guideline is provided, the current medical literature can give the basis for a successful treatment strategy, suggesting that combination of immunesuppresives and anti-VEGF is recommended.

Chronic non-infectious uveitis (NU) remains one of the most challenging problems in ophthalmology. Often, early and aggressive treatment is needed for a good visual acuity outcome. Local and oral corticosteroids remain the first line of treatment, even though side effects, such as glaucoma, cataract and Cushing Syndrome, can be serious and not tolerable. Therefore, a variety of immunosuppressive agents are used. Recently, new types of drugs, called “biologic agents”, are available. In the model of experimental autoimmuneuveitis (EAU) it has been demonstrated that tumor necrosis factor-alpha (TNF-α) may play a key role in uveitis. Beside the well known intravenous anti- TNF-α agent called infliximab, other sub cutaneous anti- TNF-α drugs have been introduced, such as Adalimumab and Golimumab. Adalimumab presents a stronger medical literature and it seems to present promising qualities. Few reports are available for Golimumab in uveitis at this time. Adalimumab can control uveitis unresponsive to the traditional immunosuppressive agents and, moreover, its subcutaneous administration makes the procedure user friendly. This drug can be used in selected cases as a rescue therapy for idiopathic non-infectious uveitis.