Abstract

Purpose:

To compare the effect of intravitreal diclofenac (IVD) versus intravitreal triamcinolone (IVT) on refractory uveitic cystoid macular edema (CME).

Methods:

In this pilot randomized clinical trial, 15 eyes were randomly assigned to an IVD group, patients (8 eyes) who received a single intravitreal injection of diclofenac (500 μg/0.1 mL), and an IVT group (7 eyes), cases who received a single intravitreal injection of triamcinolone (2 mg). Change in best-corrected VA in logMAR at week 36 was the primary outcome measure. Secondary outcomes included changes in best-corrected visual acuity (BCVA) at 12 and 24 weeks, central macular thickness (CMT), macular leakage, and potential injection-related complications.

Results:

In the IVD group, BCVA was more than the baseline values in 4 eyes at 36 weeks; however, within-group analysis disclosed no statistically significant changes in the mean BCVA in this group. Nonetheless, in the IVT group, mean BCVA improved significantly at 12, 24, and 36 weeks compared to the baseline values. It was 0.86 ± 0.37 at baseline and 0.63 ± 0.48, 0.62 ± 0.42, and 0.43 ± 0.49 logMAR at 12, 24, and 36 weeks, respectively. Mean CMT reduction diminished also significantly only in the IVT group. Nevertheless, comparing the mean BCVA and CMT changes, macular leakage, and the occurrence of any injection-related complications, no significant difference was observed between the groups at any of the follow-up visits.

Conclusion:

This pilot study demonstrated the superiority of IVT over IVD in the treatment of refractory uveitic CME regarding both functional and anatomical outcomes. Further studies are warranted to confirm potential benefit of IVD observed in this study.

PURPOSE:

To determine the changes of regional macular thickness after successful macular hole (MH) surgery with internal limiting membrane (ILM) peeling during a 24-month follow-up period.

METHODS:

In a prospective, interventional case study, the authors evaluated 24 eyes of 24 patients who underwent 23-gauge transconjunctival pars plana vitrectomy with triamcinolone-assisted ILM peeling to treat idiopathic MH. Examinations were performed before and 1, 2, 3, 6, 9, 12, and 24 months after surgery. Average regional macular thicknesses in the Early Treatment Diabetic Retinopathy Study sectors were measured by spectral-domain optical coherence tomography.

RESULTS:

The four inner sectors showed a significant reduction in the average retinal thickness at 1 month after surgery (P =< 0.0001-0.020), and the thickness continued to decrease for 24 months except in the nasal sector. The 4 outer sectors had a significant increase at postoperative 1 month (P =0.0003-0.029) and then continued to decrease until postoperative 24 months. The postoperative regional macular thinning was statistically significant even between 12 and 24 months (P =0.0007-0.026) in all sectors except in the inner nasal sector (P=0.13). The postoperative percent reduction rate was significantly different among 4 inner sectors after postoperative 3 months (P =0.0029-0.039) in the order of temporal>superior>inferior>nasal sectors.

CONCLUSIONS:

These results suggest that a progressive macular thinning occurs for at least 2 years with different patterns of the changes in the macular regions after successful MH surgery with ILM peeling.

Objectives/HypothesisThe purpose of this study was to investigate the morphological and histological change of vocal folds (VFs) after steroid injection in a rabbit model.Study DesignProspective animal study.SettingTertiary academic medical center.Subjects and MethodsTwenty-four New Zealand white rabbits were used in this study. We randomly classified rabbits into the 3 groups and triamcinolone acetonide suspension was injected to the right VF with different concentrations. Left VF was injected with the same volume of phosphate-buffered saline as control. Endoscopic evaluation was performed to measure morphological changes. The larynges were collected for histological analysis, and the VFs were stained with hematoxylin-eosin for assessing inflammatory response, glandular atrophy, and muscular atrophy and with Masson's trichrome for assessing collagen deposition.ResultsIn morphological assessment, there were no differences in VF mass reduction, mucosal atrophy, and granulation formation between both VFs. Histological assessments showed no significant difference in inflammatory response, glandular atrophy, and collagen deposition between both VFs. However, there was a difference in muscular atrophy and epithelial layer thinning in steroid injected right VFs. Muscular atrophy had been completely recovered over time, but mild epithelial thinning was continued until 12 weeks. The longer exposure time and larger dose did not increase the intensity of muscular atrophy or epithelial thinning.ConclusionWe demonstrated that the VF steroid injection resulted in no significant changes in morphology and histology of rabbit VF. However, steroid injection may induce several VF histological changes and these results are needed to be considered when treating humans.

OBJECTIVE:

To report the 12-month outcomes of the dexamethasone intravitreal implant in retinal vein occlusion (RVO), using an as-needed repeat injection protocol.

DESIGN:

Retrospective consecutive case series of 51 eyes of 49 patients with macular oedema as a result of RVO that received an intravitreal dexamethasone implant and were followed up for at least 12 months.

RESULTS:

70% of patients responded to dexamethasone implant injection with an improvement in visual acuity (VA) and macular oedema within 3 months of injection, but only 30% of eyes gained ≥15 letters. The mean change in VA letter score at 12 months compared with baseline for branch RVO (BRVO) and central RVO (CRVO) was 5.7±2.3 and 11.5±11.0 EDTRS letters, respectively. 56% of patients relapsed, with the median time to relapse being 17 weeks for patients with branch RVO and 18 weeks for patients with CRVO. Repeat injections achieved similar VA gains, but the duration of effect of repeat dexamethasone implants was much shorter at 10 weeks. 14 eyes (27%) developed a significant rise in intraocular pressure, and three of these required treatment with oral acetazolamide. Four eyes with CRVO developed neovascular glaucoma during the study.

CONCLUSIONS:

The intravitreal dexamethasone implant does not last the 6 months implied by the retreatment protocol in the GENEVA trial, and improved results can be achieved with an as-needed retreatment protocol, particularly in CRVO. However, visual outcomes remain similar to those previously seen with triamcinolone in the SCORE study and neovascular complications remain a feature of CRVO.

We report a case of unusually long persistence of triamcinolone crystals after intra-vitreal injection. Crystals were noted on fundus examination predominantly confined to the posterior pole. Optical coherence tomography localized the crystals to the posterior hyaloidal surface. Over 6 years of follow-up the patient has retained good visual acuity and no observable changes in the retina. As the condition clinically resembles both crystalline maculopathy and asteroid hyalosis, we suggest the term 'drug-induced benign crystalline hyaloidopathy'.

A 34-year-old male visited the hospital due to decreased visual acuity in the left eye following an injury from a car accident. In the left eye, best-corrected visual acuity (BCVA) was hand motion and intraocular pressure (IOP) was 8 mmHg. Choroidal vasodilation and chorioretinal folds were observed by spectral domain-optical coherence tomography (SD-OCT). Topical and systemic steroid treatments did not improve the chorioretinal folds. Twelve months after the injury, intra-vitreal triamcinolone (4 mg/0.1 ml) was injected. Six months after intra-vitreal triamcinolone injection, BCVA in the left eye had improved to 20/100. Fundus examination showed improvement in retinal vascular tortuosity and SD-OCT revealed improvements in choroidal vasodilation and chorioretinal folds. Intra-vitreal triamcinolone injection (IVTI) was effective against traumatic chorioretinal folds with no recurrence based on objective observation by fundus photography and SD-OCT.

Esophageal strictures remain the most frequent complication after esophageal atresia (EA) repair despite refinements in operative techniques. With an incidence of anastomotic stricture between 8% and 49%, EA is the most frequent cause of benign esophageal stricture in children. The mainstay of treatment for esophageal stricture is dilatation with a 58-96% success rate. In order to relieve dysphagia, between 1 and 15 dilatations will be required in each EA patient with an esophageal stricture. However dilatations may lead to complications including perforation (0.1-0.4% of all esophageal benign strictures) and sociopsychological morbidity. Fifty percent of EA strictures will improve in 6 months. However, 30% will persist and require repeat dilatations. The present article explores the variety of non-surgical alternative treatments for anastomotic strictures after EA repair, focusing on triamcinolone acetonide, mitomycin C and esophageal stents. We propose an algorithm for a more standardized therapeutic approach, with the hope that an international panel of experts could meet and establish a consensus.

PURPOSE:

To evaluate preoperative and postoperative retinal function in patients who underwent macular surgery for idiopathic macular hole.

DESIGN:

Prospective, comparative, interventional case series.

METHODS:

Thirty eyes of 30 patients with idiopathic macular hole were included in the study. Patients underwent pars plana vitrectomy and peeling of the internal limiting membrane (ILM). ILM visualization was improved in 15 patients by using triamcinolone acetonide and in the remaining 15 patients by using infracyanine green dye. Spectral-domain optical coherence tomography examination was performed to document macular hole closure. Retinal function was assessed preoperatively and postoperatively over a period of 12 months by best-corrected visual acuity (BCVA) measurement (ETDRS chart), MP-1 microperimetry, and focal electroretinogram recording (fERG). Focal electroretinograms were recorded in response to a sinusoidally modulated (41 Hz), uniform field presented to the macular (18 degrees) and foveal (2.25 degrees) region.

RESULTS:

Macular hole closure was achieved in all patients in both groups. At 12 months, visual acuity improved in both groups (P < .001), and there were no statistically significant differences between groups. Mean macular sensitivity within the central 2 and 8 degrees increased in both groups, and there were no statistically significant differences between groups at any follow-up. In the triamcinolone acetonide group, 12 months after surgery the amplitude of the fERG's first harmonic (1F) increased both in the macular region (P < .001) and in the foveal region (P < .05). In the infracyanine green group, at 12 months the amplitude of the first harmonic (1F) decreased in both areas. The decrease was significant in the macular region (P < .05) and not significant in the foveal region (P = .095).

CONCLUSION:

Vitrectomy and ILM peeling assisted with either triamcinolone acetonide or infracyanine green staining improves visual acuity and mean macular sensitivity at 12 months in patients affected by idiopathic macular hole. However, triamcinolone acetonide staining is associated with an increase of fERG's first harmonic amplitude in the foveal and macular region, whereas in the case of infracyanine green staining it seems to decrease after surgery. The reduction of the amplitude of fERG's first harmonic suggests that infracyanine green may have a late toxic effect on photoreceptor cells.

Soft tissue augmentation is one of the most frequent techniques in cosmetic dermatology. Nowadays, there are a high number of available materials. Nonanimal hyaluronic acid (HA) is one of most useful fillers for lip augmentation and for treating nasolabial folds, marionette lines, and the dynamic wrinkles of the upper face.<BR>To evaluate the type and management of undesirable effects of nonanimal reticulated or stabilized HA observed in our cosmetic unit in the past 3 years.<BR> MATERIALS andThe consecutive patients using HA attending to our clinic in the past 3 years were divided into 3 categories, according to the time of presentation of the adverse reactions: immediate, early, and late-onset complications. All patients were treated.<BR>Twenty-three patients presented to our clinic complaining of complications after soft tissue augmentation with HA. Ten patients presented immediate-onset complications, 8 showed early-onset complications, and 5 cases complaint of late-onset complications. Treatment of the first group consisted of hyaluronidase injection, massage, and topical antibiotics. Early- and late-onset complications were treated with intralesional triamcinolone acetonide. All patients improved, with the exception of a woman with recurrent granulomas.<BR>Generally, undesirable effects of HA (immediate, early, or late onset) are not frequent, and when present, they improve if treated properly. Physicians need to be aware of these possible adverse events in order to establish proper treatment and prevent scarring or other sequelae.<BR><BR> <EM>J Drugs Dermatol.</EM> 2013;12(4):e59-e62.

PURPOSE:

To evaluate the influence that vitreous incarceration may exert on the presence of postoperative conjunctival blebs over sclerotomies after transconjunctival sutureless vitrectomy (TSV). Blebs are formed by incisional leakage due to incompetent closure.

METHODS:

Experimental study in which 23-gauge TSV was performed in 146 cadaveric pig eyes. Once the vitrectomy was finished, triamcinolone was injected inside the vitreous cavity for staining residual vitreous, one of the superior cannulas was extracted over the light probe, and the other cannula was removed with the plug inserted. Postoperative conjunctival blebs in superior sclerotomies were assessed by anterior-segment optical coherence tomography (AS-OCT) in a masked fashion; non-detectable blebs were classified as grade-0 (B0), thin bleb (≤half scleral thickness) as grade-1 (B1), and thick bleb (>half scleral thickness) as grade-2 (B2). Postoperative incisional vitreous entrapment was evaluated by slit-lamp photographs in a masked way; no incarceration was classified as grade-0 (V0), thin incarceration as grade-1 (V1), and thick incarceration as grade-2 (V2).

RESULTS:

Conjunctival blebs were found in 13.7% of the sclerotomies (11.3% bleb-B1, 2.4% bleb-B2). Vitreous incarceration was found in 96.5% of the sclerotomies without bleb (B0), 81.8% of the incisions with bleb-B1, and 14.3% of the wounds with bleb-B2. Vitreous incarceration was significantly associated with the absence of conjunctival bleb (p<0.001).

CONCLUSIONS:

Vitreous incarceration in sclerotomies is related to less incisional leakage in our experimental model. Maneuvers that reduce vitreous entrapment, such as the interposition of a non-hollow probe during the cannula extraction, could decrease the sclerotomy closure competency.