Transcript MIODESOPSIE

MIODESOPSIE
LO STATO DELL’ARTE
E
LE PROSPETTIVE DI RICERCA
I POSSIBILI TRATTAMENTI
1. VITREOCTOMIA
2. VITREOLISI LASER
3. VITREOLISI ENZIMATICA
4. RIMEDI ALTERNATIVI
VITREOCTOMIA
PARS PLANA VITREOCTOMIA
PARSA PLANA VITREOCTOMIA
•
Retina. 2000;20(6):591-6.Related Articles, Links
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Pars plana vitrectomy for persistent, visually significant vitreous opacities.
Schiff WM, Chang S, Mandava N, Barile GR.
Department of Ophthalmology, Columbia University College of Physicians and Surgeons, Edward S.
Harkness Eye Institute, and St. Luke's-Roosevelt Hospital Center, New York, New York, USA.
PURPOSE: To evaluate the role of vitrectomy in patients with persistent, visually disabling vitreous opacities.
METHODS: Six consecutive eyes of five men (age 58-66 years) with pseudophakia or aphakia and vitreous
opacities resulting in visual symptoms for more than 1 year that underwent vitrectomy were retrospectively
reviewed. Postoperative questionnaires regarding functional performance and quality-of-life issues were
completed by the participants to assess subjective patient satisfaction. RESULTS: Postoperative Snellen
visual acuity was improved or equal to preoperative acuity in all cases (8-44 month follow-up) and there
were no surgical complications. All patients expressed high satisfaction with overall visual function. Analysis
of the National Eye Institute Visual Function Questionnaire-39 indicated that general vision, near activities,
distance activities, mental health, role difficulties, and peripheral vision were significantly improved (P < 0.05)
following surgical intervention. CONCLUSIONS: Vitrectomy may be indicated in a select group of patients
with visually disabling vitreous floaters, although objective assessment of visual dysfunction from vitreous
floaters requires further evaluation.
Publication Types:
•
Case Reports
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PMID: 11131410 [PubMed - indexed for MEDLINE
PARSA PLANA VITREOCTOMIA
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Ophthalmologe. 2003 Aug;100(8):639-43. Epub 2003 Jun 18.Related Articles, Links
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[Vitreous body floaters and vitrectomy with full visual acuity]
[Article in German]
Hoerauf H, Muller M, Laqua H.
Klinik fur Augenheilkunde, Universitatsklinikum Lubeck. [email protected]
PURPOSE: To evaluate the role of vitrectomy in patients with visually disturbing vitreous
body floaters and full visual acuity (VA). METHODS: A total of 9 eyes from 8 patients (2
female, 7 male, median age 57 years) with a preoperative VA of 1.0 were analysed
retrospectively. The median duration of symptoms was 12 months. In all eyes a pars plana
vitrectomy was performed. The median follow-up period was 13 months. RESULTS: No
intraoperative or postoperative complications were observed. In all patients vision improved
subjectively and objective VA remained unchanged. In 2 out of 5 phacic patients a cataract
extraction was performed during the follow-up period. CONCLUSIONS: In a selected group
of patients vitrectomy can improve subjective vision even in eyes with full objective VA. A
critical patient selection with respect to psychological criteria and the individual risk of
vitrectomy is extremely important.
PMID: 12955446 [PubMed - indexed for MEDLINE]
PARSA PLANA VITREOCTOMIA
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J Fr Ophtalmol. 2004 May;27(5):491-5.Related Articles, Links
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[Vitrectomy for floaters]
[Article in French]
Quintyn JC, Brasseur G.
Service d'Ophtalmologie, CHU de Rangueil, Toulouse. [email protected]
PURPOSE: To clarify vitrectomy indications in the treatment of vitreous floaters. METHODS:
This is a retrospective study of four patients, four eyes (age, 42-65 years), who underwent
vitrectomy for the treatment of vitreous floaters. Two patients had a total posterior vitreous
detachment. All patients were required to think about the intervention for several months
before consenting. RESULTS: Preoperative visual acuity ranged from 20/40 to 30/30 and
after the operation it ranged from 20/40 to 10/10. Minimum follow-up was 1 year. Visual
acuity did not decrease after treatment in any patients. All patients expressed satisfaction
with their postoperative visual function. DISCUSSION-CONCLUSION: Visual acuity
measures do not always accurately reflect patients' visual discomfort. Vitrectomy has been
known for many years. It can be proposed as a last resort after thorough retina examination,
after patients have received adequate information and they are psychologically ready for the
procedure.
PMID: 15179305 [PubMed - indexed for MEDLINE]
PARSA PLANA VITREOCTOMIA
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Klin Monatsbl Augenheilkd. 2005 Sep;222(9):728-32.Related Articles, Links
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[Pars plana vitrectomy for vitreous floaters.]
[Article in German]
Roth M, Trittibach P, Koerner F, Sarra G.
Klinik und Poliklinik fur Augenheilkunde, Inselspital, Universitatsspital Bern, Schweiz.
BACKGROUND: The aim of this study was to evaluate the role of pars plana vitrectomy (PPV) in patients
with persistent vitreous floaters (VF) in phakic (56.7 %) or pseudophakic (43.3 %) eyes. SUBJECTS AND
METHODS: A retrospective study of 24 consecutive patients (30 eyes) who underwent a 2-port-PPV using
indirect opthalmoscopy between 1992 and 2003 was carried out. Main outcome measures were
postoperative visual acuity (PVA), incidence of postoperative complications and patient satisfaction, which
has been assessed retrospectively using a detailed questionnaire RESULTS: Symptoms resolved in all
patients. PVA was significantly better (0.91 +/- 0.2 vs. 0.84 +/- 0.2 preoperative visual acuity) or equal in 25
patients (83.3 %). One pseudophakic patient (3.3 %) experienced a retinal detachment 48 months after
surgery. In 5 of 17 phakic eyes (35 %) a cataract extraction had to be performed during the follow-up period.
All patients were satisfied with their overall visual function. DISCUSSION: This study shows PPV to be a
safe and effective primary treatment for visually disturbing VF. In spite of the small number of cases with a
lower PVA (5 eyes/16.7 %), which in the most severe case corresponded to a reduction of VA from 1.0 to 0.6
due to a nuclear sclerosis of the lens, all patients were satisfied. As vitreoretinal complications may occur, a
critical patient selection and a careful preoperative assessment of specific risks of vitrectomy are mandatory.
PMID: 16175483 [PubMed - in process]
VITREOCTOMIA SUTURELESS
STRUMENTAZIONE 25 GAUGE
VITREOCTOMIA SUTURELESS
OSPEDALE DI LINZ-AUSTRIA
VITREOCTOMIA SUTURELESS
CATARATTA
1. <10% fino a 30 anni
2. 50% fino a 50 anni
3. 100% oltre i 65 anni
COMPLICAZIONI POST-OPERATORIE
PREVENZIONE CATARATTA
•
J Cataract Refract Surg. 2002 Apr;28(4):589-92.Related Articles, Links
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Comment in:
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J Cataract Refract Surg. 2003 Aug;29(8):1466-7; author reply 1467.
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Floaterectomy: combined phacoemulsification and deep anterior vitrectomy.
Mossa F, Delaney YM, Rosen PH, Rahman R.
Department of Ophthalmology, John Radcliffe Hospitals NHS Trust, Oxford, United Kingdom.
We describe a 1-stage surgical technique to treat vitreous floaters. Phacoemulsification is
combined with a deep anterior vitrectomy through a posterior curvilinear capsulorhexis
followed by implantation of a posterior chamber intraocular lens. The technique was used in
10 eyes of 6 patients. Six months postoperatively, 8 eyes had a best corrected visual acuity
(BCVA) of 6/6 with complete resolution of symptoms. Two eyes of 1 patient developed
cystoid macular edema that reduced final BCVA to 6/18 bilaterally. In this case, the floaters
may have been the result of previously undiagnosed intermediate uveitis.
PMID: 11955895 [PubMed - indexed for MEDLINE]
FLOATERROCTOMIA
PREVENZIONE CATARATTA
•
Exp Eye Res. 2002 Oct;75(4):459-73.Related Articles, Links
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Suppression of post-vitrectomy lens changes in the rabbit by novel benzopyranyl esters and amides.
Kuszak JR, Sivak JG, Moran KL, Scheib SA, Garner WH, Ke TL, Hellberg MR, Graff G.
Department of Ophthalmology, Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL, USA.
This study reports for the first time a therapeutic modality for the suppression of posterior subcapsular cataract (PSC) formation in
an animal model (rabbit) of vitrectomy. This therapeutic modality may also have the potential to attenuate/prevent the high
incidence of loss of vision due to cataract formation in patients that undergo vitrectomy. Unilateral, partial vitrectomy was
performed on 2.5 month old Dutch Belted rabbits with vitreous replaced by either commercially available BSS((R)) or BSS
PLUS((R)) (n=16). Alternatively, vitreous was replaced with a proprietary, modified BSS PLUS((R)) irrigating solution containing
1.25 microM AL-8417 (n=12), 5.0 microM AL-12615 (n=5) or 5.0 microM AL-17052 (n=9). Age matched, non-operated rabbits
were used as controls (n=16). Lenses were analysed by correlative structural (light, scanning electron microscopic and threedimensional computer-assisted drawings) and optical (low power helium-neon laser scan) quality analysis 6 months following
surgery. Results demonstrate that vitreous replacement with an irrigating solution that contains the ester-linked benzopyran, AL8417, the amide-linked benzopyran pro-drug, AL-17052, or its active metabolite, AL-12615, prevented abnormal post-vitrectomy
lens growth, or fiber formation. Focal length variability (FLV) assessments (sharpness of focus) confirmed the beneficial drug
effects detected morphologically, with FLV being essentially equal to that of age-matched, non-surgical controls. In contrast, lenses
of animals with vitreous replaced solely with BSS((R)) or BSS PLUS((R)) exhibited significantly higher FLV than both age-matched
controls and animals that underwent vitrectomy with drug-containing irrigating solutions. The ability of AL-8417, AL-17052 and its
active metabolite, AL-12615, to suppress vitrectomy-induced posterior lens fiber changes appears to reside in their unique
pharmacological profile, acting as antioxidant, anti-inflammatory and cytostatic agents.
PMID: 12387793 [PubMed - indexed for MEDLINE]
INIEZIONI INTRAVITREALI
VITREOCTOMIA SUTURELESS
VITREO ARTIFICIALE
VITREOCTOMIA SUTURELESS
VITREO ARTIFICIALE
VITREOCTOMIA SUTURELESS
1. distacco di retina (<0,5%)
2. infiammazioni oculari (<0,05%)
3. aumento della pressione oculare (30%)
COMPLICAZIONI POST-OPERATORIE
FLOATERS ONLY VITRECTOMY
•
•
•
•
•
For years, ophthalmologists had been cautious in recommending vitrectomy surgery for patients
suffering from floaters. Now, a new study conducted, suggests that vitrectomy may be a practical
solution for many patients.
Due to improved techniques and instrumentation, vitrectomy, a technique used to clear blood and
debris from the vitreous, a normally clear, gel-like substance that fills the center of the eye, is now
a viable option for patients suffering from floaters.
A study conducted by William M. Schiff, M.D., of the Department of Ophthalmology, Columbia
University College of Physicians and Surgeons and his colleagues, concluded that vision was
improved in 6 out of 6 eyes with no surgical complications following vitrectomy for the removal of
persistent, visually significant floaters. All patients involved in the evaluation were highly satisfied
with their visual results with a profound improvement in overall lifestyle activities in regards to
visual acuity.
Vitrectomy is rarely needed since floaters typically become less bothersome over a period of
weeks to months as they settle below the line of sight. However, vitrectomy may be indicated in a
very select group of patients with visually disabling vitreous floaters, as long as an objective
assessment of the patient's visual dysfunction from the floaters is made.
Dr. Dan Montzka, M.D., of St. Luke's Retina Institute in Tarpon Springs, Florida says "with recent
advances in vitrectomy techniques such as sutureless incisions, the risks are lower than ever in
history for most types of vitreo-retinal surgery." Dr. Montzka and his colleagues Dana M.
Deupree, M.D. and Brian Phillpotts, M.D., have been performing the state-of-the-art, sutureless
retina surgery for the past several years.
I FLOATERS DEBILITANTI
APPARTENGONO AL PASSATO
FLOATERS ONLY VITRECTOMY
CENTRI SPECIALIZZATI
VITREOLISI LASER
ND YAG LASER
VITREOLISI LASER
PROTEZIONI PER LA RETINA
VITREOLISI LASER
FOTODISTRUZIONE
VITREOLISI LASER
I RISULTATI
VITREOLISI LASER
• MIGLIORAMENTI 92% DEI CASI
• COMPLICAZIONI 0,29% DEI CASI
(cataratta, glaucoma, distacco di retina)
PRO E CONTRO
VITREOLISI LASER
• Department of Ophthalmology, Father Fox Memorial Hospital,
Tainan, Taiwan, Republic of China.
Sono stati esaminati quindici casi di floaters con serie complicazioni
psicologiche. Usando un oftalmoscopio diretto, sono state rilevate le
opacità vitreali. Le opacità sono state fotodistrutte con lo YAG laser,
usando i livelli di energia da 5 a 7,1 mj e un’energia totale da 71 a
742,0 mj. I sintomi sono spariti completamente subito dopo il
trattamento in tutti e 15 i casi. Non ci sono state né complicazioni
durante l’operazione né complicazioni postoperatorie note durante
un periodo successivo di almeno 1 anno. A nostra conoscenza, l'uso
dello YAG laser per trattare i floaters vitreali non è mai stato
descritto precedentemente. La nostra esperienza iniziale indica che
il trattamento è semplice, sicuro ed efficace.
ND YAG LASER E MIODESOPSIE
VITREOLISI ENZIMATICA
Anticipation for enzymatic vitreolysis
Other applications can be envisaged. Enzymatic vitreolysis might be useful as
a supplement to pneumatic retinopexy for rhegmatogenous retinal detachment
repair; injecting an enzyme at the time of gas injection to additionally release
vitreous traction could potentially increase the success rate of this office based
procedure. As another example patient complaints associated with vitreous
floaters are all too familiar to ophthalmologists, but the risk-benefit profile for
surgery for vitreous floaters is prohibitive. Could enzymatic vitreolysis reduce
risks sufficiently to become viable for the large number of patients with this
relatively benign but annoying visual problem? The arrival of enzymatic
vitreolysis may expand vitreoretinal practice in ways that can't be predicted.
Before enzymatic vitreolysis enters the mainstream central questions will need
to be addressed effectiveness, inflammatory responses, retinal toxicity, long
term complications. And years of work in the field of vitreolytic enzymes have
yet to yield a widely accepted alternative to mechanical vitrectomy.
Nevertheless, as the limits of conventional vitrectomy are being approached
vitreoretinal surgeons continue to look forward over the next years to a new
generation of therapies with vitreolytic enzymes.
IALURONIDASI
•
Klin Oczna. 2002;104(2):135-7.Related Articles, Links
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[Efficacy of hyaluronidaze in reducing vitreous opacites--preliminary report]
[Article in Polish]
Puchalska-Niedbal L, Millo B.
Katedry i Kliniki Okulistyki z Zakladem Patofizjologii Narzadu Wzroku Pomorskiej Akademii
Medycznej, Szczecinie.
The aim of the work: the assessment of hyaluronidase as reducer of floaters in vitreus body.
We present one patient with the floaters in vitreus body treated by subconjunctival injection
with hyaluronidase. Research work was carried out on a rabbit, which had been given 10
subconjunctival injections of hyaluronidaze. After treatment we noted subjective and local
improvement. By using biochemical tests we proved, that subconjunctival hyaluronidaze
application is a good way, to obtain an effect in the vitreous.
Publication Types:
•
Case Reports
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PMID: 12174456 [PubMed - indexed for MEDLINE]
IALURONIDASI
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Invest Ophthalmol Vis Sci. 1999 Sep;40(10):2173-8.Related Articles, Links
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Effects of hyaluronan lyase, hyaluronidase, and chondroitin ABC lyase on mammalian vitreous gel.
Bishop PN, McLeod D, Reardon A.
Department of Ophthalmology and Wellcome Trust Centre for Cell-Matrix Research, School of Biological
Sciences, University of Manchester, England, UK. [email protected]
PURPOSE: To determine the effects of enzymes on mammalian vitreous gel and to thus infer the structural
roles of hyaluronan and chondroitin sulfate in the gel. METHODS: The wet weights of bovine vitreous gels
were compared before and after incubation with Streptomyces hyaluronan lyase, chondroitin ABC lyase,
testicular hyaluronidase, or buffer alone. The extent of hyaluronan depolymerization was determined by
chromatography and that of chondroitin sulfate depolymerization by western blot analysis. RESULTS: After
digestion with Streptomyces hyaluronan lyase (30 U/gel), the gel wet weight was the same as that of
controls (incubated with buffer alone) despite 94% of the hyaluronan having been depolymerized; when
digested with 100 U/gel, the gel wet weight decreased (to 57% of original wet weight versus 86% for
controls, P = < 0.001) and hyaluronan was completely depolymerized. Chondroitin ABC lyase digestion (0.2
U/gel) resulted in a slight reduction in gel wet weight (90% versus 96%, P = < 0.001) and depolymerization
of 88% of the hyaluronan; the presence of fully digested chondroitin sulfate chains was established.
Digestions with 100 and 500 U/gel of testicular hyaluronidase resulted in a decrease (P = < 0.001, both
cases) in gel wet weight (53% versus 82%, 100 U/gel; 57%, versus 86%, 500 U/gel) with 75% and 97%
hyaluronan depolymerization, respectively. CONCLUSIONS: Depolymerization of all vitreous hyaluronan and
of chondroitin sulfate resulted in gel wet weight reduction but not gel destruction. Digestion with 30 U/gel of
Streptomyces hyaluronan lyase revealed a small pool (6%) of relatively enzyme-resistant hyaluronan that
specifically contributed toward maintaining gel wet weight.
PMID: 10476780 [PubMed - indexed for MEDLINE]
IALURONIDASI
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Retina. 1998;18(1):16-22.Related Articles, Links
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Comment in:
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Retina. 1998;18(1):1-3.
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Efficacy and safety of enzymatic posterior vitreous detachment by intravitreal injection of
hyaluronidase.
Harooni M, McMillan T, Refojo M.
Schepens Eye Research Institute, Department of Ophthalmology, Harvard Medical School, Boston,
Massachusetts, USA.
PURPOSE: To investigate the efficacy and safety of intravitreal injection of hyaluronidase in producing
liquefaction resulting in a posterior vitreous detachment. METHODS: Fifteen young pigmented rabbits were
randomized into 3 groups that received 5 (group 1), 10 (group 2), or 20 (group 3) IU of hyaluronidase. The
fellow eyes were injected with a volumetric equivalent dose of balanced salt solution as control. The rabbits
were followed for 9 weeks and examined for signs of ocular and retinal toxicity. The animals were then
euthanized and their eyes were examined histologically. RESULTS: Biomicroscopic evaluation in all but one
rabbit revealed no evidence of ocular toxicity. One rabbit showed evidence of vitreous traction on the retina
with transient retinal elevation. Biomicroscopically and histologically, all rabbits in group 3 and four of five
rabbits in group 2 had evidence of a posterior vitreous detachment. CONCLUSION: Intravitreal injection of
hyaluronidase in doses of 10 IU or higher induces posterior vitreous detachment in rabbits over a period of 5
weeks. Intravitreal doses of 20 IU or less do not appear to affect the biomicroscopic morphology or function
of ocular structures adversely. Injections of hyaluronidase, therefore, could be considered as an alternative
or adjunct to conventional mechanical vitrectomy.
PMID: 9502276 [PubMed - indexed for MEDLINE]
SICUREZZA ED EFFICACIA DELLA IALURONIDASI
IALURONIDASI
EMORAGGIE VITREALI
RETINOPATIA DIABETICA
MICROPLASMINA
ThromboGenics Ltd. Announces the Initiation of Phase II Trial of Microplasmin
Investigating New Drug for Treatment of Disorders of the "Back of the Eye“
ThromboGenics Ltd. today announced the start of a Phase II trial evaluating recombinant microplasmin in patients with
vitreoretinal disorders, also referred to as diseases of the "back of the eye". Microplasmin is a truncated form of the
human protein plasmin; ThromboGenics has developed on a proprietary basis the first stabilized and readily
manufactured form of this unique protein.
Microplasmin has the potential to simplify a surgical procedure called vitrectomy, which is used to treat visual
conditions. Vitrectomy involves separation of the vitreous (the gel-like substance in the center of the eye) from the
retina, inducing a posterior vitreous detachment (PVD), a technique considered beneficial in patients with
numerous retinal conditions, including diabetic retinopathy and macular edema.
The breakthrough procedure using plasmin for induction of PVD was invented by Drs. Michael Trese and George
Williams, the founders of NuVue Technologies, which owns exclusive rights for the use of plasmin in ophthalmic
applications. A formal licensing agreement between ThromboGenics and NuVue brings into a single portfolio all
intellectual property relating to plasmin-based compounds for treatment of eye diseases.
This Phase II trial, in which the first patient was treated in December 2004, will enroll up to 50 patients at 3 centers in
the Netherlands and Germany. The investigators for the study are Professors Marc de Smet (Amsterdam), Arnd
Gandorfer and Anselm Kampik (Munich), and Eric Feron (Rotterdam), Patients with vitreoretinal disease for whom
vitrectomy is indicated will be enrolled. The trial is primarily designed to provide valuable safety information on the
use of microplasmin in this setting, on which dose selection for future clinical trials can be based. Subject to
interim results from this trial, ThromboGenics plans to submit an Investigational New Drug (IND) application to
FDA to allow for initiation of a U.S. clinical trial with microplasmin in 2005.
VITREOCTOMIA FARMACOLOGICA
MEDICINA TRADIZIONALE CINESE
(TCM)
FLOATERS AND THEIR TREATMENT WITH CHINESE HERBS
by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon
•
•
•
Zhuling San
(Polyporus Powder) Polyporus 30 g Akebia 30 g Rhubarb 30 g Gardenia 30 g Cibotium 30 g Talc
30 g Polygonum 30 g Plantago seed 15 g Red atractylodes 15 g Instructions: grind the
ingredients to powder; one dose is 9 grams, to be consumed with salty water. Actions: This
formula clears damp-heat of the liver/gallbladder and the kidney/bladder; it is comprised mainly of
bitter herbs of cold nature. Most of the herbs are classified as diuretic in modern terms; rhubarb
and gardenia purge the gallbladder.
Heishen Tang
(Scrophularia Decoction) Scrophularia Scute Raw rehmannia Chrysanthemum Red peony Celosia
Tribulus Instructions: to grind the ingredients in equal parts to powder. Each dose is 12 grams,
with the powder boiled in water for a brief time and the resulting decoction consumed. Actions:
These herbs clear heat from the blood and dispel wind-heat from the eyes.
Bushen Wan
(Supplement Kidney Pills) Ginseng Acorus Hoelen Lycium Peony Cuscuta Alisma Cistanche
Instructions: grind equal amounts of these herbs to powder, mix with honey to form pills. The
quantity of the herbs to be used for each dose is unclear. Actions: This formula nourishes the
kidney and moistens the essence
VARIA
Am J Ophthalmol. 1956 Nov;42(5):771-2.Related Articles, Links
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Use of iodo-niacin for retinal or vitreous hemorrhages and vitreous floaters.
ABRAHAMSON IA Sr, ABRAHAMSON IA Jr.
PMID: 13372702 [PubMed - OLDMEDLINE for Pre1966]
S Afr Med J. 1958 Mar 15;32(11):296-8.Related Articles, Links
A surgical procedure for the relief of vitreous opacities (floaters).
BLUMENTHAL CJ.
PMID: 13543474 [PubMed - OLDMEDLINE for Pre1966]