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MIODESOPSIE LO STATO DELL’ARTE E LE PROSPETTIVE DI RICERCA.

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Presentation on theme: "MIODESOPSIE LO STATO DELL’ARTE E LE PROSPETTIVE DI RICERCA."— Presentation transcript:

1 MIODESOPSIE LO STATO DELL’ARTE E LE PROSPETTIVE DI RICERCA

2 I POSSIBILI TRATTAMENTI 1. VITREOCTOMIA 2. VITREOLISI LASER 3. VITREOLISI ENZIMATICA 4. RIMEDI ALTERNATIVI

3 VITREOCTOMIA PARS PLANA VITREOCTOMIA

4 PARSA PLANA VITREOCTOMIA Retina. 2000;20(6):591-6.Related Articles, LinksRelated Articles, – 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 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: Schiff WMChang SMandava NBarile GR Case Reports – PMID: [PubMed - indexed for MEDLINE

5 PARSA PLANA VITREOCTOMIA Ophthalmologe Aug;100(8): Epub 2003 Jun 18.Related Articles, LinksRelated Articles, – [Vitreous body floaters and vitrectomy with full visual acuity] [Article in German] Hoerauf H, Muller M, Laqua H. Klinik fur Augenheilkunde, Universitatsklinikum Lubeck. 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: [PubMed - indexed for MEDLINE] Hoerauf HMuller MLaqua H

6 PARSA PLANA VITREOCTOMIA J Fr Ophtalmol May;27(5):491-5.Related Articles, LinksRelated Articles, – [Vitrectomy for floaters] [Article in French] Quintyn JC, Brasseur G. Service d'Ophtalmologie, CHU de Rangueil, Toulouse. PURPOSE: To clarify vitrectomy indications in the treatment of vitreous floaters. METHODS: This is a retrospective study of four patients, four eyes (age, 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: [PubMed - indexed for MEDLINE] Quintyn JCBrasseur G

7 PARSA PLANA VITREOCTOMIA Klin Monatsbl Augenheilkd Sep;222(9): Related Articles, LinksRelated Articles, – [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 /- 0.2 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: [PubMed - in process] Roth MTrittibach PKoerner FSarra G

8 STRUMENTAZIONE 25 GAUGE VITREOCTOMIA SUTURELESS

9 OSPEDALE DI LINZ-AUSTRIA

10 VITREOCTOMIA SUTURELESS COMPLICAZIONI POST-OPERATORIE CATARATTA 1. <10% fino a 30 anni 2. 50% fino a 50 anni % oltre i 65 anni

11 PREVENZIONE CATARATTA J Cataract Refract Surg Apr;28(4): Related Articles, LinksRelated Articles, – Comment in: J Cataract Refract Surg Aug;29(8):1466-7; author reply – 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: [PubMed - indexed for MEDLINE] Mossa FDelaney YMRosen PHRahman R FLOATERROCTOMIA

12 PREVENZIONE CATARATTA Exp Eye Res Oct;75(4): Related Articles, LinksRelated Articles, – 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 (n=5) or 5.0 microM AL (n=9). Age matched, non-operated rabbits were used as controls (n=16). Lenses were analysed by correlative structural (light, scanning electron microscopic and three- dimensional 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, AL- 8417, 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 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: [PubMed - indexed for MEDLINE] Kuszak JRSivak JGMoran KLScheib SAGarner WHKe TLHellberg MRGraff G INIEZIONI INTRAVITREALI

13 VITREOCTOMIA SUTURELESS VITREO ARTIFICIALE

14 VITREOCTOMIA SUTURELESS VITREO ARTIFICIALE

15 VITREOCTOMIA SUTURELESS COMPLICAZIONI POST-OPERATORIE 1. distacco di retina (<0,5%) 2. infiammazioni oculari (<0,05%) 3. aumento della pressione oculare (30%)

16 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. vitrectomy surgery 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

17 FLOATERS ONLY VITRECTOMY CENTRI SPECIALIZZATI

18 VITREOLISI LASER ND YAG LASER

19 VITREOLISI LASER PROTEZIONI PER LA RETINA

20 VITREOLISI LASER FOTODISTRUZIONE

21 VITREOLISI LASER I RISULTATI

22 VITREOLISI LASER MIGLIORAMENTI 92% DEI CASI COMPLICAZIONI 0,29% DEI CASI (cataratta, glaucoma, distacco di retina) PRO E CONTRO

23 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

24 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.

25 IALURONIDASI Klin Oczna. 2002;104(2):135-7.Related Articles, LinksRelated Articles, – [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: Puchalska-Niedbal LMillo B Case Reports – PMID: [PubMed - indexed for MEDLINE]

26 IALURONIDASI Invest Ophthalmol Vis Sci Sep;40(10): Related Articles, LinksRelated Articles, – 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. 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: [PubMed - indexed for MEDLINE] Bishop PNMcLeod DReardon A

27 IALURONIDASI Retina. 1998;18(1):16-22.Related Articles, LinksRelated Articles, – Comment in: Retina. 1998;18(1):1-3. – 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: [PubMed - indexed for MEDLINE] Harooni MMcMillan TRefojo M SICUREZZA ED EFFICACIA DELLA IALURONIDASI

28 IALURONIDASI EMORAGGIE VITREALI RETINOPATIA DIABETICA

29 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 VITREOCTOMIA FARMACOLOGICA

30 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

31 VARIA Am J Ophthalmol Nov;42(5):771-2.Related Articles, LinksRelated Articles, – Use of iodo-niacin for retinal or vitreous hemorrhages and vitreous floaters. ABRAHAMSON IA Sr, ABRAHAMSON IA Jr. PMID: [PubMed - OLDMEDLINE for Pre1966] ABRAHAMSON IA SrABRAHAMSON IA Jr S Afr Med J Mar 15;32(11):296-8.Related Articles, LinksRelated Articles, A surgical procedure for the relief of vitreous opacities (floaters). BLUMENTHAL CJ. PMID: [PubMed - OLDMEDLINE for Pre1966] BLUMENTHAL CJ


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