Florid diabetic retinopathy and its systemic implications.
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Biomedical subjects
Publications and source records attributed to F Bandello.
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To assess whether axial length and refraction are risk factors for retinal vein occlusion, we measured these parameters in 88 consecutive patients with unilateral branch retinal vein occlusion (BRVO), in 58 consecutive patients with unilateral central retinal vein occlusion (CRVO) and in 50 patients selected as a control group. Patients and controls were free or affected by systemic or local predisposing factors. We compared eyes with CRVO with control eyes, eyes with BRVO with control eyes, and eyes with CRVO with eyes with BRVO. Comparing CRVO eyes and controls, none of the investigated variables was shown to be significant. From the analysis of BRVO eyes versus controls, it resulted that refraction was the only variable which played the role of an independent prognostic factor. When comparing BRVO eyes with CRVO eyes, we found that age was slightly related to the development of BRVO. In conclusion, faulty refraction appeared to be a risk factor for the development of BRVO. We did not find any influence of axial length on the occlusion of retinal veins.
The authors report a case of congenital bilateral corneal opacities in which one of the eyes was enucleated because of malignant glaucoma and corneal perforation. Corneal defects and iridocorneal adhesion were found, but aphakia was the major pathologic ocular finding. The clinical picture and pathology study indicated this case as a Peters' anomaly presenting congenital aphakia.
BACKGROUND AND OBJECTIVE: A randomized clinical trial using the argon-green (514 nm) and the double-frequency Nd:YAG (532 nm) lasers was carried out on 42 eyes with proliferative diabetic retinopathy (PDR), with the aim of assessing the long-term effects of double-frequency Nd:YAG panretinal photocoagulation (PRP). MATERIALS AND METHODS: Twenty-one eyes were randomized to argon laser treatment (ALT) and 21 to double-frequency Nd:YAG laser treatment (NdLT). The mean follow-up was 28.90 months (+/- 6.13) in the ALT group and 29.57 months (+/- 5.17) in the NdLT group. RESULTS: In the ALT group, 20 eyes (95.2%) showed regression of PDR and one eye (4.8%) enlargement of pre-existing new vessels. In the NdLT group, neovascularization regressed in 20 eyes (95.2%) and increased in one (4.8%). CONCLUSIONS: The long-term efficacy of double-frequency Nd: YAG laser PRP in the treatment of PDR thus appears to be similar to that of argon-green.
BACKGROUND: Sodium fluorescein staining of the vitreous following fluorescein angiography may interact with laser photocoagulation. METHODS: We evaluated the laser absorption by fluorescein in the vitreous when photocoagulation is performed following fluorescein angiography in 15 eyes of nine diabetic patients. Axial fluorescein concentration in the vitreous was measured by a scanning vitreal fluorophotometer. The amount of light absorbed by the fluorescein within the vitreous was calculated according to the Lambert-Beer law. RESULTS: The mean fluorescein concentration ranged from 2.93 ng cm-3 to 105.16 ng cm-3 at 1 h after injection of fluorescein and from 8.03 to 188.56 ng cm-3 after 4 h. Maximum laser absorption at 488 nm ranged from 6.79% (after 1 h) to 14.53% (after 4 h); at 514.5 nm it ranged from 0.96% to 2.14%; at 532 nm it ranged from 0.03% to 0.07%. At lambda > 550 nm, laser absorption was found to be negligible. CONCLUSIONS: In order to optimize the effect of photocoagulation, especially during long photocoagulation sessions, argon blue laser (488 nm) should be avoided following fluorescein angiography. Argon green laser (514.5 nm) should be used within 1 h after fluorescein injection. Frequency-doubled Nd:YAG laser (532 nm), krypton laser (647 nm) or semiconductor diode laser (810 nm) may be used at any time.
PURPOSE: To report three cases of spontaneous regression of new vessels of the disk and elsewhere in proliferative diabetic retinopathy. METHODS: We retrospectively examined the clinical records of three young women (27, 26, and 19 years old) with insulin-dependent diabetes mellitus (for 16, eight, and 17 years, respectively) associated with other systemic diseases and referred to us for treatment of retinopathy. Complete general and ophthalmologic findings, visual field, and angiographic and electroretinographic examinations were available for each patient. RESULTS: All the patients showed marked, spontaneous improvement of their proliferative retinopathy, with regression of new vessels. Assessment of metabolic control did not bring to light any noteworthy change during the period when the new vessels disappeared. Regression of new vessels was associated with a marked improvement in blood-retinal barrier breakdown as detected on fluorescein angiograms. CONCLUSIONS: Although very unusual, spontaneous regression of neovascularizations in proliferative diabetic retinopathy can happen. We can offer no explanation for the regression of the new vessels and retinovascular hyperpermeability.
We describe a case of central retinal vein and branch artery occlusion associated with inherited type I plasminogen deficiency (68%) and permanent elevation of Lp(a) (460 mg/l, S2 phenotype) in a 45 year old white woman with no associated local or systemic risk factors. Pedigree analysis revealed inheritance of plasminogen deficiency from the deceased father and of high Lp(a) levels from the mother. Both the patient's sons had plasminogen deficiency, but they had normal Lp(a) levels. In a series of 40 consecutive patients with central retinal vein occlusion we previously reported the observation of high Lp(a) levels--consistently associated with the S2 phenotype--in 30% of the patients as compared to a 10% incidence in controls. This case emphasizes the importance of screening patients with occlusion of the retinal vessels and no associated risk factors for coagulation abnormalities predisposing to thrombosis.
The complexity of the pathogenesis of diabetic retinopathy (DR) makes it difficult to produce effective drugs for its treatment. Among the active principles recently suggested, the peptide fraction of bovine factor VIII of the clotting cascade deserves particular attention. Bovine factor VIII derivatives (vascular factor, VF) have been shown to have significant effects on the capillary basement membrane and on vascular endothelium and they are able to stabilise vessel walls. The aim of this study was to assess the effectiveness of VF in diabetic patients with non-proliferative DR. Nineteen consecutive patients (37 eyes) affected by non-proliferative DR were included in the study and randomly assigned to VF or placebo. An ophthalmological examination, colour photographies and a retinal fluorescein angiography were carried out before as well as 3 and 6 months after inclusion. Every eye in the study was classified in accordance with the ETDRS criteria. While the progress of macular oedema and visual acuity was very similar in the two groups (VF and placebo), there was no deterioration, i.e., no change to a worse classification than that at the start, in any of the eyes in the group treated with VF, but deterioration was seen in 19% of the eyes treated with the placebo. On the basis of these results, VF may ensure some protection of the blood-retinal barrier against the harmful influence of diabetic microangiopathy.
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The classification of pigmented iris tumors is a difficult clinical problem. Based on the retrospective observation of colour photographs and iris angiograms of 44 pigmented iris tumors observed over 19 years, the authors present an original grading scheme with scores depending on both the biomicroscopical and the fluoroiridographic patterns of the tumors. The biomicroscopical parameters considered were: thickening of the iris in the area of tumor, pupillary distortion and/or ectropion uveae and uneven pigment density. The fluoroiridographic parameters were: early visibility of the anomalous tumoral network, hyperfluorescence inside or around the tumor, and dye leakage at sites remote from the mass. Based on the score of each tumor, the 44 cases were divided into 3 groups with the different degrees of malignancy confirmed by either histological examination or by follow-up behaviour. The authors suggest that routine use of biomicroscopic-fluoroiridographic classification of pigmented iris tumors would be useful.
Single-sweep visual evoked potential analysis would be useful in clinical electrophysiology practice because it would make possible the evaluation of transient phenomena, but recording single-sweep visual evoked potentials is difficult because of the low signal-noise ratio. To increase this ratio we used a filter based on an autoregressive with exogenous input model. We studied a group of 12 diabetic patients matched with a control group of 14 normal subjects. The model, in most cases, allowed us to extrapolate the P100 component from each single sweep of visual evoked potential. The visual evoked potential values obtained by means of averaging were not significantly different in the groups studied, but single-sweep analysis showed different distribution of the P100 component amplitude. The preliminary results of our study evidenced differences in the amplitude and latency distribution of normal and diabetic subjects, thus confirming the power of this new technique and its ability to obtain some information that is masked by the averaging method.
In order to assess the relation between diabetic iridopathy (DI) and retinopathy (DR), 225 eyes of 117 diabetics with clear media were evaluated. Each patient underwent iris and retinal fluorescein angiography, which was used to classify DI and DR. DI was classified as: absence of DI; non-proliferative DI; proliferative DI; neovascular glaucoma. DR was classified as: absence of DR; background DR; pre-proliferative DR; proliferative DR. The sensitivity of iris fluorescein angiography in assessing DR was 44.5%, the specificity 88%, the positive predictive value 92.8%, and the negative value 31.2%. In pre-proliferative and proliferative DR, fluoroiridographic detection of iris neovessels gave a sensitivity of 56% and a specificity of 100%. The positive predictive value was 100% and the negative value 65%. In conclusion, iris fluorescein angiography yields valuable information on DR and is a helpful basis for avoiding complications when scheduling eyes with dioptric media opacities for surgery.
A series of coagulation parameters and lipoprotein(a) (Lp(a)) were explored in plasma from 40 patients with central retinal vein occlusion (CRVO, non-ischemic type n = 12; ischemic type n = 28) free of local and systemic predisposing factors, 1 to 12 months after the acute event. Forty age- and sex-matched patients with cataract served as controls. Prothrombin fragment 1.2 (F1.2), D-dimer, FVII:C--but not FVII:Ag--were higher and fibrinogen was lower in CRVO patients than in controls. Patients with non-ischemic CRVO had higher F1.2 and FVII:C and lower heparin cofactor II than patients with ischemic CRVO. Lp(a) levels greater than 300 mg/l were observed in 12 patients with CRVO and in 4 controls (30% vs 10%, p < 0.025). Patients with high Lp(a)--consistently associated with the S2 phenotype--had higher FVII:C, FVII:C/Ag ratio, and fibrinogen than the remaining CRVO patients. Plasma F1.2 and D-dimer correlated fairly in controls (r = 0.41) and patients with normal Lp(a) levels (r = 0.55), but they did not in the group of patients with high Lp(a) (r = 0.19), where the latter parameter was negatively related to D-dimer (r = -0.55). There was no dependence of the abnormalities observed on the time elapsed from vein occlusion. The findings of activated FVII and high F1.2, D-dimer, and Lp(a) are not uncommon in patients with CRVO. Increased thrombin formation with fibrin deposition and impaired fibrinolysis may play a role in the pathophysiology of CRVO and require specific treatment.
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A clinical randomized study using argon-green (532 nm) and diode (810 nm) lasers was carried out on 44 eyes (34 patients) affected by proliferative diabetic retinopathy (PDR), with the aim of evaluating the long-term effects of diode panretinal photocoagulation. Of the total 44 eyes, 22 were randomized to argon laser treatment (ALT) and 22 to diode laser treatment (DLT). The mean follow-up time was 25 +/- 5 months in the ALT group versus 24 +/- 4 months in the DLT group. In the ALT group 20 eyes (91%) showed regression of PDR whereas 2 eyes (9%) deteriorated. In the DLT group regression of neovascularization was observed in 22 eyes (100%). These results show that the long-term efficacy of diode laser PRP in the treatment of PDR is similar to that of argon-green laser PRP.
Iris fluorescein angiography is not commonly employed in clinical practice, but it is the most sensitive technique for the evaluation of iris vessel abnormalities. We used iris fluorescein angiography as the gold standard against which to test the ability of iris biomicroscopy to demonstrate diabetic iridopathy (DI). One hundred and fourteen eyes of 63 diabetic patients affected by preproliferative or proliferative diabetic retinopathy (DR) (the DR groups at high risk of developing DI) were considered. The DI fluorangiographic classification used was: (1) absence of DI; (2) nonproliferative DI; (3) proliferative DI. The sensitivity of biomicroscopy in detecting DI turned out to be 57%, while the specificity was 94%. The positive predictive value was 93% and the negative predictive value 50%. Our study proved that biomicroscopy can accurately judge when DI is absent. When it is present, however, there is a high probability that biomicroscopy will be less precise in the detection of iris lesions.
Seventy-eight patients from 26 families were examined to evaluate the potentiality of congenital hypertrophy of retinal pigment epithelium (CHRPE) as a phenotypic marker for familial adenomatous polyposis (FAP). The examined subjects were divided into three different groups: Group I, patients with FAP without extra colonic manifestations (ECM); Group II, patients with FAP and ECM (desmoids/osteomas/upper gastrointestinal adenomas); and Group III, individuals at risk without FAP. Of 24 Group I patients (median age 18 years) 16 had CHRPE compared with 14 out of 24 patients (median age 29 years) in Group II and only three out of 30 patients in Group III. The overall sensitivity of CHRPE for FAP was 70% (+/- 13%) without any difference related to ECM; the predictive value was 92%. The specificity calculated from Group III (median age 26 years) was 90%, but the results should not be considered as definitive because a longer follow-up to determine the appearance of adenomas is required. The data suggest that examination for CHRPE is an inexpensive, non-invasive test for FAP, but the absence of retinal lesions does not eliminate the necessity for adequate follow-up of individuals at risk.