Purpose:The purpose of this study was to evaluate the clinical outcome of patients with refractory neurotrophic keratopathy (NK) in stages 2 and 3 treated with topical insulin.Methods:Retrospective analysis of eyes with NK in stages 2 and 3 refractory to standard medical and/or surgical treatment which were treated with topical insulin (1 unit per mL). This treatment was applied 4 times per day and was continued until the persistent epithelial defect (PED) or ulcer resolved. The primary outcome of the study was the complete reepithelialization of the PED or persistent ulcer. “Best-corrected visual acuity” pretreatment and posttreatment, “days until complete reepithelialization” data, and anterior segment photographs were obtained. Outcome measures were compared before and after treatment in both groups using paired and independent samples t tests.Results:Twenty-one eyes were included in this study, and 90% achieved complete reepithelialization of the PED and/or persistent ulcer within 7 to 45 days of follow-up. The mean number of days until complete reepithelialization was significantly lower in NK stage 2 (18 ± 9 days) when compared with NK stage 3 (29 ± 11 days) (P = 0.025). The best-corrected visual acuity improved significantly in both NK stage 2 (P < 0.001) and NK stage 3 (P = 0.004). No side effects were reported during the follow-up.Conclusions:Our results suggest that topical insulin drops may be an effective therapeutic in refractory NK. This therapy may prove extremely useful because of its low cost and high accessibility.
PurposeCompressive optic neuropathy (CON) can sometimes mimic glaucomatous optic neuropathy (GON), leading to inadequate management. Our purpose was to compare the macular area of patients with CON and GON to healthy controls (HC) and to determine if the macula area was able to distinguish between CON and GON.MethodsRetrospective, observational, cross‐sectional study, enrolling 70 patients (22 patients with CON, 25 with GON and 23 HC). Subjects were matched by age (median of 61 [±11.6]), and one eye was randomly selected. Spectral‐domain optical coherence tomography (SD‐OCT) images were generated using the Spectralis® OCT device (Heidelberg, Germany). An automated algorithm was used to segment the macular retina into nine layers and evaluate the thickness of each layer in the foveal, inner, and outer Early Treatment Diabetic Retinopathy Study (ETDRS) subfield rings. Data were compared across all study groups using Kruskal‐Wallis test, followed by pairwise comparisons for each duo. The resulting p‐values were adjusted using the Bonferroni correction and significance level was set at 0.05.ResultsHC had thicker inner retinal layer (IRL) compared with GON and CON (p < 0.05). Global retinal thickness was significantly thinner in the inner superior (IS) and inner nasal (IN) subfields in CON compared with GON (p < 0.05). The IRL is thinner in CON, specifically in the inner and outer nasal subfields, compared to GON. The IN subfield was thinner in the retinal nerve fibre, ganglion cell and inner plexiform layers (IPL) in CON compared with GON (p < 0.05). No differences were found on the inner nuclear, outer plexiform, outer nuclear and outer retinal layers between groups.ConclusionsOur findings suggest that IRL is thinner in both CON and GON, and the IN subfield is specially affected in CON compared with GON. Despite not being our primary outcome, our results suggest that, compared to HC, layer neurodegeneration in both CON and GON affects mainly the inner layers and that does not extend to layers external to IPL. In conclusion, evaluation of the macular segmented layers damage, by SD‐OCT, may be a useful add‐on tool in the differential diagnosis between these two entities, when their manifestations overlap.
PurposeTo evaluate the clinical progression of patients with refractory Neurotrophic Keratopathy (NK) treated with topical insulin eye drops and its efficacy in treating NK in stages 2 and 3.MethodsQuasi‐Experimental, randomized study, from October 2018 to December 2019, of 10 patients (11 eyes—13 to 92 years) with NK in stages 2 and 3. Patients included were refractory to standard medical and/or surgical treatment. Drops were applied 3‐4 times a day and a bandage contact lens was applied. Close follow‐up of patients was assured (daily in week one and weekly thereafter) and anterior segment photos were taken on each visit. Insulin eye drops were continued until the NK persistent epithelial defect or ulcer resolved. Treatment would be discontinued if the condition did not improve or worsened.ResultsTen out of eleven eyes had complete resolution of the NK persistent epithelial defect and/or ulcer within 12‐45 days of follow‐up. One of the patients’ epithelial defect improved significantly although the wound did not fully heal within 42 days of treatment. No side‐effects were reported during the full extent of the treatment.ConclusionsAlthough we recognize some limitations to our study (uncontrolled series of patients), our results suggest that topical insulin drops could be an effective treatment in refractory NK. Furthermore, this therapy may prove extremely useful due to its low cost and high accessibility. However, more studies are needed to evaluate the efficacy, posology, duration and side‐effects of this treatment.
Purpose: To evaluate the results of a new virtual screening service for hydroxychloroquine (HQC) and chloroquine (CQ) retinopathy. Methods: Prospective study including patients under long‐term HCQ or CQ therapy referred for screening at a single ophthalmic centre in Portugal over a one‐year period. The virtual clinic consisted of a visit for functional and structural testing, in accordance with the guidelines on HCQ retinopathy screening1,2, followed by a later review by an experienced consultant. Individualized counselling for both patients and prescribing physicians was provided on retinal toxicity risk, safe dosing, and adequate screening intervals. Results: A total of 93 patients under treatment with HCQ attended the virtual clinic. Systemic lupus erythematosus (38.7%) and rheumatoid arthritis (18.3%) were the most prevalent diagnoses. Mean daily HCQ dosing was 5.2 ± 1.6 mg/Kg, with 46.2% patients using a daily dose greater than 5 mg/Kg. Median treatment duration was 48 months (range: 1–264) and 49.5% patients had been treated for longer than 5 years. Renal disease was present in 11 patients (11.8%) and 7 (7.5%) had pre‐existing retinal conditions. Structural changes in macular optical coherence tomography and fundus autofluorescence were rarely detected (3.3%). In contrast, 16 patients (17.2%) presented with abnormal 10‐2 visual field testing. Multifocal electroretinogram was performed in 14 patients (15.1%), detecting characteristic abnormalities of drug toxicity in one patient, with a definite diagnosis of severe HCQ retinopathy. Recommendation for dose adjustment was given in 47.3% of cases, including advice to discontinue HCQ use in 7 (7.5%) patients based on risk factors. Conclusions: Retinal toxicity is a rare adverse effect of HCQ, a therapy increasingly used in the management of autoimmune disorders. Virtual clinics could be a safe and sustainable care delivery system for adequate counselling, risk assessment and early retinopathy detection. References. 1. Marmor MF, et al. Recommendations on screening for chloroquine and hydroxychloroquine retinopathy (2016 revision). Ophthalmology 2016; 123:1386–1394. 2. Royal College of Ophthalmologists. Hydroxychloroquine and chloroquine retinopathy: recommendations on monitoring. London: Royal College of Ophthalmologists, 2020.
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