Therapies for macular edema associated with central retinal vein occlusion: a report by the American Academy of Ophthalmology

Hybrid Biomembrane-Functionalized Nanorobots Penetrate the Vitreous Body of the Eye for the Treatment of Retinal Vein Occlusion

Intravitreal injections of antivascular endothelial growth factor (VEGF) agents are the primary method for treating retinal vein occlusion (RVO). However, the complex structure of eye anatomy presents ocular barriers that impede drug delivery. Additionally, these drugs only manage the complications associated with RVO and fail to address the underlying cause of vessel occlusions. Here, we describe a method that utilizes functionalized magnetically driven nanorobots to overcome ocular barriers and treat RVO. These nanorobots are developed using a hybrid biomembrane that combines stem cell membranes with liposome-derived membranes, enveloping perfluorohexane, iron oxide nanoparticles, and l-arginine. After intravitreal injection, the nanorobots can move directionally through and penetrate the vitreous body to reach the retina, driven by an external magnetic field. Subsequently, the nanorobots actively target the inflammation sites at occluded vessels due to the presence of stem cell membranes. In a rat model of RVO, enhanced targeting and accumulation in ischemic retinal vessels were demonstrated following intravitreal injections. Furthermore, the application of ultrasound triggers the release of l-arginine at the site of occlusion, stimulating the production of nitric oxide, which promotes vasodilation and restores blood flow, thereby achieving excellent therapeutic efficacy for RVO. We believe these methods hold significant promise for overcoming challenges in ocular drug delivery and effectively treating RVO in clinical applications.

Endothelial protein C receptor promotes retinal neovascularization through heme catabolism

Pathological retinal neovascularization (RNV) is one of the leading causes of blindness worldwide; however, its underlying mechanism remains unclear. Here, we found that the expression of endothelial protein C receptor (Epcr) was increased during RNV, and its ligand was elevated in the serum or vitreous body of patients with proliferative diabetic retinopathy. Deleting endothelial Epcr or using an EPCR-neutralizing antibody ameliorated pathological retinal angiogenesis. EPCR promoted endothelial heme catabolism and carbon monoxide release through heme oxygenase 1 (HO-1). Inhibition of heme catabolism by deleting endothelial Ho-1 or using an HO-1 inhibitor suppressed pathological angiogenesis in retinopathy. Conversely, supplementation with carbon monoxide rescued the angiogenic defects after endothelial Epcr or Ho-1 deletion. Our results identified EPCR-dependent endothelial heme catabolism as an important contributor to pathological angiogenesis, which may serve as a potential target for treating vasoproliferative retinopathy.

Generating Synthesized Fluorescein Angiography Images From Color Fundus Images by Generative Adversarial Networks for Macular Edema Assessment

Purpose

To assess the feasibility of generating synthetic fluorescein angiography (FA) images from color fundus (CF) images using pixel-to-pixel generative adversarial network (pix2pixGANs) for clinical applications. Research questions addressed image realism to retinal specialists and utility for assessing macular edema (ME) in Retinal Vein Occlusion (RVO) eyes.

Methods

We used a registration-guided pix2pixGANs method trained on the CF-FA dataset from Kham Eye Centre, Kandze Prefecture People's Hospital. A visual Turing test confirmed the realism of synthetic images without novel artifacts. We then assessed the synthetic FA images for assessing ME. Finally, we quantitatively evaluated the synthetic images using Fréchet Inception distance (FID) and structural similarity measures (SSIM).

Results

The raw development dataset had 881 image pairs from 349 subjects. Our approach is capable of generating realistic FA images because small vessels are clearly visible and sharp within one optic disc diameter around the macula. Two retinal specialists agreed that more than 85% of synthetic FA images have good or excellent image quality. For ME detection, accuracy was similar for real and synthetic images. FID demonstrated a 38.9% improvement over the previous state-of-the-art (SOTA), and SSIM reached 0.78 compared to the previous SOTA's 0.67.

Conclusions

We developed a pix2pixGANs model translating FA images from label-free CF images, yielding reliable synthetic FA images. This suggests potential for noninvasive evaluation of ME in RVO eyes using pix2pix GANs techniques.

Translational Relevance

Pix2pixGANs techniques have the potential to assist in the noninvasive clinical assessment of ME in RVO eyes.

Retinal Vein Occlusion-Background Knowledge and Foreground Knowledge Prospects-A Review

Thrombosis of retinal veins is one of the most common retinal vascular diseases that may lead to vascular blindness. The latest epidemiological data leave no illusions that the burden on the healthcare system, as impacted by patients with this diagnosis, will increase worldwide. This obliges scientists to search for new therapeutic and diagnostic options. In the 21st century, there has been tremendous progress in retinal imaging techniques, which has facilitated a better understanding of the mechanisms related to the development of retinal vein occlusion (RVO) and its complications, and consequently has enabled the introduction of new treatment methods. Moreover, artificial intelligence (AI) is likely to assist in selecting the best treatment option for patients in the near future. The aim of this comprehensive review is to re-evaluate the old but still relevant data on the RVO and confront them with new studies. The paper will provide a detailed overview of diagnosis, current treatment, prevention, and future therapeutic possibilities regarding RVO, as well as clarifying the mechanism of macular edema in this disease entity.

Widefield, Swept-Source Optical Coherence Tomography Angiography Metrics as Predictors of Anti-VEGF Treatment in Retinal Vein Occlusions

BACKGROUND AND OBJECTIVE

Our objective was to assess baseline widefield swept-source optical coherence tomography angiography (WF SSOCTA) microvascular metrics as predictors for the number of anti-vascular endothelial growth factor (VEGF) injections and visual acuity (VA) at 12-months follow-up in patients with retinal vein occlusion (RVO).

PATIENTS AND METHODS

This was a prospective study including 49 RVO eyes from 49 patients who had not received an anti-VEGF injection for at least 3 months prior to imaging. Microvascular metrics from 6×6-mm and 12×12-mm angiograms were assessed using linear regression models, adjusting for age.

RESULTS

Reductions in the vessel density (VD) and vessel skeletonized density (VSD) vascular metrics were associated both with a higher number of anti-VEGF injections at all follow-up time points and reduced VA 12 months after imaging in all RVO eyes.

CONCLUSIONS

WF SS-OCTA VD and VSD micro-vascular metrics at baseline can prognosticate VA and number of anti-VEGF injections required at 3, 6, and 12 months in RVO eyes. [Ophthalmic Surg Lasers Imaging Retina 2024;55:374-382.].

Anatomical and Functional Results of Early or Late Switching from Anti-VEGF to Dexamethasone Implant in Case of Poor Anatomical Response in Naïve Patients with Macular Edema Secondary to Branch Retinal Vein Occlusion

PURPOSE

To compare the outcomes of early or late switching from intravitreal (IV) anti-vascular endothelial growth factor (anti-VEGF) injection to IV Dexamethasone (DEX) implant injection in treatment-naïve patients with macular edema secondary to branch retinal vein occlusion.

METHODS

This study included 68 eyes of 68 treatment-naïve BRVO patients who started anti-VEGF treatment. After the loading dose, the patients were divided into two groups: Early DEX group (n:34) (DEX implant treatment started after 3 loading doses) and Late DEX group (n:34) (DEX implant treatment started after 6 months). Visual acuity and examination findings were recorded at baseline, 3rd, 6th, and 12th month follow-ups. Optical coherence tomography data were recorded for central macular subfield thickness assessment.

RESULTS

A total of 30 (44.1%) women and 38 (55.9%) men participated, and the average age was 67.6 ± 6.4 years. The mean letter gains at week 52 was 15.1 and 20.9 in the Early DEX and Late DEX groups, respectively. The group with the highest gain of ≥15 letters was the Late DEX group (26/34 patients) and the gain of ≥15 letters was 14/34 in the Early DEX group (p: 0.006). At week 52, the anatomical gain was 115.3 µm and 136.9 µm in the Early DEX and Late DEX groups, respectively.

CONCLUSIONS

A gain of 15 or more letters was demonstrated to be higher in patients who switched to DEX implant late after anti-VEGF treatment. If it is necessary to switch, the late switch may be more effective for more visual gain at the end of the first year.

VITRECTOMY FOR VITREOUS HEMORRHAGE ASSOCIATED WITH RETINAL VEIN OCCLUSION: Visual Outcomes, Prognostic Factors, and Sequelae

PURPOSE

To report the outcomes of pars plana vitrectomy for vitreous hemorrhage (VH) associated with retinal vein occlusion and to identify prognostic indicators.

METHODS

Interventional, retrospective consecutive case series between 2015 and 2021.

RESULTS

The study included 138 eyes of 138 patients (64 female and 74 male); 81 patients had branch retinal vein occlusion and 57 had central retinal vein occlusion. The mean age was 69.8 years. The mean duration between the diagnosis of VH and surgery was 79.6 ± 115.3 (range, 1-572) days. The mean follow-up was 27.2 months. The logarithm of the minimum angle of resolution visual acuity significantly improved from 1.95 ± 0.72 (Snellen equivalent, 20/1782) to 0.99 ± 0.87 (20/195) at 6 months and to 1.06 ± 0.96 (20/230) at the final visit (both P < 0.001). The visual acuity at 6 months improved by three or more lines in 103 eyes (75%). Postoperative complications during follow-up included recurrent VH in 16 eyes (12%) (of which 8 eyes underwent reoperations), rhegmatogenous retinal detachment in six eyes (4%), and new neovascular glaucoma in three eyes (2%). Worse final visual acuity was significantly associated with older age ( P = 0.007), concurrent neovascular glaucoma ( P < 0.001), central retinal vein occlusion ( P < 0.001), worse preoperative visual acuity ( P < 0.001), postoperative new neovascular glaucoma ( P = 0.021), and postoperative retinal detachment ( P < 0.001). The duration of VH was not associated with visual outcomes ( P = 0.684). Preoperative antivascular endothelial growth factor injections and tamponade did not prevent postoperative recurrent VH.

CONCLUSION

Pars plana vitrectomy is effective for VH associated with retinal vein occlusion, regardless of the duration of hemorrhage. However, pre-existing risk factors and postoperative sequelae may limit visual recovery.

Ocular Pharmacokinetic Properties of Intravitreally Injected Aflibercept in Rabbits After Using Brinzolamide/Timolol Eye Drops

Purpose: To investigate the ocular pharmacokinetic properties of intravitreally injected aflibercept in rabbits after using brinzolamide 1%/timolol maleate 0.5% fixed-combination eye drops. Methods: The right eye of 5 rabbits was topically administered 30 μL of brinzolamide and timolol maleate eye drops twice a day (q12h). The 2 eyes of each rabbit were injected with 1.0 mg (0.025 cc) of aflibercept on the 2nd day after instilling the eye drops. The intraocular pressure of the rabbits was measured before injection and sampling. The aqueous humor was drawn at 1, 3, 7, 14, 21, and 28 days. Aflibercept concentrations in aqueous humor and vitreous humor (28 days) were measured by enzyme-linked immunosorbent assay. Results: The aflibercept aqueous concentrations in the right eye at days 7, 14, 21, and 28 after injection were all significantly higher than those in the left eye (P > 0.05, n = 5). The peak aqueous concentrations of aflibercept in right eyes (49.5 μg/mL) and left eyes (50.9 μg/mL) were both observed at 1 day after injection. The elimination half-life of aflibercept in the aqueous humor of the right eye (4.70 days) was 1 day longer than that of the left eye (3.65 days). The average percentage of residual aflibercept in the vitreous humor of the right eye (3.35%) was also significantly higher than that of the left eye (0.63%). Conclusions: Brinzolamide 1%/timolol maleate 0.5% fixed-combination eye drops can significantly extend the ocular residence time of intravitreally injected aflibercept.

Mechanisms of macular edema

Macular edema is the pathological accumulation of fluid in the central retina. It is a complication of many retinal diseases, including diabetic retinopathy, retinal vascular occlusions and uveitis, among others. Macular edema causes decreased visual acuity and, when chronic or refractory, can cause severe and permanent visual impairment and blindness. In most instances, it develops due to dysregulation of the blood-retinal barrier which permits infiltration of the retinal tissue by proteins and other solutes that are normally retained in the blood. The increase in osmotic pressure in the tissue drives fluid accumulation. Current treatments include vascular endothelial growth factor blockers, corticosteroids, and non-steroidal anti-inflammatory drugs. These treatments target vasoactive and inflammatory mediators that cause disruption to the blood-retinal barrier. In this review, a clinical overview of macular edema is provided, mechanisms of disease are discussed, highlighting processes targeted by current treatments, and areas of opportunity for future research are identified.

Anti-Vascular Endothelial Growth Factor Treatment Patterns and Outcomes in Retinal Vein Occlusion in Routine Clinical Practice

BACKGROUND AND OBJECTIVE

To characterize treatment patterns for retinal vein occlusion (RVO)-related macular edema (ME) in routine clinical practice and its impact on long-term best-corrected visual acuity (BCVA) and central subfield thickness (CST).

PATIENTS AND METHODS

Retrospective study of 365 eyes with branch RVO (BRVO) or central/hemi-RVO (CRVO/HRVO)-related ME between 2003 and 2020. Regression analysis identified factors associated with maintenance injection interval (MII). Subgroup analysis compared outcomes between different MIIs.

RESULTS

51.3% of BRVO patients received injections ≤q8 weeks, 26.4% received injections q8-12 weeks, and 22.3% received injections >q12 weeks. 45.2% of CRVO/HRVO patients received injections ≤q8 weeks, 32.1% received injections q8-12 weeks, and 22.6% received injections >q12 weeks. Age, diabetes, and baseline CST were found to predict MII. There was no significant difference in BCVA and CST at baseline, 12, or 24 months in all MII groups in BRVO and CRVO/HRVO.

CONCLUSION

There exists a significant heterogeneity in anti-VEGF treatment frequency for RVO-associated ME in routine clinical practice. [Ophthalmic Surg Lasers Imaging Retina 2022;53:626-633.].

Real-world treatment intensities and pathways of macular edema following retinal vein occlusion in Korea from Common Data Model in ophthalmology

Despite many studies, optimal treatment sequences or intervals are still questionable in retinal vein occlusion (RVO) macular edema. The aim of this study was to examine the real-world treatment patterns of RVO macular edema. A retrospective analysis of the Observational Medical Outcomes Partnership Common Data Model, a distributed research network, of four large tertiary referral centers (n = 9,202,032) identified 3286 eligible. We visualized treatment pathways (prescription volume and treatment sequence) with sunburst and Sankey diagrams. We calculated the average number of intravitreal injections per patient in the first and second years to evaluate the treatment intensities. Bevacizumab was the most popular first-line drug (80.9%), followed by triamcinolone (15.1%) and dexamethasone (2.28%). Triamcinolone was the most popular drug (8.88%), followed by dexamethasone (6.08%) in patients who began treatment with anti-vascular endothelial growth factor (VEGF) agents. The average number of all intravitreal injections per person decreased in the second year compared with the first year. The average number of injections per person in the first year increased throughout the study. Bevacizumab was the most popular first-line drug and steroids were considered the most common as second-line drugs in patients first treated with anti-VEGF agents. Intensive treatment patterns may cause an increase in intravitreal injections.

Future Perspectives of Therapeutic, Diagnostic and Prognostic Aptamers in Eye Pathological Angiogenesis

Aptamers are single-stranded DNA or RNA oligonucleotides that are currently used in clinical trials due to their selectivity and specificity to bind small molecules such as proteins, peptides, viral particles, vitamins, metal ions and even whole cells. Aptamers are highly specific to their targets, they are smaller than antibodies and fragment antibodies, they can be easily conjugated to multiple surfaces and ions and controllable post-production modifications can be performed. Aptamers have been therapeutically used for age-related macular degeneration, cancer, thrombosis and inflammatory diseases. The aim of this review is to highlight the therapeutic, diagnostic and prognostic possibilities associated with aptamers, focusing on eye pathological angiogenesis.

Intravitreal ranibizumab versus aflibercept versus bevacizumab for macular oedema due to central retinal vein occlusion: the LEAVO non-inferiority three-arm RCT

BACKGROUND

Licensed ranibizumab (0.5 mg/0.05 ml Lucentis®; Novartis International AG, Basel, Switzerland) and aflibercept (2 mg/0.05 ml Eylea®; Bayer AG, Leverkusen, Germany) and unlicensed bevacizumab (1.25 mg/0.05 ml Avastin®; F. Hoffmann-La Roche AG, Basel, Switzerland) are used to treat macula oedema due to central retinal vein occlusion, but their relative clinical effectiveness, cost-effectiveness and impact on the UK NHS and Personal Social Services have never been directly compared over the typical disease treatment period.

OBJECTIVE

The objective was to compare the clinical effectiveness and cost-effectiveness of three intravitreal antivascular endothelial growth factor agents for the management of macula oedema due to central retinal vein occlusion.

DESIGN

This was a three-arm, double-masked, randomised controlled non-inferiority trial.

SETTING

The trial was set in 44 UK NHS ophthalmology departments, between 2014 and 2018.

PARTICIPANTS

A total of 463 patients with visual impairment due to macula oedema secondary to central retinal vein occlusion were included in the trial.

INTERVENTIONS

The participants were treated with repeated intravitreal injections of ranibizumab (n = 155), aflibercept (n = 154) or bevacizumab (n = 154).

MAIN OUTCOME MEASURES

The primary outcome was an increase in the best corrected visual acuity letter score from baseline to 100 weeks in the trial eye. The null hypothesis that aflibercept and bevacizumab are each inferior to ranibizumab was tested with a non-inferiority margin of -5 visual acuity letters over 100 weeks. Secondary outcomes included additional visual acuity, and imaging outcomes, Visual Function Questionnaire-25, EuroQol-5 Dimensions with and without a vision bolt-on, and drug side effects. Cost-effectiveness was estimated using treatment costs and Visual Function Questionnaire-Utility Index to measure quality-adjusted life-years.

RESULTS

The adjusted mean changes at 100 weeks in the best corrected visual acuity letter scores were as follows - ranibizumab, 12.5 letters (standard deviation 21.1 letters); aflibercept, 15.1 letters (standard deviation 18.7 letters); and bevacizumab, 9.8 letters (standard deviation 21.4 letters). Aflibercept was non-inferior to ranibizumab in the intention-to-treat population (adjusted mean best corrected visual acuity difference 2.23 letters, 95% confidence interval -2.17 to 6.63 letters; p = 0.0006), but not superior. The study was unable to demonstrate that bevacizumab was non-inferior to ranibizumab in the intention-to-treat population (adjusted mean best corrected visual acuity difference -1.73 letters, 95% confidence interval -6.12 to 2.67 letters; p = 0.071). A post hoc analysis was unable to demonstrate that bevacizumab was non-inferior to aflibercept in the intention-to-treat population (adjusted mean best corrected visual acuity difference was -3.96 letters, 95% confidence interval -8.34 to 0.42 letters; p = 0.32). All per-protocol population results were the same. Fewer injections were required with aflibercept (10.0) than with ranibizumab (11.8) (difference in means -1.8, 95% confidence interval -2.9 to -0.8). A post hoc analysis showed that more bevacizumab than aflibercept injections were required (difference in means 1.6, 95% confidence interval 0.5 to 2.7). There were no new safety concerns. The model- and trial-based cost-effectiveness analyses estimated that bevacizumab was the most cost-effective treatment at a threshold of £20,000-30,000 per quality-adjusted life-year.

LIMITATIONS

The comparison of aflibercept and bevacizumab was a post hoc analysis.

CONCLUSION

The study showed aflibercept to be non-inferior to ranibizumab. However, the possibility that bevacizumab is worse than ranibizumab and aflibercept by 5 visual acuity letters cannot be ruled out. Bevacizumab is an economically attractive treatment alternative and would lead to substantial cost savings to the NHS and other health-care systems. However, uncertainty about its relative effectiveness should be discussed comprehensively with patients, their representatives and funders before treatment is considered.

FUTURE WORK

To obtain extensive patient feedback and discuss with all stakeholders future bevacizumab NHS use.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN13623634.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 38. See the NIHR Journals Library website for further project information.

Outcomes of Eyes Lost to Follow-Up in Patients with Central Retinal Vein Occlusion Who are Receiving Anti-Vascular Endothelial Growth Factor Treatment

Background

To evaluate the anatomic and functional outcomes in eyes of patients with macular edema (ME) caused by central retinal vein occlusion (CRVO) who were lost to follow-up (LTFU) for more than 6 months following treatment with anti-vascular endothelial growth factor (VEGF) therapy and to determine the predictive factors of visual prognosis in these patients.

Methods

This study was conducted as a retrospective, case series investigation. Patients whose eyes were receiving intravitreal anti-VEGF treatment for CRVO-ME, with the next follow-up visit occurring more than 6 months following treatment were identified. Baseline disease characteristics (at the last visit before being LTFU), cause and duration of treatment interruption, and the resulting disease progression, complications, and outcomes were assessed. Baseline characteristics predictive of visual outcome were also analyzed.

Results

This study included a total of 17 eyes of 17 patients. The mean duration of being LTFU was 7.8 ± 2.1 months. On the return visit after being LTFU, 7 of 17 eyes (41.2%) developed neovascular complications. Despite treatment, 12 eyes (70.1%) lost ≥3 best-corrected visual acuity (BCVA) lines, with 2 eyes (11.8%) developing a final BCVA of hand motion or more severe. At the final visit, the mean logarithm of minimal angle of resolution (logMAR) BCVA deteriorated significantly compared to before being LTFU (P < 0.001). The increasing duration of being LTFU is associated with a deterioration of visual acuity prognosis.

Conclusion

In CRVO-ME patients who are receiving anti-VEGF therapy, unintentional treatment interruptions can cause visually disastrous consequences, including irreversible blindness. Patients who were LTFU for a long period should be strongly warned about their poor visual prognosis.

Diabetic and Retinal Vascular Eye Disease

The retinal vasculature is the only neurovascular system directly visible to the human eye, easily evaluated by fundoscopy and many imaging modalities. This window allows physicians to diagnose and treat retinal pathologies and detect systemic diseases including diabetes, hypertension, hypercoagulable/hyperviscosity syndromes, and vasculitis. Diabetic retinopathy is the most common retinal vascular disease, followed by retinal vein and artery occlusion. Patients with these conditions require medical optimization to prevent further damage to the eyes and to the other organs. Both the internists and medical subspecialists play a crucial role in the prevention, detection, evaluation, and management of vision-threatening retinal vascular diseases.

Patterns and Predictors of Successful Treatment Discontinuation in Retinal Vein Occlusions With Macular Edema in the Real World

BACKGROUND AND OBJECTIVE

To identify factors associated with successful treatment discontinuation in eyes with retinal vein occlusions (RVOs) and macular edema (ME) in real-world settings.

PATIENTS AND METHODS

Retrospective study of 214 eyes with RVO and ME with 24-month follow-up at five academic centers. Regression analyses identified factors associated with (1) successful treatment discontinuation for at least 6 months without fluid recurrence and (2) best-corrected visual acuity (BCVA) at 24 months.

RESULTS

Forty percent of eyes with branch RVO and 35% with central RVO (CRVO) / hemi-retinal RVO (HRVO) successfully discontinued therapy without fluid recurrence, with median time to discontinuation of 6 and 7 months, respectively. Lower 6-month central subfield thickness was associated with greater likelihood of treatment discontinuation within 24 months for eyes with CRVO/HRVO (P = .001), whereas better 6-month BCVA was associated with better 24-month BCVA for all RVO subtypes (P < .001).

CONCLUSION

Early anatomic response at 6 months is associated with greater likelihood of stopping treatments. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:84-92.].

Ocular hypertension and severe intraocular pressure elevation after posterior subtenon injection of triamcinolone acetonide for various diseases

AIM

To evaluate and compare the incidences of ocular hypertension and severe intraocular pressure (IOP) elevation after posterior subtenon injection of triamcinolone acetonide (PSTA) for various diseases.

METHODS

Totally 179 eyes that had received PSTA for diabetic macular edema (n=108), pseudophakic cystoid macular edema (n=20), branch retinal vein occlusion (n=16), central retinal vein occlusion (CRVO, n=14), choroidal neovascularization (n=14) or noninfectious uveitis (n=7) were retrospectively enrolled. The primary outcomes included ocular hypertension defined as an IOP>21 mm Hg, and severe IOP elevation defined as a rise of 10 mm Hg or more in IOP compared with baseline. Cox regression models were used to analyze the hazard ratios (HRs) among different diseases.

RESULTS

After PSTA, the mean IOPs from month 1 to month 6 all significantly increased (P<0.05). Ocular hypertension occurred in 30.7% of eyes (median time: 8wk), and severe IOP elevation occurred in 16.2% of eyes (median time: 9wk). Patients receiving PSTA for CRVO or uveitis had a significantly higher risk for ocular hypertension (HR=3.049, P=0.004 for CRVO; HR=5.464, P=0.019 for uveitis) and severe IOP elevation (HR=2.913, P=0.034 for CRVO; HR=7.650, P=0.009 for uveitis).

CONCLUSION

IOP significantly increases within 6mo after PSTA, with the onset of ocular hypertension happening mostly at 2 to 3mo. Patients of CRVO or noninfectious uveitis have a higher risk of ocular hypertension or severe IOP elevation after PSTA and should be monitored for IOP more carefully.

Prediction of post-treatment retinal sensitivity by baseline retinal perfusion density measurements in eyes with branch retinal vein occlusion

In this study, we investigated the longitudinal correlation between macular sensitivity and perfusion density (PD) in retinas affected by branch retinal vein occlusion. Retinal sensitivity was measured using microperimetry and PD was measured by optical coherence tomography angiography. We also investigated the possibility that the PD, 1 month after anti-vascular endothelial growth factor (VEGF) treatment, is a predictor of retinal sensitivity after 1 year of successful macular oedema management with anti-VEGF. The correlation between measurements of retinal sensitivity and PD at baseline (1 M) and at 6 and 12 months were investigated. There was a significant positive correlation between retinal sensitivity and PD at all time points (baseline (1 M), r = 0.67, P < 0.0001; 6 months, r = 0.59, P < 0.0001; 12 months, r = 0.62, P < 0.0001) and between the PD at 1 month and retinal sensitivity at 12 months (r = 0.63, P < 0.0001). Unlike in areas that showed a mild to moderate decline in PD, retinal sensitivity in areas where the decrease in PD was severe at baseline did not show significant improvement with treatment over time. These findings suggest that the PD value measured using optical coherence tomography angiography at or soon after the baseline can predict retinal sensitivity after 1 year of anti-VEGF treatment.

Current Best Clinical Practices-Management of Retinal Vein Occlusion

Retinal vein occlusion (RVO) is the second most common cause of vision loss from retinal vascular diseases in adults in the United States. Visual loss arises as a result of a host of factors, including macular ischemia and macular edema. Primary antivascular endothelial growth factor therapy is the current standard of care, with level I evidence demonstrating sustained visual gains up to 2 years after treatment in both branch and central RVO. Prompt antivascular endothelial growth factor therapy is important because delays in treatment yield lesser visual gains. Steroid therapy also improves visual outcomes in RVO but with higher rates of adverse effects, including cataract formation and ocular hypertension. Although the treatment burden can be high, these drugs have collectively revolutionized treatment outcomes in this disease state, providing improved visual outcomes over previous laser therapies.

Visual and Anatomic Outcomes following Cataract Surgery in Patients with Pre-operative Macular Edema Due to Retinal Vein Occlusions Managed with Intravitreal anti-VEGF

PURPOSE

The purpose of this study was to investigate the visual and anatomic outcomes in patients with macular edema due to retinal vein occlusions (RVO) who were actively managed with intravitreal anti-vascular endothelial growth factor (VEGF) before and after cataract surgery.

METHODS

Retrospective, cohort study of all patients with RVO who underwent cataract surgery and were receiving intravitreal anti-VEGF injections from January 1st, 2012 through October 31st, 2018. There were 31 eyes that underwent cataract surgery and received at least one intravitreal anti-VEGF injection for a diagnosis of RVO within 6 months prior to surgery. Data collected included the development of subretinal or intraretinal macular fluid in the 6 months following surgery, timing of injections, number of injections, best corrected visual acuity (BCVA), and central subfield thickness (CST).

RESULTS

There was a significant improvement between pre- and post-operative BCVA when comparing all eyes (p values < .0001) and no significant difference in CST before and after surgery (p > .05). Eyes without fluid pre-operatively saw an improvement in visual acuity, but with an initial significant increase in CST (p = .03) that normalized over time (p = .33) without an increase in frequency of anti-VEGF injections.

CONCLUSION

Patients with cataracts who are actively managed for macular edema due to RVO with anti-VEGF agents may undergo cataract surgery, knowing they will have a transient increase in macular thickness that resolves without adjusting the frequency of intravitreal injections and is not visually significant.

Long-Term Follow-Up Changes of Central Choroidal Thickness Thinning after Repeated Anti-VEGF Therapy Injections in Patients with Central Retinal Vein Occlusion-Related Macular Edema with Systemic Hypertension

PURPOSE

We investigated the thinning of central choroidal thickness (CCT) following intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) drugs to treat central retinal vein occlusion (CRVO)-related macular edema in patients with and without systemic hypertension (HT) to assess the influence of repeated anti-VEGF therapy and HT on the choroid in CRVO eyes.

METHODS

We conducted a retrospective study involving 27 patients with CRVO-related macular edema from January 2014 to July 2017, with follow-ups exceeding 18 months. Visual acuity (VA), central retinal thickness (CRT), and CCT were evaluated before and after initial anti-VEGF drug treatment during follow-up.

RESULTS

The mean follow-up period was 35.2 months. Seventeen (63.0%) patients had HT. At 1 month after treatment, VA had improved in 21 (77.8%) patients, and CRT had decreased in 25 (92.6%). At the final visit, 22 (81.5%) showed improved VA, 19 (70.4%) had resolved macular edema, and the CCT had gradually become thinner with additional drug injections in all the patients. Furthermore, the mean CCT in HT patients (209.0 µm) was significantly lower than in non-HT patients (256.1 µm), and the mean injections were 7.8 and 5.3, respectively (p = 0.2067).

CONCLUSION

The CCTs were thinner in eyes with HT than in eyes without HT both before and after the repeated anti-VEGF injections.

Atrophy of the central neuroretina in patients treated for diabetic macular edema

Purpose

To examine the prevalence of central retinal atrophy in patients treated for diabetic macular edema (DME) in a clinical setting.

Methods

Retrospective data analysis of patients with DME, focusing on those who developed central retinal thinning after DME treatment at the Department of Ophthalmology, Medical University Vienna. Patient characteristics and clinical data including best‐corrected visual acuity (BCVA), spectral domain optical coherence tomography and fluorescence angiography images were reviewed and DME treatment strategies analysed using descriptive statistics. The correlation between visual acuity and ocular, systemic or DME treatment factors was calculated using linear regression models and ancovas.

Results

A total of 6684 outpatient visits by 1437 patients with diabetes were analysed. Out of 149 patients, who had had a central subfield thickness (CST) below 200 μm, 32 (36 eyes) had previously been diagnosed with a centre involving DME with an average CST of 473 ± 103 μm and average visual acuity of 0.62 ± 0.44 logMAR at first presentation. At the time of central atrophy, 29 (81%) out of 36 eyes had a history of laser treatment, 11 (31%) a vitrectomy, 32 (88%) repeated intravitreal injections of anti‐vascular endothelial growth factor (VEGF; mean 5.3 ± 3.8) and 22 (61%) intravitreal corticosteroid injections (mean 2.5 ± 2.7). Visual function (0.67 ± 0.43 logMAR) at the time of atrophy was not significantly correlated to central retinal thickness (191 ± 7 μm) or any other ocular, systemic or treatment factors.

Conclusions

Only 4% of patients treated for DME developed central retinal thinning in our observation period. On average, our atrophy patients had higher CST and lower BCVA when they first presented with DME compared to the overall DME cohort, and they received a combination of intravitreal injections and laser for DME treatment. Central retinal atrophy might not be attributed to excessive use of intravitreally applied anti‐VEGF or any other DME therapy alone.

Clinical efficacy evaluation of treatment of different degrees of retinal vein occlusion with ranibizumab combined with an argon ion laser

The aim of this study was to evaluate the clinical efficacy of an intravitreal injection of ranibizumab combined with argon ion laser photocoagulation therapy in the treatment of different degrees of central retinal vein occlusion (CRVO). A total of 112 CRVO patients including 25 cases of trunk occlusion, 50 cases of branch occlusion and 37 cases of hemiretinal vein-occlusion were enrolled in this study. Patients were treated with an intravitreal injection of 0.5 mg ranibizumab, followed by argon ion laser photocoagulation therapy after 7 days. Patients were followed up for 6 months and the best corrected visual acuity (BCVA), central retinal thickness (CRT), macular edema, and surgical complications were compared. Compared with the control treated with 0.5 mg ranibizumab, the BCVA and macular edema improved while CRT was significantly reduced in all groups treated with 0.5 mg ranibizumab combined with the argon ion laser. Furthermore, no obvious complications were observed in these groups and the effects of ranibizumab combined with argon ion laser photocoagulation on branch occlusion group were the best. Intravitreal injection of ranibizumab combined with argon ion laser photocoagulation therapy has better safety and effectiveness in the treatment of different degrees of CRVO. The trial registration number is 2015–318 and date of registration is 12/10/2015.

Deep Neural Network-Based Method for Detecting Central Retinal Vein Occlusion Using Ultrawide-Field Fundus Ophthalmoscopy

The aim of this study is to assess the performance of two machine-learning technologies, namely, deep learning (DL) and support vector machine (SVM) algorithms, for detecting central retinal vein occlusion (CRVO) in ultrawide-field fundus images. Images from 125 CRVO patients (n=125 images) and 202 non-CRVO normal subjects (n=238 images) were included in this study. Training to construct the DL model using deep convolutional neural network algorithms was provided using ultrawide-field fundus images. The SVM uses scikit-learn library with a radial basis function kernel. The diagnostic abilities of DL and the SVM were compared by assessing their sensitivity, specificity, and area under the curve (AUC) of the receiver operating characteristic curve for CRVO. For diagnosing CRVO, the DL model had a sensitivity of 98.4% (95% confidence interval (CI), 94.3–99.8%) and a specificity of 97.9% (95% CI, 94.6–99.1%) with an AUC of 0.989 (95% CI, 0.980–0.999). In contrast, the SVM model had a sensitivity of 84.0% (95% CI, 76.3–89.3%) and a specificity of 87.5% (95% CI, 82.7–91.1%) with an AUC of 0.895 (95% CI, 0.859–0.931). Thus, the DL model outperformed the SVM model in all indices assessed (P < 0.001 for all). Our data suggest that a DL model derived using ultrawide-field fundus images could distinguish between normal and CRVO images with a high level of accuracy and that automatic CRVO detection in ultrawide-field fundus ophthalmoscopy is possible. This proposed DL-based model can also be used in ultrawide-field fundus ophthalmoscopy to accurately diagnose CRVO and improve medical care in remote locations where it is difficult for patients to attend an ophthalmic medical center.

Impact of Time to Anti-Vascular Endothelial Growth Factor Intervention on Visual Outcomes for Patients Diagnosed With Retinal Vein Occlusion

BACKGROUND AND OBJECTIVES

To analyze the impact of time to treatment with anti-vascular endothelial growth factor (VEGF) for patients with macular edema (ME) secondary to retinal vein occlusions (RVO) in routine clinical practice.

PATIENTS AND METHODS

One hundred fifty-five eyes with ME secondary to RVO were identified. Patients were divided into initiation of anti-VEGF treatment at 28 days or fewer after symptom onset (Group A), between 28 and 84 days (Group B), and 84 days or more (Group C).

RESULTS

A significant central subfield thickness (CST) decrease at 12 months was observed in Groups A, B, and C (-184.14 µm, -204.55 µm, and -170.71 µm, respectively; P < .001). At 12 months, Groups A and B showed significant BCVA improvement (19.14 and 21.11, respectively; P ≤ .001), whereas Group C showed no significant improvement from baseline (4.01; P < .28).

CONCLUSIONS

Anatomical response as measured by CST did not differ between groups, whereas delays in treatment resulted in smaller BCVA improvement with anti-VEGF treatment. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:832-837.].

Efficacy and Safety of an Aflibercept Treat-and-Extend Regimen in Treatment-Naïve Patients with Macular Oedema Secondary to Central Retinal Vein Occlusion (CRVO): A Prospective 12-Month, Single-Arm, Multicentre Trial

OBJECTIVES

To evaluate efficacy and safety of an aflibercept treat-and-extend (TAE) regimen in patients with macular oedema (MO) secondary to central retinal vein occlusion (CRVO).

DESIGN SETTING AND PATIENTS

Phase IV, prospective, open-label, single-arm trial in 11 Spanish hospitals. Treatment-naïve patients with <6 month diagnosis of MO secondary to CRVO and best-corrected visual acuity (BCVA) of 73-24 ETDRS letters were included between 23 January 2015 and 17 March 2016.

INTERVENTION

Intravitreal aflibercept 2 mg monthly (3 months) followed by proactive individualized dosing.

MAIN OUTCOMES

Mean change in BCVA after 12 months.

RESULTS

24 eyes (24 patients) were included; mean (SD) age: 62.8 (15.0) years; 54.2% male; median (IQR) time since diagnosis: 7.6 (3.0, 15.2) days. Mean BCVA scores significantly improved between baseline (56.0 (16.5)) and Month 12 (74.1 (17.6)); mean (95% CI) change: 14.8 (8.2, 21.4); P=0.0001. Twelve (50.0%) patients gained ≥15 ETDRS letters. Foveal thickness improved between baseline (mean: 569.4 (216.8) µm) and Month 12 (mean 257.4 (48.4) µm); P < 0.0001. At Month 12, 8.3% patients had MO. The mean (SD) number of injections: 8.3 (3.0). No treatment-related AEs were reported. Five (20.8%) patients experienced ocular AEs. Two nonocular serious AEs were reported.

CONCLUSIONS

An aflibercept TAE regimen improves visual acuity in patients with MO secondary to CRVO over 12 months with good tolerability.

Non-viral ocular gene therapy, pEYS606, for the treatment of non-infectious uveitis: Preclinical evaluation of the medicinal product

Non-infectious uveitis (NIU) is the first cause of blindness that can be cured if optimal anti-inflammatory therapy can be achieved. Systemic anti-TNF (Tumor Necrosis Factor) agents have been recently approved for NIU but no local delivery of anti-TNF is available. For sustained production of secreted therapeutic proteins into the eye, non-viral gene therapy using plasmid electrotransfer in the ciliary muscle has been proposed. In this paper, we report the development steps of pEYS606, a clinical-grade plasmid DNA, devoid of antiobiotic selection gene, encoding a fusion protein consisting of the extracellular domain of the soluble p55 TNF-α receptor linked to the human IgG1 Fc domain (hTNFR-Is/hIgG1 or Protein 6), with high affinity for human TNF-α, for non-viral gene transfer into the ocular ciliary muscle. Electrotransfer of pEYS606 in the ciliary muscle significantly reduced ocular inflammation in two well-established rat models of uveitis, the endotoxin-induced uveitis (EIU) and the experimental autoimmune uveitis (EAU). In addition, in EAU, a significant protection of photoreceptors was demonstrated after pEYS606 treatment. The improved pharmacokinetic profile of intraocularly-secreted protein as compared to direct intravitreous injection of recombinant protein allowed to demonstrate Protein 6 efficacy at very low concentrations. Based on these results, a phase I/II clinical trial is conducted [ClinicalTrials.gov Identifier: NCT03308045].

Dexamethasone implant in silicone oil: in vitro behavior

Background

To determine the effect of the silicone on the dexamethasone intravitreal implant.

Methods

Basic, experimental, prospective and transversal study performed at the hospital “Nuestra Señora de la Luz” in Mexico City. One dexamethasone implant was placed in a test tube with 4 mL of each tamponade medium: 1000cS, 5000cS and heavy silicone oil; basic saline solution was used as the control medium. Photographs were taken weekly for 12 months. 200 µL samples were taken from each medium at 24 h, 1, 2 weeks and monthly for 12 months. ELISA test was performed to quantify dexamethasone release in every sample. An inflammatory stimulus was created and later exposed it to every sample in order to test their anti-inflammatory capacity by cytokine analysis using cytometric bead array. Statistically significant results were obtained with p < 0.05.

Results

Photographic follow-up showed disintegration of the implant in control medium. Implants in silicone oil suffered no changes during follow-up. Dexamethasone levels in control medium showed stability from month 2 to 12. Silicone oil mediums showed irregular dexamethasone release during the 1 year period. Dexamethasone in control medium had inhibitory effects on TNF-α starting at 24 h (p < 0.001) and remained stable. Dexamethasone in 1000cS silicone oil showed inhibitory effects from month 2 (p < 0.001) until month 6 (p < 0.001). Implants in denser silicone oils showed no inhibitory effects in any of the samples.

Conclusions

Denser mediums altered the implant pharmacokinetics and showed no anti-inflammatory effects even when concentrations were quantified at levels similar to control medium in vitro.

Optical coherence tomography angiography

Optical coherence tomography (OCT) was one of the biggest advances in ophthalmic imaging. Building on that platform, OCT angiography (OCTA) provides depth resolved images of blood flow in the retina and choroid with levels of detail far exceeding that obtained with older forms of imaging. This new modality is challenging because of the need for new equipment and processing techniques, current limitations of imaging capability, and rapid advancements in both imaging and in our understanding of the imaging and applicable pathophysiology of the retina and choroid. These factors lead to a steep learning curve, even for those with a working understanding dye-based ocular angiography. All for a method of imaging that is a little more than 10 years old. This review begins with a historical account of the development of OCTA, and the methods used in OCTA, including signal processing, image generation, and display techniques. This forms the basis to understand what OCTA images show as well as how image artifacts arise. The anatomy and imaging of specific vascular layers of the eye are reviewed. The integration of OCTA in multimodal imaging in the evaluation of retinal vascular occlusive diseases, diabetic retinopathy, uveitis, inherited diseases, age-related macular degeneration, and disorders of the optic nerve is presented. OCTA is an exciting, disruptive technology. Its use is rapidly expanding in clinical practice as well as for research into the pathophysiology of diseases of the posterior pole.

Changes in retinal ischaemic index correlate with recalcitrant macular oedema in retinal vein occlusion: WAVE study

AIM

To evaluate changes in the ischaemic index (ISI) after targeted retinal photocoagulation (TRP) and to investigate the correlation between these changes and macular oedema (ME).

METHOD

Twenty-four eyes of 24 patients with retinal vein occlusion (RVO) with recurrent ME were included. Ultra-widefield fluorescein angiography (UWFFA; Optos 200Tx) was obtained at baseline and every 4 months. The regions of retinal non-perfusion and the total gradable retina were manually segmented on UWFFA images for calculating the global ISI. ISI was also computed for specific regions defined by a standardised grid: perimacular area (PMA), near-peripheral area (NPA), mid-peripheral area (MPA) and far-peripheral area (FPA). Global and regional ISIs and change in ISI over time were correlated with central macular thickness (CMT).

RESULTS

The ISIs of entire retina, PMA, NPA, MPA and FPA at baseline were 30.5%±23.3, 17.7%±20.6, 21.9%±19.0, 33.0%±27.9 and 48.0%±32.9, respectively. The ISIs at final follow-up were 23.5%±19.9, 15.7%±22.2, 16.5%±16.7, 24.7%±24.7 and 24.7%±24.7, respectively. A significant correlation was found between CMT and global ISI during follow-up (r=0.22, p=0.03). Among the different retinal zones, PMA showed a correlation with CMT (r=0.27, p=0.007). The change in ISI for the total retina (Δtotal), PMA (ΔPMA) and NPA (ΔNPA) retinal regions was positively correlated with the change in CMT (ΔCMT) (r=0.45, 0.42 and 0.50, respectively, p=0.006, 0.009 and 0.002, respectively).

CONCLUSION

The severity of ME was correlated with the ISIs of the entire retina and the PMA. The reduction in ME was correlated with the reduction in ISI of the entire retina as well as the ISIs for the NPA and PMA following TRP. The role of TRP, particularly to these regions (NPA, PMA), warrants further investigation in recalcitrant RVO-associated ME.

Intravitreal Injection of Anti-vascular Endothelial Growth Factor Agents for Ocular Vascular Diseases: Clinical Practice Guideline

PURPOSE

To provide the clinical recommendations for the administration of intravitreal anti-vascular endothelial growth factor (VEGF) drugs especially bavacizumab for ocular vascular diseases including diabetic macular edema, neovascular age-related macular degeneration, myopic choroidal neovascularization, retinal vein occlusion and central serous chorioretinopathy.

METHODS

Twenty clinical questions were developed by the guideline technical committee. Relevant websites and databases were searched to find out the pertinent clinical practice guidelines to answer the questions. The technical committee provided possible answers (scenarios) according to the available evidences for each question. All scenarios along with their levels of evidence and the supported articles were sent to the experts for external review. If the experts did not agree on any of the scenarios for one particular clinical question, the technical committee reviewed all scenarios and their pertinent evidences and made the necessary decision. After that, the experts were asked to score them again. All confirmed scenarios were gathered as the final recommendations.

RESULTS

All the experts agreed on at least one of the scenarios. The technical committee extracted the agreed scenario for each clinical question as the final recommendation. Finally, 56 recommendations were developed for the procedure of intravitreal anti-VEGF injection and their applications in the management of ocular vascular diseases.

CONCLUSION

The implementation of this guideline can standardize the management of the common ocular vascular diseases by intravitreal injection of anti-VEGF agents. It can lead to better policy-making and evidence-based clinical decision by ophthalmologists and optimal evidence based eye care for patients.

Mechanisms of vision loss in eyes with macular edema associated with retinal vein occlusion

Anti-vascular endothelial growth factor agents reduce macular edema and improve vision in eyes with macular edema associated with retinal vein occlusion (RVO), including branch RVO (BRVO) and central RVO. However, not all eyes with resolved macular edema show satisfactory best corrected visual acuity. Photoreceptor impairment can mostly explain the vision loss in these cases. Photoreceptor damage can be caused by subretinal hemorrhage in the central fovea and hard exudates or their precursor derived from concentrated lipoproteins originating from leaky retinal vessel extravasation. The contribution of neuron impairment in the inner retina, including the impairment of bipolar and ganglion cells by ischemia, indicated by the presence of a non-perfusion area (NPA), to vision loss in eyes with BRVO is insignificant. This is because the papillomacular bundle area is usually spared from NPAs in BRVO cases.

QUALITATIVE AND QUANTITATIVE FOLLOW-UP USING OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY OF RETINAL VEIN OCCLUSION TREATED WITH ANTI-VEGF: Optical Coherence Tomography Angiography Follow-up of Retinal Vein Occlusion

PURPOSE

To evaluate changes of vascular flow of patients treated with intravitreal injections of anti-vascular endothelial growth factor for macular edema secondary to retinal vein occlusion (RVO) with optical coherence tomography angiography (OCTA).

METHODS

Patients with RVO with macular edema and treated with intravitreal injections of anti-vascular endothelial growth factors were retrospectively evaluated. The following examinations were performed before and after treatment: best-corrected visual acuity, spectral domain optical coherence tomography, fluorescein angiography, and OCTA (Optovue, Inc). Automatic measurement of vascular density of the superficial and deep capillary plexus was also performed and compared with age- and sex-matched healthy subjects.

RESULTS

Twenty-eight eyes of 28 patients (mean age 66.2 years; males 19%) were evaluated, including 13 central RVO, 11 branch RVO, and 4 hemicentral RVO. After treatment, mean central macular thickness significantly decreased from 644 μm to 326 μm and best-corrected visual acuity increased from 20/125 to 20/63 (P < 0.01 for both results). On OCTA, perifoveal capillary disruption (P = 0.029) and the number of cysts in the superficial capillary plexus and deep capillary plexus (P < 0.002) significantly decreased after treatment. The mean vascular density in the superficial capillary plexus slightly decreased during follow-up from 46.44% to 45.01% (not significantly). These densities were significantly less than those observed in healthy controls (P < 0.001).

CONCLUSION

Optical coherence tomography angiography showed regression of macular edema, reduced capillary disruption and cysts, and slight decrease in mean macular vascular density with time and despite treatment. Thus, OCTA enables qualitative and quantitative evaluation during follow-up of patients treated for RVO.

Aflibercept in macular edema secondary to retinal vein occlusion: A real life study

Purpose

To evaluate the real life outcomes of intravitreal aflibercept (IVAfl) treatment in patients with macular edema (ME) secondary to retinal vein occlusion (RVO) during the first year of treatment.

Methods

Retrospective case series. Newly diagnosed or persistent ME patients secondary to RVO who were treated with IVAfl and had a follow-up period of at least 12 months were included. Twenty-two patients (54.8%) received 3 loading month loading doses IVAfl initially, whereas 20 patients (45.2%) did not receive. Then the patients were treated on an as-needed treatment regimen. Primary outcome measures of this study included the change in best corrected visual acuity (BCVA) and central retinal thickness (CRT). Secondary outcome measures were the number of visits and injections.

Results

Forty-two eyes of 42 patients were included. Fourteen patients (33.3%) had central RVO, and 28 (66.7%) had branch RVO. Mean BCVA at baseline and month 12 was 0.98 ± 0.58 and 0.82 ± 0.65 LogMAR, respectively (p = 0.04). Mean CRT at baseline and month 12 was 511 ± 141 and 304 ± 95 μm, respectively (p < 0.0001). Mean number of visits was 5.9 ± 2.1 (range 3–11) and injections was 3.2 ± 1.7 (range 1–8) at month 12.

Conclusion

In conclusion, IVAfl treatment seemed to be effective in patients with ME secondary to RVO with respect to visual and anatomical outcomes in real life. In this study the number of visits and injections was lower that randomized controlled trials, but the functional and anatomical outcomes are probably still acceptable.

Central Retinal Vein Occlusion in 2 Patients Using Antipsychotic Drugs

Purpose

To report our findings in 2 patients who developed a central retinal vein occlusion (CRVO) and were chronic users of antipsychotic medications.

Case Presentation

Case 1 was a 62-year-old woman who had a sudden reduction of vision in her right eye to 20/2,000. Her fundus showed signs of an impending CRVO with marked macular edema. She had been taking antipsychotic drugs (quetiapine fumarate and risperidone) for about 2 years. She refused anti-VEGF therapy for her macular edema but selected systemic kallidinogenase. Two days later, the macular edema was significantly reduced but the number of cotton wool spots (CWS) was increased. Ten days later, the macular edema was resolved and her BCVA improved to 20/60. The CWS gradually disappeared, and her BCVA improved to 20/20. Case 2 was a 43-year-old man who presented with vision reduction in his right eye of 1 week's duration. His BCVA was 20/50 and his fundus showed signs of a CRVO-related macular edema with CWS in the peripapillary area. He had been taking sulpiride (Dogmatyl^™) for depression for 1 year, and his blood test showed an increase in red blood cells and hematocrit. Anti-VEGF therapy was performed, and the macular edema was resolved with vision improving to 20/20. There has been no recurrence to date in both cases.

Conclusions

These results indicate that a CRVO can be a complication of chronic use of antipsychotic medications. However, early treatment can lead to good outcomes. Clinicians should question patients who develop a sudden CRVO whether they are using antipsychotic medications.

CHOROIDAL THICKNESS CHANGES AFTER INTRAVITREAL DEXAMETHASONE IMPLANT INJECTION FOR THE TREATMENT OF MACULAR EDEMA DUE TO RETINAL VEIN OCCLUSION

PURPOSE

To investigate changes in choroidal thickness after intravitreal injection of a dexamethasone implant for macular edema due to retinal vein occlusion.

METHODS

Thirty-one eyes of 31 patients, treated with a single dose of a dexamethasone implant for retinal vein occlusion-associated macular edema, were included. Subfoveal choroidal thickness (SFCT) and central macular thickness of the affected eyes were compared with those of the normal contralateral eyes at baseline and 1, 3, and 5 months after injection.

RESULTS

The mean SFCT of the affected eyes (296.3 μm ± 61.6 μm) was significantly higher than that of the contralateral eyes (251.2 μm ± 57.7 μm; P < 0.001) at baseline. After injection, the mean SFCT was decreased compared with baseline in the treated eyes at months 1, 3, and 5. There was a correlation between SFCT and central macular thickness in the affected eyes at baseline (r = 0.397, P = 0.027). The change in SFCT was not correlated with the change in central macular thickness after injection. In the contralateral eyes, the mean SFCT did not change significantly.

CONCLUSION

Subfoveal choroidal thickness in eyes with macular edema due to retinal vein occlusion was higher than that of the contralateral eyes. Intravitreal injection of a dexamethasone implant was associated with a reduction in the choroidal thickness of the treated eye.

Angiographically Documented Macular Ischemia after Single Bevacizumab for Macular Edema Secondary to Central Retinal Vein Occlusion

This report describes a case of angiographically documented foveal avascular zone (FAZ) enlargement after a single intravitreal injection of bevacizumab for macular edema secondary to central retinal vein occlusion (CRVO). A 71-year-old female was treated with an intravitreal bevacizumab injection for macular edema following CRVO. Despite successfully decreased edema one month after injection, the postinjection best-corrected visual acuity immediately decreased from 20/40 to 20/1000 (Snellen equivalent). The FAZ area increased from 0.37 mm² to 3.11 mm² (8.4-fold increase). While intravitreal anti-vascular endothelial growth factor is effective and should be considered as a first-line treatment for macular edema secondary to CRVO, it may aggravate macular ischemia.

Optical coherence tomography angiography in retinal vein occlusion treated with dexamethasone implant: a new test for follow-up evaluation

PURPOSE

To quantitatively and qualitatively analyze patients with macular edema secondary to retinal vein occlusion (RVO) and treated with the intravitreal dexamethasone implant using optical coherence tomography angiography (OCTA).

METHODS

The files of patients treated with intravitreal injection of dexamethasone implant for macular edema secondary to RVO were retrospectively analyzed. Before and after injection, the following data were recorded: best-corrected visual acuity (BCVA), central macular thickness (CMT) measured using spectral-domain optical coherence tomography, fluorescein angiography, and OCTA (Optovue, Inc., Fremont, CA, USA). Results of automatic measurement of vascular density of the superficial capillary plexus (SCP) and deep capillary plexus were obtained before and after treatment and compared to those of healthy subjects matched for age and sex.

RESULTS

Seven eyes of 7 patients (mean age, 76 years; 57% male) were analyzed, including 3 cases of central RVO and 4 cases of branch RVO. All patients received 1 intravitreal injection of dexamethasone implant. After a mean follow-up of 2 months, CMT significantly decreased from 657 µm to 324 µm on average and BCVA increased from 20/100 to 20/50 (p = 0.017 and p&lt;0.001, respectively). At the SCP, the mean whole en face vascular density slightly decreased during follow-up from 43.21% to 42.76% (not statistically significant). Vascular densities were largely inferior to those observed in control subjects (p≤0.01 in all quadrants).

CONCLUSIONS

This study confirms the potential contribution of OCTA as a novel noninvasive imaging technology that enables a quantitative and qualitative evaluation of the follow-up of macular edema in RVO. Optical coherence tomography angiography may complement advantageously multimodal imaging to monitor patients with RVO.

Correlation between optic nerve head circulation and visual function before and after anti-VEGF therapy for central retinal vein occlusion: prospective, interventional case series

BACKGROUND

To determine the correlation between the optic nerve head (ONH) circulation determined by laser speckle flowgraphy and the best-corrected visual acuity or retinal sensitivity before and after intravitreal bevacizumab or ranibizumab for central retinal vein occlusion.

METHODS

Thirty-one eyes of 31 patients were treated with intravitreal bevacizumab or ranibizumab for macular edema due to a central retinal vein occlusion. The blood flow in the large vessels on the ONH, the best-corrected visual acuity, and retinal sensitivity were measured at the baseline, and at 1, 3, and 6 months after treatment. The arteriovenous passage time on fluorescein angiography was determined. The venous tortuosity index was calculated on color fundus photograph by dividing the length of the tortuous retinal vein by the chord length of the same segment. The blood flow was represented by the mean blur rate (MBR) determined by laser speckle flowgraphy. To exclude the influence of systemic circulation and blood flow in the ONH tissue, the corrected MBR was calculated as MBR of ONH vessel area - MBR of ONH tissue area in the affected eye divided by the vascular MBR - tissue MBR in the unaffected eye. Pearson's correlation tests were used to determine the significance of correlations between the MBR and the best-corrected visual acuity, retinal sensitivity, arteriovenous passage time, or venous tortuosity index.

RESULTS

At the baseline, the corrected MBR was significantly correlated with the arteriovenous passage time and venous tortuosity index (r = -0.807, P < 0.001; r = -0.716, P < 0.001; respectively). The corrected MBR was significantly correlated with the best-corrected visual acuity and retinal sensitivity at the baseline, and at 1, 3, and 6 months (all P < 0.050). The corrected MBR at the baseline was significantly correlated with the best-corrected visual acuity at 6 months (r = -0.651, P < 0.001) and retinal sensitivity at 6 months (r = 0.485, P = 0.005).

CONCLUSIONS

The pre-treatment blood flow velocity of ONH can be used as a predictive factor for the best-corrected visual acuity and retinal sensitivity after anti-VEGF therapy for central retinal vein occlusion.

TRIAL REGISTRATION

TRIAL REGISTRATION NUMBER

UMIN000009072. Date of registration: 10/15/2012.

Update in the Management of Macular Edema Following Retinal Vein Occlusions

Retinal vein occlusion (RVO) is a common retinal vascular disease classified according to the anatomical location of the occlusion in central (CRVO) or branch (BRVO) retinal vein occlusion. RVO is an important cause of visual loss worldwide and frequently results in visual impairment and ocular complications. Major causes of vision loss in BRVO and CRVO include macular edema (ME), capillary non-perfusion, and neovascularization, causing glaucoma, vitreous hemorrhage and/or tractional retinal detachment.[1-4] Macular edema is the leading cause of decreased central visual acuity in RVO.[5] Recently, there was a paradigm shift in the treatment of ME due to RVO with the advent of new pharmacotherapy treatment strategies and combination therapies. This paper reviews the current thinking and discusses the evidence behind the emerging treatment options for ME following RVO, including laser photocoagulation, intravitreal anti-vascular endothelial growth factor (VEGF), intravitreal corticosteroid-based pharmacotherapies, and surgical management.

Cotton Wool Spots after Anti-Vascular Endothelial Growth Factor Therapy for Macular Edema Associated with Central Retinal Vein Occlusion

PURPOSE

To report a case series, whereby we encountered a transient increase in retinal cotton wool spots (CWS) following anti-vascular endothelial growth factor (anti-VEGF) therapy for the treatment of macular edema secondary to central retinal vein occlusion (CRVO).

METHODS

Eighteen eyes were treated with intravitreal aflibercept (IVA), and 5 were treated with intravitreal ranibizumab (IVR). Fundus photographs obtained 1 month after initial IVA or IVR injections were retrospectively evaluated for the presence of CWS.

RESULTS

Twenty-one (91.3%) patients had the following systemic diseases: hypertension, diabetes mellitus without retinopathy, dyslipidemia, or chronic renal failure requiring dialysis. One month after treatment, reduced macular edema was observed in 21 (91.3%) eyes. Initial injections facilitated complete resolution in 14 eyes, and CWS gradually became fainter with additional injections.

CONCLUSION

Some eyes with CRVO-related macular edema can show a transient increase in CWS after initial anti-VEGF therapy; however, macular edema, retinal hemorrhage, and visual acuity were improved in almost every case.

The early effects of intravitreal anti vascular endothelial growth factor agents on intraocular pressure and central corneal thickness

To investigate the early effects of two intravitreal (IV) anti vascular endothelial growth factor agents (anti-VEGF), bevacizumab and ranibizumab, on intraocular pressure (IOP) and central corneal thickness (CCT) within the first post-injection month. This prospective study comprised 109 eyes of 109 adult cases who had IV bevacizumab or ranibizumab injections because of age-related macular degeneration (ARMD), retinal venous occlusion (RVO), diabetic retinopathy, and macular edema or central serous chorioretinopathy (CSCR). None of the cases had medical histories of any kinds of glaucoma or increased IOP and IV injection before and all of them underwent a detailed ocular examination including measurements of IOP by non-contact tonometer and CCT by ultrasonic pachymeter pre-injection. IOP measurements were repeated at 30 min and 1st, 7th, and 30th day after the injection. CCT measurements were repeated at the 7th and 30th post-injection day. Paired sample t tests were used for the statistical analysis in order to evaluate the significance of changes in IOP and CCT. The mean age of 56 male and 53 female cases was 63.58 ± 11.04 years. Fifty-six cases (51.4 %) had diabetic retinopathy, 33 cases (30.3 %) had ARMD, 11 cases (10.1 %) had RVO, and 9 cases (8.3 %) had CSCR. Bevacizumab was used in 97 (89 %) cases and ranibizumab was used in 12 (11 %) cases. The IOP increased significantly 30 min after the injection (p < 0.001) but significant decreases were observed at the 1st, 7th, and 30th day post-injection (p < 0.001). No significant differences were observed in CCT between pre-injection and 7th and 30th post-injection day values (p = 0.924 and p = 0.589, respectively). Intravitreal bevacizumab and ranibizumab injections can cause hyper acute increase in IOP because of vitreal expansion but this effect is generally reversible in non-glaucomatous cases.