Management of pseudophakic cystoid macular edema

Incisional choroidal surgery

The choroid is a thin layer of highly vascular uveal tissue enclosed externally by sclera and internally by neurosensory retinal tissue. The choroid is a "middle layer" ocular tissue with anatomically challenging surgical access. The primary functional role of the choroid is to provide rapid, oxygenated, and nutrient-rich blood flow to both the highly metabolic retinal pigment epithelium and outer retina (i.e. photoreceptors) while simultaneously removing waste products. Historically, incisional choroidal surgery (ICS) has involved tumor biopsy or excision, removal of choroidal neovascular complex or autologous choroidal translocations; however, ICS also holds unique potential for novel and innovative approaches to address macular pathology. Using large-animal surgical studies, researchers have explored ICS with the objective of finding safer and more effective techniques to reduce surgical risks such as bleeding, tissue contraction, and scar tissue formation. We explore the relevant anatomy and embryology, existing surgical techniques, discuss the implications for retinal drug delivery, define ICS guiding principles, and offer a rationale for implementation of ICS into a vitreoretinal surgical practice. We also identify other future challenges and anticipate future innovations that will advance ICS.

Risk factors and incidence of Macular Edema in eyes with retinal Vein Occlusion after uneventful cataract surgery: The MEVO study

PURPOSE

The current study aims to assess incidence of postoperative macular edema (PME), risk factors behind PME and outcomes after cataract surgery in eyes with retinal vein occlusion (RVO).

METHODS

This retrospective study included 162 eyes of 162 RVO patients, who underwent cataract surgery between 1 January 2015 and 31 December 2019. Eyes with RVO which did not have cystoid macular edema (CME) on optical coherence tomography (OCT) within the immediate 1 month prior to surgery were included.

RESULTS

Patients were followed up for an average duration of 13 ± 10.9 months after cataract surgery (range, 6-60 months). The mean time to PME development was 1.87 ± 1.7 months. Postoperative macular edema developed within 3 months after surgery in 40.1% of all eyes, 21% eyes with no previous CME, 57.3% of eyes with previous CME, and in 50% of eyes of patients with diabetes. Significant risk factors of PME identified were diabetes (OR = 2.1) and previous CME (OR = 4.62) requiring treatment with anti-VEGF (OR = 4.83). The visual acuity (VA) of operated eyes significantly improved from 0.85 ± 0.55 logMAR at baseline to 0.365 ± 0.39 logMAR ( P <0.0001) at the final follow-up. A significant proportion of eyes showed improvement of their VA beyond Snellen 6/12 at final follow-up ( P < 0.0001); however, eyes with PME had a higher chance of poorer vision gain (worse than 6/18). Poor prognostic factors for vision were presence of PME, previous CME and treatment history with injections, central RVO and poor VA at baseline.

CONCLUSION

The study demonstrates that RVO eyes with previous CME requiring intravitreal treatment are at significant risk of postoperative macular edema after uneventful cataract surgery, and this risk increases in people with diabetes. The incidence is not affected by the type of RVO. Considering almost 2/3 rd of PME developed within the 1 st month of surgery, we recommend a routine OCT scan as a part of postoperative assessment at the 1 st visit after surgery, in eyes at risk. Eyes developing PME may have poorer visual outcomes, especially eyes with CRVO; hence, patients need to be counseled carefully regarding outcomes of cataract surgery. The outcomes might depend on the previous treatment course they have received, and they may need to undergo a repeat cycle of treatment due to a risk of return of macular edema.

ANTERIOR SUBTENON TRIAMCINOLONE INJECTION FOR REFRACTORY MACULAR EDEMA: A Retrospective Case Series

PURPOSE

To evaluate the effectiveness of anterior subtenon triamcinolone (AST) injections in the management of refractory macular edema.

METHODS

This is a retrospective case series of consecutive eyes with refractory macular edema treated with AST at a single vitreoretinal surgeon's practice at Toronto Western Hospital, University of Toronto, Canada in 2018 to 2023. Refractory was defined as persistent macular edema with a central subfield thickness of 250 µ m or greater over a 24-week period, receiving at least four intravitreal antivascular endothelial growth factor injections. Vision outcomes and optical coherence tomography features for all eyes were compared for three visits pre-AST treatment and two visits post-AST treatment.

RESULTS

Ninety-three patients (119 eyes); diabetic macular edema (26%), and pseudophakic cystoid macular edema (74%), with a mean follow-up duration of 161 days were included. The presence of subretinal fluid ( P = 0.0013), central subfield macular thickness ( P < 0.0001), cube average thickness ( P = 0.0024), and macular cube volume ( P = 0.0017) significantly improved from pre-AST to post-AST treatment. Visual acuity also significantly improved from pre-AST treatment to post-AST treatment ( P < 0.0001). There was no significant change in the intraocular pressures from pre-AST to post-AST ( P = 0.7920), and no complications were noted throughout the follow-up period.

CONCLUSION

The findings from this study suggest that AST injections show modest improvement in anatomical and functional outcomes and are safe for the treatment and management of refractory macular edema.

Cystoid macular edema prophylaxis in cataract surgery: A protocol for network meta-analysis

OBJECTIVE

Cataracts are the leading cause of global preventable and treatable blindness. Cystoid macular edema (CME) is among the most common complications following cataract surgery. The development of CME impacts patients' quality of life and has economic implications for patients and healthcare systems. The purpose of this review is to synthesize the evidence from randomized controlled trials evaluating patients receiving prophylactic treatment with nonsteroidal anti-inflammatory drugs or corticosteroid medications to determine the comparative effectiveness of each specific regimen on retinal thickness, visual acuity, the development of CME, patient quality of life, intraocular pressure and adverse events following uncomplicated, age-related cataract surgery performed by phacoemulsification.

METHODS

A systematic review and random effects Bayesian network meta-analysis (NMA) will be performed and will be reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) extension statement for NMA. A comprehensive electronic search will be performed of the MEDLINE, EMBASE and CENTRAL databases, as well as of the ClinicalTrials.gov and World Health Organization International Clinical Trials Registries. Data will be collected and synthesized for seven pre-specified outcomes at 6 weeks and 3 months following surgery: i) change in central retinal thickness measured by optical coherence tomography (OCT), ii) best-recorded visual acuity iii) the rate of CME measured by OCT, and fluorescein angiography (FA) iv) the rate of patients experiencing clinically significant macular edema defined as the presence of CME and pre-specified thresholds for decreased visual acuity, v) patient quality of life, vi) intraocular pressure and vii) the number of patients experiencing one or more pre-specified adverse events. The certainty of evidence for each outcome will be assessed using GRADE NMA guidelines.

DISCUSSION

The results of this NMA will provide a comprehensive evaluation of the evidence for this critical question with significant clinical equipoise.

TRIAL REGISTRATION

Systematic Review Registration: PROSPERO Registration Number: CRD42024531150.

Applications of artificial intelligence in diagnosis of uncommon cystoid macular edema using optical coherence tomography imaging: A systematic review

Cystoid macular edema (CME) is a sight-threatening condition often associated with inflammatory and diabetic diseases. Early detection is crucial to prevent irreversible vision loss. Artificial intelligence (AI) has shown promise in automating CME diagnosis through optical coherence tomography (OCT) imaging, but its utility needs critical evaluation. This systematic review assesses the application of AI to diagnosis CME, specifically focusing on disorders like postoperative CME (Irvine Gass syndrome) and retinitis pigmentosa without obvious vasculopathy, using OCT imaging. A comprehensive search was conducted across 6 databases (PubMed, Scopus, Web of Science, Wiley, ScienceDirect, and IEEE) from 2018 to November, 2023. Twenty-three articles met the inclusion criteria and were selected for in-depth analysis. We evaluate AI's role in CME diagnosis and its performance in "detection", "classification", and "segmentation" of OCT retinal images. We found that convolutional neural network (CNN)-based methods consistently outperformed other machine learning techniques, achieving an average accuracy of over 96 % in detecting and identifying CME from OCT images. Despite certain limitations such as dataset size and ethical concerns, the synergy between AI and OCT, particularly through CNNs, holds promise for significantly advancing CME diagnostics.

Prophylactic regimens for the prevention of pseudophakic cystoid macular edema: systematic review and meta-analysis

BACKGROUND

Pseudophakic cystoid macular edema (PCME) is a known complication of cataract surgery that contributes to decreased visual acuity. Mechanical manipulation associated with the release of inflammatory mediators is the leading hypothesis for PCME. To date, no standardized prophylactic protocol has been established to effectively reduce the incidence of PCME. This study assessed the efficacy and safety of nonsteroidal anti-inflammatory drops (NSAIDs) and corticosteroids for the prevention of PCME.

METHOD

We searched the following databases MEDLINE, EMBASE, and Cochrane Central. Register of Controlled Trials and included randomized controlled trials (RCTs) that studied the efficacy of NSAID vs. placebo, NSAID vs. steroid, or NSAID + steroid vs. placebo, reporting the incidence of PCME, macular thickness, and best-corrected visual acuity. The risk ratio (RR) with a 95% confidence interval (CI) and a random-effects model was used. The risk of bias was assessed using the revised Cochrane risk-of-bias tool.

RESULTS

A total of 18 RCTs were included in this study (n = 2959). Nine RCT showed low risk of bias, 7 RCT showed unclear risk of bias, and 2 RCT had high risk of bias. The incidence of cystoid macular edema among patients treated with NSAIDs was significantly lower (RR = 0.33, P < 0.001). Subgroup analysis revealed a statistically significant low risk of edema among patients treated with NSAIDs alone (P < 0.001) compared to others. NSAIDs were associated with significantly low mean corrected visual acuity values using LogMar (P < 0.001).

CONCLUSION

NSAID alone or in combination with steroids showed its efficacy in reducing the incidence of PCME post-operatively. Future double-blind randomized controlled trials are required to standardize the protocol for different patient population.

Refractive Lens Exchange: A Review

In recent decades, technical advancements in lens surgery have considerably improved safety and refractive outcomes. This has led to a much broader range of indications for refractive lens exchange (RLE). Effective restoration of uncorrected distance and near visual acuity is possible with modern presbyopia correcting intraocular lenses (IOLs). Hyperopic patients who are fully presbyopic were identified as ideal candidates for RLE. For myopic patients, an increased risk of retinal detachment has been reported, which leads to a higher threshold to perform RLE in this patient group. The most frequent postoperative complications include posterior capsular opacification, deviation from the target refraction and cystoid macular edema. Thus, adequate planning of surgery, careful patient selection, as well as comprehensive counseling are crucial for successful RLE.

Macular changes after cataract surgery

Purpose

This article aims to highlight if the central macular retina suffers changes after cataract surgery, and to evaluate the eventually discovered changes regarding persistence.

Material and method

This retrospective study, which lasted over three years (2021-2023), included patients who underwent cataract surgery performed by one surgeon. Spectral-domain optical coherence tomography (SD-OCT) imaging assessed macular changes and measured the central macular thickness.

Results

A total of 240 eyes with diagnosed senile cataract were included in this study. The mean age was 66 years ± 4 years. Preoperative central foveal thickness was 210 ± 27.3 µm, the postoperative thickness on day 1 was 234.3 ± 40.2 µm, at 6 months 230.5 ± 35.2 µm, and the 1-year follow-up 229.2 ± 30.3 µm.

Discussion

Macular changes after cataract surgery are easily confirmed by SD-OCT. The evaluation and monitoring of macular changes can be done by using central macular thickness assessment.

Conclusions

The study provides data from a Romanian pool of patients. The values correlated well with those from similar studies of SD-OCT examinations, but differences were still observed, as there were different devices for performing SD-OCTs.

SUSTAINED-RELEASE LOW-DOSE FLUOCINOLONE ACETONIDE INTRAVITREAL IMPLANT FOR CHRONIC POSTOPERATIVE CYSTOID MACULAR EDEMA: TWO CASE REPORTS

BACKGROUND/PURPOSE

To describe two cases of patients diagnosed with chronic postoperative cystoid macular edema associated with noninfectious posterior uveitis who had limited treatment response to previous corticosteroid modalities and then received a single intravitreal fluocinolone 0.18-mg implant. Chronic postoperative cystoid macular edema (CME) may occur after intraocular surgery and is a common cause of postoperative visual loss. Sometimes called Irvine-Gass syndrome or persistent pseudophakic CME, chronic postoperative CME complicates roughly 0.1% to 2.0% of low-risk, small-incision phacoemulsification surgeries. There are a number of conventional approaches to chronic postoperative CME management, including topical corticosteroids with or without nonsteroidal anti-inflammatory drugs, intravitreal corticosteroid injections, and vascular endothelial growth factor (VEGF) inhibitor injections, but these options have several limitations. A major shortcoming of conventional formulations of anti-inflammatory therapies for chronic postoperative CME (i.e., topical drops, intraocular, and periocular injections) is the need for repeated dosing in chronic cases, which is expensive and burdensome to patients.

METHODS

Series of two case reports. Patient 1, a 75-year-old Latina woman, presented with a history of longstanding, recurrent inflammation after cataract extraction and subsequent vitreoretinal surgeries. Patient 2, an 85-year-old white woman, presented with acute blurred vision, swelling, and pain 5 years after cataract surgery and laser peripheral iridotomy. Both were diagnosed with chronic postoperative CME and ultimately treated with the 3-year sustained-release fluocinolone acetonide intravitreal implant (FAi) 0.18 mg.

RESULTS

Compared with baseline, both patients experienced resolution of their disease symptoms, >3 lines of visual acuity improvement, and macular edema reduction of 56.2% and 38.4% at 15 and 6 months, respectively, after the fluocinolone implant. No steroid related adverse events including any intraocular pressure measurement >25 mmHg were observed.

CONCLUSION

A single intravitreal fluocinolone 0.18-mg implant can effectively and safely treat vision loss and increased central macular thickness because of chronic postoperative cystoid macular edema associated with noninfectious posterior uveitis. The FAi 0.18 mg provides a safe, long-acting, low-dose anti-inflammatory treatment in patients with noninfectious posterior-segment inflammation associated with chronic postoperative CME.

Clinical efficacy of femtosecond laser-assisted phacoemulsification in diabetic cataract patients

BACKGROUND

Diabetic patients with cataracts encounter specific difficulties during cataract surgery due to alterations in microcirculation, blood supply, metabolism, and the microenvironment. Traditional phacoemulsification may not fully tackle these issues, especially in instances with substantial preoperative astigmatism. The utilization of femtosecond laser-assisted phacoemulsification, in conjunction with Toric intraocular lens (IOL) implantation, offers a potentially more efficient strategy. This research seeks to evaluate the efficacy and possible complications of this approach in diabetic cataract patients.

AIM

To investigate the clinical efficacy and complications of femtosecond laser-assisted phacoemulsification combined with Toric IOL implantation in diabetic cataract patients, comparing it with traditional phacoemulsification methods.

METHODS

This retrospective study enrolled 120 patients with diabetes cataract from May 2019 to May 2021. The patients were divided into two groups: the control group underwent traditional phacoemulsification and Toric IOL implantation, while the treatment group received Len Sx femtosecond laser-assisted treatment. Outcome measures included naked eye vision, astigmatism, high-level ocular phase difference detection, clinical efficacy, and complication.

RESULTS

There were no significant preoperative differences in astigmatism or naked eyesight between the two groups. However, postoperative improvements were observed in both groups, with the treatment group showing greater enhancements in naked eye vision and astigmatism six months after the procedure. High-level corneal phase difference tests also indicated significant differences in favor of the treatment group.

CONCLUSION

This study suggests that femtosecond laser-assisted phacoemulsification combined with Toric IOL implantation appears to be more effective in enhancing postoperative vision in diabetic cataract patients compared to traditional methods offering valuable insights for clinical practice.

Bilateral effect following off label unilateral intravitreal brolucizumab injection in patient with pseudophakic cystoid macular edema

PURPOSE

To report a bilateral reduction in pseudophakic cystoid macular edema (PCME) after unilateral intravitreal injection (IVI) of brolucizumab.

OBSERVATIONS

A 64-year-old female with bilateral recalcitrant PCME was treated with one dose of intravitreal ozurdex implant and triamcinolone acetonide each in both the eyes, with an equivocal response. On switching to IVI brolucizumab in the right eye (OD), the patient showed significant improvement in the best-corrected visual acuity (BCVA) with a notable reduction in the intraretinal fluid (IRF) and central subfield thickness (CST) in both the eyes at one month.

CONCLUSIONS AND IMPORTANCE

In conclusion, IVI brolucizumab is effective for the management of recalcitrant PCME with good visual and anatomical outcomes at one month. However, this molecule can also have therapeutic efficacy in the uninjected eye possibly due to systemic escape. More research into the pharmacokinetic properties of this novel molecule is needed to validate our findings.

Intravitreal acetazolamide implant for pseudophakic cystoid macular edema

BACKGROUND

Pseudophakic cystoid macular edema (PCME) is the most common cause of visual acuity deterioration after uncomplicated cataract surgery. There is no consensus regarding how to manage recurrent or refractory cases.

REPORT

A 54-year-old woman complained of decreased vision and central metamorphopsia in the right eye (OD) 3 months after uneventful cataract surgery. Visual acuity was 0.3 logMAR (20/40) OD and 0.1 logMAR (20/25) OS. Reduced macular brightness was seen OD on funduscopy associated with increased macular thickness on optical coherence tomography (OCT). Pseudophakic cystoid macular edema (PCME) was diagnosed, and treatment with oral acetazolamide was tried without success. The patient underwent a single intravitreal injection of an acetazolamide implant (260 μg) OD as off-label treatment. Four weeks following the injection, she reported complete resolution of her metamorphopsia and visual loss OD. Four months later, her visual acuity was 0.0 logMAR (20/20) in OD and 0.1 logMAR (20/25) in OS. The patient reported no discomfort after the injection procedure. Laboratory and ophthalmologic tests did not identify any adverse effects of the medication.

CONCLUSION

We show that PCME refractory to conventional treatment improved after intravitreal acetazolamide implant injection. Further investigation is warranted to confirm these preliminary findings.

0.18 MG FLUOCINOLONE ACETONIDE INSERT FOR THE TREATMENT OF CHRONIC POSTOPERATIVE PSEUDOPHAKIC CYSTOID MACULAR EDEMA

PURPOSE

To report the outcomes of the 0.18 mg fluocinolone acetonide insert (FAi) in the treatment of chronic (>6 months) postoperative cystoid macular edema after cataract surgery.

METHODS

This was a retrospective consecutive case series of eyes with chronic postoperative cystoid macular edema treated with the FAi. Visual acuity, intraocular pressure, optical coherence tomography metrics, and supplemental therapies were extracted from the charts before and at 3, 6, 12, 18, and 21 months after FAi placement, when available.

RESULTS

Nineteen eyes of 13 patients with chronic postoperative cystoid macular edema after cataract surgery underwent FAi placement with an average follow-up of 15.4 months. Ten eyes (52.6%) had a ≥2-line gain in visual acuity. Sixteen eyes (84.2%) had a ≥20% reduction in optical coherence tomography central subfield thickness. Eight eyes (42.1%) had complete resolution of CME. Improvements in central subfield thickness and visual acuity were sustained throughout individual follow-up. Compared with 18 eyes (94.7%) requiring local corticosteroid supplementation before FAi, only six eyes (31.6%) required supplementation after FAi. Similarly, of the 12 eyes (63.2%) that were on corticosteroid drops before FAi, only 3 (15.8%) required drops after FAi.

CONCLUSION

Eyes with chronic postoperative cystoid macular edema after cataract surgery treated with the FAi had improved and sustained visual acuity and optical coherence tomography metrics, along with a reduction in supplemental treatment burden.

Should Multifocal Intraocular Lenses Become a Standard in Phacoemulsification Cataract Surgery?

Cataracts impair daily activities such as reading, outdoor sports, and driving, which may not match best-corrected visual acuity at optimal room light conditions, but can be just as important to patients [...].

Management of inflammation after the cataract surgery

PURPOSE OF REVIEW

To review most recent studies and clinical trials regarding pathogenesis, treatment, and prevention of inflammation after the cataract surgery.

RECENT FINDINGS

FLACS gave opportunity to evaluate inflammatory cytokines in the aqueous humour right after the laser procedure, which led to acknowledging the inflammation pathogenesis during the phacoemulsification. Although there is still a lack of evidence, which would prove the long-term benefit of NSAIDs, they are indicated and effective when risk factors for PCME are present. PREMED studies showed that combination of NSAID and steroids after the surgery for healthy subjects is cost-effective. The triamcinolone injection together with topical steroids and NSAIDs for diabetic patients after the cataract surgery was the most cost-effective in preventing PCME according to the PREMED. Dropless cataract surgery is another emerging topic: dexamethasone implants and suspensions look promising as we await more clinical trials with drug-loaded IOLs.

SUMMARY

Inflammation after the cataract surgery can be prevented, and these methods are one of the most essential topics with growing phacoemulsification rate. Topical NSAIDs are cost-effective not only for patients with risk factors for PCME but also for healthy subjects. New dropless techniques are being successfully introduced in the clinical practice.

Minimally Invasive Glaucoma Surgery: Safety of Individual Devices

Primary open-angle glaucoma progression in those already on maximal medical therapy has traditionally been treated with trabeculectomy, a surgical procedure that carries a high degree of morbidity. In the last few decades, significant advances have been made in the field of minimally invasive glaucoma surgery (MIGS) devices, which aim to defer or prevent trabeculectomy via less arduous surgical techniques in certain types of glaucoma. Although reviews have been published examining the efficacy of various MIGS techniques, no article synthesises the comparative safety of all available devices. We performed a literature review examining the safety of MIGS devices. Fifteen devices were included, variously attempting to increase aqueous outflow through the trabecular meshwork or the suprachoroidal space, shunting into the subconjunctival space, or reducing aqueous production through ciliary body ablation. Notably, the earliest product attempting to increase outflow to the suprachoroidal space, Alcon's CyPass Micro-Stent, was withdrawn from the market due to concerns regarding increased corneal endothelial cell loss at five years post-implantation. All other devices were described as well-tolerated, with the most common adverse effects including hyphaema, intraocular pressure spikes, and device migration or obstruction. MIGS devices are purported to be uniformly safe, and many studies report no statistically significant increased complications beyond those associated with cataract surgery alone. It is important to note, however, the generally poor quality of current studies, with a dearth of randomised, or even prospective, data, and a large proportion of studies funded by device producers.

Topical NSAIDs and Oral Acetazolamide for Macular Edema after Uncomplicated Phacoemulsification: Outcome and Predictors of Non-Response

Purpose: To investigate the effectiveness of nonsteroidal anti-inflammatory eye drops (NSAIDs) combined with oral acetazolamide for postoperative macular edema (PME) after uncomplicated phacoemulsification (PE) and identify predictors of non-response. Methods: We analyzed data of uncomplicated PE and identified eyes with PME. First-line therapy included topical NSAIDs combined with oral acetazolamide. In the case of non-response, triamcinolone was administered subtenonally. Outcome measures included best-corrected visual acuity (BCVA) and central macular thickness (CMT). Results: 94 eyes out of 9750 uncomplicated PE developed PME, of which 60 eyes were included. Follow-ups occurred 6.4 ± 1.8, 12.5 ± 3.7 and 18.6 ± 6.0 weeks after diagnosis. BCVA and CMT improved significantly in all follow-ups. In total, 40 eyes showed a response to first-line therapy at the first follow-up (G1). The remaining 20 eyes showed no response and required subtenon triamcinolone (G2), of which 11 eyes showed complete regression at the second follow-up and 4 eyes at third follow-up. A further 5 eyes showed no response and required intravitreal injection. Multivariate linear regression model showed that Diabetes mellitus (DM) and increased cumulative dissipated energy (CDE) are predictors of non-response. Conclusion: Topical NSAIDs with acetazolamide resulted in complete regression of PME in 67% of all cases. DM and increased CDE might be considered as predictors of non-response to this treatment.

Maculopathies in Glaucoma

In the presence of glaucoma, various changes in the macula can occur during the course of the disease itself or its treatment. Maculopathies that can be observed in glaucoma include cystoid macular edema, hypotony maculopathy, and microcystic macular edema. The following article discusses the pathophysiology, causes, course, clinical presentation, and treatment of these maculopathies.

Efficacy of Intravitreal Injection of Filtered Modified Low-Dose Triamcinolone Acetonide and Ranibizumab on Pseudophakic Cystoid Macular Edema

Purpose

To compare the visual and morphological effects between intravitreal injection of filtered modified 2 mg triamcinolone acetonide (TA) and 0. 5 mg ranibizumab in patients with pseudophakic cystoid macular edema (PCME).

Methods

A retrospective, interventional study was conducted from January 2015 to February 2020 involving patients with PCME after uneventful cataract surgery. A total of 25 patients (25 eyes) with PCME received an intravitreal injection of 0.22 μm filtered modified 2 mg TA, while 15 patients (15 eyes) received 0.5 mg ranibizumab injection. Central macular thickness (CMT), best-corrected visual acuity (BCVA), intraocular pressure (IOP), times of repeated injections, and other side effects were observed at 2 weeks, 1 month, 3 months, and 6 months after injection; then, the data were compared with preinjection information in each group and between the two groups.

Results

Both the TA and ranibizumab intravitreal injection can achieve improved BCVA and reduced CMT in patients with PCME (P < 0.05), with a trend toward greater improvement in the TA group, but the difference was only significant at 3 months (P < 0.05). IOP was in the normal range without any significant difference (P > 0.05). Thirty-three percent of patients in the ranibizumab group required repeated intravitreal injection compared to 4% in the TA group. Further stratified analysis showed that the better therapeutic effect of the TA group at 3 months after injection only existed in patients with diabetes mellitus (DM), while not in patients without DM. There was no repeat injection in the TA group and 12.5% in the ranibizumab group for patients without DM, while 16.7% in the TA group and 57.1% in the ranibizumab group required repeated injection for patients with DM, which had a significant difference (P < 0.05).

Conclusion

Intravitreal injection of filtered modified 2 mg TA is safe, effective, and an inexpensive alternative to antivascular endothelial growth factor (anti-VEGF) agents for patients with PCME, especially for patients concurrently with DM. A large number of clinical randomized controlled studies along with long-term follow-up observations are needed.

Topical NSAIDs, intravitreal dexamethasone and peribulbar triamcinolone for pseudophakic macular edema

Background

The purpose of this study is to assess the effectiveness of topical nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids (intravitreal dexamethasone and peribulbar triamcinolone) in treating pseudophakic macular edema (PME).

Methods

Retrospective study of 33 eyes. Variables included best corrected visual acuity (BCVA; logMAR scale) and central retinal thickness (CRT) and central choroidal thickness (CCT) assessed with swept-source OCT. All patients were initially prescribed topical NSAIDs and reevaluated after 2 months. If improvement in BCVA or CRT was noted, topical NSAIDs were continued until resolution. If no improvement was observed at 2 months or subsequent visits, intravitreal dexamethasone implant was performed. Patients who refused intravitreal treatment were offered peribulbar triamcinolone.

Results

After treatment with topical NSAIDs for a median of 2 months, BCVA increased significantly from 0.5 to 0.3 while CRT decreased significantly from 435 to 316 μm. PME resolved in 19 of the 33 eyes (57.6%). Of the 14 recalcitrant cases, 13 were treated with corticosteroids. Of these 13 cases, 9 (69.2%) resolved. BCVA increased non-significantly from 0.7 to 0.4. CRT and CCT decreased significantly from 492 to 317 μm and from 204 to 182 μm respectively.

Conclusions

The overall success rate of the treatment algorithm was greater than 80%, a remarkable finding considering that no randomized study has yet been conducted to determine the optimal therapeutic protocol for PME. This is the first study to evaluate choroidal thickness in PME using SS-OCT, which could play a key role in its pathophysiology and provide useful information to improve the management of PME.

Current Management Options in Irvine-Gass Syndrome: A Systemized Review

Irvine-Gass syndrome (IGS) remains one of the most common complications following uneventful cataract surgery. In most cases, macular edema (ME) in IGS is benign, self-limiting, and resolves spontaneously without visual impairment; however, persistent edema and refractory cases may occur and potentially deteriorate visual function. Despite the relatively high prevalence of IGS, no solid management guidelines exist. We searched the PUBMED database for randomized clinical trials (RCT) or case series of at least 10 cases published since 2000 evaluating different treatment strategies in patients with cystoid macular edema (CME). The search revealed 28 papers that fulfilled the inclusion criteria with only seven RCTs. The scarceness of material makes it impossible to formulate strong recommendations for the treatment of IGS. Clinical practice and theoretical background support topical non-steroidal anti-inflammatory drugs (NSAIDs) as the first-line therapy. Invasive procedures, such as periocular steroids, intravitreal corticosteroids, and anti-vascular endothelial growth factor (anti-VEGF), are usually applied in prolonged or refractory cases. Results of novel applications of subthreshold micropulse laser (SML) are also promising and should be studied carefully in terms of the safety profile and cost effectiveness. Early initiation of invasive treatment for providing better functional results must be examined in further research.

Prednisolone and Ketorolac vs Ketorolac Monotherapy or Sub-Tenon Prophylaxis for Macular Thickening in Cataract Surgery: A Randomized Clinical Trial

Question

Is a combination of corticosteroid and nonsteroidal anti-inflammatory drug (NSAID) eye drops superior to NSAID eye drops alone or dropless surgery with a sub-Tenon dexamethasone depot in controlling postoperative central macular thickening after uncomplicated cataract surgery?

Findings

In this randomized clinical trial with 470 participants, no differences in central subfield thickness or visual acuity across treatment arms were identified, although approximately half of the group given the sub-Tenon depot received additional anti-inflammatory treatment.

Meaning

Therapy with NSAID plus corticosteroid eye drops was not superior to NSAID monotherapy or sub-Tenon depot for postoperative central macular thickening after uncomplicated cataract surgery.

Importance

The choice of anti-inflammatory prophylaxis parallel to cataract surgery is important for patient safety and successful outcome of surgery, but which regimen to choose is contested.

Objectives

To determine whether a combination of prednisolone and nonsteroidal anti-inflammatory drug (NSAID) eye drops was superior in preventing increased central macular thickness (central subfield thickness [CST]) after uncomplicated cataract surgery compared with NSAID monotherapy and sub-Tenon capsule depot (dropless surgery), and to test whether preoperative initiation of eye drop treatment was superior to initiation on the day of surgery.

Design, Setting, and Participants

This investigator-driven, single-center, randomized clinical trial with masked statistical analyses enrolled patients at the Department of Ophthalmology, Rigshospitalet Glostrup, Glostrup, Denmark, from February 1, 2018, to August 15, 2019. Follow-up was completed December 18, 2019. Participants included low-risk patients undergoing phacoemulsification for age-related cataract by an experienced surgeon (1 eye per participant). Data were analyzed from February 17 to June 15, 2020.

Interventions

Participants scheduled for cataract removal were randomized to 1 of 5 anti-inflammatory prophylactic regimens: eye drops with a combination of prednisolone, 1%, and ketorolac tromethamine, 0.5%, with or without preoperative initiation (preoperative prednisolone plus NSAID [control] and postoperative prednisolone plus NSAID groups), ketorolac monotherapy with or without preoperative initiation (preoperative and postoperative NSAID groups), or sub-Tenon depot of dexamethasone phosphate (sub-Tenon group). Eye drops were administered 3 times per day until 3 weeks postoperatively.

Main Outcomes and Measures

CST 3 months postoperatively.

Results

A total of 470 participants (mean [SD] age, 72.2 [7.0] years; 290 women [61.7%]) with 94 participants in each group were included in the analysis. Three months after surgery, the mean CST was 250.7 (95% CI, 247.6-253.7) μm in the preoperative prednisolone plus NSAID group, 250.7 (95% CI, 247.8-253.7) μm in the postoperative prednisolone plus NSAID group, 251.3 (95% CI, 248.2-254.4) μm in the preoperative NSAID group, 249.2 (95% CI, 246.2-252.3) μm in the postoperative NSAID group, and 255.2 (95% CI, 252.0-258.3) μm in the sub-Tenon group. There were no significant differences in CST or visual acuity compared with control and no differences between preoperative and postoperative groups, but 47 of 83 participants (56.6%) in the sub-Tenon group needed additional anti-inflammatory treatment.

Conclusions and Relevance

No differences in CST or visual acuity were detected between the combination of prednisolone and NSAID eye drops vs NSAID monotherapy or sub-Tenon dexamethasone depot, although more than one-half of patients in the sub-Tenon arm received additional anti-inflammatory treatment. Initiating prophylaxis 3 days preoperatively was not superior to initiation on the day of surgery. Monotherapy with NSAIDs may be preferred in uncomplicated cataract surgery.

Trial Registration

ClinicalTrials.gov Identifier: NCT03383328

Case Report: Subconjunctival Bevacizumab for the Treatment of Refractory Pseudophakic Cystoid Macular Edema

SIGNIFICANCE

In this report, the authors present a case of a 63-year-old man with recurrent pseudophakic cystoid macular edema. Macular edema was refractory to the treatments with periocular corticosteroid injection and topical anti-inflammatory medications. It was treated with subconjunctival bevacizumab (2.5 mg) injections.

PURPOSE

The purpose of this report was to demonstrate the efficacy and safety of repeated injections of subconjunctival bevacizumab in pseudophakic cystoid macular edema.

CASE REPORT

A 63-year-old White man presented with ongoing blurred vision in his left eye 4 months after a complicated cataract surgery. Despite the administration of sub-Tenon triamcinolone in the first-month visit because of cystoid macular edema and the use of topical steroid and nonsteroidal anti-inflammatory medications during the 4 months, there was no change in his vision. The first subconjunctival bevacizumab injection was performed 16 weeks after cataract surgery. The best-corrected visual acuity was significantly improved, and central retinal thickness dramatically decreased after the first injection. Macular edema reoccurred 26 and 46 weeks after cataract surgery. At these relapses, repeated subconjunctival injections of bevacizumab were influential in resolving macular edema and restoration of vision, even in the chronic phase. After 6 months, visual acuity (20/20) and central retinal thickness (274 μm) were stable after four total injections. No drug-related adverse events were observed during the follow-up period.

CONCLUSIONS

The repeated subconjunctival injections of bevacizumab were effective and well tolerated in pseudophakic cystoid macular edema. Subconjunctival bevacizumab may be a safe alternative to intravitreal applications in patients with pseudophakic cystoid macular edema.

Visual outcomes and incidence of pseudophakic cystoid macular oedema in eyes with cataract and idiopathic epiretinal membrane after two-step sequential surgery

OBJECTIVES

To determine whether pars plana vitrectomy (PPV) or cataract surgery should be performed first in concurrent epiretinal membrane (ERM) and cataract treatment with respect to visual outcome and pseudophakic cystoid macular oedema (PCMO) incidence.

METHODS

Patients who underwent PPV and cataract surgery sequentially at a tertiary medical centre were retrospectively recruited. Best-corrected visual acuity (BCVA) and central macular thickness (CMT) measured from optical coherence tomography (OCT) images collected before and after each surgery were documented. OCT-defined PCMO incidence and its influence on visual outcomes were analysed.

RESULTS

In total, 259 and 159 eyes received PPV (ERM-CATA) before and after cataract surgery (CATA-ERM), respectively. The ERM-CATA group had better final BCVA (logMAR: 0.274 vs. 0.558, p < 0.001) and greater BCVA gain (logMAR VA change: -0.379 vs. -0.220, p = 0.001) than did the CATA-ERM group. Baseline BCVA was positively correlated with final BCVA (p < 0.001), whereas baseline CMT, final CMT, and postoperative CMT changes were not. PCMO incidence did not differ significantly between the two groups (15.4% vs. 19.5%, p = 0.287), and final BCVA changes did not significantly differ between eyes with and without PCMO. PCMO incidence was much higher (29.40% vs. 16.30%, p = 0.008) in eyes with baseline CMT ≥ 500 μm.

CONCLUSIONS

When managing ERM and cataract, PPV should be performed before cataract surgery to yield better visual outcomes. Both surgical sequences yield similar PCMO rates. Greater baseline CMT is a risk factor for PCMO after cataract surgery.

INTRAVITREAL DEXAMETHASONE IMPLANT MIGRATION INTO THE ANTERIOR CHAMBER: A Multicenter Study From the Pan-American Collaborative Retina Study Group

PURPOSE

To establish the prevalence and risk factors for intravitreal dexamethasone implant migration into the anterior chamber in eyes with macular edema.

METHODS

This was a multicenter, retrospective, observational chart review of data that included patients with macular edema who had been treated with at least one intravitreal dexamethasone injection. Patients with incomplete chart information during the follow-up period were excluded.

RESULTS

The prevalence of implant migration in 468 patients, considering the number of injections, was 1.6%, with significant associations between implant migration and cataract surgery (P = 0.043) and intraocular lens status (P = 0.005) and a trend toward statistical significance (P = 0.057) with vitrectomy. A higher rate of implant migration into the anterior chamber was observed in vitrectomized eyes (4.8%) when compared with patients who did not undergo a vitrectomy (1.6%). The implants that migrated were removed with forceps with/without viscoelastic expression or with 20-gauge cannulas connected to the vitreous cutter machine.

CONCLUSION

The risk of implant migration into the anterior chamber was 1.6%. Risk factors were a history of cataract surgery or vitrectomy and aphakia. When anterior migration occurs, rapid removal is advised, especially if corneal edema is present.

Intravitreal Dexamethasone Implant for Postoperative Macular Oedema Secondary to Vitrectomy for Epiretinal Membrane and Retinal Detachment: A Systematic Review and Meta-Analysis

PURPOSE

To evaluate the efficacy of intravitreal dexamethasone implant (DEX) for the treatment of macular oedema secondary to vitrectomy for epiretinal membrane (ERM) and retinal detachment (RD) by conducting a systematic review with meta-analysis of published studies.

METHODS

Studies reporting clinical outcomes of DEX use for the treatment of macular oedema secondary to ERM and RD vitrectomy were searched on PubMed and Embase databases. The primary outcome was best-corrected visual acuity (BCVA) change between baseline and post-DEX treatment, reported as mean difference (MD) with 95% confidence interval (CI). Mean central macular thickness (CMT) change was assessed as a secondary outcome. Postimplant adverse events, including intraocular pressure rise and cataract development, were reported as well.

RESULTS

Five uncontrolled studies, 1 nonrandomized controlled study, and 1 randomized controlled study were included, with a total of 5 cohorts and 3 cohorts in the ERM group and RD group, respectively. Considering the last available follow-up, a significant improvement in postimplant BCVA was found in the overall population, irrespective of the indication for vitrectomy (MD = -0.28, 95% CI = -0.37, -0.20; p < 0.001), but with significant heterogeneity. In either group, mean BCVA significantly improved following the implant (in the ERM group, MD = -0.31, 95% CI = -0.40, -0.22; in the RD group, MD = -0.22, 95% CI = -0.41, -0.03), with no difference between the two groups (p=0.41). However, there was significant heterogeneity in both groups. Considering the last available follow-up, a significant CMT reduction was found in the overall population, irrespective of the indication for vitrectomy (MD = -129.75, 95% CI = -157.49, -102.01; p < 0.001). In the ERM group, a significant CMT reduction was shown following DEX (MD = -133.41, 95% CI = -155.37, -111.45; p < 0.001), with no heterogeneity. In the RD group, mean CMT reduction was borderline significant (MD = -128.37, 95% CI = -253.57, -3.18; p=0.040), with significant heterogeneity. No difference in CMT improvement was found between the two groups (p=0.94).

CONCLUSION

This meta-analysis showed that DEX yielded a significant improvement in visual and anatomical outcomes, even if limited by significant heterogeneity. Dexamethasone implant represents an effective treatment for postoperative macular oedema secondary to ERM and RD vitrectomy.

Effect of anti-inflammatory regimen on early postoperative inflammation after cataract surgery

PURPOSE

To investigate whether a combination of topical nonsteroidal anti-inflammatory drugs (NSAIDs) and steroids were superior in controlling early postoperative inflammation after cataract surgery compared with topical NSAIDs alone and with dropless surgery where a sub-Tenon depot of steroid was placed during surgery.

SETTING

Department of Ophthalmology, Rigshospitalet-Glostrup, Denmark.

DESIGN

Prospective randomized controlled trial with masked statistical analyses.

METHODS

Patients undergoing phacoemulsification for age-related cataract were randomized to 1 of 5 regimens: ketorolac and prednisolone eyedrops combined (Pred+NSAID-Pre [control group] and Pred+NSAID-Post group) vs ketorolac monotherapy (NSAID-Pre and NSAID-Post groups) vs sub-Tenon depot of dexamethasone (dropless group). Drops were used until 3 weeks postoperatively, starting 3 days preoperatively in the Pre groups and on the day of surgery in the Post groups. Aqueous flare was measured at baseline and 3 days postoperatively.

RESULTS

Four hundred fifty-six participants, with a mean age of 72.1 (SD 7.0) years and 283 (62%) women, were included. Flare increased significantly more in the dropless group compared with the control group (Pred+NSAID-Pre), but none of the other groups differed significantly from the control group. Intraocular pressure decreased in all groups but significantly less in groups receiving prednisolone eyedrops (Pred+NSAID-Pre and Pred+NSAID-Post groups) compared with NSAID monotherapy and dropless groups. No differences in postoperative visual acuity were found compared with the control group.

CONCLUSIONS

No differences were found between groups randomized to NSAID monotherapy or combination of NSAID and steroid in controlling early inflammation after cataract surgery, but sub-Tenon depot of dexamethasone was less efficient. Initiating prophylactic eyedrops prior to surgery did not influence early postoperative anterior chamber inflammation.

Fluocinolone Acetonide 0.19 mg Implant in Patients with Cystoid Macular Edema Due To Irvine-Gass Syndrome

Background

Cystoid macular edema (CME) due to Irvine–Gass syndrome (IGS) is one of the common causes of painless visual impairment post-cataract extraction. The treatment of recurrent cases remains unstandardized.

Objective

To evaluate the effectiveness and safety of fluocinolone acetonide intravitreal implant (0.2 µg/day; ILUVIEN^®) in the off-label treatment of recurrent CME due to IGS.

Methods

Retrospective 36-month case series in the Ophthalmology Department of Centro Hospitalar Universitário do Porto, Portugal. Consecutive eyes of patients with recurrent cystoid macular edema due to Irvine–Gass syndrome who underwent a single intravitreal injection of fluocinolone acetonide intravitreal implant were included. Best-corrected visual acuity (logMAR), central macular thickness (µm) and safety (intraocular pressure, mmHg) at baseline and at 6, 12, 24 and 36 months post-administration of the fluocinolone acetonide intravitreal implant were recorded.

Results

Five eyes from three patients were included. The duration of cystoid macular edema was 67.8±25.9 months and all five eyes received more than 2 intravitreal injections of a corticosteroid (triamcinolone and/or dexamethasone implant) prior to fluocinolone acetonide intravitreal implantation. At baseline (median – interquartile range), best-corrected visual acuity was 0.3–0.3; central macular thickness was 492.0–38.0; and intraocular pressure was 16.0–0. By Month 36, best-corrected visual acuity was 0.4 −0.3; central macular thickness was reduced to 369.0–324.0 and intraocular pressure was 17.0–3.0. Four of five eyes had increased intraocular pressure and were managed with intraocular pressure-lowering eye drops.

Conclusion

We report improved functional and anatomical outcomes after treatment with fluocinolone acetonide intravitreal implant, indicating its use as a therapeutic alternative in recurrent cases of cystoid macular edema due to Irvine–Gass syndrome. Additionally, in eyes with suboptimal response to intravitreal therapies, fluocinolone acetonide intravitreal implant may provide longer recurrence-free periods with reduced treatment burden.

Midterm Results of Microhook ab Interno Trabeculotomy in Initial 560 Eyes with Glaucoma

All the 560 glaucomatous eyes of 375 Japanese subjects (181 men, 194 women; mean age ± standard deviation, 76.0 ± 13.2 years) who underwent microhook ab interno trabeculotomy (µLOT) alone (159 eyes, 28%) or combined µLOT and cataract surgery (401 eyes, 72%) performed by one surgeon at Matsue Red Cross Hospital between May 2015 and March 2018 to control intraocular pressure (IOP) were retrospectively assessed. Preoperative and postoperative IOPs, numbers of antiglaucoma medications, the logarithm of the minimum angle of resolution visual acuity (logMAR VA), anterior chamber (AC) flare, visual field mean deviation (MD), and corneal endothelial cell density (CECD) were compared up to 36 months. Surgical complications and required interventions were described. The duration of the follow-up was 405 ± 327 (range, 2–1326) days. The mean preoperative IOP (20.2 ± 7.0 mmHg) and number of antiglaucoma medications (2.8 ± 1.1) decreased to 13.9 ± 4.5 mmHg (31% reduction, p < 0.0001) and 2.5 ± 1.0 (11% reduction, p < 0.0001), respectively, at the final visit. After combined surgery, compared with preoperatively, the final VA improved 0.11 logMAR (p < 0.0001), AC flare increased 4.5 photon counts/msec (p = 0.0011), MD improved 0.6 decibel (p < 0.0001), and the CECD decreased 6% (p < 0.0001). Layered hyphema (172 eyes, 31%) and hyphema washout (26 eyes, 5%) were the most common postoperative complication and intervention, respectively. At the final visit, 379 (69%) eyes achieved successful IOP control of ≤18 mmHg and ≥20% IOP reduction, and 349 (64%) eyes achieved successful IOP control of ≤15 mmHg and ≥20% IOP reduction. Older age, steroid-induced glaucoma, developmental glaucoma, and the absence of postoperative complications were associated with lower final IOP; exfoliation glaucoma, other types of glaucoma, and higher preoperative IOP were associated with higher final IOP. µLOT has a significant IOP-lowering potential in patients with glaucoma, and improves visual function when combined with cataract surgery.

Macular edema after rhegmatogenous retinal detachment repair: risk factors, OCT analysis, and treatment responses

PURPOSE

To investigate risk factors, imaging characteristics, and treatment responses of cystoid macular edema (CME) after rhegmatogenous retinal detachment (RRD) repair.

METHODS

Consecutive, retrospective case-control series of patients who underwent pars plana vitrectomy (PPV) and/or scleral buckling (SB) for RRD, with at least six months of follow-up. Clinical and surgical parameters of patients with and without CME (nCME), based on spectral-domain optical coherence tomography (OCT), were compared.

RESULTS

Of 99 eyes enrolled, 25 had CME while 74 had nCME. Patients with CME underwent greater numbers of surgeries (P < 0.0001). After adjusting for number of surgeries, macula-off RRD (P = 0.06), proliferative vitreoretinopathy (PVR) (P = 0.09), surgical approach (PPV and/or SB, P = 0.21), and tamponade type (P = 0.10) were not statistically significant, although they all achieved significance on univariate analysis (P = 0.001 or less). Intraoperative retinectomy (P = 0.009) and postoperative pseudophakia or aphakia (P = 0.008) were more frequent in the CME group, even after adjustment. Characteristics of cCME on OCT included diffuse distribution, confluent cysts, and absence of subretinal fluid or intraretinal hyperreflective foci. Macular thickness improved significantly with intravitreal triamcinolone (P = 0.016), but not with anti-vascular endothelial growth factor agents (P = 0.828) or dexamethasone implant (P = 0.125). After adjusting for number of surgeries and macular detachment, final visual acuities remained significantly lower in the CME vs nCME group (P = 0.012).

CONCLUSION

Risk factors of CME include complex retinal detachment repairs requiring multiple surgeries, and pseudophakic or aphakic lens status. Although this cCME was associated with poor therapeutic response, corticosteroids were the most effective studied treatments.

Effect of nepafenac 0.1% on retinal thickness after cataract surgery in patients without risk factors for cystoid macular edema

AIM

To evaluate the effect of topical preoperative nepafenac 0.1% treatment on postoperative macular edema using optical coherence tomography (OCT) after uncomplicated cataract surgery.

METHODS

Ninety eyes of 90 patients without any risk factors were included in the study. The patients were assigned to three groups: group 1, treated with topical prednisolone acetate 1%; group 2, treated with topical nepafenac 0.1% in addition to prednisolone acetate (1%); and group 3, those who started receiving nepafenac 0.1% treatment 3d prior to surgery and continued the treatment postoperatively in addition to prednisolone acetate (1%). Central retinal thickness (CRT) and macular volume values were recorded using OCT at weeks 3 and 6.

RESULTS

The increases in macular volume in the central 1 mm area after 3 and 6wk were significantly lower in patients who used prophylactic topical nepafenac preoperatively (group 3) compared with those in group 1 (P=0.028 and 0.008, respectively). No significant differences in the increase in macular volume and CRT were noted between groups 2 and 3 (P>0.05). In group 1, the increases in macular volume in the central 3 mm area at weeks 3 and 6 were significantly higher than that in group 2 and 3 (3^rd week, P=0.004; 6^th week, P=0.005).

CONCLUSION

Nepafenac 0.1% treatment in addition to topical steroids after uncomplicated cataract surgery reduce the increase in macular volume in the early postoperative period.

Anti-interleukin-6 receptor therapy with tocilizumab for refractory pseudophakic cystoid macular edema

Purpose

To describe the clinical course of a patient with refractory pseudophakic cystoid macular edema treated with interleukin-6 receptor antagonist tocilizumab.

Observations

An 80-year-old Caucasian man with past ocular history significant for glaucoma (right eye) and iritis presented with cystoid macular edema (CME) in the right eye (OD). His ocular surgery history was significant for cataract extraction with posterior chamber intraocular lenses in 1999 and YAG laser capsulotomy in 2014 in both eyes (OU). His medications at time of presentation included latanoprost and dorzolamide-timolol in OD for glaucoma, as well as prednisolone in OD for iritis. Upon examination, his visual acuity was 20/250 in OD and 20/20 in the left eye (OS). Intraocular pressure was 20 mmHg in OD and 10 mmHg in OS. Slit-lamp examination revealed no cells or flare in OU. Dilated fundus exam showed CME and a cup-to-disk ratio of 0.9 in OD and normal findings in OS. Initial spectral domain optical coherence tomography (SD-OCT) demonstrated intraretinal fluid in both outer and inner layers as well as mild subretinal fluid with an intact ellipsoid zone in OD. Fluorescein angiography revealed perifoveal leakage in OD. Laboratory evaluations, including infectious work-up, were unremarkable. While the patient's CME initially improved after initiation of therapy with topical prednisolone and oral acetazolamide, the CME later recurred after systemic acetazolamide was stopped due to intolerable side effects. Despite multiple therapeutic approaches, including topical and systemic corticosteroids (both oral and intravenous) and topical interferon α2b over the course of more than one year, the patient's visual acuity continued to worsen with increasing intra- and subretinal fluid in the macula. Due to the refractory CME, the patient was started on monthly infusions of anti-interleukin (IL)-6 receptor tocilizumab (8 mg/kg) with three days of methylprednisolone infusions (500 mg/day). After nine cycles of treatment, SD-OCT demonstrated restoration of normal foveal contour with complete resolution of CME.

Conclusions and Importance

IL-6 inhibition with tocilizumab may be a safe and effective treatment for refractory CME. Further studies are needed to elucidate the nature and extent of therapeutic IL-6 inhibition in CME.

The incidence and management of persistent cystoid macular oedema following uncomplicated cataract surgery-a Scottish Ophthalmological Surveillance Unit study

Purpose

Post-operative cystoid macular oedema (CMO) can cause deterioration of vision following routine cataract surgery. The incidence of persistent CMO (pCMO; defined as CMO present after 3 months) following uncomplicated surgery is uncertain. We wished to identify the incidence, management and visual outcomes of such patients.

Methods

A Scottish Ophthalmological Surveillance Unit (SOSU) questionnaire was sent monthly to every ophthalmic specialist in Scotland over an 18-month period from 1st January 2018 asking them to report all new patients with pCMO confirmed on OCT scanning following uncomplicated cataract surgery. A follow-up questionnaire was sent 9 months after initial presentation.

Results

Fourteen cases of pCMO were reported, giving an incidence of 2.2 cases of pCMO per 10,000 uncomplicated cataract surgeries. Mean age was 74.9 years (SD 10.2; range 44–86) with a male preponderance (72.7%). Two patients developed pCMO in each eye. Six cases (46.2%) had hypertension and one had diabetes. Three eyes required intracameral adjuncts (two iris hooks, one intracameral phenylephrine). Postoperative visual acuity (VA) at 3 months was logMAR 0.48 (0.2–0.8). Average mean central retinal thickness (CRT) at 3 months was 497microns (270–788). The most common initial treatment comprised topical steroids and topical NSAIDs (61.5%). Other management strategies included systemic steroids, intravitreal steroids and oral acetazolamide. At 1-year post-op, mean VA was logMAR 0.18 (0.1–0.3) with average mean CRT of 327microns (245–488).

Conclusions

We identified a low incidence of pCMO following uncomplicated cataract surgery in Scotland (0.02%), with inconsistent and variable management regimes. A nationally agreed treatment protocol is required.

Evaluation of Functional Outcomes and OCT-Biomarkers after Intravitreal Dexamethasone Implant for Postoperative Cystoid Macular Edema in Vitrectomized Eyes

Purpose

To evaluate the efficacy of dexamethasone implant (DEX) for the treatment of postoperative cystoid macular edema (PCME) in vitrectomized eyes and to investigate visual and morphological OCT predictive factors.

Methods

In this retrospective study, eyes with PCME after vitrectomy were treated with at least one DEX injection and were observed over 12 months. Indications for surgery were epiretinal membrane (ERM) or rhegmatogenous retinal detachment (RRD) without macular involvement. Prior treatments, if any, were noted. Best corrected visual acuity (BCVA), central foveal thickness (CFT), and OCT morphology including the presence of intraretinal cysts/fluid or subretinal fluid (IRF/SRF) and ellipsoid zone (EZ) continuity were evaluated. Correlations between OCT measures and visual outcomes were analyzed by the generalized estimating equations procedure.

Results

Forty-six eyes with ERM and 15 eyes with RRD were enrolled. The ERM group was more likely to gain BCVA than RRD (odds ratio (OR), 1.168; 95% confidence interval (CI), 1.003–1.360; p=0.046). The absence of SRF (OR, 0.860; 95% CI, 0.743–0.995; p=0.043) was predictive of worse BCVA, whereas the integrity of EZ (OR, 1.094; 95% CI, 0.951–1.257; p=0.209) or naïve status (OR, 0.946; 95% CI, 0.871–1.137, p=0.853) was not. Eyes with a worse baseline BCVA were more likely to gain >1 line after 12 months (OR, 1.485; 95% CI, 1.171–1.884; p=0.001).

Conclusion

The efficacy of the treatment of PCME in vitrectomized eyes seems to be affected by baseline BCVA, the absence of SRF, and the indication for surgery. Naïve status appears not to play any significant role in the prediction of BCVA. This trial is registered with DRKS00018955.

In Vitro and Ex Vivo Evaluation of Nepafenac-Based Cyclodextrin Microparticles for Treatment of Eye Inflammation

The aim of this study was to design and evaluate novel cyclodextrin (CD)-based aggregate formulations to efficiently deliver nepafenac topically to the eye structure, to treat inflammation and increase nepafenac levels in the posterior segment, thus attenuating the response of inflammatory mediators. The physicochemical properties of nine aggregate formulations containing nepafenac/γ-CD/hydroxypropyl-β (HPβ)-CD complexes as well as their rheological properties, mucoadhesion, ocular irritancy, corneal and scleral permeability, and anti-inflammatory activity were investigated in detail. The results were compared with a commercially available nepafenac suspension, Nevanac^® 3 mg/mL. All formulations showed microparticles, neutral pH, and negative zeta potential (–6 to –27 mV). They were non-irritating and nontoxic and showed high permeation through bovine sclera. Formulations containing carboxymethyl cellulose (CMC) showed greater anti-inflammatory activity, even higher than the commercial formulation, Nevanac^® 0.3%. The optimized formulations represent an opportunity for topical instillation of drugs to the posterior segment of the eye.

A matched case-control study of the clinical, economic, and patient-reported outcomes of cystoid macular edema complicating phacoemulsification surgery

PURPOSE

To assess the visual outcomes of pseudophakic cystoid macular edema (CME) as compared with age- and copathology-matched control subjects, the costs of treatment and follow-up, and the patient-reported outcomes using the new Cat-patient-reported outcome measures (PROM) 5 questionnaire.

SETTING

West Suffolk Hospital NHS Foundation Trust, United Kingdom.

DESIGN

Matched case-control study.

METHODS

Fifty-two eyes of 49 patients developed CME over an 18-month period. Age- and copathology-matched patients were identified from clinical records over the same time period in a 2:1 ratio (90 eyes). Postoperative clinical outcomes were recorded including treatments received, costs of treatments, and patient-reported outcome measures using the Cat-PROM5.

RESULTS

Patients with CME reported a significantly worse outcome from surgery than control subjects. Furthermore, patients with CME had significantly worse visual acuity postoperatively than control subjects (CME: logarithm of the minimum angle of resolution 0.40 ± 0.33, n = 37; control subjects: 0.30 ± 0.33; P < .05) despite there being no difference in preoperative visual acuity. In patients with epiretinal membrane (ERM), notably those with CME had worse patient-reported outcomes than control subjects with ERM, and only 18% received prophylactic corticosteroid injection at surgery compared with 63.6% of control subjects. CME resulted in an excess of 266 outpatient appointments, with 388 weeks of topical therapy, 18 orbital floor injections, 6 intravitreal steroid injections, 5 intravitreal antivascular endothelial growth factor injections, and 1 intravitreal dexamethasone implant with an excess expenditure of £216.81 per case.

CONCLUSIONS

Patients developing CME after cataract surgery had reduced visual acuity at 4 to 6 weeks, patient-reported visual outcomes, and increased number of hospital appointments, treatments, and costs.

Cystoid macular edema related to cataract surgery and topical prostaglandin analogs: Mechanism, diagnosis, and management

Cystoid macular edema (CME) is a form of macular retina thickening that is characterized by the appearance of cystic fluid-filled intraretinal spaces. It has classically been diagnosed upon investigation after a decrease in visual acuity; however, improvements in imaging technology make it possible to noninvasively detect CME even before a clinically significant decrease in central vision. Risk factors for the development of CME include diabetic retinopathy, retinal vein occlusion, uveitis, and cataract surgery. It has been proposed that eyes with elevated intraocular pressure after cataract surgery, including those treated with prostaglandin analog eye drops, may be at higher risk for the development of CME. We summarize the current knowledge of the molecular mechanisms underlying CME, the potential role of ocular surgery and topical glaucoma medication in increasing the risk of CME, the newly developed imaging methods for diagnosing CME, and the clinical management of CME.

Novel Triamcinolone Acetonide-Loaded Liposomal Topical Formulation Improves Contrast Sensitivity Outcome After Femtosecond Laser-Assisted Cataract Surgery

Purpose: To assess visual results, macular modifications, and the incidence of clinically significant macular edema (CSME) in patients using a topical triamcinolone acetonide-loaded liposomal formulation (TA-LF) after femtosecond laser-assisted cataract surgery (FLACS). Methods: Fifty-six eyes after FLACS were selected. Twenty-eight eyes in the combined therapy group (P + N) were treated with prednisolone 1% and nepafenac 0.1% for 21 days postoperatively, whereas 28 eyes in the TA-LF group received a liposomal formulation containing 2 mg/mL of TA (0.2%) for the same period of time. Follow-up visits at 1 day, 6 weeks, and 12 weeks after surgery consisted of visual acuity, contrast sensitivity (CS), central foveal thickness (CFT), total macular volume (TMV) measurements, and the detection of CSME. Results: CS improved in the TA-LF group (basal value: 1.087 ± 0.339 vs. 1.276 ± 0.147 at week 12, P = 0.0346), whereas in the P + N group, CS was not different from the baseline (basal value: 1.130 ± 0.331 vs. 1.274 ± 0.133 at week 12, P = 0.1276). There were similar increases in postoperative CFT and TMV in both groups. CFT and TMV significantly correlate with CS only in the TA-LF group. The r² for CFT and CS was 0.1963 (P = 0.0206), whereas the r² for TMV and CS was 0.3615 (P = 0.0007) at 12 weeks. No difference was observed in the incidence of CSME between the groups. Conclusion: TA-LF is associated with better CS outcomes compared to combined therapy after FLACS.

RESPONSE OF INFLAMMATORY CYSTOID MACULAR EDEMA TO TREATMENT USING ORAL ACETAZOLAMIDE

PURPOSE

To determine the treatment effect of oral acetazolamide on refractory inflammatory macular edema.

METHODS

A retrospective review of identified patients with uveitic or pseudophakic macular edema treated using acetazolamide between 2007 and 2014. Visual acuity and central macular subfield thickness was determined at baseline and at first follow-up. Baseline optical coherence tomography features were analyzed as predictors of acetazolamide response.

RESULTS

Sixteen patients (19 eyes) of 61 screened met all criteria. Mean age was 57.9 years (19.7-81.1). The most common diagnosis was idiopathic uveitis (n = 6, 31.6%). Mean uveitis duration was 4.4 years (0.2-27.5). Average central macular subfield thickness decreased significantly (from 471.8 ± 110.6 μm to 358.3 ± 50.4 μm) (P < 0.0001). Average visual acuity (logarithm of the minimum angle of resolution) improved significantly from 20/54 (0.43 ± 0.25) to 20/37 (0.27 ± 0.16) (P = 0.003). Pretreatment optical coherence tomographies demonstrated intraretinal fluid (n = 19, 100%), subretinal fluid (n = 8, 42.1%), epiretinal membrane (n = 13, 68.3%), and vitreomacular traction (n = 1, 5.2%). No optical coherence tomography characteristic was predictive of a response to therapy.

CONCLUSION

There is a significant benefit to vision and central macular subfield thickness after acetazolamide treatment in patients with inflammatory macular edema. In patients with refractory inflammatory macular edema, treatment using acetazolamide can provide anatomical and visual benefit without corticosteroid-related adverse effects.

Novel Triamcinolone Acetonide-Loaded Liposomes Topical Formulation for the Treatment of Cystoid Macular Edema After Cataract Surgery: A Pilot Study

Purpose: To report tolerability, safety, and efficacy of a topical triamcinolone acetonide-loaded liposomes formulation (TA-LF) in targeting the macular area in patients with refractory pseudophakic cystoid macular edema (PCME).

Methods: For tolerability, safety and efficacy evaluation, 12 eyes of 12 patients with refractory PCME were exposed to one drop of TA-LF (TA at 0.2%) every 2 h for 90 days or until best-corrected visual acuity (BCVA) was achieved. Intraocular pressure (IOP), slit lamp examination, and central foveal thickness (CFT) were analyzed at every visit.

Results: Patients with refractory PCME under TA-LF therapy showed a significant improvement in BVCA and CFT without significant IOP modification (P = 0.94). On average CFT decreased to 206.75 ± 135.72 μm and BCVA improved to 20.08 ± 10.35 letters (P < 0.0005). BCVA was achieved at 10.58 ± 6.70 weeks (range 2–18). TA-LF was well tolerated in all cases. Neither ocular surface abnormalities nor adverse events were recorded.

Conclusion: TA-LF was well tolerated and improved BCVA and CFT on patients with refractory PCME.

A Comparative Study of Characteristics and Outcomes of Patients with Proved and Suggested Sarcoid Uveitis Occurring after Ophthalmic Procedure

Purpose

To describe patients with new onset sarcoid uveitis occurring after an ophthalmic procedure and compare them with patients with sarcoid uveitis without ocular procedure.

Methods

Retrospective analysis of case records from patients with postophthalmic procedure sarcoid uveitis seen at our institution between April 2004 and October 2016. Patients with a previous history of uveitis were not included. Each patient was randomly matched with four controls from our incident cohort of new onset sarcoid uveitis without ophthalmic procedure.

Results

We identified 11 patients (8.5%) from our incident cohort of sarcoid uveitis (n=130), who were all women, with a postophthalmic procedure uveitis (mostly after cataract surgery (36%)). These patients were older (69.7 vs 52.7 years) and presented more synechiae than controls. After a mean follow-up of 30 (3–60) months, there was no significant difference between the postprocedure and the control group with regard to demography, clinical presentation, disease course, treatment, and outcome.

Conclusions

Sarcoid uveitis has similar characteristics in patients with new onset sarcoid uveitis after or without ophthalmic procedure. As a consequence, ophthalmic intervention should be seen as a potential trigger of latent sarcoidosis.