Management of macular oedema due to retinal vein occlusion: An evidence-based systematic review and meta-analysis

Baseline macular structural and vascular changes as predictive markers of visual improvement in central retinal vein occlusion

OBJECTIVE

This study aims to evaluate the changes in posterior segment parameters that affect visual prognosis in patients with central retinal vein occlusion (CRVO).

METHODS

This retrospective study included 58 eyes of 58 CRVO patients. Best-corrected visual acuity (BCVA), intraocular pressure, central macular thickness (CMT), hyperreflective foci (HRF), ellipsoid zone (EZ) loss, disorganization of retinal inner layers (DRIL), intraretinal cystic changes, posterior vitreous detachment (PVD), and macular superficial and deep vascular density (VD), as well as superficial and deep foveal avascular zone (FAZ) areas, were assessed at baseline and 3 months follow-up after treatment. The treatments (intravitreal injections and laser) received were recorded.

RESULTS

The mean age was 63.02±9.91 years, 37 (63.8%) were female, and 39 (67.3%) were classified as having non-ischemic CRVO. The mean baseline BCVA was 0.64±0.85 logMAR; at 3 months, it improved to 0.39±0.65 logMAR (p<0.001). The mean baseline CMT was 478.9±82.6 µm, and at 3 months, it reduced to 288.56±72.39 µm (p<0.001). At baseline, HRF in 31% of eyes, EZ disruption in 44.8% of eyes, DRIL in 17.2% of eyes, intraretinal cysts in 55.2% of eyes, and PVD in 43.1% of eyes. A significant decrease in BCVA was observed in patients with EZ loss (p<0.001), while the presence of intraretinal cysts had significant impact on CMT (p=0.007). Furthermore, a statistically significant negative correlation was observed between foveal and superior VD in both the superficial and deep capillary plexus (SCP, DCP) and changes in BCVA (logMAR). In contrast, a positive correlation was found between superficial FAZ area and BCVA (logMAR). Additionally, a statistically significant positive correlation was noted between foveal VD in both the SCP and DCP and changes in CMT.

CONCLUSION

The study emphasizes the importance of structural and vascular changes in predicting functional outcomes and suggests the utility of optical coherence tomography (OCT) and OCT angiography in early visual prognosis and treatment planning.

Efficacy of Ozurdex implants as second-line therapy for non-responders to anti-VEGF in retinal vein occlusion-associated macular edema: a retrospective cohort study

PURPOSE

Retinal vein occlusion (RVO) is a prevalent retinal vascular disorder characterized by retinal haemorrhage, neovascularization, and macular edema This study aimed to assess the structural and functional effects of intravitreal implant (Ozurdex) treatment as a second-line for RVO-associated macular edema in patients who did not respond to first-line anti-VEGF therapy.

MATERIALS AND METHODS

We conducted a retrospective observational cohort study using electronic health records of RVO patients at Salisbury District Hospital between January 2014 and December 2019. Inclusion criteria included patients diagnosed with central or branch RVO. Patients underwent ophthalmic evaluations at baseline, including central retinal thickness (CRT) and best-corrected visual acuity (BCVA) assessments. Statistical analysis was performed using IBM SPSS Statistics, employing various tests to determine significance.

RESULTS

Sixteen eyes of 16 White British patients were evaluated. Most patients had branch RVO (52.95%), and 47.05% had central RVO. While anti-VEGF treatment significantly improved BCVA (p = 0.0061), Ozurdex did not result in additional gain (p = 0.747). Both treatments significantly reduced CRT (p = 0.0055 for anti-VEGF; p = 0.0079 for Ozurdex). No significant differences were observed between diabetic and non-diabetic BCVA patients receiving either treatment.

CONCLUSION

Ozurdex emerges as a safe and effective option for persistent macular edema in RVO patients unresponsive to anti-VEGF therapy. Although structural improvements in CRT were observed following Ozurdex treatment, they did not correlate with additional gain in BCVA. Despite this, the reduced treatment frequency of Ozurdex compared to anti-VEGF injections may be advantageous, particularly for frail non-responding patients minimizing treatment burden.

Zerumbone Inhibits the Viability, Motility, and Angiogenesis of Human Retinal Microvascular Endothelial Cells (HRCECs) by Inhibiting Vascular Endothelial Growth Factor

PURPOSE

To uncover the possible effects of zerumbone on the viability, motility, and angiogenesis of human retinal microvascular endothelial cells and to clarify the mechanism.

METHODS

5-Ethynyl-2'-deoxyuridine assays were conducted to confirm the effects of zerumbone on the viability of human retinal microvascular endothelial cells. Wound healing, tube formation, and immunoblot assays were conducted to confirm the role of zerumbone in human retinal microvascular endothelial cell motility and angiogenesis, and regulation on vascular endothelial growth factor expression. ELISA was performed to confirm its effects on vascular endothelial growth factor secretion. Colivelin was used to activate the STAT3.

RESULTS

We revealed that zerumbone suppressed the viability of human retinal microvascular endothelial cells. Zerumbone restrained the motility and angiogenesis of human retinal microvascular endothelial cells via targeting STAT3 and regulating the expression and secretion of vascular endothelial growth factor in vitro. Zerumbone treatment suppressed the angiogenesis, whereas Colivelin treatment reversed the suppression of angiogenesis caused by zerumbone.

CONCLUSION

Zerumbone restrained the viability, motility and angiogenesis of human retinal microvascular endothelial cells by inhibiting vascular endothelial growth factor expression.

Associations between the Vessel Density in Deep Vascular Plexus and Macular Edema Recurrences in Patients with Retinal Vein Occlusion

INTRODUCTION

The aim of this study was to study the relationships between vessel density (VD) in different retinal vascular plexus and retinal vein occlusion-macular edema (RVO-ME) recurrence using wide-field swept source optical coherence tomography angiography (OCTA).

METHODS

Patients with a history of central retinal vein occlusion (CRVO) or branch retinal vein occlusion (BRVO) with macular edema in the Department of Ophthalmology, Shanghai General Hospital, from May 25, 2020, to January 12, 2023, were retrospectively reviewed and recruited. All patients were followed up for at least 6 months and divided in the release group and the recurrence group. The optical coherence tomography and OCTA examination were performed. Demographics, retinal structural, and angiographic data were collected and compared between two groups. The ordinal logistic regression was performed to assess the risk factors for RVO-ME.

RESULTS

A total of 85 patients were enrolled in this study. Among them, 30 patients had CRVO, while 55 had BRVO. The VD in the 6-9 mm ring in deep vascular plexus (DVP) was significantly higher in the recurrence group (25.414 ± 6.068% in the release group vs. 27.574 ± 7.767% in the recurrence group, p = 0.036). More patients with mean VD of the 6-9 mm ring in DVP no less than 30% were observed in the recurrence group (observed n = 20, expected n = 14.4, p = 0.043). The ordinal logistic regression reported that patients with mean VD of the 6-9 mm ring in DVP ≥30% had risk of RVO-ME increased to 11.508 (95% CI: 1.745-75.944, p = 0.011), when compared to the patients with mean VD of the 6-9 mm ring in DVP <20%, even with RVO type, baseline central macular thickness weighed.

CONCLUSION

High vessel density of the 6-9 mm ring in DVP, especially those ≥30%, was associated with macular edema recurrences in patients with retinal vein occlusion.

Automated interpretation of retinal vein occlusion based on fundus fluorescein angiography images using deep learning: A retrospective, multi-center study

Purpose

Fundus fluorescein angiography (FFA) is the gold standard for retinal vein occlusion (RVO) diagnosis. This study aims to develop a deep learning-based system to diagnose and classify RVO using FFA images, addressing the challenges of time-consuming and variable interpretations by ophthalmologists.

Methods

4028 FFA images of 467 eyes from 463 patients were collected and annotated. Three convolutional neural networks (CNN) models (ResNet50, VGG19, InceptionV3) were trained to generate the label of image quality, eye, location, phase, lesions, diagnosis, and macular involvement. The performance of the models was evaluated by accuracy, precision, recall, F-1 score, the area under the curve, confusion matrix, human-machine comparison, and Clinical validation on three external data sets.

Results

The InceptionV3 model outperformed ResNet50 and VGG19 in labeling and interpreting FFA images for RVO diagnosis, achieving 77.63%-96.45% accuracy for basic information labels and 81.72%-96.45% for RVO-relevant labels. The comparison between the best CNN and ophthalmologists showed up to 19% accuracy improvement with the inceptionV3.

Conclusion

This study developed a deep learning model capable of automatically multi-label and multi-classification of FFA images for RVO diagnosis. The proposed system is anticipated to serve as a new tool for diagnosing RVO in places short of medical resources.

Systematic review of clinical practice guidelines for the diagnosis and management of retinal vein occlusion

BACKGROUND/OBJECTIVES

To assess the methodological quality of Clinical Practice Guidelines (CPG) for the diagnosis and management of Retinal Vein Occlusion (RVO).

METHODS

A systematic review of CPGs for the diagnosis and management of RVO was carried out with a search in databases, metasearch engines, CPG development institutions, ophthalmology associations and CPG repositories until April 2022. Search update was performed on April 2023, with no new record available. Five CPGs published in the last 10 years in English/Spanish were selected, and 5 authors evaluated them independently, using the Appraisal of Guidelines for Research and Evaluation (AGREE-II) instrument. An individual assessment of each CPG by domain (AGREE-II), an overall assessment of the guide, and its use with or without modifications were performed. Additionally, a meta-synthesis of the recommendations for the most relevant outcomes was carried out.

RESULTS

The lowest score (mean 18.8%) was for domain 5 'applicability', and the highest score (mean 62%) was for domain 4 'clarity of presentation'. The 2019 American guideline (PPP) presented the best score (40.4%) in domain 3 'rigour of development'. When evaluating the overall quality of the CPGs analysed, all CPGs could be recommended with modifications. In the meta-synthesis, anti-VEGF therapy is the first-choice therapy for macular oedema associated with RVO, but there is no clear recommendation about the type of anti-VEGF therapy to choose. Recommendations for diagnosis and follow-up are similar among the CPGs appraised.

CONCLUSION

Most CPGs for the diagnosis and management of RVO have a low methodological quality assessed according to the AGREE-II. PPP has the higher score in the domain 'rigour of development'. Among the CPGs appraised, there is no clear recommendation on the type of anti-VEGF therapy to choose.

Relationship between ischemic index, leakage index, and macular edema in branch retinal vein occlusion

PURPOSE

To investigate the combined association of the ischemic index and leakage index with macular edema on ultra-widefield fluorescein angiography (UWFFA) in patients with branch retinal vein occlusion (BRVO).

METHODS

Retrospective image analysis study. The leakage index and ischemic index were calculated using Fiji after aligning early and late UWFFA images. Differences in the ischemic index, leakage index, and central macular thickness (CMT) between ischemic and non-ischemic BRVO were compared. Moreover, the association between the ischemic index, leakage index, and macular edema was analyzed.

RESULTS

Eighty-three patients with BRVO were enrolled, including 53 non-ischemic BRVO and 30 ischemic BRVO patients. No significant differences were observed in leakage index and CMT between ischemic BRVO and non-ischemic BRVO (all P > 0.05). In all included patients, CMT correlated with the panretina and all subregion leakage indexes (all P < 0.01), but not with the ischemic index (all P > 0.05). In the ischemic BRVO group, CMT showed a correlation with the leakage index in several regions, but not with the ischemic index. After adjusting for the ischemic index and other clinical features, CMT remained significantly correlated with the leakage index in all regions.

CONCLUSION

The leakage index may be a more effective biomarker for monitoring BRVO-associated macular edema compared to the ischemic index. Further follow-up studies are warranted to validate these findings.