Characterizing the Journey of Geographic Atrophy Patients in Routine Ophthalmic Practice

BACKGROUND AND OBJECTIVE

Geographic atrophy (GA) is a form of late-stage age-related macular degeneration (AMD). This study aims to characterize the journey of patients with GA in real-world ophthalmology practice.

PATIENTS AND METHODS

This is a retrospective cohort study of 100 patients with GA and 100 with intermediate AMD (iAMD).

RESULTS

Approximately one-third of GA patients' eyes had GA at the time of their initial AMD diagnosis, and nearly half of the iAMD patients' eyes had iAMD at that time. When holding confounders constant, GA patients experienced significantly worse visual acuity outcomes, and a significantly higher proportion required referrals for low vision evaluation, needed assistance for activities of daily living, failed to meet driving standards, and met criteria for legal blindness when compared to iAMD controls.

CONCLUSIONS

Many patients have already progressed to GA by the time they receive an AMD diagnosis, emphasizing the importance of providing early detection and intervention, especially considering novel treatment options. [Ophthalmic Surg Lasers Imaging Retina 2024;55:204-210.].

Ophthalmic sequelae of prematurity in late childhood and adulthood: A review

Advances in the care of premature infants have resulted in unprecedented rates of survival of these infants into adulthood, including those born at very low gestational ages. Ophthalmologists have historically followed premature infants to assess for the presence of and potential need for treatment of retinopathy of prematurity. However, a growing body of literature suggests that the ophthalmic consequences of prematurity extended beyond retinopathy of prematurity and that ophthalmic sequelae of prematurity can endure through adulthood even among formerly preterm adults who were never diagnosed with retinopathy of prematurity. These abnormalities can include a range of both anterior segment and posterior segment sequelae, including higher rates of corneal aberrations, ocular hypertension, strabismus, foveal anomalies, and retinal tears and detachments. This review aims to summarise this literature, underscoring the importance of lifelong examinations and regular monitoring for these complications among adults who were born prematurely.

Effect of Prefilled vs Vial-Drawn Syringes on Sustained Increases in Intraocular Pressure in Patients Treated With Aflibercept

Purpose: To evaluate the effect of syringe type on developing sustained intraocular pressure (IOP) increases. Methods: This retrospective cohort study included patients in a single academic center receiving antivascular endothelial growth factor (anti-VEGF) injections from 2012 to 2022 for various indications. Patients were grouped by anti-VEGF treatment of either vial-drawn or prefilled syringe delivery. Trends in IOP were recorded for 1 year after treatment began. Development of sustained IOP increase, ocular hypertension, and glaucoma was recorded. Sustained IOP increase was defined as ≥5 mm Hg above baseline for at least 4 weeks. Results: Of 257 total patients, 6 (2.3%) developed sustained IOP increases throughout the study's duration. No significant differences were noted with respect to prefilled versus vial-drawn syringe status on the development of sustained IOP increases or incident glaucoma (IOP: 1.8% vs 2.7%, respectively, P = .65; glaucoma: 0.0% vs 2.0%, respectively, P = .14). Patients treated with prefilled syringes were significantly less likely to develop ocular hypertension (2.8% vs 8.8%, P < .05). Conclusions: This study found that aflibercept intravitreal injection with prefilled syringes was not associated with a significant increase in IOP-related adverse effects when compared with those treated with vial-drawn syringes.

Outcomes in patients with retinal vein occlusion with good baseline visual acuity

BACKGROUND

Intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) are first-line therapy for macular oedema in retinal vein occlusion (RVO). Appropriate management for RVO with good visual acuity at diagnosis has not been evaluated. The purpose of this study is to analyse the visual and anatomic outcomes from anti-VEGF treatment among RVO patients with good vision at baseline.

METHODS

This retrospective cohort study evaluated patients diagnosed with macular oedema secondary to RVO from January 2012 to February 2021 at a tertiary ophthalmic centre. Patients had a Snellen acuity of 20/32 or better at diagnosis. Three cohorts were compared: patients with no anti-VEGF treatment, delayed anti-VEGF treatment (initial injection >30 days post-diagnosis) and immediate anti-VEGF treatment (initial injection ≤30 days post-diagnosis). Central subfield thickness (CST) and best visual acuity (BVA) were collected at diagnosis and 6-, 12- and 24-month follow-up appointments.

RESULTS

Among 131 eyes, mean BVA values among treatment groups did not differ at 6-, 12- or 24-month follow up visits (P = 0.521, 0.426, 0.356, respectively). The percentage of eyes with at least a 5-letter BVA decrease at 24 months was 24.1%, 65.0% and 30.8% in the no treatment, delayed and immediate treatment groups respectively (P = 0.010). There was no significant difference in the percentage of eyes with at least a 10% decrease in CST at 24 months among groups (P = 0.095).

CONCLUSIONS

Close observation with initiation of treatment in patients with good visual acuity with macular oedema secondary to RVO as indicated has similar outcomes in the setting of routine clinical practice.

Visual Acuity in Patients Requiring Intravitreal Injections: Short-Term and Long-Term Effects of Delay in Care

Purpose: To assess the short-term and long-term effects of a delay in care on visual acuity (VA) in patients requiring intravitreal injections. Methods: This retrospective cohort study comprised patients with neovascular age-related macular degeneration (nAMD), diabetic macular edema (DME), or retinal vein occlusion (RVO) receiving intravitreal injections. The visual and anatomic outcomes at the next completed visit and at the 1-year follow-up were studied. Results: Of 1172 patients, 38% had a delay in care (mean 5.7 weeks). Compared with baseline, these patients lost VA (Early Treatment Diabetic Retinopathy Study letters) (mean −2.13 ± 0.49 SE) in the short-term ( P = .0003) and had a thicker central subfield. Patients with no delay in care had a net VA gain (0.97 ± 0.39) ( P = .0067). There was no difference in VA between 1 year and the baseline in either group. Long term, patients with nAMD in both groups had VA loss (no delay in care: −1.76 ± 0.60; delayed care: −2.44 ± 0.78) ( P = .0005 and P = .0114, respectively). Patients with DME and no delay in care maintained gains in vision (4.68 ± 1.86) but those with delayed care did not (1.72 ± 2.24) ( P = .0202 and P = .3756, respectively). In both groups, patients with RVO had no significant difference in vision from baseline. Conclusions: In patients requiring intravitreal injections, a delay in care of 5.7 weeks affected vision outcomes in the short term but not the long term.

Visual, Anatomic Outcomes, and Natural History of Retinal Nerve Fiber Layer Schisis in Patients Undergoing Epiretinal Membrane Surgery

PURPOSE

To evaluate the anatomic and visual outcomes of patients with idiopathic epiretinal membranes (ERMs) complicated by schisis of the retinal nerve fiber layer (sRNFL) in routine clinical practice.

DESIGN

Retrospective case-control study.

PARTICIPANTS

Patients undergoing idiopathic ERM surgery at Cole Eye Institute from 2013 to 2021.

METHODS

Patients were grouped by the presence or absence of sRNFL before surgery. Preoperative and postoperative data were collected regarding visual acuity (VA), changes in central subfield thickness (CST) over time, and presence of cystoid macular edema.

MAIN OUTCOME MEASURES

Frequency of sRNFL in patients undergoing idiopathic ERM surgery.

RESULTS

Overall, 48 (53.9%) of 89 patients presented with sRNFL. Schisis of the retinal nerve fiber layer patients presented with significantly decreased VA compared with those without (58.63 ± 12.48 vs. 67.68 ± 7.84 ETDRS letters, P < 0.001, respectively). At the final follow-up after ERM removal, there was no significant difference in final VA in patients with sRNFL compared with those without (71.16 ± 2.93 vs. 74.11 ± 2.76, P = 0.467). At presentation, patients with sRNFL had greater CST than those without (454 ± 10.01 vs. 436 ± 0.23, P = 0.23). This difference persisted at the 90-day follow-up after ERM removal (402 ± 8.08 vs. 375 ± 10.19 μm, P = 0.043). The resolution of sRNFL was reported at postoperative week 1 in 30 (96.7%) of 31 cases.

CONCLUSIONS

Schisis of the retinal nerve fiber layer is a microstructural feature in > 50% of idiopathic ERMs in routine clinical practice and carries visual significance on presentation and anatomic significance postoperatively.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

The Utilization of Phone Communication with Patient Companions During a Pandemic

Involvement of companions is a critical aspect of patient-centered care. This retrospective cross-sectional study examined patients who were asked, by utilizing electronic medical record (EMR) preset questions (SmartPhrase template), if they wanted another individual called during the assessment and plan portion of an ophthalmology visit. Of 518 patients, 14.5% wanted another individual called. New patients as well as those who needed procedural or surgical intervention were more likely to want a companion called. Adoption of a SmartPhrase template within clinical workflow may be a feasible and effective method to increase communication with companions of physically unaccompanied patients and promote patient-centered care.

Ophthalmology Provider Ratings and Patient, Disease, and Appointment Factors

The purpose of the current study is to examine how nonmodifiable sociodemographic, disease, appointment, management, and survey factors correlate with provider rating. This was a retrospective cross-sectional study conducted on 29 857 patient Clinician and Group Consumer Assessment of Healthcare Providers and Systems surveys collected from January 2017 to January 2019 at a tertiary eye center. We included surveys of patients aged 18 years or older, who answered at least 4 of 6 subfield questions, and completed the survey within 90 days of the appointment. The main outcome was the odds of receiving top box score (TBS) of 10/10 on the survey question regarding overall provider rating. The results showed that the variables with higher odds of TBS included higher overall appointment attendance (odds ratio [OR]: 2.66 [95% CI: 1.23-5.75], P = .013); older patient age (OR 2.44 [95% CI: 2.08-2.87], P < .001]; higher percentage of survey questions completed (OR: 2.02 [95% CI: 1.79-2.27], P < .001); better best corrected visual acuity (OR: 1.85 [95% CI: 1.3-2.64], P = .001); optometry clinic visit (OR: 1.25 [95% CI: 1.15-1.36], P < .001); having procedures (OR: 1.19 [95% CI: 1.04-1.36], P = .013), surgery scheduled (OR: 1.18 [95% CI: 1.03-1.36], P = .020], or refraction done (OR: 1.16 [95% CI: 1.08-1.25], P < .001); being seen by male providers (OR: 1.11 [95% CI: 1.04-1.17], P = .001); and having additional eye testing performed (OR: 1.06 [95% CI: 1.00-1.13], P = .048). Variables associated with lower odds of TBS included longer time to complete survey (OR: 0.42 [95% CI: 0.3-0.58], P = .001); new patient encounter (OR: 0.62 [95% CI: 0.58-0.65], P < .001); and glaucoma (OR: 0.66 [95% CI: 0.59-0.75], P < .001), cornea (OR: 0.79 [95% CI: 0.71-0.87], P < .001), or comprehensive clinic visits (OR: 0.86 [95% CI: 0.79-0.94], P < .001). Thus, nonmodifiable factors may affect the provider rating, and these factors should be studied further and accounted for when interpreting the results of patient experience surveys.

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.].

The Effect of Delay in Care among Patients Requiring Intravitreal Injections

PURPOSE

To examine the effect of delay in care on visual acuity (VA) in patients requiring intravitreal injections (IVIs).

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients 18 years of age or older with diabetic macular edema (DME), proliferative diabetic retinopathy (PDR), or both; neovascular age-related macular degeneration (nAMD); or retinal vein occlusion (RVO) scheduled to see a retina specialist during the mandated lockdown period (March 14 - May 4, 2020 [the coronavirus disease 2019 period]) and who had received an IVI in the 12 weeks prior.

METHODS

Chart review was performed and demographics, diagnoses, procedures, and VA were recorded.

MAIN OUTCOME MEASURES

VA in patients who completed, canceled, and no-showed for the scheduled visit.

RESULTS

Of the 1041 total patients, 620 (60%) completed the scheduled visit, whereas 376 (36%) canceled and 45 (4%) no-showed. In patients who missed the visit, the average delay in care was 5.34 weeks. In those who missed a visit, VA was assessed at the subsequent visit. Patients who canceled a visit were older, and patients who no-showed had lower baseline vision (mean Early Treatment Diabetic Retinopathy Study letters ± standard error [SE]: no-show, 53.27 ± 3.21 letters; canceled, 60.79 ± 1.11 letters; and completed, 62.81 ± 0.84 letters; P = 0.0101) and were more likely to have DME, PDR, or both (no-show, 13 patients [29%]; canceled, 56 patients [16%]; completed, 81 patients [13%]; P = 0.0456). Patients who missed a visit lost vision as compared with the patients who completed one (no-show, -5.024 ± 1.88 letters; canceled, -1.633 ± 0.65 letters; completed, 0.373 ± 0.50 letters; P = 0.0028). Patients with DME, PDR, or both (-3.48 ± 1.95 letters vs. 2.71 ± 1.75 letters; P = 0.0203), with RVO (-3.22 ± 1.41 letters vs. 0.95 ± 1.23 letters; P = 0.0230), and, to lesser degree, with nAMD (-1.23 ± 0.70 letters vs. -0.24 ± 0.56 letters; P = 0.2679) lost vision compared with patients with same diagnoses who completed the scheduled visit.

CONCLUSIONS

In patients requiring IVIs, a delay in care of 5.34 weeks resulted in vision loss. It was seen in all patients, but was more prominent in patients with DME, PDR or both and RVO. Further studies are necessary to examine whether these vision changes persist over a longer duration.

Characterization of Kiosk Usage for Ophthalmic Outpatient Visits

BACKGROUND AND OBJECTIVES

This study aims to characterize check-in kiosk usage within a multidisciplinary ophthalmic clinic.

PATIENTS AND METHODS

Chart review of patients aged 18 or older seen at Cole Eye Institute, Cleveland Clinic, from August 1, 2019, to October 31, 2019. Primary endpoint was percentage of patients who used a check-in kiosk. Secondary endpoints were demographic characteristics and visual acuity (VA) of the two groups.

RESULTS

Of 13,752 patients, 3,542 (26%) used a check-in kiosk. Kiosk users were significantly younger than kiosk non-users (median [interquartile range (IQR)]: 63.6 [49.4-72.6] vs. 66.6 [55.0-75.4]; P < .0001), had a lower proportion of Medicaid patients (282 [8%] vs. 930 [10%]; P < .0001), and lived in areas with a greater median income (mean [± standard error]: $58,421 [± 399) vs. $54,992 [±236]; P < .0001). On average, they also had better VA (mean ETDRS [95% confidence interval]: 80.5 [80-80.9] vs. 78.3 [78-78.6]; P < .0001).

CONCLUSIONS

Significant demographic and VA differences were observed between kiosk users and non-users and may influence kiosk usage. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:684-690.].

Patient-Reported Complications after Intravitreal Injection and Their Predictive Factors

Purpose

The intravitreal injection (IVI) of pharmacologic agents is the most commonly performed ocular procedure and is associated with a host of complications. Most IVI-related complications data are derived from randomized controlled clinical trials, which report a high adverse event rate. The nature of these protocol-driven trials limit their applicability to the diverse circumstances seen in routine clinical practice. The goal of this study was to determine the prevalence of patient-reported IVI-related complications, their risk factors, and the manner in which patients sought treatment at a tertiary eye care center.

Design

Retrospective, institutional review board–approved study.

Participants

Forty-four thousand seven hundred thirty-four injections in 5318 unique patients at the Cleveland Clinic Cole Eye Institute from 2012 through 2016.

Methods

Intravitreal injection.

Main Outcome Measures

Complication occurrence within 15 days of injection.

Results

From 2012 through 2016, a total of 44734 injections were performed in 5318 unique patients. Overall, complication rates were low, representing 1.9% of all injections, with 1031 unique complications in 685 patients (12.9%). The most common minor complications, or those not requiring intervention, were irritation (n = 312) and subconjunctival hemorrhage (n = 284). The most common serious complications, or those requiring intervention, were corneal abrasion (n = 46) and iritis (n = 31). Most complications (66%) were managed adequately by a telephone or Epic (Epic Systems Corp., Verona, WI) electronic message encounter only. Importantly, no injection protocol parameter, such as type of anesthesia, preparation, or post-injection medication, increased the risk of a complication. However, a patient’s gender, age, number of previous injections, and provider strongly influenced the risk of patient-reported complications.

Conclusions

Overall, complication rates seen in routine clinical practice were low compared with clinical trial reporting. Providers should feel confident in the safety and administration of IVI during times when follow-up office visits and resources may be limited. When performing an IVI, factors such as a patient’s gender, age, number of previous injections, and provider must be taken into account to ensure the best possible outcomes.

Impact of Drusen Burden on Incidence of Subclinical CNV With OCTA

BACKGROUND AND OBJECTIVE

To evaluate the impact of drusen burden on the detection of subclinical choroidal neovascularization (CNV) on optical coherence tomography angiography (OCTA) in nonexudative age-related macular degeneration (AMD).

PATIENTS AND METHODS

A subanalysis of the AVATAR study, subjects diagnosed with nonexudative AMD without subfoveal atrophy were included. Subclinical CNV was assessed using OCTA software, and drusen burden was graded utilizing the advanced retinal pigment epithelium (RPE) analysis.

RESULTS

Among eligible 58 eyes, 26 eyes (45%) had high drusen burden. Of the three eyes (5%) that demonstrated subclinical CNV, only one eye had high drusen burden, and all three eyes had neovascular AMD in the fellow eye. Extrafoveal RPE atrophy (odds ratio [OR] = 20.0; 95% confidence interval [CI], 1.53-261) and older age (OR = 1.27; 95% CI, 1.01-1.59) were predictive factors for subclinical CNV.

CONCLUSION

Extrafoveal RPE atrophy, older age, and fellow-eye CNV were significant risk factors for underlying subclinical CNV in nonexudative AMD. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:22-30.].

iOCT-assisted macular hole surgery: outcomes and utility from the DISCOVER study

BACKGROUND/AIMS

This study aimed to characterise the clinical outcomes and utility of intraoperative optical coherence tomography (iOCT)-assisted macular hole (MH) repair.

METHODS

This was a post hoc analysis of eyes in the D etermination of feasibility of I ntraoperative S pectral domain microscope C ombined/integrated O CT V isualization during E n face R etinal and ophthalmic surgery (DISCOVER) study undergoing surgical MH repair with use of iOCT. Functional and surgical outcome data were collected through 12 months postoperatively. MH closure rate, postoperative visual acuity (VA), percentage of cases in which iOCT provided valuable feedback and altered surgical decision making were measured.

RESULTS

Eighty-four eyes were included in this study. The mean preoperative VA measured 20/114. The mean postoperative VA improved to 20/68 (p<0.001) at month 1, 20/48 (p<0.001) at month 3 and 20/45 (p<0.001) at month 12 or later. In 43 cases (51%), surgeons reported that iOCT provided valuable information (eg, confirming release of vitreomacular traction and identification of occult residual membranes). In 10 cases (12%), iOCT data specifically altered surgical decision making. Postoperative day 1 transtamponade OCT confirmed tissue apposition and apparent hole closure in 74% of eyes (21/26). All five open holes on postoperative day 1 closed following positioning. Single-surgery MH closure was achieved in 97.6% of cases. One persistent MH was successfully closed with a subsequent surgical repair for a final overall closure rate of 98.8%. Due to chronicity and MH size, additional repair was not recommended for the single remaining persistent MH.

CONCLUSION

This study suggests that iOCT may have important utility in MH surgery, including impacting surgical decision making. iOCT-assisted MH surgery resulted in significant improvement in VA and high single-surgery success rate.

Correlation between Argus II array-retina distance and electrical thresholds of stimulation is improved by measuring the entire array

PURPOSE

To describe two methods of measuring Argus II array-retina distance and to correlate array-retina distance to electrode stimulation thresholds.

METHODS

This was a case series of eight patients implanted with the Argus II. Spectral domain-optical coherence tomography array-retina distance was measured by two methods and correlated to corresponding electrode thresholds: (1) array-retina distance at each array corner and the largest array-retina distance and (2) using manual optical coherence tomography segmentation, the average array-retina distance was determined for each group of four electrodes. Patients 1-5 and 6-8 were analyzed separately due to a different threshold programming software.

RESULTS

The Spearman's rank coefficient between array-retina distance and thresholds was -0.006 (p = 0.98) for patients 1-5, and 0.16 (p = 0.59) for patients 6-8 with the first method. The Spearman's rank coefficient was 0.25 (p < 0.001) for patients 1-5 and 0.36 (p < 0.001) for patients 6-8 with the second method.

CONCLUSION

There is a positive correlation between array-retina distance and threshold measurements when measuring the entire array but not when using a faster measurement method of four corners and largest array-retina distance.

Noninvasive Structural Imaging of a Retinal Cavernous Hemangioma Using SS-OCTA and Correlation to Previously Reported Histopathology

Optical coherence tomography angiography (OCTA) is a novel imaging modality, and its role in the clinical evaluation of patients remains to be defined. In this report, the authors describe a case of a retinal cavernous hemangioma and show that OCTA of the lesion recapitulates many structural features first described in previous histopathologic studies, including aneurysmal architecture, septated blood flow, and epiretinal membrane. Thus, OCTA provides a new, noninvasive means of studying retinal cavernous hemangioma structure, a unique capability that may also be clinically relevant to the evaluation of other pathologic retinal vascular tumors, such as capillary and racemose hemangiomas. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:e320-e323.].

Detection of Choroidal Neovascular Membrane Beneath Pigment Epithelial Detachment Using SD-OCTA

BACKGROUND AND OBJECTIVE

To identify choroidal neovascular membrane (CNVM) associated with spectral-domain optical coherence tomography (SD-OCT)-defined pigment epithelial detachment (PED) using SD-OCT angiography (SD-OCTA).

PATIENTS AND METHODS

Sixty-nine patients with same-day OCT and OCTA imaging were reviewed, and 41 eyes of 29 patients with PEDs were included. OCTs were analyzed for PED type, fluid, and subretinal hyperreflective material (SHRM).

RESULTS

Twenty-seven eyes (66%) demonstrated CNVM on OCTA beneath all subtypes of PED. Twenty-two eyes (75.9%) with fluid or SHRM demonstrated CNVM on OCTA (P = .036). Fluid corresponded in a statistically significant manner with treatment (P = .0032), whereas SHRM did not (P = .613). OCTA-defined CNVM showed borderline statistically significant correlation to treatment (P = .05). Increased choroidal flow signal seen in 50% of eyes did not demonstrate statistically significant correlation to the presence of fluid on SD-OCT (P = .2798) or treatment decision (P = .678). A subset of 14 untreated eyes with CNVM was analyzed, 21% of which required treatment at subsequent visits.

CONCLUSIONS

OCTA-defined CNVM was seen in all subtypes of PED in clinically active and inactive disease. The role of OCTA in predicting need for treatment remains to be established. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:620-626.].

Eplerenone for the treatment of chronic central serous chorioretinopathy: 3-year clinical experience

Background/aims

The efficacy of mineralocorticoid receptor antagonist eplerenone to treat chronic central serous chorioretinopathy (CSCR) has been established. However, previous studies have been limited by small cohort size and short follow-up duration. This study aims to report 3-year clinical outcomes of patients treated with eplerenone for chronic CSCR.

Methods

Institutional review board-approved retrospective chart analysis at a single institution from 2012 to 2018. Baseline best-corrected visual acuity and anatomical measurements related to degree of subretinal fluid (SRF) were collected at eplerenone initiation. Follow-up data were collected at the closest date to 12, 24 and 36 months.

Results

Data were obtained for 100 eyes of 83 patients at 1-year (mean 11.18 ± 4.00 months), 49 eyes at 2-year (24.01 ± 3.33 months) and 33 eyes at 3-year (mean 35.5 ± 7.89 months) follow-up visits. The rate of complete SRF resolution was 31%, 28% and 33%, respectively. At final follow-up, logarithm of the minimum angle of resolution visual acuity change from baseline was +0.10 ± 0.24 (p = 0.130). Average change from baseline at final follow-up for central subfield thickness was −97 ± 140.6 µm (p < 0.001), cube volume was –1.07 ± 1.71 mm3 (p < 0.001), macular thickness –28. 5 ± 47.5 µm (p < 0.001), maximum SRF height was −95.6 ± 160.5 µm (p < 0.001) and maximum SRF diameter was −1169.0 ± 1638.7 µm (p = 0.008).

Conclusion

Anatomical improvement occurs primarily within the first year of eplerenone treatment for chronic CSCR.

Heterogeneity of cultured melanocyte elongation and proliferation factor in bilateral diffuse uveal melanocytic proliferation

A patient with bilateral diffuse uveal melanocytic proliferation (BDUMP) associated with endometrial cancer was treated with plasmapheresis, but failed therapy with progressive serous retinal detachment. We collected plasma before and after plasmapheresis therapy. Our goal was to determine if the cultured melanocyte elongation and proliferation (CMEP) factor and hepatocyte growth factor (HGF) was present in the IgG enriched fraction and understand why our patient failed plasmapheresis therapy. Melanocytes were cultured for 3-5 days in the presence of control medium, unfractionated pre-plasmapheresis BDUMP medium, IgG enriched or IgG depleted BDUMP medium, or unfractionated post-plasmapheresis BDUMP medium. Subretinal fluid was collected from patients with BDUMP and control retinal detachments and analyzed by electropheresis with immunoblotting. Medium with unfractionated BDUMP plasma stimulated melanocyte growth 1.4-1.5 fold compared to control medium on days 3-5 (p < 0.001 for all). Both IgG enriched and IgG depleted BDUMP medium mildly increased melanocyte growth 1.3 fold (p < 0.05 for enriched, p < 0.01 for depleted) compared to control. In comparison, unfractionated BDUMP medium caused a 1.7-fold increase in melanocyte growth, which was significantly more than the enriched (p < 0.01) and depleted (p < 0.05) fractions. Pre-plasmapheresis and post-plasmapheresis unfractionated BDUMP medium equally stimulated melanocyte growth 1.7-fold (p < 0.05) compared to control. HGF was present in IgG depleted, pre-plasmapheresis, and post-plasmapheresis samples, but absent in the IgG enriched fraction. There was no enrichment of IgG in the subretinal fluid from eyes with BDUMP. In conclusion, CMEP factor is not concentrated in the IgG enriched plasma fraction in our patient who failed plasmapheresis therapy. HGF levels have no correlation with melanocyte growth. Because plasmapheresis preferentially removes immunoglobulins from the plasma, our patient responded poorly to plasmapheresis treatment with worsening retinal detachment.

Optical Coherence Tomography Angiography in Eyes with Indeterminate Choroidal Neovascularization: Results from the AVATAR study

OBJECTIVE

To evaluate the use of optical coherence tomography angiography (OCTA) to detect choroidal neovascularization (CNV) in eyes with indeterminate CNV features on conventional imaging.

DESIGN

The AVATAR study is a prospective observational study of OCTA in patients undergoing routine spectral-domain optical coherence tomography (SD-OCT) for macular disease.

PARTICIPANTS

Subjects enrolled in the AVATAR study for which CNV was considered as part of a differential diagnosis based on clinical exam and/or prior imaging, but in whom the presence of CNV was not definitive on SD-OCT and fluorescein angiography (FA) imaging.

INTERVENTIONS

All patients were imaged with the Avanti RTVue XR HD (Optovue, Fremont, CA) and the Cirrus HD-OCT (Zeiss, Oberkochen, Germany) systems.

MAIN OUTCOME MEASURES

OCTA scans were assessed for the presence or absence of CNV. SD-OCT scans were assessed for the presence of fluid, hyperreflective material, serous pigment epithelial detachment (PED), shallow irregular PED, vitreomacular adhesion, epiretinal membrane, retinal pigment epithelium atrophy and central subfield retinal thickness. Univariate and multivariate logistic regression analyses were performed to identify features on SD-OCT associated with the presence of CNV on OCTA.

RESULTS

Twenty-nine eyes of 29 patients met the criteria for inclusion. A CNV lesion was detected on OCTA in 8 (28%) eyes; 21 (72%) eyes were negative for CNV. After adjusted for age, gender and central subfield retinal thickness, the presence of shallow irregular PED [odds ratio, 148; 95% confidence interval, 3.22-6830; p = 0.011], as well as the combinations of intraretinal fluid and sub-retinal pigment epithelium material [odds ratio, 16.8; 95% confidence interval, 1.43-198; p = 0.025] on SD-OCT were significantly associated with the presence of CNV on OCTA.

CONCLUSIONS

OCTA enabled the identification of CNV that was otherwise indeterminate with prior imaging in select eyes. The presence of a shallow irregular PED as well as intraretinal fluid combined with sub-retinal pigment epithelium material were both associated with the presence of CNV. OCTA may be a valuable adjunct to conventional SD-OCT and FA imaging in the detection and surveillance of CNV, particularly in diagnostic dilemmas.

Subfoveal choroidal thickness as a prognostic factor in exudative age-related macular degeneration

AIMS

To investigate the relationship between subfoveal choroidal thickness (SFCT), visual acuity (VA), optical coherence tomography (OCT) features and total anti-vascular endothelial growth factor (VEGF) treatments to determine whether SFCT serves as a prognostic factor in age-related macular degeneration (AMD).

METHODS

This is a retrospective case series of 62 consecutive treatment-naive patients with exudative AMD followed for 1 year and treated with treat-and-extend or pro re nata anti-VEGF protocols. SFCT was measured at three locations using Cirrus HD-OCT (the foveal centre and 500 um nasal and temporal to the fovea) at presentation, 3, 6 and 12 months. Demographic characteristics, OCT imaging biomarkers and VA were recorded.

RESULTS

Mean SFCT at baseline was 187 µm (range: 70-361 µm). There was a trend of decreasing SFCT at 1 year (173 µm) compared with 3 months (175 µm) and baseline (188 µm) (p=0.2). There was no correlation between baseline SFCT and presence of subretinal fluid (p=0.2), intraretinal fluid (p=0.6) or subretinal hyper-reflective material (p=0.4) at baseline. The mean number of injections at 1 year was 6.6 (range: 2-12). Increased SFCT at baseline showed statistically significant correlation with a higher number of intravitreal injections at 1 year (p=0.004). Eyes with SFCT>1 SD above the mean required 50% more injections compared with others. There was no association between SFCT on presentation with baseline and 1 year VA (p=0.7 and p=0.2).

CONCLUSIONS

SFCT in naïve patients with exudative AMD may be an important prognostic tool in determining treatment burden. Patients with thicker subfoveal choroid may require increased intravitreal injections.

Choriocapillaris and retinal vascular plexus density of diabetic eyes using split-spectrum amplitude decorrelation spectral-domain optical coherence tomography angiography

BACKGROUND/AIMS

Split-spectrum amplitude decorrelation angiography for spectral-domain optical coherence tomography has enabled detailed, non-invasive assessment of vascular flow. This study evaluates choriocapillaris and retinal capillary perfusion density (CPD) in diabetic eyes using optical coherence tomography angiography (OCTA).

METHODS

Records of 136 eyes that underwent OCTA imaging at a single institution were reviewed. Eyes were grouped as non-diabetic controls (37 eyes), patients with diabetes mellitus (DM) without diabetic retinopathy (DM without DR, 31 eyes), non-proliferative diabetic retinopathy (NPDR, 41 eyes) and proliferative diabetic retinopathy (PDR, 27 eyes). Quantitative CPD analyses were performed on OCTA images for assessing perfusion density of the choriocapillaris and retinal plexus for all patients and compared between groups.

RESULTS

Eyes with NPDR and PDR showed significantly decreased choriocapillaris CPD compared with controls, while DM eyes without DR did not show significant change. Choriocapillaris whole-image CPD was decreased by 8.3% in eyes with NPDR (p<0.01) and decreased by 7.1% in eyes with PDR (p<0.01). Choriocapillaris parafoveal CPD was decreased by 8.9% in eyes with NPDR (p<0.01) and decreased by 8.2% in eyes with PDR (p<0.01). Compared with controls, only eyes with PDR showed significantly decreased retinal CPD, as well as significantly increased foveal avascular zone (FAZ) area. In those patients, retinal whole-image CPD was decreased by 9.7% (p<0.01), retinal foveal CPD was decreased by 20.5% (p<0.01) and retinal parafoveal CPD was decreased by 11.4% (p<0.01). FAZ area was increased by 50.9% (p<0.01).

CONCLUSIONS

Choriocapillaris and retinal CPD are reduced in diabetic retinopathy, while FAZ area is increased in eyes with PDR. Vascular changes captured by new imaging modalities can further characterise diabetic choroidopathy.

Intraoperative OCT Imaging of the Argus II Retinal Prosthesis System

BACKGROUND AND OBJECTIVE

Optimal placement of the Argus II Retinal Prosthesis System (Second Sight Medical Products, Sylmar, CA) is critical. Intraoperative optical coherence tomography (OCT) allows for intrasurgical visualization and confirmation of array placement. In this study, two different OCT systems were evaluated to assess the feasibility and utility of this technology during Argus II surgery.

PATIENTS AND METHODS

Intraoperative OCT was performed on five patients undergoing Argus II implantation at Cole Eye Institute from June 2015 to July 2016. The EnVisu portable OCT (Bioptigen, Morrisville, NC) and microscope-integrated RESCAN 700 (Zeiss, Oberkochen, Germany) intraoperative OCT systems were utilized. The EnVisu was used in three patients and the RESCAN 700 in three of the five patients. Following array tacking, intraoperative OCT was performed over the entire array including the edges and tack.

RESULTS

Intraoperative OCT allowed for visualization of the array/retina interface. Microscope integration of the OCT system facilitated ease of focusing, real-time feedback, surgeon-directed OCT scanning to the areas of interest, and enhanced image quality at points of interest.

CONCLUSIONS

Intraoperative imaging of the Argus II electrode array is feasible and provides information about electrode array-retina interface and distance to help guide a surgeon. Microscope integration of OCT appears to provide an optimal and efficient approach to intraoperative OCT during Argus II array placement. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:999-1003.].

Open Payments Database: Anti-Vascular Endothelial Growth Factor Agent Payments to Ophthalmologists

PURPOSE

To analyze anti-vascular endothelial growth factor (anti-VEGF) agent-associated industry payments to ophthalmologists using the Centers for Medicare and Medicaid Services (CMS) Open Payments and Provider Utilization and Payment data.

DESIGN

Retrospective database review using 2 national databases.

METHODS

Payments from 2013 to 2014 were analyzed by anti-VEGF agent, payment category, and dollar amount. Ranibizumab and aflibercept usage was correlated by performing log-ratio analysis.

RESULTS

A total of 3207 ophthalmologists received 13 449 payments totaling $4 454 325 associated with ranibizumab and aflibercept. As 7% of ophthalmologists received 90% of payments, the Gini index was 0.92, demonstrating unequal distribution of payments. Consulting fees and speaker fees were associated with highest payment amounts to fewest providers. For 2383 providers (74%), greater than 90% of the anti-VEGF payments were associated exclusively with either ranibizumab or aflibercept. A total of 1382 ophthalmologists were matched in both databases. Providers receiving >90% of payments from ranibizumab were more likely to use ranibizumab, and those receiving >90% of payments from aflibercept were more likely to use aflibercept over bevacizumab as compared to those who received no payments.

CONCLUSIONS

The distribution of all anti-VEGF payments is unequal. Ophthalmologists who received aflibercept or ranibizumab payments were more likely to receive the majority of payments from one source or the other, but not both. Those who received anti-VEGF payments were more likely to use ranibizumab or aflibercept, as compared to off-label bevacizumab, than those who did not receive any payment.

Comparison of anti-VEGF therapies on fibrovascular pigment epithelial detachments in age-related macular degeneration

BACKGROUND

The aim is to compare the therapeutic effects of three antivascular endothelial growth factor (VEGF) drugs (bevacizumab, aflibercept and ranibizumab) on fibrovascular pigment epithelial detachments (fvPEDs) in age-related macular degeneration (AMD).

METHODS

This was a retrospective, comparative, consecutive case series of 88 unique eyes with fvPEDs in neovascular AMD treated with anti-VEGF monotherapy for a minimum of 6 months. All eyes were treatment naive. Diagnosis was confirmed retrospectively by fluorescein angiography and spectral-domain optical coherence tomography. Exclusion criteria included serous/drusenoid PEDs or patients who switched anti-VEGF. Mean follow-up across all therapies was 313.9±85.3 days.

RESULTS

Average age of all patients was 80.6 years. Baseline maximum subfoveal PED height was 326.8±185.1 μm, 394.5±238.6 μm and 258.0±145.3 μm for bevacizumab, aflibercept and ranibizumab, respectively (p=0.05). All patients had subretinal fluid, intraretinal fluid or a combination of the two at an initial presentation. Central retinal thickness decreased at all time points compared with baseline across all three anti-VEGF therapies. Subfoveal PED height decreased in patients treated with aflibercept at all time points and decreased in patients treated with bevacizumab at 1-month, 3-month and 6-month time points. Aflibercept reduced PED height more than bevacizumab at 1-month and 12-month follow-ups (p=0.02 and p=0.03, respectively) and ranibizumab at 1-month and 6-month follow-ups (p=0.03 and p=0.02, respectively). No differences in best-corrected visual acuity were appreciated at any time point between drugs.

CONCLUSIONS

There was a significant reduction in subfoveal PED height for aflibercept and bevacizumab compared with baseline. A direct comparison of drugs demonstrated a beneficial reduction of PED height, albeit inconsistently, favouring aflibercept. There were no differences in visual acuity across the groups at any time point.

Argus II retinal prosthesis system: An update

This review focuses on a description of the Argus II retinal prosthesis system (Argus II; Second Sight Medical Products, Sylmar, CA) that was approved for humanitarian use by the FDA in 2013 in patients with retinitis pigmentosa with bare or no light perception vision. The article describes the components of Argus II, the studies on the implant, and future directions.

The Spectrum of Pediatric Orbital BB Gun Injuries: A Case Series

Three cases of pediatric BB orbital injury are reported demonstrating varying outcomes. Pediatric orbital BB injuries have a wide spectrum of clinical outcomes depending on the ocular structures involved. Improved safety education of patients and parents is necessary to reduce the burden of these vision-threatening injuries.

An unusual ophthalmic finding in Lane-Hamilton syndrome

Lane-Hamilton syndrome is a rare condition that is characterized by idiopathic pulmonary hemosiderosis and celiac disease. We report the case of an 18-month-old girl with Lane-Hamilton syndrome who had unilateral pigmentary retinopathy.

A 10-year study of membrane filter system versus blood culture bottles in culturing vitrectomy cassette vitreous in infectious endophthalmitis

PURPOSE

To compare the microbiological outcomes of membrane filter system and blood culture bottle techniques in culturing diluted vitrectomy cassette vitreous.

DESIGN

Retrospective comparative case series.

METHODS

Diluted vitrectomy cassette vitreous specimens from March 25, 2002 to July 11, 2012 were cultured using both membrane filter system and blood culture bottles. The isolates were divided into 3 groups: ones that had positive cultures with (1) both membrane filter system and blood culture bottles, (2) membrane filter system only, and (3) blood culture bottles only. The 48-hour as well as 2-week results were documented.

RESULTS

A total of 447 patients with 168 positive cultures were studied. At the 48-hour time point, 126 isolates were documented. Of those, 104 (82%) were culture positive with both membrane filter system and blood culture bottles, 15 (12%) were culture positive only with membrane filter system, and 7 (6%) were culture positive only with blood culture bottles. At the 2-week time point, an additional 42 organisms were isolated. Of those, 19 (45%) were culture positive with both membrane filter system and blood culture bottles, 11 (26%) with membrane filter system only, and 12 (29%) with blood culture bottles only. Out of 168 total isolates, 123 (73%) were culture positive with both membrane filter system and blood culture bottles, 26 (16%) with membrane filter system only, and 19 (11%) with blood culture bottles only. Among all microbiological outcomes, there was no significant difference between membrane filter system and blood culture bottle (P = .37). Of those organisms that were culture positive only with either membrane filter system or blood culture bottle, mold and Mycobacterium species were culture positive more commonly with membrane filter system (P = .034 and P = .016, respectively), and gram-positive organisms were culture positive more commonly with blood culture bottles (P = .021).

CONCLUSIONS

In the current study, a combination of membrane filter system and blood culture bottles for culture of diluted vitrectomy cassette vitreous provides the highest number of positive culture outcomes. The blood culture bottle method is technically easier and represents a viable alternative to the more complex membrane filter system technique.

Correlation between baseline echographic features of endophthalmitis, microbiological isolates, and visual outcomes

Background

The purpose of this study was to examine the baseline echographic features in culture-positive and culture-negative endophthalmitis and to correlate these echographic features with final visual outcomes.

Methods

We identified a retrospective noncomparative case series of patients with a clinical diagnosis of endophthalmitis and a baseline echographic examination between 1996 and 2010 at a single institution. Graded echographic features studied included: dense, moderate, and mild vitreous opacities; marked, moderate, and mild vitreous membranes; retinal detachment; and choroidal detachment. These were compared between culture-negative, coagulase-negative staphylococci, and other culture-positive cases of endophthalmitis, and were correlated with final visual outcomes.

Results

Of 149 patients reviewed, 60 were culture-negative, 26 grew coagulase-negative staphylococci, and 60 grew other culture-positive species. Three had multiple culture isolates. The presence of dense, moderate, and mild vitreous opacities, marked, moderate, and mild vitreous membranes, retinal detachment, and choroidal detachment was not significantly different between the three groups (P = 0.86, P = 0.56, P = 0.34, P = 0.45, respectively). The presence of advanced echographic features of dense vitreous opacities, marked vitreous membranes, retinal detachment, and choroidal detachment was correlated with poorer visual acuity outcomes (P = 0.005, P = 0.0001, P < 0.0001, and P < 0.0001, respectively).

Conclusion

No correlation could be made between echographic features and the organism. The presence of advanced echographic features, such as dense vitreous opacities, marked vitreous membranes, retinal detachment, and choroidal detachment, was correlated with worse visual outcomes.

Cutting edge: NKT cells constitutively express IL-23 receptor and RORgammat and rapidly produce IL-17 upon receptor ligation in an IL-6-independent fashion

Th17 cells require IL-6 and TGFbeta for lineage commitment and IL-23 for maintenance. Unexpectedly, naive IL-6(-/-) splenocytes stimulated with anti-CD3 and IL-23 produced normal amounts of IL-17 during the first 24 h of culture. These rapid IL-6-independent IL-17 producers were identified as predominantly DX5(+) TCRbeta(+) NKT cells, and a comparable response could be found using the invariant NKT-specific ligand alpha-galactosylceramide. Human NKT cells also produced IL-17. NKT cells constitutively expressed IL-23R and RORgammat. Ligation of either TCR or IL-23R triggered IL-17 production and both together had a synergistic effect, suggesting independent but convergent pathways. IL-17 production was not restricted to a particular subset of NKT cells but they were NK1.1 negative. Importantly, in vivo administration of alpha-galactosylceramide triggered a rapid IL-17 response in the spleen. These data suggest an important biological role for innate IL-17 production by NKT cells that is rapid and precedes the adaptive IL-17 response.