Comparison of the horizontal diameter to a modeled area of traction in eyes with vitreomacular traction: is the diameter close enough to the truth?

PURPOSE

In daily practice, vitreomacular traction (VMT) is described by the horizontal diameter of its attachment site implying a regular round shape of VMT. We investigated the deviation from this circular area of vitreous traction in patients with VMT.

METHODS

A retrospective analysis of optical coherence tomography (OCT) scans was performed. The area of vitreomacular attachment was determined using six radial OCT scans (A_measured). The assumed circular area of traction was calculated based on measuring the maximal horizontal diameter for comparison (A_circular).

RESULTS

Thirty-seven eyes of 37 patients with pure VMT were included. Patients' mean age was 72.8 ± 8.2 years. Mean horizontal VMT diameter was 400.8 ± 230.5 μm (median 361 μm; range 44-991 μm). While there was no difference between mean areas of traction for A_circular and A_measured (P = 0.93), the individual difference (|A_circular - A_measured|) was 0.042 (± 0.044) mm² in mean or relative 73.0% (± 135.8%). A difference of ≥ 30% of A_measured to A_circular was found in 16 eyes (43.2%) and ≥ 100% in 7 eyes (18.9%), respectively.

CONCLUSION

Vitreous attachment sites possess an irregular non-circular shape in a significant number of eyes with VMT. Consequently, the area of traction appears inaccurately described by its horizontal VMT diameter alone. As the area of traction is important for therapeutic recommendation, our results emphasize the need for a more precise description of the area of traction in eyes with VMT.

Demographics of patients receiving Intravitreal anti-VEGF treatment in real-world practice: healthcare research data versus randomized controlled trials

BACKGROUND

While randomized controlled trials (RCTs) are based on strict inclusion/exclusion criteria, non-interventional studies (NISs) might provide additional information to guide management in patients more representative to the real-world setting. The aim of this study was to compare baseline characteristics of patients receiving intravitreal treatment in the NIS OCEAN with those from published RCTs.

METHODS

The ongoing OCEAN study enrolled patients treated with ranibizumab for neovascular age-related macular degeneration (nAMD), diabetic macular oedema (DME) or branch/central retinal vein occlusion (B/CRVO). Baseline patient characteristics were compared by indication within the OCEAN cohort. Furthermore, the characteristics were set in reference to those of published RCTs in the same indications. Confidence intervals (CIs) were calculated and assessed for statistically significant differences as indicated by non-overlapping CIs.

RESULTS

Patient characteristics in the NIS OCEAN were evaluated for 3,614 patients with nAMD, 1,211 with DME, 204 with BRVO and 121 with CRVO. Between these groups, significant differences in mean age, gender distributions, and mean baseline VA were seen, reflecting known differences between the indications. Compared to the patient characteristics of published RCTs (trials selected by literature search: nAMD: 13 RCTs, DME: 9, RVO: 5), the OCEAN patients' mean age was significantly higher in every indication. The gender distributions across the trials were comparable, with only few differences between OCEAN and the RCTs. Regarding the mean baseline VA, notable differences were found in nAMD and in DME, with VA significantly higher in some RCTs and lower in others.

CONCLUSIONS

The described differences underline the complementarity of NISs and RCTs. OCEAN covers a broader spectrum and more variability of patients than do RCTs. As baseline values may have impact on the treatment response (ceiling effect), there is an ongoing need for research in all patient subgroups. Country-specific assessments of patient populations can better reflect the real-world situation. NISs can deliver insights that RCTs may not, as NISs can include non-typical patients, patients with comorbidities, a broader age spectrum and patients of various disease stages.

TRIAL REGISTRATION

The NIS OCEAN was registered on www.clinicaltrials.gov (identifier: NCT02194803 ).

[Self-relaxation techniques for glaucoma patients. Significance of autogenic training, hypnosis and music therapy]

BACKGROUND

Glaucoma is currently the second most common cause of severe visual impairment and blindness worldwide. Standard pharmaceutical and surgical interventions often fail to prevent progression of glaucomatous optic neuropathy.

OBJECTIVES

To evaluate whether adjuvantly applied self-relaxation techniques can significantly impact intraocular pressure, ocular perfusion and the overall mental state of affected patients.

MATERIAL AND METHODS

A search of the literature was carried out and a comprehensive overview of currently available data is presented.

RESULTS

Autogenic training, hypnosis and music therapy can significantly impact intraocular pressure, ocular perfusion and overall mental state of patients suffering from glaucoma.

CONCLUSION

As all of these adjuvant therapeutic options are cost-effective, available almost everywhere and at anytime as well as without any known side effects, they can be useful additional techniques in the overall concept for treating glaucoma patients. Regular ocular examinations by an ophthalmologist are, however, mandatory.

[Regional Differences in the Care of Patients with Neovascular Age-Related Macular Degeneration, Based on the Non-Interventional OCEAN Study]

Background: The main cause of blindness in the elderly in Germany is neovascular age-related macular degeneration (nAMD). In the non-interventional OCEAN study, data were prospectively collected on the routine clinical care of patients treated with the drug ranibizumab. Patients: As part of an interim analysis within the ongoing study (NCT02194803), stratification was performed by the 17 regions of the German associations of panel physicians and by areas of different population density. Only data were analysed for patients for whom the first treatment with ranibizumab was documented. Results: A total of 5,606 patients were documented. The present manuscript reviews 2,658 treatment-naive patients with nAMD, documented by 324 ophthalmologists. Most patients receiving an intravitreal injection were female (60 %). The average patient was aged 77.7 ± 8.2 years at study start. The great majority of patients had statutory health insurance (91 %). At baseline, fluorescein angiography (FLA) was performed for 72 % of patients, while optical coherence tomography (OCT) was carried out for 76 %. A combination of both was performed for 54 % of patients, varying regionally from 26 % (Saxony-Anhalt) to 100 % (Berlin). The average waiting time between the first examination and the first injection was 20.0 ± 18.5 days. With different statistical models (ANOVA adjusted, with/without interactions), significant effects on treatment delay were found for district type (population density), federal state and type of specialist. Conclusion: No major regional differences were observed in the demographic characteristics of the patient population. The main regional disparities in the care of nAMD patients were in the application of diagnostic methods and the waiting times between the first examination and the first drug administration. The regional variations in treatment delays could clearly influence the risk of worse functional outcome.

[Retropupillary iris claw intraocular lens implantation technique for aphakia]

BACKGROUND

Overview of the retropupillary implantation of iris claw intraocular lenses (Artisan®,Ophtec, Groningen, Niederlande and Verisyse(TM),AMO, Santa Ana CA).

MATERIAL AND METHODS

A literature search and review of implantation techniques, patient selection, potential complications and management strategies.

RESULTS

This approach has the advantage of a simple implantation technique, an anatomically correct implantation site (as compared to endocapsular implantation) and a relatively low complication rate. An intact iris is, however, a prerequisite for this technique. Ischemic vitreoretinopathies, such as diabetes or vascular occlusive entities, as well as uveitis might be considered as contraindications.

CONCLUSIONS

The retropupillary implantation of iris claw intraocular lenses is an interesting and especially time-effective rehabilitation technique for aphakia.

Can dynamic contour tonometry and ocular pulse amplitude help to detect severe cardiovascular pathologies?

We demonstrate the close relationship between a conspicuous ocular pulse amplitude and severe underlying cardiovascular disease. Two otherwise symptom-free glaucoma patients without any previously diagnosed underlying cardiovascular pathology but with a conspicuous ocular pulse amplitude and who underwent routine examinations in our glaucoma department were referred to the appropriate specialty for further diagnostic procedures. In both patients, the diagnosis of a tachyarrhythmia was made as suspected on dynamic contour tonometry measurements. In addition to medical treatment, one patient underwent electric cardioversion and the second patient was scheduled for pacemaker implantation. A third patient with an unexpected high ocular pulse amplitude despite severe cardiovascular pathology underwent major surgery due to an aortic aneurysm. Carotid stenosis was diagnosed due to side differences in ocular pulse amplitude as well. Ocular pulse amplitude might be a noninvasive and affordable screening tool and could be used to detect severe cardiovascular disease. A prospective study including a larger number of patients is needed to prove this hypothesis.

[Combination of different techniques for secondary anchoring of intraocular lenses]

BACKGROUND

The four fundamental techniques of secondary intraocular lens (IOL) fixation, namely sulcus placement, scleral or iris suture fixation and scleral haptic fixation can be combined in special situations.

AIM

When is a combination of different techniques advisable?

METHODS

This article describes our experiences and gives an example of combined technique use.

RESULTS

These situations arise in cases when neighboring ocular structures are only partially preserved or show particular distinctive defects that can be repaired at the time of secondary IOL anchoring. This article presents a case of IOL-induced iris chafing and traumatic iridodialysis which was closed by a combined technique of iris suture and scleral suture fixation.

CONCLUSION

A combination of different anchoring techniques for secondary IOL implantation can achieve a simultaneous repair of perilenticular structures and reduce the amount of suture material used.

[Implantation of intraocular lenses in the ciliary sulcus]

Implantation of an intraocular lens (IOL) into the ciliary sulcus is the second most common implantation site after the regular capsular bag (in the bag) placement of an IOL. Although mainly not primarily intended, it is very often used in both complicated cataract surgery and secondary implantation due to IOL dislocation or aphakia. In most cases stable positioning is possible, especially when using optic capture techniques. A variety of difficulties can occur with sulcus implantation depending on the anatomical and surgical conditions present at the time of implantation. The most anterior position of the sulcus lense has to be considered for calculation of the refractive power of the IOL.

[Pseudophakic cystoid macular oedema]

Pseudophakic cystoid macular oedema is still a relevant clinical disease entity although major progress in modern cataract surgery has been made within the last decades. The relevance is attributed to the large number of cases that are performed each year. Even after uneventful surgery, a pseudophakic cystoid macular oedema can develop and may lead to severe and lasting visual impairments. In respect to the pathophysiology, four consecutive steps have to be considered: (i) surgical procedure-related induction and release of various inflammation mediators into the anterior chamber; (ii) removal of the physiological lens barrier between the anterior and posterior segments of the eye, leading consecutively to an increase in diffusion rate in either direction; (iii) local action of the inflammation mediators towards the macular area; and (iv) increased vitreoretinal traction due to the anteriorly oriented drive of the vitreous. To prevent the development of a pseudophakic cystoid macular oedema, systemic and ocular pathologies should be treated consequently prior to surgery. Furthermore, an individual risk profile of each patient needs to be evaluated to define the best pre- and postsurgical medical treatment. A less traumatic surgical approach can help to prevent macular oedema development additionally. The diagnosis is made by performing biomicroscopy, fluorescence angiography and optical coherence tomography as well as by evaluating the patients' major complaints. Standard operation procedures or recommended guidelines by the specialised eye associations to prevent and treat pseudophakic cystoid macular oedema are not available up to date. A synopsis of recommendations in the literature suggests a step-wise treatment regimen, including topical medical treatment on the one hand and a surgical approach on the other hand as well as a combination of both, if needed. Topical medical treatment options include the use of non-steroidal, corticosteroid and/or carbonic anhydrase inhibitor eye drops. Surgical interventions include pars plana vitrectomy.