Faricimab Treat-and-Extend for Diabetic Macular Edema: Two-Year Results from the Randomized Phase 3 YOSEMITE and RHINE Trials

PURPOSE

To evaluate the 2-year efficacy, durability, and safety of dual angiopoietin-2 and vascular endothelial growth factor (VEGF) A pathway inhibition with intravitreal faricimab according to a personalized treat-and-extend (T&E)-based regimen with up to every-16-week dosing in the YOSEMITE and RHINE (ClinicalTrials.gov identifiers, NCT03622580 and NCT03622593, respectively) phase 3 trials of diabetic macular edema (DME).

DESIGN

Randomized, double-masked, noninferiority phase 3 trials.

PARTICIPANTS

Adults with visual acuity loss (best-corrected visual acuity [BCVA] of 25-73 letters) due to center-involving DME.

METHODS

Patients were randomized 1:1:1 to faricimab 6.0 mg every 8 weeks, faricimab 6.0 mg T&E (previously referred to as personalized treatment interval), or aflibercept 2.0 mg every 8 weeks. The T&E up to every-16-week dosing regimen was based on central subfield thickness (CST) and BCVA change.

MAIN OUTCOME MEASURES

Included changes from baseline in BCVA and CST, number of injections, durability, absence of fluid, and safety through week 100.

RESULTS

In YOSEMITE and RHINE (n = 940 and 951, respectively), noninferior year 1 visual acuity gains were maintained through year 2; mean BCVA change from baseline at 2 years (weeks 92, 96, and 100 average) with faricimab every 8 weeks (YOSEMITE and RHINE, +10.7 letters and +10.9 letters, respectively) or T&E (+10.7 letters and +10.1 letters, respectively) were comparable with aflibercept every 8 weeks (+11.4 letters and +9.4 letters, respectively). The median number of study drug injections was lower with faricimab T&E (YOSEMITE and RHINE, 10 and 11 injections, respectively) versus faricimab every 8 weeks (15 injections) and aflibercept every 8 weeks (14 injections) across both trials during the entire study. In the faricimab T&E arms, durability was improved further during year 2, with > 60% of patients receiving every-16-week dosing and approximately 80% receiving every-12-week or longer dosing at week 96. Almost 80% of patients who achieved every-16-week dosing at week 52 maintained every-16-week dosing without an interval reduction through week 96. Mean CST reductions were greater (YOSEMITE/RHINE weeks 92/96/100 average: faricimab every 8 weeks -216.0/-202.6 µm, faricimab T&E -204.5/-197.1 µm, aflibercept every 8 weeks -196.3/-185.6 µm), and more patients achieved absence of DME (CST < 325 μm; YOSEMITE/RHINE weeks 92-100: faricimab every 8 weeks 87%-92%/88%-93%, faricimab T&E 78%-86%/85%-88%, aflibercept every 8 weeks 77%-81%/80%-84%) and absence of intraretinal fluid (YOSEMITE/RHINE weeks 92-100: faricimab every 8 weeks 59%-63%/56%-62%, faricimab T&E 43%-48%/45%-52%, aflibercept every 8 weeks 33%-38%/39%-45%) with faricimab every 8 weeks or T&E versus aflibercept every 8 weeks through year 2. Overall, faricimab was well tolerated, with a safety profile comparable with that of aflibercept.

CONCLUSIONS

Clinically meaningful visual acuity gains from baseline, anatomic improvements, and extended durability with intravitreal faricimab up to every 16 weeks were maintained through year 2. Faricimab given as a personalized T&E-based dosing regimen supports the role of dual angiopoietin-2 and VEGF-A inhibition to promote vascular stability and to provide durable efficacy for patients with DME.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Incidence and Clinical Features of Immunologic Rejection After Deep Anterior Lamellar Keratoplasty

PURPOSE

The aim of this study was to investigate the incidence and clinical features of immunologic rejection after deep anterior lamellar keratoplasty (DALK).

METHODS

This study included 411 patients (464 eyes, median age [interquartile range; IQR] 55.8 years [36.1-69.5]) who underwent DALK at Tokyo Dental College between June 1997 and 2021. Of 411 patients, 24 (24 eyes [5.2%], 51.9 years [IQR 31.6-65.4]) developed immunologic rejection. We characterized the clinical features, risk factors associated with immunologic rejection, and prognosis.

RESULTS

The interval between DALK and immunologic rejection was 14.5 (range, 5-78) months. Immunologic rejection occurred after cessation/reduction of topical steroid in 9 (47.4%) and suture removal in 4 eyes (21.1%). The postoperative duration of topical steroid use in eyes with immunologic rejection was significantly shorter (10.0 months, [IQR 6.0-14.0]) than those without immunologic rejection (28.3 [IQR 15.8-42.7], P = 0.001). Immunologic rejection manifested as stromal edema in 19 (100.0%), ciliary hyperemia in 17 (89.5%), keratic precipitates in 13 (68.4%), epithelial edema in 13 (68.4%), infiltration in 9 (47.4%), corneal opacity in 4 (21.1%), and Descemet membrane detachment in 2 eyes (10.5%). After treatment, corneal clarity was restored in 17 eyes (89.5%); however, immunologic rejection led to corneal endothelial decompensation in 2 eyes (10.5%). Endothelial cell density decreased from 1795.7 ± 722.6 to 1651.6 ± 655.6 cells/mm2 after immunologic rejection (P = 0.074).

CONCLUSIONS

Post-DALK immunologic rejection was associated with specific clinical triggers such as reduction/cessation of topical steroids or suture removal.

OCT-angiography based artificial intelligence-inferred fluorescein angiography for leakage detection in retina [Invited]

Optical coherence tomography angiography (OCTA) covers most functions of fluorescein angiography (FA) when imaging the retina but lacks the ability to depict vascular leakage. Based on OCTA, we developed artificial intelligence-inferred-FA (AI-FA) to delineate leakage in eyes with diabetic retinopathy (DR). Training data of 19,648 still FA images were prepared from FA-photo and videos of 43 DR eyes. AI-FA images were generated using a convolutional neural network. AI-FA images achieved a structural similarity index of 0.91 with corresponding real FA images in DR. The AI-FA generated from OCTA correctly depicted vascular occlusion and associated leakage with enough quality, enabling precise DR diagnosis and treatment planning. A combination of OCT, OCTA, and AI-FA yields more information than real FA with reduced acquisition time without risk of allergic reactions.

Ocular findings in patients with acquired ATTRv amyloidosis following domino liver transplantation

PURPOSE

To investigate the presence of amyloidosis-related ocular findings in patients who received domino liver transplantation from ATTRv amyloidosis donors.

METHODS

We reviewed the ocular findings in patients who had previously undergone domino liver transplantation and received ophthalmologic examinations between January 2009 and March 2023. The presence of amyloidosis-related ocular findings was retrospectively assessed by two ophthalmologists.

RESULTS

During the study period, a total of 7 patients with 14 eyes were examined. All patients were considered as acquired ATTRv amyloidosis. The mean age at the final visit was 64.6±8.4 years (52-75 years), and the mean time since domino liver transplantation was 167.6±76.2 months (69-257 months). The two evaluators' assessments for amyloidosis-related ocular findings were completely identical. No amyloid fibril deposition was observed in the pupil, lens, or vitreous. Five patients (10 eyes) had a Schirmer test result of 5mm or less than 5 mm, and four patients with a total of 8 eyes underwent fluorescein angiography and indocyanine green angiography, and no evidence of retinal amyloid angiopathy was found on fluorescein angiography. However, three patients with 6 eyes showed choroidal amyloid angiopathy on indocyanine green angiography.

CONCLUSION

While cases of choroidal amyloid angiopathy were observed, serious amyloidosis-related ocular complications such as vitreous opacity or secondary glaucoma did not occur even in the long term after domino liver transplantation.

Efficacy, Durability, and Safety of Faricimab in Patients From Asian Countries With Diabetic Macular Edema: 1-Year Subgroup Analysis of the Phase III YOSEMITE and RHINE Trials

PURPOSE

To assess the 1-year efficacy, durability, and safety of faricimab in patients with diabetic macular edema from Asian and non-Asian countries.

DESIGN

Global, multicenter, randomized, double-masked, active comparator-controlled, phase III trials.

METHODS

Subgroup analysis of patients from Asian (N=144) and non-Asian (N=1747) countries randomized to faricimab 6.0 mg every 8 weeks (Q8W), faricimab per personalized treatment interval (PTI), or aflibercept 2.0 mg Q8W in the YOSEMITE/RHINE (NCT03622580/NCT03622593) trials. Primary endpoint: best-corrected visual acuity (BCVA) changes from baseline at 1 year, averaged over weeks 48, 52, and 56.

RESULTS

Mean BCVA change from baseline at 1 year in the Asian country subgroup was similar between arms: faricimab Q8W (n=50), +10.9 (95% CI: 8.6-13.2); faricimab PTI (n=48) +10.0 (7.7-12.4) letters; aflibercept Q8W (n=46) +9.0 (6.6-11.4) letters. BCVA gains in the non-Asian country subgroup (n=582, 584, 581) were +11.3 (10.5-12.1), +11.2 (10.5-12.0), and +10.7 (9.9-11.5) letters, respectively. At 1 year, 49% of Asian country patients in the faricimab PTI arm achieved Q16W dosing (vs. 52% non-Asian) and 78% achieved ≥Q12W dosing (vs. 72% non-Asian). Anatomic improvementswere generally greater with faricimab versus aflibercept and similar between the Asian and non-Asian country subgroups. Faricimab was well tolerated, with no new safety signals.

CONCLUSIONS

Vision, durability, anatomic, and safety outcomes were generally similar between the Asian and non-Asian country subgroups, suggesting that global YOSEMITE/RHINE results may be generalized to the Asian population. These data support the benefit-risk profile of faricimab for treating Asian patients with diabetic macular edema.

Long-term surgical results of trabeculectomy for secondary glaucoma in Val30Met hereditary transthyretin amyloidosis

This study reports the long-term results of trabeculectomy (LEC) for secondary glaucoma in hereditary transthyretin (ATTRv) amyloidosis patients and its correlation with prior vitrectomy. A retrospective case series was conducted involving 31 consecutive eyes of 20 ATTRv amyloidosis patients who underwent LEC between 2007 and 2020. The mean follow-up period was 73.2 ± 37.0 months (range: 20-181 months). Postoperative intraocular pressures (IOPs) were evaluated based on the following criteria: (a) IOP between 6 and 21 mmHg without additional glaucoma surgeries, except for laser suture lysis, (b) IOP between 6 and 15 mmHg without additional glaucoma surgeries, except for laser suture lysis, and (c) IOP between 6 and 21 mmHg without additional glaucoma surgeries, except for needling and laser suture lysis. Kaplan-Meier analysis revealed survival rates after LEC of 0.52 at 36 months, 0.42 at 60 months, and 0.25 at 84 months under criterion (a); 0.49 at 36 months, 0.27 at 60 months, and 0.11 at 84 months under criterion (b); and 0.76 at 36 months, 0.71 at 60 months, and 0.65 at 84 months under criterion (c). Eyes with a history of small gauge transconjunctival vitrectomy (SGTV) exhibited a tendency towards lower survival rates, although no statistically significant difference was observed (log-rank test; p = 0.193 under criterion (a) and p = 0.0553 under criterion (b)). Our findings suggest that LEC and additional needling procedures can provide some control over IOP; however, the overall postoperative outcomes of LEC for ATTRv amyloidosis remain unsatisfactory, even in the era of SGTV with reduced conjunctival scarring.

Evaluating initial responses to brolucizumab in patients undergoing conventional anti-VEGF therapy for diabetic macular edema: a retrospective, single-center, observational study

Our retrospective, single-center, observational study aimed to evaluate the initial responses to intravitreal injection of brolucizumab (IVBr) in patients undergoing anti-vascular endothelial growth factor (VEGF) therapy for diabetic macular edema (DME). In total, 23 eyes of 20 patients with DME treated with at least one intravitreal injection of ranibizumab or aflibercept within one year and then switched to IVBr were included. Best corrected visual acuity (BCVA), central macular thickness (CMT), and macular volume (MV) on optical coherence tomography images were evaluated just before the most recent conventional anti-VEGF (ranibizumab/aflibercept) injection therapy (V1), one month after the most recent traditional anti-VEGF therapy (V2), just before the first IVBr (V3), and one month after the first IVBr (V4). BCVA, CMT, MV, and presence of intraocular inflammation (IOI) were evaluated at each visit. Anterior chamber flare values were also examined at V3 and V4. BCVA showed significant improvement at V2 (0.30 ± 0.23) than V1 (0.39 ± 0.29) and at V4 (0.34 ± 0.26) than V3 (0.48 ± 0.34) (P = 0.002, P < 0.001). However, no significant difference was observed between V2 and V4 (P = 0.257). CMT was significantly thinner at V2 (346.8 ± 90.2 µm) than V1 (495.5 ± 123.8 µm), and at V4 (322.2 ± 95.7 µm) than V3 (536.5 ± 166.0 µm) (P < 0.001, P < 0.001), but no significant difference was observed between V2 and V4 (P = 0.140). MV was significantly smaller at V2 (11.6 ± 2.0 mm³) than V1 (12.6 ± 1.9 mm³) and at V4 (11.2 ± 2.0 mm³) than V3 (12.6 ± 2.0 mm³) (P < 0.001, P < 0.001), and even significantly smaller at V4 than V2 (P = 0.009). No patient had IOI. No significant changes were observed in anterior chamber flare values between V3 and V4 (25.6 ± 14.6 vs. 24.0 ± 11.5 photon count/ms; P = 0.543). Both CMT and MV significantly reduced without any adverse events one month after switching from conventional anti-VEGF to IVBr therapy for DME, including IOI. MV was significantly lower for IVBr than anti-VEGF therapy after one month of treatment. Therefore, brolucizumab may be a viable treatment option for DME patients considering switching from conventional anti-VEGF agents for various reasons, such as poor response or inability to extend dosing intervals.

Protein-Ligand Interaction Analyses with Nuclear Magnetic Resonance Spectroscopy Enhanced by Dissolution Triplet Dynamic Nuclear Polarization

Solution-state nuclear magnetic resonance spectroscopy (NMR) is a powerful method for the analysis of intermolecular interactions within a biomolecular system. However, low sensitivity is one of the major obstacles of NMR. We improved the sensitivity of solution-state ¹³C NMR for the observation of intermolecular interactions between protein and ligand using hyperpolarized solution samples at room temperature. Eutectic crystals composed of ¹³C-salicylic acid and benzoic acid doped with pentacene were hyperpolarized by dynamic nuclear polarization using photoexcited triplet electrons, and a ¹³C nuclear polarization of 0.72 ± 0.07% was achieved after dissolution. The binding of human serum albumin and ¹³C-salicylate was observed with several hundred times sensitivity enhancement under mild conditions. The established ¹³C NMR was applied for pharmaceutical NMR experiments by observation of the partial return of the ¹³C chemical shift of salicylate by competitive binding with other non-isotope-labeled drugs.

Patient referral flow between physician and ophthalmologist visits for diabetic retinopathy screening among Japanese patients with diabetes: A retrospective cross-sectional cohort study using the National Database

AIMS/INTRODUCTION

Regular screening for diabetic retinopathy is essential. This study aimed to show the process and current situation of diabetic retinopathy screening prescribed by physicians (internists) and ophthalmologists for Japanese patients with diabetes.

MATERIALS AND METHODS

This retrospective cohort study used data from the Japanese National Database of Insurance Claims between April 2016 and March 2018. Ophthalmology visits and fundus examinations are defined using specific medical procedure codes. The proportion of ophthalmology visits for patients with diabetic medication and for fundus examination among those who visited ophthalmologists was calculated in the fiscal year 2017. A modified Poisson regression analysis was carried out to identify factors associated with retinopathy screening. Similarly, quality indicators by prefectures were also calculated.

RESULTS

Among 4,408,585 patients receiving diabetic medications (57.8% men, 14.1% insulin use), 47.4% visited the ophthalmology department and 96.9% of those underwent fundus examination. Regression analysis showed that female sex, older age, insulin use, medical facilities with Japan Diabetes Society certification and large medical facilities were predictors of fundus examination. By prefecture, the ophthalmology consultation rate and the fundus examination ranged 38.5-51.0% and 92.1-98.7%, respectively.

CONCLUSIONS

Less than half of the patients who were prescribed antidiabetic medication by their physicians visited an ophthalmologist. However, most of the patients who visited an ophthalmologist had a fundus examination carried out. A similar tendency was noted for each prefecture. It is essential to reaffirm the necessity of recommending ophthalmologic examinations to physicians and healthcare professionals who care for patients with diabetes.

Corneal higher-order aberrations in corneal endothelial decompensation secondary to obstetric forceps injury

Forceps corneal injuries during infant delivery cause Descemet membrane (DM) breaks, that cause corneal astigmatism and corneal endothelial decompensation. The aim of this study is to characterise corneal higher-order aberrations (HOAs) and corneal topographic patterns in corneal endothelial decompensation due to obstetric forceps injury. This retrospective study included 23 eyes of 21 patients (54.0 ± 9.0 years old) with forceps corneal injury, and 18 healthy controls. HOAs and coma aberrations were significantly larger in forceps injury (1.05 [0.76-1.98] μm, and 0.83 [0.58-1.69], respectively) than in healthy controls (0.10 [0.08-0.11], and 0.06 [0.05-0.07], respectively, both P < 0.0001). Patient visual acuity was positively correlated with coma aberration (r_s = 0.482, P = 0.023). The most common topographic patterns were those of protrusion and regular astigmatism (both, six eyes, 26.1%), followed by asymmetric (five eyes, 21.7%), and flattening (four eyes, 17.4%). These results indicate that increased corneal HOAs are associated with decreased visual acuity in corneal endothelial decompensation with DM breaks and corneal topography exhibits various patterns in forceps injury.

Subtype prevalence and baseline visual acuity by age in Japanese patients with neovascular age-related macular degeneration

PURPOSE

To investigate age-specific prevalence of disease subtypes and baseline best-corrected visual acuity (BCVA) in Japanese patients with treatment-naïve neovascular age-related macular degeneration (nAMD).

STUDY DESIGN

Retrospective multicenter case series.

METHODS

We reviewed the records of patients with treatment-naïve nAMD who underwent initial treatment in 14 institutions in Japan sometime during the period from 2006 to 2015. In patients in whom both eyes were treated, only the eye treated first was included for analysis. The patients were stratified by age for the analysis.

RESULTS

In total, 3096 eyes were included. The overall prevalence of subtypes was as follows: typical AMD, 52.6%; polypoidal choroidal vasculopathy (PCV), 42.8%; retinal angiomatous proliferation (RAP), 4.6%. The number of eyes in each age group was as follows: younger than 60 years, 199; 60s, 747; 70s, 1308; 80s, 784; 90 years or older, 58. The prevalence of typical AMD in each age group was 51.8%, 48.1%, 52.1%, 57.7%, and 55.2%, respectively. The prevalence of PCV was 46.7%, 49.1%, 44.7%, 34.4%, and 19.0%, respectively. The prevalence of RAP was 1.5%, 2.8%, 3.2%, 7.9%, and 25.9%, respectively. The prevalence of PCV decreased with age, whilst that of RAP increased. The prevalence of RAP was higher than that of PCV in patients aged 90 years or older. The mean baseline BCVA (logMAR) was 0.53. In each age group, the mean baseline BCVA was 0.35, 0.45, 0.54, 0.62, and 0.88, respectively. The mean logMAR BCVA at baseline significantly worsened with age (P < 0.001).

CONCLUSION

The prevalence of nAMD subtypes differed according to age in Japanese patients. The baseline BCVA worsened with age.

Impact of local COVID-19 alert levels on rhegmatogenous retinal detachment

PURPOSE

To investigate the impact of the local alert levels regarding coronavirus disease 2019 (COVID-19) on the clinical patterns of rhegmatogenous retinal detachment (RRD) in Japan.

STUDY DESIGN

Retrospective, single-center, consecutive case series.

METHODS

We compared two groups of RRD patients, a COVID-19 pandemic group and a control group. Based on the local alert levels in Nagano, five periods during the COVID-19 pandemic were further analyzed: epidemic 1 (state of emergency), inter-epidemic 1, epidemic 2 (second epidemic duration), inter-epidemic 2, and epidemic 3 (third epidemic duration). Patients' characteristics, including symptoms' duration before visiting our hospital, macula status, and retinal detachment (RD) recurrence rate in each period, were compared with those in a control group.

RESULTS

There were 78 patients in the pandemic group and 208 in the control group. The pandemic group had a longer duration of symptoms than the control group (12.0 ± 13.5 days vs. 8.9 ± 14.7 days, P = 0.0045). During the epidemic 1 period, patients had a higher rate of macula-off RRD (71.4% vs. 48.6%) and RD recurrence (28.6% vs. 4.8%) than the control group. This period also demonstrated the highest rates compared to all other periods in the pandemic group.

CONCLUSION

During the COVID-19 pandemic, RRD patients significantly delayed visiting a surgical facility. They showed a higher rate of macula-off and recurrence compared to the control group during the state of emergency than during other periods of the COVID-19 pandemic, although the difference was not statistically significant due to the small sample size.

Wide-field swept-source OCT angiography (23 × 20 mm) for detecting retinal neovascularization in eyes with proliferative diabetic retinopathy

PURPOSE

Xephilio OCT-S1 can capture single-acquisition 23 × 20-mm wide-field swept-source optical coherence tomography angiography (SS-OCTA) images and high-resolution images using artificial intelligence. We aimed to evaluate the ability of wide-field SS-OCTA in the detection of retinal neovascularizations (NVs) in eyes with proliferative diabetic retinopathy (PDR).

METHODS

This retrospective study included 64 eyes of 36 patients (age, 57 ± 10 years; 10 female, 26 male) with PDR. All patients underwent a comprehensive ophthalmological examination, including fluorescein angiography (FA), as well as fovea- and disc-centered 23 × 20-mm OCTA imaging (A-scan/B-scan, 928/807). We compared and examined the number of NV sites identified using conventional methods (merging the findings from biomicroscopy/color fundus photography, FA) and the number of NV sites identified using vitreoretinal interface and superficial retinal slabs of wide-field SS-OCTA images, including the position of NVs (nasal upper, nasal lower, temporal upper, temporal lower, or disc).

RESULTS

We identified 168 NVs (32/40/45/35/16, in the abovementioned order) using the conventional method. Fovea-centered 23 × 20-mm OCTA images revealed 162 (96%) NVs (27/39/45/35/16). This method tended to miss nasal NV. In contrast, disc-centered 23 × 20-mm OCTA images identified nearly all NVs, detecting 166 (99%) NVs (32/40/44/34/16) in total. All NVs could be visualized using two wide-field OCTA images: fovea- and disc-centered.

CONCLUSION

Wide-field (23 × 20 mm) SS-OCTA-especially disc-centered-using Xephilio OCT-S1 identified nearly all NVs in eyes with PDR, with a single acquisition, thereby demonstrating its potential clinical application.

Role of Adrenomedullin 2/Intermedin in the Pathogenesis of Neovascular Age-Related Macular Degeneration

Adrenomedullin 2 (AM2; also known as intermedin) is a member of the adrenomedullin (AM) peptide family. Similarly to AM, AM2 partakes in a variety of physiological activities. AM2 has been reported to exert protective effects on various organ disorders; however, its significance in the eye is unknown. We investigated the role of AM2 in ocular diseases. The receptor system of AM2 was expressed more abundantly in the choroid than in the retina. In an oxygen-induced retinopathy model, physiological and pathologic retinal angiogenesis did not differ between AM2-knockout (AM2-/-) and wild-type mice. In contrast, in laser-induced choroidal neovascularization, a model of neovascular age-related macular degeneration, AM2-/- mice had enlarged and leakier choroidal neovascularization lesions, with exacerbated subretinal fibrosis and macrophage infiltration. Contrary to this, exogenous administration of AM2 ameliorated the laser-induced choroidal neovascularization-associated pathology and suppressed gene expression associated with inflammation, fibrosis, and oxidative stress, including that of VEGF-A, VEGFR-2, CD68, CTGF, and p22-phox. The stimulation of human adult retinal pigment epithelial (ARPE) cell line 19 cells with TGF-β2 and TNF-α induced epithelial-to-mesenchymal transition (EMT), whereas AM2 expression was also elevated. The induction of EMT was suppressed when the ARPE-19 cells were pretreated with AM2. A transcriptome analysis identified 15 genes, including mesenchyme homeobox 2 (Meox2), whose expression was significantly altered in the AM2-treated group compared with that in the control group. The expression of Meox2, a transcription factor that inhibits inflammation and fibrosis, was enhanced by AM2 treatment and attenuated by endogenous AM2 knockout in the early phase after laser irradiation. The AM2 treatment of endothelial cells inhibited endothelial to mesenchymal transition and NF-κB activation; however, this effect tended to be canceled following Meox2 gene knockdown. These results indicate that AM2 suppresses the neovascular age-related macular degeneration-related pathologies partially via the upregulation of Meox2. Thus, AM2 may be a promising therapeutic target for ocular vascular diseases.

Retinal arterial occlusive vasculitis after multiple intravitreal brolucizumab injections for diabetic macular edema

Purpose

To describe a case of unilateral retinal arterial occlusive vasculitis after multiple intravitreal brolucizumab (IVBr) treatments for diabetic macular edema (DME).

Observations

A 68-year-old Japanese woman who had a 3-year history of insulin-dependent diabetes mellitus presented with decreased vision in the right eye (oculus dexter, OD). After two consecutive IVBr (3 mg) treatments for DME, spaced 6 weeks apart, her best corrected visual acuity improved from 20/32 to 20/28 OD, as central macular thickness (CMT) decreased from 368 μm to 253 μm on optical coherence tomography (OCT). Immediately after the 3rd IVBr, the right intraocular pressure (IOP) increased. One week later, iritis (aqueous flares: 65.0 photon count [PC]/ms) was observed, followed by localized vasculitis 2 weeks later. One month after the 3rd IVBr, extensive vasculitis and vasculitis occluding retinal arterioles were identified. Based on the history of IVBr use and clinical findings, intraocular inflammation (IOI) and subsequent retinal arterial occlusive vasculitis due to IVBr was diagnosed. Topical steroid administration (i.e., eye drops and subtenon injection) resulted in improvement of IOI after 3 months. She subsequently underwent two intravitreal aflibercept injections for DME and panretinal photocoagulation (PRP) to prevent the development of proliferative changes due to diabetic retinopathy. One year after the diagnosis of retinal arterial occlusive vasculitis, the patient had slight loss of vision (20/50) compared to baseline, due to the progression of cataracts, and OCT angiography (OCTA) showed extensive non-perfusion area on the temporal side. However, other examination findings (IOP: 16 mmHg, aqueous flares: 30.5 PC/ms, CMT: 283 μm) were stable.

Conclusions and importance

Diagnosis and treatment at a relatively early stage after the onset of IOI prevented severe visual impairment in this case. Topical betamethasone eye drops reduced anterior chamber inflammation associated with IVBr; however, vascular sheathing worsened when topical drops alone was used. Occlusive retinal vasculitis, diagnosed with fluorescein angiography (FA) and OCTA, appeared to stabilize when subtenon triamcinolone injection was added to topical steroid administration. Because the central macula was not involved, severe vision loss was prevented. It is unknown if topical steroid administration would be adequate to prevent worsening of occlusive vasculitis in other cases. Although not used in this case, oral prednisone is one treatment option that may prevent severe vision loss. However, it requires monitoring of side effects, such as elevated blood glucose levels. PRP is also an option in cases where progression of proliferative changes is a concern, as was done in this case. With these considerations in mind, it is important to diagnose brolucizumab-associated IOI and subsequent retinal arterial occlusive vasculitis in DME patients early and initiate treatment to prevent severe visual impairment. Diagnosing new IOI and subsequent retinal arterial occlusive vasculitis is more difficult in DME than in neovascular age-related macular degeneration because of the inflammatory component often associated vascular occlusions. Therefore, early IOI diagnosis and follow-up using various instruments such as laser flare cell meter, wide-field color imaging, OCT/OCTA, and FA, in addition to usual comprehensive ophthalmologic examinations, is crucial.

Temporal Change in Anterior Chamber Depth after Combined Vitrectomy and Cataract Surgery Using Different Sizes of Intraocular Lens

This study aimed to investigate the temporal changes in the anterior chamber depth (ACD) and refractive prediction error (RPE) of 6 and 7 mm diameter intraocular lenses (IOLs) after cataract surgery or phacovitrectomy with or without sulfur hexafluoride (SF6) gas. We reviewed 120 eyes (120 patients) and divided them into six groups: three groups of cataract surgery alone and phacovitrectomy (with or without SF6), which were further divided according to IOL diameter (6 and 7 mm) used. We examined the ACD and IOL position using a swept-source anterior segment optical coherence tomograph at 1 day, 1 week, and 1 month postoperatively; and the RPE at 1 month postoperatively. The ACD and IOL position at postoperative day 1 in the SF6 injection groups were significantly smaller than those in the other groups (p < 0.01). At 1 week, the ACD and IOL position of the 6 mm IOL SF6 injection group was smaller than those in the other groups (p < 0.01); thus, complications such as synechia or pupillary capture should be considered in the early postopera-tive period of phacovitrectomy with SF6, especially in the 6 mm IOL. The ACD, IOL position, and RPE at 1 month did not significantly differ among the groups, regardless of the IOL diameter or SF6. In the SF6 injection groups, the ACD and IOL position gradually deepened with less gas.

Application of optical coherence tomography angiography to assess systemic severity in patients with hereditary transthyretin amyloidosis

Hereditary transthyretin amyloidosis is an autosomal dominant form of amyloidosis caused by an abnormality in transthyretin, with various ocular manifestations. Among these, ocular amyloid angiopathy has attracted attention because of its direct link to visual impairment and its correlation with systemic severity. We hypothesized that optical coherence tomography angiographic parameters would be useful biomarkers of amyloidosis systemic severity and investigated their correlation with the systemic severity score. The primary outcome was the correlation between the systemic severity score and choriocapillaris flow deficit percentage. Secondary outcomes were the correlations between the systemic severity score and retinal optical coherence tomography angiographic parameters, including foveal avascular zone size and circularity and superficial/deep/total retinal perfusion and vessel densities. The choroidal and retinal vasculature was quantified in 36 eyes from 36 patients (age, 51.8±12.1 years; disease duration, 13.4±6.2 years). Ten eyes had a history of vitrectomy for vitreous opacity. Choriocapillaris flow deficit percentage was not significantly correlated with the systemic severity score (Spearman’s rank correlation: r = 2.96×10⁻², p = 0.863). Similarly, foveal avascular zone size and circularity, and superficial/deep/total retinal perfusion and vessel densities were not significantly correlated with the systemic severity score. These results may indicate that optical coherence tomography angiographic parameters are not sufficient to predict amyloidosis severity.

Optical coherence tomography angiography findings before and after onset of foveal retinal neovascularization in diabetic retinopathy

Purpose

To report a rare case of foveal retinal neovascularization (RNV) in a patient with diabetic retinopathy in whom the retinal microcirculation structure before and after the onset of the disease was evaluated using optical coherence tomography angiography (OCTA).

Observations

A 54-year-old woman with diabetes mellitus was referred to our department for fundus evaluation, and was diagnosed with cataract and severe non-proliferative diabetic retinopathy in the left eye. Two years after we performed cataract surgery and pan-retinal photocoagulation in the left eye, OCTA detected a previously unidentified foveal RNV arising from the perifoveal capillary network. The vitreous retinal interface slab of OCTA and cross-sectional OCT images confirmed that this foveal RNV was an aberrant vessel invading the vitreous cavity.

Conclusions and Importance

The findings in this case indicate that foveal RNV in diabetic retinopathy is derived from vessels outside the foveal avascular zone (FAZ), and OCTA is a useful examination for the diagnostic investigation of foveal RNV.

Treatment of diabetic macular edema in real-world clinical practice: the effect of aging

Aims/Introduction

In older patients, the management of diabetic macular edema (DME) can be complicated by comorbidities, geriatric syndrome, and socioeconomic status. This study aims to evaluate the effects of aging on the management of DME.

Materials and Methods

This is a real‐world clinical study including 1,552 patients with treatment‐naïve center‐involved DME. The patients were categorized into 4 categories by age at baseline (C1, <55; C2, 55–64; C3, 65–74; and C4, ≥75 years). The outcomes were the change in logarithm of the minimum angle of resolution best‐corrected visual acuity (logMAR BCVA) and central retinal thickness (CRT), and the number of treatments from baseline to 2 years.

Results

From baseline to 2 years, the mean changes in logMAR BCVA from baseline to 2 years were −0.01 in C1, −0.06 in C2, −0.07 in C3, and 0.01 in C4 (P = 0.016), and the mean changes in CRT were −136.2 μm in C1, −108.8 μm in C2, −100.6 μm in C3, and −89.5 μm in C4 (P = 0.008). Treatments applied in the 2 year period exhibited decreasing trends with increasing age category on the number of intravitreal injections of anti‐VEGF agents (P = 0.06), selecting local corticosteroid injection (P = 0.031), vitrectomy (P < 0.001), and laser photocoagulation outside the great vascular arcade (P < 0.001).

Conclusions

Compared with younger patients with DME, patients with DME aged ≥75 years showed less frequent treatment, a lower BCVA gain, and a smaller CRT decrease. The management and visual outcome in older patients with DME would be unsatisfactory in real‐world clinical practice.

A Case of Diagnosis of Occipital Lobe Epilepsy Complicated by Right Hemianopsia Associated with Left Occipital Lobe Cerebral Infarction

We report a case of occipital lobe epilepsy (OLE) in a patient with occipital lobe stroke whose diagnosis was complicated by homonymous hemianopsia. An 81-year-old woman presented with a complaint of "blurred vision" on the right side and was kept under outpatient observation at the Hirabayashi Eye Clinic for homonymous lower right hemianopsia, glaucoma, and post-cataract surgery. Her past medical history included hypertension, angina pectoris, atrial fibrillation, diabetes mellitus, and left occipital lobe cerebral infarction. The corrected visual acuity and intraocular pressure were 20/16 and 12 mm Hg and 20/20 and 13 mm Hg in the right and left eye, respectively, and no change was observed in the fundus and visual field defect; hence, the patient was placed under observation. Two days later, the patient voluntarily visited a neurosurgical hospital and underwent magnetic resonance imaging. No abnormalities were detected other than the left obsolete occipital lobe stroke. Five days later, she returned to our clinic because she felt "something wobbly" on her right side. Upon examination, we suspected a transient ischemic attack based on the wobbling, closed eyelids, and loss of consciousness, and referred her to the same neurosurgical hospital. Electroencephalography (EEG) revealed spikes and waves with occipital lobe predominance, and the diagnosis of OLE was made. The patient had right-sided homonymous hemianopsia owing to left occipital lobe cerebral infarction and "blurred vision" on the same side. Thus, it is inferred that EEG is imperative for ruling out epileptic seizures.

OCULAR ANGIOGRAPHIC FEATURES IN JAPANESE PATIENTS WITH VAL30MET HEREDITARY TRANSTHYRETIN AMYLOIDOSIS

PURPOSE

To investigate ocular angiographic features of hereditary transthyretin amyloidosis with transthyretin Val30Met mutation (hATTR-V30M) in Japanese patients.

METHODS

We retrospectively reviewed 102 eyes of 51 patients with hATTR-V30M who underwent fluorescein angiograms and indocyanine green angiograms between 2012 and 2018. Systemic severity score, fluorescein angiograms, indocyanine green angiograms, and ocular amyloidosis presentations at the final angiograms and subsequent neovascular events were evaluated. Primary outcomes were the frequency of choroidal amyloid angiopathy and retinal amyloid angiopathy (RAA). Secondary outcomes were their correlations to the systemic severity score.

RESULTS

Six eyes could not be evaluated by fluorescein angiogram because of vitreous opacity. Of 96 eyes evaluated, RAA was detected in 36 (37.5%). Neovascularization was not detected. Indocyanine green angiogram indicated choroidal amyloid angiopathy in 46/51 patients (90.2%), with distinct patterns-diffuse (n = 6), focal (n = 14), and punctiform (n = 26)-based on late-phase hypercyanescence. Retinal amyloid angiopathy and choroidal amyloid angiopathy grades were associated with systemic severity (ρ = 0.57 and 0.50, respectively; both P < 0.05). At 35.4 ± 28.4 (0-96) months, iris-rubeosis was observed in one eye and vitreous hemorrhage in two.

CONCLUSION

Retinal amyloid angiopathy was less common and choroidal amyloid angiopathy was frequent, and their severity correlated with the systemic severity score. The frequencies of RAA and subsequent neovascular events in this study may suggest regional differences in the ocular angiographic features of hATTR-V30M.

Bilateral Adie's Pupil following Laser Treatment of the Ischemic Peripheral Retina for Uveitis: A Case Report

Adie's pupil is a neurological condition of unknown origin with unusual, asymmetric presentation known as anisocoria with the enlarged pupil failing to react to light. It is believed that this pupillary abnormality results from damage to the ciliary ganglion or postganglionic short ciliary nerves. Affected individuals (usually female) may be symptomatic with photophobia or difficulty reading in the diseased eye. Although most Adie's pupil cases are idiopathic, previous studies have associated photocoagulation and uveitis with symptom onset. To the best of our knowledge, there have been no reports of specific means of preventing Adie's pupil. We describe a patient who experienced varying severities of Adie's pupil after separate laser treatments of the ischemic peripheral retina for uveitis. Fluorescein angiography revealed peripheral retinal nonperfusion in the bilateral eyes of a 37-year-old Japanese female who had been suffering from posterior uveitis. To avoid proliferative changes, 360° laser photocoagulation of the retinal nonperfusion region located in the far periphery was first delivered to the left eye over 2 sessions. Soon after treatment, the patient complained of acute photophobia and blurred vision in the treated eye. Ocular examination revealed left pupil dilation and poor light sensitivity, although the pupil was reactive to a close stimulus. The left pupil also displayed positive denervation sensitivity based on the dilute pilocarpine (0.125%) test. Adie's pupil was diagnosed based on these observations. Three months later, similar, albeit milder, findings were observed in her right eye after 360° peripheral laser photocoagulation that was more conservatively performed over 4 sessions. Four months after the first treatment, her subjective visual function had improved, and the pupil diameter had decreased to a normal size in both eyes without additional treatment. We encountered a patient whose severity of Adie's pupil was apparently reduced by more conservative laser photocoagulation of the ischemic peripheral retina.

POS0286 INCIDENCE OF MALIGNANCIES IN JAPANESE PATIENTS WITH RHEUMATOID ARTHRITIS: DATA FROM A LARGE JAPANESE NATIONAL REGISTRY

Background:

Patients (pts) with rheumatoid arthritis (RA) have an increased risk of some malignancies vs the general population, and this can vary by region/race.1,2 Data on the epidemiology and impact of biological (b)DMARDs and targeted synthetic (ts)DMARDs, such as Janus kinase (JAK) inhibitors, on the incidence of malignancies in Japanese pts with RA are limited. The National Database of Rheumatic Diseases in Japan (NinJa) is one of the largest RA registries in Japan.

Objectives:

To evaluate the incidence of malignancies in Japanese pts with RA using NinJa registry data.

Methods:

This retrospective observational study analysed NinJa registry data for Japanese pts with RA aged ≥18 years with ≥1 data entry between 2013 (first JAK inhibitor approval for RA in Japan) and 2018. The overall cohort included all pts with RA, and two sub-cohorts were analysed: pts exposed and unexposed to bDMARDs (exposure defined as ≥1 bDMARD reported in database). Crude incidence rates (IRs) for malignancies (including non-melanoma skin cancer) were calculated as the number of events per 100 pt-years of follow-up (time between start of follow-up or the date of first bDMARD exposure [for bDMARD-exposed pts] and end of observation period, or withdrawal from database). The most recent data for incidence of malignancy in the Japanese general population (2013–2017 data from the National Cancer Center, Japan) were used to calculate standardised incidence ratios (SIRs) and age- and sex-adjusted standardised rates (ASRs) for malignancies. Cross-sectional (per calendar year) and cumulative analyses were performed for the overall cohort. Cumulative rates were calculated for sub-cohorts, and all cumulative analyses were repeated excluding pts exposed to JAK inhibitors (ie ≥1 JAK inhibitor reported in database).

Results:

Data were collected for 26 607 Japanese pts with RA from 2013–2018. In the cross-sectional analysis (Table 1), the SIR and ASR for malignancies in all pts with RA were generally consistent from 2013–2018. In the cumulative analysis, the SIR (95% CI) for malignancies from 2013–2018 was 0.97 (0.91, 1.03) in all pts with RA, and 0.93 (0.82, 1.04) and 0.99 (0.92, 1.07) in pts exposed and unexposed to bDMARDs, respectively (Figure 1). Adjusting for age/sex, the cumulative ASR (95% CI) for malignancies from 2013–2018 was 0.83 (0.76, 0.90) in all pts with RA, and 0.82 (0.69, 0.95) and 0.86 (0.77, 0.96) in pts exposed and unexposed to bDMARDs, respectively (Figure 1). In all cohorts, the cumulative SIR and ASR were similar when pts exposed to JAK inhibitors were excluded (Figure 1).

Table 1.

Cross-sectional analysis of the incidence of malignancies in Japanese pts with RA from 2013–2018

All RA2013 (N=13 423)2014 (N=15 584)2015 (N=15 751)2016 (N=16 107)2017 (N=15 994)2018(N=15 003)Total follow-up, PY13 35314 86614 82914 97014 74814 898Pts with events, n140164174168161211Crude IRa(95% CI)1.05(0.89, 1.24)1.10(0.95, 1.29)1.17(1.01, 1.36)1.12(0.97, 1.31)1.09(0.94, 1.27)1.42(1.24, 1.62)ASRa,b(95% CI)0.76(0.60, 0.93)0.76(0.62, 0.90)0.90(0.68, 1.11)0.88(0.68, 1.07)0.80(0.62, 0.98)0.88(0.74, 1.01)SIRb(95% CI)0.97(0.82, 1.14)1.01(0.86, 1.17)1.02(0.87, 1.18)0.88(0.75, 1.02)0.86(0.73, 1.00)1.10(0.95, 1.25)

aIR/ASR were calculated as number of events per 100 PY of follow-up

bData from a Japanese general population database of malignancy incidence from 2013–2017, provided by the Center for Cancer Control and Information Services, National Cancer Center, Japan

PY, pt-years

Conclusion:

The incidence of malignancies in Japanese pts with RA, registered in the NinJa database from 2013–2018, was similar to that in the Japanese general population. The SIR and ASR for malignancies were comparable in pts exposed and unexposed to bDMARDs. In all cohorts, rates did not increase when pts exposed to JAK inhibitors were included.

References:

[1] Dougados et al. Ann Rheum Dis 2014; 73: 62-68.

[2] Parikh-Patel et al. Cancer Causes Control 2009; 20: 1001-1010.

Acknowledgements:

Study sponsored by Pfizer Inc. Medical writing support was provided by Christina Viegelmann, CMC Connect, and funded by Pfizer Inc.

Disclosure of Interests:

Toshihiro Matsui Speakers bureau: Astellas, Ayumi, Chugai, Daiichi-Sankyo, Eli Lilly, Ono, Pfizer Inc, Takeda, Tanabe-Mitsubishi, Consultant of: Pfizer Inc, Grant/research support from: Chugai, Naonobu Sugiyama Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Shigeyuki Toyoizumi Employee of: Pfizer R&D Japan, Fujio Matsuyama Consultant of: Pfizer Inc, Employee of: CRECON Medical Assessment Inc, Tatsunori Murata Consultant of: Pfizer Inc, Employee of: CRECON Medical Assessment Inc, Yukitomo Urata Speakers bureau: Asahi Kasei, Chugai, Eli Lilly, Pfizer Inc, Consultant of: AbbVie, Asahi Kasei, Chugai, Pfizer Inc, Kimito Kawahata Speakers bureau: Pfizer Inc, Consultant of: Pfizer Inc, Grant/research support from: Pfizer Inc, Shigeto Tohma Speakers bureau: Astellas, Ayumi, Chugai, Ono, Pfizer Inc, Takeda, Consultant of: Pfizer Inc

Adrenomedullin-Receptor Activity-Modifying Protein 2 System Ameliorates Subretinal Fibrosis by Suppressing Epithelial-Mesenchymal Transition in Age-Related Macular Degeneration

Age-related macular degeneration (AMD) is a leading cause of visual impairment. Anti-vascular endothelial growth factor drugs used to treat AMD carry the risk of inducing subretinal fibrosis. We investigated the use of adrenomedullin (AM), a vasoactive peptide, and its receptor activity-modifying protein 2, RAMP2, which regulate vascular homeostasis and suppress fibrosis. The therapeutic potential of the AM-RAMP2 system was evaluated after laser-induced choroidal neovascularization (LI-CNV), a mouse model of AMD. Neovascular formation, subretinal fibrosis, and macrophage invasion were all enhanced in both AM and RAMP2 knockout mice compared with those in wild-type mice. These pathologic changes were suppressed by intravitreal injection of AM. Comprehensive gene expression analysis of the choroid after LI-CNV with or without AM administration revealed that fibrosis-related molecules, including Tgfb, Cxcr4, Ccn2, and Thbs1, were all down-regulated by AM. In retinal pigment epithelial cells, co-administration of transforming growth factor-β and tumor necrosis factor-α induced epithelial-mesenchymal transition, which was also prevented by AM. Finally, transforming growth factor-β and C-X-C chemokine receptor type 4 (CXCR4) inhibitors eliminated the difference in subretinal fibrosis between RAMP2 knockout and wild-type mice. These findings suggest the AM-RAMP2 system suppresses subretinal fibrosis in LI-CNV by suppressing epithelial-mesenchymal transition.

Micropulse laser trabeculoplasty under maximal tolerable glaucoma eyedrops: treatment effectiveness and impact of surgical expertise

AIM

To evaluate the effectiveness of micropulse laser trabeculoplasty (MLT) for eyes with open angle glaucoma (OAG) under maximal tolerable glaucoma eyedrops and to assess the effect of expertise performing MLT on its clinical effectiveness.

METHODS

Medical records of 42 consecutive eyes of 34 patients diagnosed with OAG who underwent MLT were retrospectively reviewed. The effectiveness was determined using the Kaplan-Meier survival analysis. Failure was defined as an intraocular pressure (IOP) reduction of <20% from baseline, an IOP >21 mm Hg during two consecutive follow-up visits, or surgical intervention for OAG. To determine the impact of MLT surgical expertise on clinical effectiveness, the eyes were divided into two groups according to whether the procedure was conducted by an experienced specialist (defined as a glaucoma specialist who had conducted at least ten MLT procedures) or a less experienced glaucoma specialist. The difference in expertise was determined using a log-rank test.

RESULTS

MLT was conducted by three glaucoma specialists. The overall survival rates were 0.76, 0.48, and 0.44 at 1, 3, and 6mo, respectively. The survival rates for MLT performed by a less experienced glaucoma specialist were 0.62, 0.31, and 0.25 (n=21 eyes) at 1, 3, and 6mo, respectively, whereas the survival rates for MLT performed by an experienced glaucoma specialist were 0.90, 0.64, and 0.64 (n=21 eyes) at 1, 3, and 6mo, respectively. The log-rank test showed a significant difference in the survival curves of the two groups (P=0.0061).

CONCLUSION

The 6-month effectiveness of MLT for controlling IOP is relatively limited in eyes with OAG using maximal tolerable glaucoma eyedrops. However, its effectiveness may be improved if performed by a glaucoma specialist with sufficient MLT experience.

The randomized ZIPANGU trial of ranibizumab and adjunct laser for macular edema following branch retinal vein occlusion in treatment-naïve patients

The ZIPANGU study assessed the efficacy and safety of ranibizumab as a one loading dose + pro re nata (one + PRN) regimen with/without focal/grid laser among treatment-naïve patients suffering from macular edema (ME) following branch retinal vein occlusion (BRVO). ZIPANGU was a phase IV, prospective, randomized, open-label, active-controlled, 12-month, two-arm, multicenter study. Treatment-naïve patients with visual impairment (19–73 letters) caused by ME, defined as central subfield thickness (CSFT) > 300 µm, due to BRVO were randomly assigned to ranibizumab monotherapy (n = 29) or combination therapy (ranibizumab + focal/grid short-pulse laser, n = 30). The primary endpoint was the number of ranibizumab injections. Secondary endpoints were mean changes in best-corrected visual acuity (BCVA) and CSFT, and safety. There were no statistically significant differences in the mean number of ranibizumab injections between monotherapy (4.3 injections) vs. combination (4.1 injections) therapy, or in CSFT. BCVA improvement in the monotherapy arm (22.0 letters) was better than the combination therapy arm (15.0 letters) (p = 0.035). Overall, both regimens appeared to be safe and well tolerated. One + PRN ranibizumab is safe and efficacious in treatment-naïve patients with ME secondary to BRVO. A conjunctive laser treatment did not lead to better functional outcomes or fewer ranibizumab injections.

Deposits on Retinal Surface Seen on OCT in Ocular Amyloidosis

PURPOSE

To investigate the tomographic features in patients with hereditary amyloidosis transthyretin (hATTR).

DESIGN

Retrospective case series and analysis of B-scan OCT images.

PARTICIPANTS

A total of 120 patients (240 eyes) diagnosed with hATTR.

METHODS

We performed a retrospective review of the treatment history and retrospective analysis of the OCT images of patients with hATTR. The parameters analyzed were the age at which the last OCT was performed, presence of ocular amyloidosis, history of pars plana vitrectomy (PPV), systemic treatment, and genetic mutations. Two independent evaluators evaluated the OCT images for characteristic needle-shaped pattern deposits on the retinal surface, and a third evaluator resolved any differences in their evaluations.

MAIN OUTCOME MEASURES

The frequency of characteristic needle-shaped deposits on the retinal surface seen on OCT.

RESULTS

The mean age at the time of the last OCT was 56.5 ± 14.9 years. Ninety-nine patients had gene encoding transthyretin (TTR) with the Val30Met mutation, and 21 patients had other mutations. Of 240 eyes, 128 had signs of ocular amyloidosis. Fifty of 73 eyes (68.5%) with a history of PPV for vitreous opacities exhibited characteristic deposits on OCT. Four of 31 eyes with vitreous opacity but without a history of PPV showed deposits on the retinal surface. No eyes without a history of vitreous opacities revealed the characteristic needle-shaped deposits.

CONCLUSIONS

Characteristic needle-shaped deposits on the retinal surface seen on OCT are significant because they are seen in most of the vitrectomized eyes presenting with ocular amyloidosis.

Ten-year changes in visual acuity at baseline and at 2 years after treatment in a Japanese population with age-related macular degeneration

PURPOSE

We investigated 10-year changes in baseline best-corrected visual acuity (BCVA), as well as functional and anatomical changes at 1 and 2 years after initial treatment, in eyes with treatment-naïve neovascular age-related macular degeneration (nAMD).

METHODS

This retrospective, multicenter, case series reviewed patients with treatment-naïve nAMD who underwent initial treatment from 2006 to 2015, using photodynamic therapy (PDT), anti-vascular endothelial growth factor (VEGF), or a combination of PDT and anti-VEGF. BCVA and central retinal subfield thickness (CRST), were measured at baseline and at 1 or 2 years of follow-up.

RESULTS

In total, 3096 eyes of 3096 patients were included from 14 hospitals. Mean BCVA at baseline became significantly better over the 10-year study period (P < 0.001). BCVA at 1 year significantly improved from baseline in patients who underwent initial treatment from 2009 to 2015 (P = 0.001, 2009; P = 0.004, 2010; P = 0.01, 2011; P < 0.001, 2012-2015). BCVA at 2 years significantly improved from baseline in patients who underwent initial treatment from 2012 to 2015 (P < 0.001, 2012; P < 0.001, 2013-2015). CRST at 1 year decreased significantly from CRST at baseline, each year from 2006 to 2015 (P < 0.001, 2006-2015). CRST at 2 years decreased significantly from CRST at baseline, each year from 2006 to 2015 (P = 0.03, 2006; P < 0.001, 2007-2015).

CONCLUSION

Baseline BCVA with treatment-naïve nAMD tended to become better during the study period. BCVA at 1 year improved in the era of anti-VEGF; BCVA at 2 years improved in patients who underwent initial treatment in 2012 or later; and CRST decreased in each year during the study period.

Statins bring the prognostic impact only in peripheral artery disease patients with elevated c-reactive proteins -subanalysis from multicenter registry-

Introduction

Recent trials demonstrated favorable effects of statins on the clinical prognosis, partly through anti-inflammatory properties, in patients with coronary artery disease. However, this favorable effect has not been fully verified in patients with peripheral arterial disease (PAD). We hypothesized that statins exert different prognostic effects depending on the degrees of inflammation at the time of endovascular therapy (EVT).

Methods

This study is a subanalysis from the Toma-Code Registry that is a Japanese prospective cohort of 2,321 consecutive patients with PAD treated by endovascular therapy in hospitals from 2014 to 2016. After the exclusion of patients without information of C-reactive protein (CRP) at the time of index EVT, 2,039 patients including 1,039 statin users and 1,000 statin non-users were ultimately analyzed. The patient enrolled were divided into 4 categories depending on CRP level at the time of EVT; Low-CRP (&lt;0.1 mg/dL), Intermediate-low-CRP (0.1–0.3 mg/dL), Intermediate-High-CRP (0.3–1.0 mg/dL), and High-CRP (&gt;1.0 mg/dL). A composite of death, stroke, myocardial infarction, and major amputation as the primary endpoint of this study was compared between statin users and non-users in each CRP category.

Results

The composite endpoint occurred in 255 patients during the observation period. Overall, statin users had a significantly lower event rate than non-users (Log-rank test: P&lt;0.001). However, there were no significant difference in the event rates between statin users and non-users in the Low-, and Intermediate-Low-CRP categories. Only in the Intermediate-High- and the High-CRP categories, statin users showed a significantly lower event rates than non-users (P=0.02 and P=0.008, respectively, Figures). Additionally, multivariate Cox regression analysis in the High-CRP group revealed that statin use was independently associated with the primary endpoint (adjusted hazard ratio: 0.67 [95% confidence interval: 0.45–0.99]), even after the adjustment of covariants.

Conclusion

Statins may exert a favorable prognostic effect in PAD patients with highly elevated CRP, but not in those with low to moderate CRP level.

Event free survival

Funding Acknowledgement

Type of funding source: None

Prostaglandin D2 metabolite is not a useful clinical indicator for assessing atopic dermatitis

Prostaglandin D₂ (PGD₂ ) plays an important role in atopic dermatitis (AD), and 11,15-dioxo-9α-hydroxy-2,3,4,5-tetranorprostan-1,20-dioicacid (PGDM) is a major metabolite of PGD₂ . We investigated the relationship between urinary PGDM levels and severity of paediatric AD. In total, 31 patients with AD and 21 healthy controls (HCs) without AD were recruited, and urinary PGDM levels were measured. Of the 31 patients with AD, 14 were reassessed for urinary PGDM after topical steroid therapy. There was no difference in urinary PGDM levels between patients with AD and HCs. Although there was a significant positive correlation between the SCORing Atopic Dermatitis (SCORAD) index and the serum level of thymus and activation-regulated chemokine (TARC), the urinary PGDM levels did not correlate with either SCORAD or serum TARC. Moreover, both SCORAD and serum TARC were significantly improved by topical steroid therapy; however, urinary PGDM levels were not changed. In conclusion, the level of urinary PGD₂ metabolites in children with AD is substantially the same as that in HCs even if the disease is severe.

Real-world management of treatment-naïve diabetic macular oedema: 2-year visual outcome focusing on the starting year of intervention from STREAT-DMO study

Background/aims

To investigate the yearly change of real-world outcomes for best corrected visual acuity (BCVA) after 2-year clinical intervention for treatment-naïve diabetic macular oedema (DMO).

Methods

Retrospective analysis of aggregated, longitudinal medical records obtained from 27 retina specialised institutions in Japan from Survey of Treatment for DMO database. A total of 2049 treatment-naïve centre involving DMO eyes of which the initial intervention started between 2010 and 2015, and had been followed for 2 years, were eligible. As interventions, antivascular endothelial growth factor (VEGF) agents, local corticosteroids, macular photocoagulation and vitrectomy were defined. In each eye, baseline and final BCVA, the number of each intervention for 2 years was extracted. Each eye was classified by starting year of interventional treatment.

Results

Although baseline BCVA did not change by year, 2-year improvement of BCVA had been increased, and reached to +6.5 letters in the latest term. There is little difference among starting year about proportions of eyes which BCVA gained >15 letters, in contrast to those which lost >15 letters were decreased by year. The proportion of eyes receiving anti-VEGF therapy was dramatically increased, while those receiving the other therapies were gradually decreased. The proportion of eyes which maintained socially good vision of BCVA>20/40 has been increased and reached to 59.0% in the latest term.

Conclusion

For recent years, treatment patterns for DMO have been gradually but certainly changed; as a result, better visual gain, suppression of worsened eyes and better final BCVA have been obtained. Anti-VEGF therapy has become the first-line therapy and its injection frequency has been increasing.

Vitreoretinal Interface Slab in OCT Angiography for Detecting Diabetic Retinal Neovascularization

PURPOSE

To compare neovascularization identified in proliferative diabetic retinopathy (PDR) eyes by widefield swept-source (SS) OCT angiography (OCTA) using vitreoretinal interface (VRI) slab images, composed by automated and manual segmentation, with that identified by fluorescein angiography (FA).

DESIGN

Retrospective study.

PARTICIPANTS

Forty-two eyes of 30 treatment-naïve PDR patients who visited the outpatient clinic of the Department of Ophthalmology, Shinshu University, from June 2018 through October 2019.

METHODS

All patients underwent comprehensive ophthalmologic examinations, including SS-OCTA and FA.

MAIN OUTCOME MEASURES

Neovascularization detected by en face SS-OCTA 15 × 15-mm VRI slab images and by FA in the same 15 × 15-mm areas were compared in terms of number and structure.

RESULTS

Among 100 neovascularizations detected by FA, 73 also were visualized as neovascularization in SS-OCTA VRI slab images using automated segmentation. The sensitivity of VRI slab images for detecting neovascularization was 73%. Among the remaining 27 neovascularizations detected only by FA, but not by VRI slab, 15 were intraretinal microvascular abnormalities with fluorescence leakage, 1 was a diabetic papillopathy, and 11 were flat neovascularizations on the internal limiting membrane surface that were missed because of segmentation error. Conversely, among the 98 neovascularizations detected on VRI slab images, 25 were not detected as neovascularizations by FA. They included 9 small neovascularizations that exhibited too little leakage on FA and 16 false-positive results that were the result of segmentation errors. After reconstruction of SS-OCTA VRI slab images by means of manual segmentation, the sensitivity of VRI slab images for detecting neovascularizations increased to 84%.

CONCLUSIONS

The efficacy of SS-OCTA VRI slab images for detecting neovascularizations in PDR was comparable with that of FA. Swept-source OCTA VRI slab images may be better than FA for identifying intraretinal microvascular abnormalities and diabetic papillopathy from neovascularizations. Notably, however, FA and SS-OCTA VRI slab images demonstrated differences in identification efficacy in cases of small and flat neovascularizations. Further exploration of SS-OCTA technology is warranted to address this issue.

Cytohistology of morule in cribriform-morular variant of papillary thyroid carcinoma

INTRODUCTION

Cribriform-morular variant (CMV) is a rare variant of papillary thyroid carcinoma. It frequently occurs in association with familial adenomatous polyposis (FAP), although some cases are sporadic. Herein, we report a case of CMV and analyse morule cytohistology.

CASE REPORT

The patient was a 47-year-old woman with no familial history of FAP. A 3.0-cm unifocal mass was identified in the left thyroidal lobe. Fine-needle aspiration cytology revealed papillary clusters of atypical cells with nuclear grooves, which was suspected to be conventional papillary thyroid carcinoma. Histologically, the tumour comprised a papillary and cribriform growth of atypical cells with cytoplasmic accumulation and nuclear translocation of b-catenin. In addition, frequent morule formation was identified.

DISCUSSION

In this case, we performed morule analysis through correlative light and electron microscopy (CLEM), and revealed its ultrastructure. Although CMV is a rare form of thyroid carcinoma, it should be considered along with its distinct clinicopathological characteristics.

Real-world management of treatment-naïve diabetic macular oedema in Japan: two-year visual outcomes with and without anti-VEGF therapy in the STREAT-DME study

Background/Aims

To investigate real-world outcomes for best-corrected visual acuity (BCVA) after 2-year clinical intervention for treatment-naïve, centr-involving diabetic macular oedema (DME).

Methods

Retrospective analysis of longitudinal medical records obtained from 27 institutions specialising in retinal diseases in Japan. A total of 2049 eyes with treatment-naïve DME commencing intervention between 2010 and 2015 who were followed for 2 years were eligible. Interventions for DME included anti-vascular endothelial growth factor (VEGF) therapy, local corticosteroid therapy, macular photocoagulation and vitrectomy. Baseline and final BCVA (logMAR) were assessed. Eyes were classified by the treatment pattern, depending on whether anti-VEGF therapy was used, into an anti-VEGF monotherapy group (group A), a combination therapy group (group B) and a group without anti-VEGF therapy (group C).

Results

The mean 2-year improvement of BCVA was −0.04±0.40 and final BCVA of >20/40 was obtained in 46.3% of eyes. Based on the treatment pattern, there were 427 eyes (20.9%) in group A, 807 eyes (39.4%) in group B and 815 eyes (39.8%) in group C. Mean improvement of BCVA was −0.09±0.39, –0.02±0.40 and −0.05±0.39, and the percentage of eyes with final BCVA of >20/40 was 49.4%, 38.9%, and 52.0%, respectively.

Conclusion

Following 2-year real-world management of treatment-naïve DME in Japan, BCVA improved by 2 letters. Eyes treated by anti-VEGF monotherapy showed a better visual prognosis than eyes receiving combination therapy. Despite treatment for DME being selected by specialists in consideration of medical and social factors, a satisfactory visual prognosis was not obtained, but final BCVA remained >20/40 in half of all eyes.