Phototoxicity avoidance is a potential therapeutic approach for retinal dystrophy caused by EYS dysfunction

Inherited retinal dystrophies (IRDs) are progressive diseases leading to vision loss. Mutation in the eyes shut homolog (EYS) gene is one of the most frequent causes of IRD. However, the mechanism of photoreceptor cell degeneration by mutant EYS has not been fully elucidated. Here, we generated retinal organoids from induced pluripotent stem cells (iPSCs) derived from patients with EYS-associated retinal dystrophy (EYS-RD). In photoreceptor cells of RD organoids, both EYS and G protein-coupled receptor kinase 7 (GRK7), one of the proteins handling phototoxicity, were not in the outer segment, where they are physiologically present. Furthermore, photoreceptor cells in RD organoids were vulnerable to light stimuli, and especially to blue light. Mislocalization of GRK7, which was also observed in eys-knockout zebrafish, was reversed by delivering control EYS into photoreceptor cells of RD organoids. These findings suggest that avoiding phototoxicity would be a potential therapeutic approach for EYS-RD.

Factors Associated with Success of Switching to Faricimab for Neovascular Age-Related Macular Degeneration Refractory to Intravitreal Aflibercept

We investigated the factors associated with the success of switching to faricimab for type 1 macular neovascularization (MNV) refractory to intravitreal aflibercept (IVA). This retrospective cohort study included patients with type 1 MNV who were switched to faricimab because they were refractory to IVA at two centers. The primary endpoint was a more than two-week extension of the treatment interval after 6 months. In addition, factors related to the success or failure of extension and visual and anatomical outcomes were assessed. The analysis included 43 eyes from 43 patients. Extended dosing intervals of >2 weeks were identified in 14 eyes (32.6%). A short dosing interval before switching, absence of polypoidal lesions, and thin central choroidal thickness before switching were identified as factors involved in successful extension. For patients with refractory type 1 MNV, switching to faricimab is a safe and potential option to extend existing dosing intervals.

MACULAR CHORIORETINAL ATROPHY AND VISUAL OUTCOMES IN RANIBIZUMAB- OR AFLIBERCEPT-TREATED MYOPIC CHOROIDAL NEOVASCULARIZATION

PURPOSE

To investigate the predictors of macular chorioretinal atrophy, consisting of patchy atrophy (PA) at the macula and choroidal neovascularization (CNV)-related macular atrophy (CNV-MA), during treatment with ranibizumab or aflibercept for myopic CNV (mCNV) and its impact on visual outcomes.

METHODS

This retrospective study included 82 eyes with treatment-naïve mCNV who were treated with pro re nata injections of ranibizumab or aflibercept.

RESULTS

Nine eyes (11.0%) presented with macular PA at baseline (PA group), and 73 eyes (89.0%) did not (non-PA group). VA improved during the first year in the non-PA group; a similar trend was noted in the PA group until 3 months after initial treatment. This improvement was maintained until 24 months ( P < 0.001) in the non-PA group, but not in the PA group. In the PA group, macular chorioretinal atrophy progressed faster ( P < 0.0001), and CNV-MA was more frequent during the 2 years of treatments ( P = 0.04). Even non-PA group eyes sometimes developed CNV-MA (42% at Month 24) if they had a larger CNV and thinner subfoveal choroidal thickness at baseline, resulting in poorer visual prognosis ( P < 0.01).

CONCLUSION

Macular PA at baseline was a risk factor for CNV-MA development and was associated with poor visual outcomes.

Paracentral acute middle maculopathy in systemic sclerosis and subsequent branch retinal artery occlusion

Purpose

We report a case of systemic sclerosis-associated paracentral acute middle maculopathy (PAMM) in a young woman who subsequently developed branch retinal artery occlusion.

Observations

A 22-year-old woman presented with a paracentral scotoma. Optical coherence tomography (OCT) revealed bilateral paracentral acute middle maculopathy. Upon systemic examination, she was diagnosed with systemic sclerosis (SSc). She subsequently developed branch retinal artery occlusion despite vasodilator medications. After the prescription of aspirin, she did not experience a new event for one year.

Conclusion and importance

This case illustrates that SSc may affect the retinal vascular system and vision and cause PAMM. The optimal prophylaxis for patients with recurrent retinal events should be investigated in future studies.

TEN-YEAR VISUAL OUTCOME AND CHANGE IN CHORIORETINAL ATROPHY AFTER INTRAVITREAL RANIBIZUMAB FOR MACULAR NEOVASCULARIZATION IN PATHOLOGIC MYOPIA

PURPOSE

To investigate the 10-year visual outcome and chorioretinal atrophy after a single intravitreal ranibizumab injection followed by a pro re nata regimen for myopic macular neovascularization in pathologic myopia, and to identify the factors associated with 10-year best-corrected visual acuity (BCVA).

METHODS

This retrospective observational study evaluated 26 consecutive treatment-naïve eyes (26 patients) with myopic macular neovascularization in pathologic myopia who underwent a single intravitreal ranibizumab followed by a pro re nata regimen of intravitreal ranibizumab and/or intravitreal aflibercept injection and observed over 10 years. We assessed changes in BCVA and morphological parameters, including the META-PM Study category as a chorioretinal atrophy index.

RESULTS

The logarithm of the minimum angle of resolution BCVA changed from 0.36 (Snellen, 20/45) ± 0.39 to 0.39 (20/49) ± 0.36 over 10 years of observation. Compared to baseline, 1-year BCVA improved ( P = 0.002), whereas 2 to 10-year BCVA was not significantly different. Total injection frequency was 3.8 ± 2.6. In none of the eyes, 10-year BCVA was 20/200 or less. Ten-year BCVA correlated with baseline BCVA ( P = 0.01, r = 0.47). The META-PM Study category progressed in 60% of eyes. There were no drug-induced complications.

CONCLUSION

Best-corrected visual acuity in eyes with myopic macular neovascularization in pathologic myopia was maintained for 10 years after a single intravitreal ranibizumab followed by a pro re nata regimen without drug-induced complications. The META-PM Study category progressed in 60% of eyes, especially those with older baseline age. Early diagnosis and treatment of myopic macular neovascularization are essential to maintain good long-term BCVA.

Investigating the clinical validity of the guided progression analysis definition with 10-2 visual field in retinitis pigmentosa

PURPOSE

To investigate the clinical validity of the Guided Progression Analysis definition (GPAD) and cluster-based definition (CBD) with the Humphrey Field Analyzer (HFA) 10-2 test in retinitis pigmentosa (RP).

METHODS

Ten non-progressive RP visual fields (VFs) (HFA 10-2 test) were simulated for each of 10 VFs of 111 eyes (10 simulations × 10 VF sequencies × 111 eyes = 111,000 VFs; Dataset 1). Using these simulated VFs, the specificity of GPAD for the detection of progression was determined. Using this dataset, similar analyses were conducted for the CBD, in which the HFA 10-2 test was divided into four quadrants. Subsequently, the Hybrid Definition was designed by combining the GPAD and CBD; various conditions of the GPAD and CBD were altered to approach a specificity of 95.0%. Subsequently, actual HFA 10-2 tests of 116 RP eyes (10 VFs each) were collected (Dataset 2), and true positive rate, true negative rate, false positive rate, and the time required to detect VF progression were evaluated and compared across the GPAD, CBD, and Hybrid Definition.

RESULTS

Specificity values were 95.4% and 98.5% for GPAD and CBD, respectively. There were no significant differences in true positive rate, true negative rate, and false positive rate between the GPAD, CBD, and Hybrid Definition. The GPAD and Hybrid Definition detected progression significantly earlier than the CBD (at 4.5, 5.0, and 4.5 years, respectively).

CONCLUSIONS

The GPAD and the optimized Hybrid Definition exhibited similar ability for the detection of progression, with the specificity reaching 95.4%.

INVESTIGATION OF INCIDENCE AND CAUSES OF ACUTE VISION LOSS DURING ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY FOR NEOVASCULAR AGE-RELATED MACULAR DEGENERATION DURING A FOUR-YEAR FOLLOW-UP

PURPOSE

To investigate the incidence, risk factors, and outcomes of patients with age-related macular degeneration who experienced acute vision loss despite periodic injections of anti-vascular endothelial growth factor treatment for 4 years.

METHODS

This retrospective cohort study included patients who were diagnosed with treatment-naive neovascular age-related macular degeneration and completed a 4-year follow-up. The incidence and risk factors for the occurrence of three or more lines of visual loss at every checkup were investigated.

RESULTS

The analysis included 76 eyes of 76 patients. Acute vision loss occurred in 30 eyes (39.5%) over 4 years. Lower baseline best-corrected visual acuity and disrupted ellipsoid zone were independent predictors of vision loss occurrence. Although the causes and timing of visual acuity loss varied, retinal pigment epithelium tears were observed only in the first year. Most patients (86.7%) who experienced vision loss recovered their vision to pre-loss levels at least once; however, the final best-corrected visual acuity was worse than that in the group that did not experience acute vision loss.

CONCLUSION

Approximately half of the patients with age-related macular degeneration experienced acute vision loss during a 4-year follow-up, despite continuous anti-vascular endothelial growth factor treatment. Most patients recovered from vision losses temporarily; however, they experienced worse visual outcomes subsequently.

Relationship between visual acuity and visual field and its reproducibility in patients with retinitis pigmentosa

BACKGROUND/OBJECTIVES

To investigate the association between visual acuity (VA) and visual field (VF) and its reproducibility in patients with retinitis pigmentosa (RP).

SUBJECTS/METHODS

The study cohort comprised 227 eyes of 227 patients with RP. The reproducibility of two Humphrey VF tests (10-2 Swedish Interactive Threshold Algorithm [SITA] tests) performed within a period of 3 months was calculated using the root mean squared error (RMSE) of each VF test point's sensitivity. The association between the logarithm of the minimum angle of resolution (logMAR) VA and VF sensitivity was investigated. Additionally, the relationship between RMSE and age, fixation loss, false positives, false negatives, and logMAR VA was determined.

RESULTS

The association between visual sensitivity and VA was most tight at the fovea, and it became weak toward the peripheral region in an eccentric manner. VF reproducibility appreciably increased as VA decreased. In particular, reproducibility was significantly decreased when logMAR VA was >0.5 compared with logMAR VA ≤ 0.

CONCLUSION

Reproducibility of VF tests decreases with a decrease in VA. Careful consideration is necessary when a patient's logMAR VA is >0.5.

Estimation of Visual Function Using Deep Learning From Ultra-Widefield Fundus Images of Eyes With Retinitis Pigmentosa

Importance

There is no widespread effective treatment to halt the progression of retinitis pigmentosa. Consequently, adequate assessment and estimation of residual visual function are important clinically.

Objective

To examine whether deep learning can accurately estimate the visual function of patients with retinitis pigmentosa by using ultra-widefield fundus images obtained on concurrent visits.

Design, Setting, and Participants

Data for this multicenter, retrospective, cross-sectional study were collected between January 1, 2012, and December 31, 2018. This study included 695 consecutive patients with retinitis pigmentosa who were examined at 5 institutions. Each of the 3 types of input images-ultra-widefield pseudocolor images, ultra-widefield fundus autofluorescence images, and both ultra-widefield pseudocolor and fundus autofluorescence images-was paired with 1 of the 31 types of ensemble models constructed from 5 deep learning models (Visual Geometry Group-16, Residual Network-50, InceptionV3, DenseNet121, and EfficientNetB0). We used 848, 212, and 214 images for the training, validation, and testing data, respectively. All data from 1 institution were used for the independent testing data. Data analysis was performed from June 7, 2021, to December 5, 2022.

Main Outcomes and Measures

The mean deviation on the Humphrey field analyzer, central retinal sensitivity, and best-corrected visual acuity were estimated. The image type-ensemble model combination that yielded the smallest mean absolute error was defined as the model with the best estimation accuracy. After removal of the bias of including both eyes with the generalized linear mixed model, correlations between the actual values of the testing data and the estimated values by the best accuracy model were examined by calculating standardized regression coefficients and P values.

Results

The study included 1274 eyes of 695 patients. A total of 385 patients were female (55.4%), and the mean (SD) age was 53.9 (17.2) years. Among the 3 types of images, the model using ultra-widefield fundus autofluorescence images alone provided the best estimation accuracy for mean deviation, central sensitivity, and visual acuity. Standardized regression coefficients were 0.684 (95% CI, 0.567-0.802) for the mean deviation estimation, 0.697 (95% CI, 0.590-0.804) for the central sensitivity estimation, and 0.309 (95% CI, 0.187-0.430) for the visual acuity estimation (all P < .001).

Conclusions and Relevance

Results of this study suggest that the visual function estimation in patients with retinitis pigmentosa from ultra-widefield fundus autofluorescence images using deep learning might help assess disease progression objectively. Findings also suggest that deep learning models might monitor the progression of retinitis pigmentosa efficiently during follow-up.

Geometric Morphometrics Can Predict Postoperative Visual Acuity Changes in Patients With Epiretinal Membrane: A Retrospective Study

Purpose

To investigate the efficacy of the geometric morphometrics method for the evaluation of retinal deformation in patients with epiretinal membrane (ERM) and determine whether the degree of deformation can serve as a predictive factor for postoperative visual outcome.

Methods

We retrospectively evaluated data from 29 eyes of 29 patients with primary ERM. Preoperative optical coherence tomography images were compared with images of their normal fellow eyes using the geometric morphometrics thin-plate spline technique. Conventional parameters such as retinal layer thickness and previously reported indices were also measured. The correlation between the preoperative parameters and visual acuity was evaluated. Statistical comparisons were performed using a paired t-test, and associations between the optical coherence tomography image parameters and visual acuity were determined using Spearman's rank correlation coefficient.

Results

Bending energy, which was calculated using geometric morphometrics, was significantly associated with visual acuity as well as conventional optical coherence tomography parameters and previously reported indices. Multiple regression analysis showed that bending energy was an independent predictive factor for postoperative visual acuity changes.

Conclusions

The geometric morphometrics method is an effective approach for evaluating the severity of ERM and predicting the efficacy of surgery.

Translational Relevance

Geometric morphometrics can effectively evaluate retinal deformation in eyes with epiretinal membrane.

Optic disc hemorrhage in a young female following mRNA coronavirus disease 2019 vaccination: a case report

BACKGROUND

Since the development of the coronavirus disease 2019 vaccine, there have been many reports of its adverse effects. While respiratory symptoms are common, many other symptoms in various organs have been reported. Herein, we report a case of optic disc and retinal hemorrhage that developed immediately after coronavirus disease 2019 vaccination.

CASE PRESENTATION

A healthy 18-year-old Japanese female noticed floater in the left eye 1 day after the second vaccination for coronavirus disease 2019 (Pfizer Inc.). Her visual acuity was 20/20 in the left eye, and Goldmann visual field test showed a relative scotoma around blind spot and in the temporal lower quadrant. It was considered due to subretinal hemorrhage and optic disc swelling. Fundus examination revealed retinal and optic disc hemorrhage. Pupillary reflex was intact and central critical flicker was not impaired, indicating that optic nerve was not involved. There was no sign of inflammation, vascular abnormality, nor history of an intense Valsalva maneuver. The hemorrhage resolved spontaneously within 5 months.

CONCLUSION

This case expands the clinical presentation of coronavirus disease 2019 vaccination-associated ocular adverse events, and it should be kept in mind when patients with similar symptoms visit clinics. The case report will help clinicians avoid unnecessary and invasive examinations and treatment.

Choriocapillaris flow deficit in a pachychoroid spectrum disease using en face optical coherence tomography angiography averaging

Purpose

To investigate the choriocapillaris changes associated with pachychoroid pigment epitheliopathy (PPE) in comparison with healthy eyes.

Methods

Nine 3 × 3 mm macular optical coherence tomography angiography images were acquired in patients with PPE and age-matched healthy participants. Multiple en face image averaging of the choriocapillaris was binarized for quantitative image analysis of the flow voids. In PPE eyes, we evaluated the presence of pachyvessels and the association between the location of the choriocapillaris flow deficit and pachyvessels.

Results

Thirty-two eyes with PPE and 30 eyes of healthy participants were included. In PPE eyes, the mean total area (1.16 ± 0.18 vs. 0.91 ± 0.16, p < 0.001) and average size of the flow voids (790 ± 144 vs. 520 ± 138; p < 0.001) were significantly larger than those in control eyes. Composite images of the choriocapillaris and choroid showed choriocapillaris flow deficits just above and outside the pachyvessels. The mean proportion of the flow void area overlying the pachyvessels against the whole flow void area of the choriocapillaris was 21.3% ± 10.2% (9.38%-44.42%) in PPE eyes.

Conclusions

In PPE eyes, the blood flow area of the choriocapillaris decreased diffusely within the macular area compared to control eyes, and the choriocapillaris flow deficit was not necessarily related to pachyvessel location.

Bilateral Orbital Inflammation as a Manifestation of Paraneoplastic Syndrome

Paraneoplastic neurologic syndromes (PNS) constitute a rare group of disorders whose optimal treatment is yet to be established. We report a patient with bilateral orbital inflammation associated with PNS, who responded well to surgical resection of the primary tumor. An 83-year-old woman was referred to our department for treatment of a progressive reduction in visual acuity and palpebral swelling in both eyes for the past 2 months. She was scheduled to undergo thoracic surgery for lung cancer. The best-corrected visual acuity (BCVA) in the right and left eye had worsened from 0.3 to 0.5 one month before she was referred to our department to 0.03 and 0.07, respectively. A slit-lamp examination revealed edema in both eyelids. Goldmann perimetry revealed several paracentral scotomas with constriction of the peripheral visual fields of both eyes, along with central absolute scotomas in V-4e isopter in the right eye. Magnetic resonance imaging revealed swelling of the bilateral extraocular muscles, which compressed the bilateral optic nerves at the orbital apex. Seven days after the resection of the lung cancer, the BCVA improved to 0.07 and 0.15 in the right and left eyes, respectively, without concomitant immunotherapy. Intravenous methylprednisolone (500 mg/day) was administered for 3 days to treat the residual orbital inflammation. Fourteen days after surgery, the BCVA further improved to 0.4 and 0.5 in the right and left eyes, respectively. Swelling of the bilateral extraocular muscles and the visual field abnormalities improved dramatically. Early diagnosis is crucial for the management of PNS.

Rescue Photodynamic Therapy for Age-Related Macular Degeneration Refractory to Anti-Vascular Endothelial Growth Factor Monotherapy

BACKGROUND

To evaluate the 3-year outcome in eyes with neovascular age-related macular degeneration (nAMD) treated with intravitreal anti-vascular endothelial growth factor monotherapy or rescue therapy using standard verteporfin photodynamic therapy (PDT), and corroborate efficacy of rescue PDT.

METHODS

Patients were administered aflibercept injections once a month for 3 months followed by once every 2 months in the first year. After year 1, treatment with aflibercept monotherapy as indicated or in combination with PDT at the retinal specialist's discretion. Only cases completing the three-year follow-up were included. Regression analysis with visual acuity and macular atrophy at year 3 was performed for the dependent variable.

RESULTS

Of the 292 eyes, 15 eyes underwent rescue PDT following year 1. The best-corrected visual acuity (logarithm of minimal angle of resolution, mean/Snellen equivalent ± SD) was 0.35 (20/45) ± 0.38, 0.23 (20/30) ± 0.36, 0.26 (20/35) ± 0.38, and 0.31 (20/40) ± 0.42 at baseline, year 1, year 2, and year 3, respectively. Multiple regression analysis revealed that the rescue PDT was significantly associated with macular atrophy and poor visual outcome at year 3 (odds ratio = 1.2, p < 0.001; β = 0.23, p = 0.0029, respectively).

CONCLUSIONS

The visual outcome in eyes with nAMD retained baseline levels at year 3; however, patients treated with rescue PDT developed macular atrophy more frequently and poor visual outcomes.

Effect of inverted internal limiting membrane flap technique on small-medium size macular holes

Inverted internal limiting membrane (ILM) flap technique was developed to achieve macular hole (MH) closure in large MH and refractory cases. In this study, we evaluate the effect of the technique for small-medium size MH. We recruited patients who underwent vitrectomy for small-medium size (< 400 μm) MH with either inverted ILM flap technique (flap group) or with conventional ILM peeling (peeling group). Using propensity score, 21 eyes of 21 patients in the peeling group were matched against 21 eyes of 21 patients in the flap group. We compared MH closure rate, postoperative visual acuity, and recovery of the external limiting membrane (ELM) and ellipsoid zone (EZ). The MH closure rate was not different between the two groups (flap vs peeling: 90% vs 100%, P = 0.49). Whereas there was no significant difference in visual acuity improvement between the two groups, the flap group showed more disruption of the ELM 3 months after surgery and of the EZ at 3 and 6 months after surgery (P = 0.02, P = 0.03, and P = 0.04, respectively). The result suggested that inverted ILM flap technique does not have additional benefits for small-medium size MHs and may delay recovery of retinal integrity.

Association between the number of visual fields and the accuracy of future prediction in eyes with retinitis pigmentosa

Purpose

To evaluate the minimum number of visual fields (VFs) required to precisely predict future VFs in eyes with retinitis pigmentosa (RP).

Methods

A series of 12 VFs (Humphrey Field Analyzer 10–2 test (8.9 years in average) were analysed from 102 eyes of 52 patients with RP. The absolute error to predict the 12th VF using the prior 11 VFs was calculated in a pointwise manner, using the linear regression, and the 95% CI range was determined. Then, using 3–10 initial VFs, next VFs (4th to 11th VFs, respectively) were also predicted. The minimum number of VFs required for the mean absolute prediction error to reach the 95% CI was identified. Similar analyses were iterated for the second and third next VF predictions. Similar analyses were conducted using mean deviation (MD).

Results

In the pointwise analysis, the minimum number of VFs required to reach the 95% CI for the 12th VF was five (first and second next VF predictions) and six (third next VF prediction). For the MD analysis, three (first and second next VF predictions) and four (third next VF prediction) VFs were required to reach 95% CI for the 12th VF.

Conclusions

The minimum number of VFs required to obtain accurate predictions of the future VF was five or six in the pointwise analysis and three or four in the analysis with MD.

Detecting Progression of Retinitis Pigmentosa Using the Binomial Pointwise Linear Regression Method

Purpose

A method of evaluating central visual field (VF) progression in eyes with retinitis pigmentosa (RP) has still to be established. We previously reported the potential merit of applying a binomial test to pointwise linear regression (binomial PLR) in glaucoma progression. In the current study, we investigated the usefulness of binomial PLR in eyes with RP.

Methods

A series of 10 VFs (VF 1–10, Humphrey field analyzer, 10-2 test) from 196 eyes of 103 patients with RP were collected retrospectively. The PLR was performed by regressing the total deviation of all test points with the complete series of 10 VFs. The accuracy (positive predictive value, negative predictive value, and false-positive rate) and the time required to detect VF progression with shorter VF series (from VF 1–5 to VF 1–9) were compared across the binomial PLR, a permutation analysis of PLR (PoPLR), and a mean deviation (MD) trend analysis.

Results

In evaluating VF progression, the binomial PLR was comparable with the PoPLR and MD trend analyses in its positive predictive value (0.55 to 0.95), negative predictive value (0.67 to 0.92), and false-positive rate (0.01 to 0.05). The binomial PLR required significantly less time to detect VF progression (5.0 ± 2.0 years) than the PoPLR and MD trend analyses (P < 0.01, P < 0.001, respectively).

Conclusions

The application of a binomial PLR achieved reliable and earlier detection of central VF progression in eyes with RP.

Translational Relevance

A binomial PLR was useful in assessing VF progression in RP.

Detection Sensitivity of Retinitis Pigmentosa Progression Using Static Perimetry and Optical Coherence Tomography

Purpose

To compare the detection sensitivities of the progression of retinitis pigmentosa (RP) by automated perimetry to obtain the mean deviation (MD) and total point score and by optical coherence tomography (OCT) to determine the residual ellipsoid zone (EZ) length and thickness of retinal layers.

Methods

Twenty-two eyes of 22 patients with RP who underwent annual automated perimetry (Humphrey Field Analyzer 10-2) and OCT examinations during the same period more than four times were included. Disease progression was evaluated using linear regression analysis with the least-squares method. The disease progression speed and interinspection fluctuations for the different examinations were compared using standardized values. The progression detection ability factor, defined as the average of the least squares divided by the square of annual change, was used to compare the sensitivities of the examinations for detecting the progression of RP.

Results

EZ length showed a high correlation with MD (R = 0.87; P = 1.12E-07) at baseline. Disease progression was detected more frequently using EZ length (12/22 eyes) than using MD (3/22 eyes; P = 0.004) or central retinal thickness (1/11 eyes; P = 0.012). Linear regression using standardized values showed that the EZ length had the fastest annual change, with the smallest least absolute values. EZ length was more sensitive for detecting RP progression than MD, total point score, visual acuity, or central retinal thickness.

Conclusions

EZ measurement was sensitive for detecting RP progression, and the results of this study indicate that EZ length is appropriate for end points in clinical trials.

Translational Relevance

The study provides a basis for conducting future clinical trials.

Development and validation of a visual field cluster in retinitis pigmentosa

The aim was to establish and evaluate a new clustering method for visual field (VF) test points to predict future VF in retinitis pigmentosa. A Humphrey Field Analyzer 10-2 test was clustered using total deviation values from 858 VFs. We stratified 68 test points into 24 sectors. Then, mean absolute error (MAE) of the sector-wise regression with them (S1) was evaluated using 196 eyes with 10 VF sequences and compared to pointwise linear regression (PLR), mean sensitivity of total area (MS) and also another sector-wise regression basing on VF mapping for glaucoma (29 sectors; S2). MAE with S1 were smaller than with PLR when between the first-third and first-seventh VFs were used. MAE with the method were significantly smaller than those of S2 when between the first-sixth and first-ninth VFs were used. The MAE of MS was smaller than those with S1 only when first to 3rd and first to 4th VFs were used; however, the prediction accuracy became far larger than any other methods when larger number of VFs were used. More accurate prediction was achieved using this new sector-wise regression than with PLR. In addition, the obtained cluster was more useful than that for glaucoma to predict progression.

Effects of Intravitreous Aflibercept Injection in Pachychoroid Neovasculopathy: Comparison with Typical Neovascular Age-Related Macular Degeneration

Purpose

To compare the 12-month efficacy of intravitreous aflibercept (IVA) injection between eyes with pachychoroid neovasculopathy and neovascular age-related macular degeneration (AMD).

Methods

Retrospective, comparative case series analysis. Twenty-seven eyes with pachychoroid neovasculopathy and sixty-three eyes with neovascular AMD. All patients received three initial monthly, followed by bimonthly, IVA injections.

Results

Twelve months after initial treatment, the mean best-corrected visual acuity (BCVA) had improved both in pachychoroid neovasculopathy (from 0.28 to 0.14 logMAR; P = 0.001) and neovascular AMD (from 0.40 to 0.29 logMAR; P < 0.001). Twelve months after initial treatment, eyes with pachychoroid neovasculopathy exhibited decreased mean central retinal thickness (CRT) and subfoveal choroidal thickness (both, P < 0.001) and presence of polyps (P = 0.039) and improved integrity of external limiting membrane (ELM) (P = 0.008) and ellipsoid zone band (P = 0.001). At the 12-month follow-up, 77% and 68% of eyes with pachychoroid neovasculopathy and neovascular AMD, respectively, exhibited dry macula (P = 0.30). Baseline CRT was correlated with 12-month BCVA in eyes with pachychoroid neovasculopathy (P = 0.02). In eyes with neovascular AMD, CRT (P = 0.005) and presence of intact ELM (P = 0.007) were significant predictors of 12-month BCVA.

Conclusion

Periodic IVA injection leads to anatomical and functional improvement in eyes with pachychoroid neovasculopathy and in eyes with neovascular AMD.

Genotype and Long-term Clinical Course of Bietti Crystalline Dystrophy in Korean and Japanese Patients

PURPOSE

To investigate the genotype and long-term clinical phenotype of patients with Bietti crystalline dystrophy (BCD) in Korea and Japan.

DESIGN

Retrospective case series.

PARTICIPANTS

We analyzed 62 patients with clinical features of BCD who harbor pathogenic biallelic CYP4V2 variants in their homozygote or compound heterozygote.

METHODS

Data were collected from patient charts, including age, best-corrected visual acuity (BCVA), Goldmann perimetry results, fundus photography, OCT findings, fundus autofluorescence results, and electroretinography findings. We compared the clinical course of the patients with homozygous c.802-8_810de117insGC [exon7del], the most common mutation in the East Asian population, with those of the patients with other genotypes.

MAIN OUTCOME MEASURES

Best-corrected visual acuity, visual field (VF), and their changes during follow-up.

RESULTS

The mean age at the first visit was 55.2 years, with a mean follow-up of 7.1 years. The mean BCVAs at the first and last visits were 0.28 logarithm of the minimum angle of resolution (logMAR) and 0.89 logMAR, respectively. In genetic testing, c.802-8_810de117insGC was detected in 86 of 124 alleles of the patients, and 36 patients were homozygous for this mutation. The age, BCVA, VF area, central foveal thickness, and abnormal hypoautofluorescent area at either the first or last visit were not different between the exon7del homozygotes and the others. The mean BCVA changes per year were 0.089 logMAR in the exon7del homozygotes and 0.089 logMAR in the others. An age- and gender-adjusted linear regression analysis showed no association between the exon7del homozygote status and the rate of vision loss. Characteristic crystalline deposits in the posterior pole were generally observed in younger patients and disappeared over time along with progressive retinochoroidal atrophy.

CONCLUSIONS

Patients with BCD and a homozygote for c.802-8_810de117insGC accounted for more than 50% of this cohort of Korean and Japanese patients, and the clinical effect of this deleterious variant was not severe in the spectrum of CYP4V2 retinopathy.

Clinical and Genetic Characteristics of Pachydrusen in Eyes with Central Serous Chorioretinopathy and General Japanese Individuals

PURPOSE

To survey the prevalence and clinical and genetic characteristics of pachydrusen in eyes with central serous chorioretinopathy (CSC) and those of Japanese individuals in the general population.

DESIGN

Prospective, observational cohort study.

PARTICIPANTS

One thousand thirty-seven Japanese patients were included in this study. Three hundred seven patients (614 eyes) had treatment-naïve CSC without choroidal neovascularization in either eye, whereas 730 individuals (1640 eyes) were Japanese individuals from the general population without explicit ocular diseases.

METHODS

Pachydrusen were detected using color fundus photography, and subfoveal choroidal thickness was measured using OCT. Genotypic distributions of 3 single nucleotide polymorphisms, ARMS2 A69S, CFH I62V, and CFH Y402H, were evaluated.

MAIN OUTCOME MEASURES

Prevalence of pachydrusen and association with choroidal thickness.

RESULTS

The prevalence of pachydrusen was significantly higher among CSC patients than among the general population group (40.1% vs. 15.6%; P < 0.001). Individuals with pachydrusen in either group were significantly older than those without pachydrusen (CSC patients: 62.1 years vs. 48.8 years [P < 0.001]; general individuals: 70.3 years vs. 51.9 years [P < 0.001]). No significant difference was found in subfoveal choroidal thickness between those with and without pachydrusen (CSC patients: 370 μm vs. 375 μm; [P = 0.574]; general population: 297 μm vs. 303 μm [P = 0.521]). However, after adjusting for age, gender, and refractive error, subfoveal choroidal thickness was notably thicker in individuals with pachydrusen than that in individuals without pachydrusen in both groups (P = 0.003 and P = 0.013, respectively). No significant difference was found in genotype distributions between CSC patients with pachydrusen and those without it; whereas, the T allele frequency of ARMS2 A69S was higher in general population individuals with pachydrusen than that in general population individuals without pachydrusen (42.2% vs. 33.9%; P < 0.001; OR, 1.86, adjusted for age, gender, and choroidal thickness).

CONCLUSIONS

Pachydrusen was observed more frequently in CSC patients compared with individuals from the general population. In both groups, pachydrusen was associated with a thicker choroid, suggesting that pachydrusen should be considered as a significant sign of pachychoroid.

Analysis of Retinal Nerve Fibre Thickening in Progressive and Non-progressive Non-arteritic Anterior Ischaemic Optic Neuropathy Using Optical Coherence Tomography

The study aims to investigate the longitudinal changes in the circumpapillary retinal nerve fibre layer thickness (cpRNFLT) in progressive and non-progressive non-arteritic anterior ischaemic optic neuropathy (NAION). This retrospective observational case series study analysed 17 eyes with NAION. Patients sustaining any additional visual loss (additional decrease in visual acuity (VA) ≥0.2 logMAR) within two months after initial onset of symptoms were classified as having progressive NAION. Of the 17 eyes with NAION, 13 (76.5%) were diagnosed as non-progressive and 4 (23.5%) were diagnosed as progressive. Compared with control eyes, eyes with non-progressive NAION showed greater cpRNFLT in all four optic disc quadrants at the initial visit (temporal and superior: P < .001; nasal and inferior: P = .002). In contrast, compared with control eyes, eyes with progressive NAION showed greater cpRNFLT in the superior and nasal quadrants (P = .004 and 0.028, respectively), but not in the temporal and inferior quadrants. During progression, eyes with progressive NAION showed a significant increase in cpRNFLT in the inferior quadrants; furthermore, there was significant increase in cpRNFLT in the nasal sector before visual loss developed after the initial visit. Progressive NAION showed development of the disc swelling from the superior to inferior portion of optic disc via the nasal swelling, suggesting that swollen axons in one ischaemic part may lead to secondary vascular infarction in another part of the optic disc. This enlargement could constitute the earliest sign of progressive NAION.

Characteristics of pachychoroid neovasculopathy

Recently, several research groups have reported a newly recognized clinical entity of choroidal neovascularization, termed pachychoroid neovasculopathy. However, its characteristics have yet to be well described. The purpose of this study was to investigate the clinical and genetic characteristics of pachychoroid neovasculopathy regardless of treatment modality. This study included 99 eyes of 99 patients with treatment-naïve pachychoroid neovasculopathy. Mean initial best-corrected visual acuity (BCVA) was 0.20 ± 0.32 logMAR, and did not change (P = 0.725) during follow-up period (mean ± SD, 37.0 ± 17.6 months). Subretinal hemorrhage (SRH) (≥ 4 disc areas in size) occurred in 20 eyes (20.2%) during follow-up. Age, initial BCVA, central retinal thickness, SRH (≥ 4 disc areas in size) and treatment (aflibercept monotherapy) were significantly associated with the final BCVA (P = 0.024, < 0.001, 0.031, < 0.001, and 0.029, respectively). Multiple regression analysis showed initial BCVA and presence of SRH to be significant predictors of final BCVA (both P < 0.001). Polypoidal lesions were more common in the SRH group than in the non-SRH group (85.0% vs 48.1%, P = 0.004). There was no significant difference in the frequency of the risk allele in ARMS2 A69S, CFH I62V, CFH Y402H between these groups (P = 0.42, 0.77, and 0.85, respectively). SRH (29.1% vs 9.1%, P = 0.014) and choroidal vascular hyperpermiability (65.5% vs 43.2%, P = 0.027) were seen more frequently in the polypoidal lesion (+) group than in the polypoidal lesion (−) group. There was considerable variation in lesion size and visual function in patients with pachychoroid neovasculopathy, and initial BCVA and presence of SRH at the initial visit or during the follow-up period were significant predictors of final BCVA.

Wavelength of light and photophobia in inherited retinal dystrophy

Inherited retinal dystrophy (IRD) patients often experience photophobia. However, its mechanism has not been elucidated. This study aimed to investigate the main wavelength of light causing photophobia in IRD and difference among patients with different phenotypes. Forty-seven retinitis pigmentosa (RP) and 22 cone-rod dystrophy (CRD) patients were prospectively recruited. We designed two tinted glasses: short wavelength filtering (SWF) glasses and middle wavelength filtering (MWF) glasses. We classified photophobia into three types: (A) white out, (B) bright glare, and (C) ocular pain. Patients were asked to assign scores between one (not at all) and five (totally applicable) for each symptom with and without glasses. In patients with RP, photophobia was better relieved with SWF glasses {“white out” (p < 0.01) and “ocular pain” (p = 0.013)}. In CRD patients, there was no significant difference in the improvement wearing two glasses (p = 0.247–1.0). All RP patients who preferred MWF glasses had Bull’s eye maculopathy. Meanwhile, only 15% of patients who preferred SWF glasses had the finding (p < 0.001). Photophobia is primarily caused by short wavelength light in many patients with IRD. However, the wavelength responsible for photophobia vary depending on the disease and probably vary according to the pathological condition.

Clinical and genetic characteristics of 10 Japanese patients with PROM1-associated retinal disorder: A report of the phenotype spectrum and a literature review in the Japanese population

Variants in the PROM1 gene are associated with cone (-rod) dystrophy, macular dystrophy, and other phenotypes. We describe the clinical and genetic characteristics of 10 patients from eight Japanese families with PROM1-associated retinal disorder (PROM1-RD) in a nationwide cohort. A literature review of PROM1-RD in the Japanese population was also performed. The median age at onset/examination of 10 patients was 31.0 (range, 10-45)/44.5 (22-73) years. All 10 patients showed atrophic macular changes. Seven patients (70.0%) had spared fovea to various degrees, approximately half of whom had maintained visual acuity. Generalized cone (-rod) dysfunction was demonstrated in all nine subjects with available electrophysiological data. Three PROM1 variants were identified in this study: one recurrent disease-causing variant (p.Arg373Cys), one novel putative disease-causing variant (p.Cys112Arg), and one novel variant of uncertain significance (VUS; p.Gly53Asp). Characteristic features of macular atrophy with generalized cone-dominated retinal dysfunction were shared among all 10 subjects with PROM1-RD, and the presence of foveal sparing was crucial in maintaining visual acuity. Together with the three previously reported variants [p.R373C, c.1551+1G>A (pathogenic), p.Asn580His (likely benign)] in the literature of Japanese patients, one prevalent missense variant (p.Arg373Cys, 6/9 families, 66.7%) detected in multiple studies was determined in the Japanese population, which was also frequently detected in the European population.

Effect of smoking on macular function and retinal structure in retinitis pigmentosa

Retinitis pigmentosa is an inherited neurodegenerative disease of the retina. We investigated smoking as a modifiable environmental factor for the progression of this currently untreatable disease. Clinical data, smoking history, macular function and morphology including visual acuity, visual field sensitivity, ellipsoid zone width and central retinal thickness were investigated. Association between pack × years and these parameters were evaluated using generalized estimating equation models to adjust confounding factors such as age and sex. A total of 410 patients with retinitis pigmentosa (≥20 years old; 209 female) were included, 164 had a smoking history. Patients without smoking history revealed a better visual acuity than smokers (0.39 versus 0.57, P = 0.001). The pack × years index was associated with worse visual acuity and thinner central retinal thickness after adjusting for age and sex (P = 0.0047 and 0.0099, respectively). Visual field and ellipsoid zone width showed a non-significant decline with increasing pack × years. This study indicates an association of smoking with worse macular function and structural integrity in retinitis pigmentosa patients, and hence a potential detrimental effect of smoking on the disease course.

Generation of a human induced pluripotent stem cell line, BRCi004-A, derived from a patient with age-related macular degeneration

Age-related macular degeneration (AMD) is a late-onset progressive blinding disease. We established human induced pluripotent stem cells (iPSCs) from an AMD patient. The generated iPSC line showed pluripotency markers and three-germ layer differentiation ability in vitro. This iPSC line will be useful for elucidating the pathomechanisms of and drug discovery for AMD.

Wide-field fundus autofluorescence imaging in patients with hereditary retinal degeneration: a literature review

Background

Inherited retinal degeneration (IRD) refers to a heterogenous group of progressive diseases that cause death of photoreceptor cells and subsequent vision loss. These diseases often affect the peripheral retina, objective evaluation of which has been difficult until recently. Fundus autofluorescence (FAF) is a non-invasive retinal imaging technique that depicts the distribution of intrinsic fluorophores in the retina. The primary source of retinal autofluorescence is lipofuscin, which is contained in the retinal pigment epithelium (RPE). Excessive accumulation of lipofuscin and a window defect attributable to loss of photoreceptor pigment result in increased FAF whereas loss of the RPE results in decreased FAF. These changes can be seen during the course of IRD.

Mainbody

While conventional modalities are limited in their angle of view, recent technologic advances, known as wide-field and ultra-widefield FAF imaging, have enabled visualization of the far peripheral retina. Although clinical application of this technique in patients with IRD is still in its infancy, some studies have already indicated its usefulness. For example, an area with decreased FAF correlates well with a visual field defect in an eye with retinitis pigmentosa (RP) or cone-rod dystrophy. An abnormal FAF pattern may help in the diagnosis of IRD and associated diseases. In addition, female carriers of X-linked RP and female choroideremia show characteristic appearance. Conversely, absence of abnormal FAF despite severe retinal degeneration helps differentiation of cancer-associated retinopathy.

Conclusion

This paper reviews the principles of FAF, wide-field imaging, and findings in specific diseases. Wide-field imaging, particularly wide-field FAF, will provide further information for the characteristics, prognosis, and pathogenesis of IRD.

Genome-wide association analyses identify two susceptibility loci for pachychoroid disease central serous chorioretinopathy

The recently emerged pachychoroid concept has changed the understanding of age-related macular degeneration (AMD), which is a major cause of blindness; recent studies attributed AMD in part to pachychoroid disease central serous chorioretinopathy (CSC), suggesting the importance of elucidating the CSC pathogenesis. Our large genome-wide association study followed by validation studies in three independent Japanese and European cohorts, consisting of 1546 CSC samples and 13,029 controls, identified two novel CSC susceptibility loci: TNFRSF10A-LOC389641 and near GATA5 (rs13278062, odds ratio = 1.35, P = 1.26 × 10-13; rs6061548, odds ratio = 1.63, P = 5.36 × 10-15). A T allele at TNFRSF10A-LOC389641 rs13278062, a risk allele for CSC, is known to be a risk allele for AMD. This study not only identified new susceptibility genes for CSC, but also improves the understanding of the pathogenesis of AMD.

Polypoidal Choroidal Vasculopathy Associate With Diminished Regulatory T Cells That Are Polarized Into a T Helper 2-Like Phenotype

Purpose

To investigate possible roles of T helper (Th) cells, regulatory T cells (Tregs), and the recently mapped Th-like Tregs in patients with polypoidal choroidal vasculopathy (PCV).

Methods

In this prospective case-control study, we obtained fresh venous blood from patients with PCV (n = 24), age-matched healthy controls (n = 32), and patients with neovascular AMD (n = 45). All participants underwent a comprehensive ocular examination including fluorescein and indocyanine green angiography for where retinal disease was suspected. Using flow cytometry, we identified Th subsets, Tregs, and Th-like Tregs. Plasma samples were stored at -80°C to investigate plasma cytokines of interest.

Results

Compared to healthy controls, patients with PCV had lower percentages of Tregs (8.7% ± 2.8% vs. 7.3% ± 1.7%, P = 0.027), which were significantly more Th2-like polarized (42.6% ± 13.3% vs. 50.5% ± 13.0%, P = 0.029). These changes differed from that observed in neovascular AMD, which compared to healthy controls had fewer Th1/Th17 cells (3.6% ± 2.7% vs. 2.4% ± 2.5%, P = 0.049), comparable Treg levels, and no distinct polarization of Th-like Tregs. Because of these findings, we measured plasma IL-4 and IL-33 levels. Plasma IL-33 in patients with PCV (median 0.30 pg/mL) was twice as high compared to healthy controls (median 0.16 pg/mL; P = 0.037).

Conclusions

PCV associate with diminished Tregs that are polarized more into a Th2-like phenotype. This is correlated to IL-33 levels, which we also find increased in patients with PCV. Our findings suggest a possible role for Th2-like Tregs and IL-33 in PCV.

Five major sequence variants and copy number variants in the EYS gene account for one-third of Japanese patients with autosomal recessive and simplex retinitis pigmentosa

PURPOSE

To elucidate the variant spectrum of the EYS gene in a large cohort of Japanese patients with autosomal recessive and simplex retinitis pigmentosa (arRP and sRP).

METHODS

We performed a direct sequencing analysis of 44 exons of the EYS gene in 469 patients with RP (including 144 arRP, 288 sRP, and 17 autosomal dominant RP (adRP) cases) in eastern and western regions of Japan and a multiplex ligation-dependent probe amplification (MLPA) of patients who had a single heterozygous pathogenic variant.

RESULTS

We identified six pathogenic and 16 likely pathogenic variants from a total of 186 nucleotide sequence variants, of which five variants, c.2528G>A (p.(Gly843Glu)), c.4957dupA (p.(Ser1653Lysfs*2)), c.6557G>A (p.(Gly2186Glu)), c.6563T>C (p.(Ile2188Thr)), and c.8868C>A (p.(Tyr2956*)), were prevalent in patients with arRP and sRP. The homozygous and heterozygous combinations of these five variants accounted for 32.4% (140/432) of Japanese patients with arRP and sRP. Five patients with adRP also had these variants. These five variants segregated with the phenotype in 15 families with RP. MLPA revealed seven copy number variations (CNVs) of the EYS exon(s).

CONCLUSIONS

This study showed that five major sequence variants and CNVs in the EYS gene account for one-third of Japanese patients with arRP and sRP, and these variants are also responsible for RP showing an autosomal dominant inheritance pattern. This is the first report showing the pathogenicity of three missense variants (p.(Gly843Glu), p.(Gly2186Glu), and p.(Ile2188Thr)) and the presence of CNVs in the EYS gene of Japanese patients with arRP and sRP.

[Clinical presentations of Ross syndrome have changed in their lateralities following the anteriotemporal lobectomy for refractory focal epilepsy]

We describe a 60-year-old woman with medically refractory left mesial temporal lobe epilepsy accompanied by Ross syndrome. The patient had a partial triad of Ross syndrome with hypohydrosis only on her right side (contralateral to the epileptic seizure focus), Adie's tonic pupil on the right, and areflexia while her seizures used to be medically refractory. However, her hypohidrosis and Adie's tonic pupil have completely changed in terms of laterality following nearly complete seizure freedom resutling from left temporal lobectomy. This unique change in laterality in Ross syndrome is most likely caused by remote effects of the near-absent epileptic acitivity, and it also may contribute to understanding the pathophysiological mechanism of Ross syndrome.

Olfactory Dysfunction in Patients With CNGB1-Associated Retinitis Pigmentosa

Importance

Co-occurrence of retinitis pigmentosa (RP) and olfactory dysfunction may have a common genetic cause.

Objective

To report olfactory function and the retinal phenotype in patients with biallelic mutations in CNGB1, a gene coding for a signal transduction channel subunit expressed in rod photoreceptors and olfactory sensory neurons.

Design, Setting, and Participants

This case series was conducted from August 2015 through July 2017. The setting was a multicenter study involving 4 tertiary referral centers for inherited retinal dystrophies. Participants were 9 patients with CNGB1-associated RP.

Main Outcomes and Measures

Results of olfactory testing, ocular phenotyping, and molecular genetic testing using targeted next-generation sequencing.

Results

Nine patients were included in the study, 3 of whom were female. Their ages ranged between 34 and 79 years. All patients had an early onset of night blindness but were usually not diagnosed as having RP before the fourth decade because of slow retinal degeneration. Retinal features were characteristic of a rod-cone dystrophy. Olfactory testing revealed reduced or absent olfactory function, with all except one patient scoring in the lowest quartile in relation to age-related norms. Brain magnetic resonance imaging and electroencephalography measurements in response to olfactory stimulation were available for 1 patient and revealed no visible olfactory bulbs and reduced responses to odor, respectively. Molecular genetic testing identified 5 novel (c.1312C>T, c.2210G>A, c.2492+1G>A, c.2763C>G, and c.3044_3050delGGAAATC) and 5 previously reported mutations in CNGB1.

Conclusions and Relevance

Mutations in CNGB1 may cause an autosomal recessive RP-olfactory dysfunction syndrome characterized by a slow progression of retinal degeneration and variable anosmia or hyposmia.

Efficacy of Photodynamic Therapy for Polypoidal Choroidal Vasculopathy Associated with and without Pachychoroid Phenotypes

PURPOSE

To compare the efficacy of photodynamic therapy (PDT) in eyes with polypoidal choroidal vasculopathy (PCV) associated with and without pachychoroid phenotypes (pachychoroid PCV and nonpachychoroid PCV, respectively).

DESIGN

Retrospective chart review.

PARTICIPANTS

Patients previously diagnosed with PCV and initially treated with PDT.

METHODS

Patients were classified as having pachychoroid- or nonpachychoroid-driven conditions. The long-term visual outcome and its associated factors were investigated.

MAIN OUTCOME MEASURES

Visual acuity (VA) outcomes at 1, 2, 3, 4, and 5 years after initial PDT in pachychoroid and nonpachychoroid PCV.

RESULTS

Of the 158 eyes, 88 (55.7%) met the criteria for pachychoroid PCV; 70 (44.3%) did not (nonpachychoroid PCV). In cases of pachychoroid PCV, VA improved significantly at 1 year (P = 0.042) and maintained baseline level at 5 years (P = 0.38). By contrast, VA continued to deteriorate in the nonpachychoroid PCV group during the follow-up period and had already declined significantly by the second year (P = 0.022, compared with baseline). Despite no difference in baseline VA between pachychoroid and nonpachychoroid PCV groups (P = 0.11), the VA at 5 years was significantly better in the pachychoroid PCV group compared with the nonpachychoroid PCV group (0.54±0.47 vs. 0.93±0.63, respectively; P = 0.23 × 10^-3). The incidence of massive submacular hemorrhage (SMH) or vitreous hemorrhage (VH) was not different between groups at 5 years (P = 0.67), and their occurrence was associated with decreased VA in both the nonpachychoroid and pachychoroid PCV groups (coefficient β, 0.361 and 0.481; P = 0.59 × 10^-3 and P < 1.0 × 10^-5, respectively).

CONCLUSIONS

Five years after PDT treatment, VA was maintained at the baseline level in the pachychoroid PCV group but not in the nonpachychoroid PCV group. Massive SMH or VH during the follow-up period affected the final visual outcomes in both conditions.

The European Eye Epidemiology spectral-domain optical coherence tomography classification of macular diseases for epidemiological studies

PURPOSE

The aim of the European Eye Epidemiology (E3) consortium was to develop a spectral-domain optical coherence tomography (SD-OCT)-based classification for macular diseases to standardize epidemiological studies.

METHODS

A European panel of vitreoretinal disease experts and epidemiologists belonging to the E3 consortium was assembled to define a classification for SD-OCT imaging of the macula. A series of meeting was organized, to develop, test and finalize the classification. First, grading methods used by the different research groups were presented and discussed, and a first version of classification was proposed. This first version was then tested on a set of 50 SD-OCT images in the Bordeaux and Rotterdam centres. Agreements were analysed and discussed with the panel of experts and a final version of the classification was produced.

RESULTS

Definitions and classifications are proposed for the structure assessment of the vitreomacular interface (visibility of vitreous interface, vitreomacular adhesion, vitreomacular traction, epiretinal membrane, full-thickness macular hole, lamellar macular hole, macular pseudo-hole) and of the retina (retinoschisis, drusen, pigment epithelium detachment, hyper-reflective clumps, retinal pigment epithelium atrophy, intraretinal cystoid spaces, intraretinal tubular changes, subretinal fluid, subretinal material). Classifications according to size and location are defined. Illustrations of each item are provided, as well as the grading form.

CONCLUSION

The E3 SD-OCT classification has been developed to harmonize epidemiological studies. This homogenization will allow comparing and sharing data collection between European and international studies.

Genetic testing in patients with retinitis pigmentosa: Features of unsolved cases

IMPORTANCE

Uncommon characteristics in genetically unsolved retinitis pigmentosa (RP) patients may indicate an incorrect clinical diagnosis or as yet unknown genetic causes resulting in specific retinal phenotypes. The diagnostic yield of targeted next-generation sequencing may be increased by a reasonable preselection of RP-patients.

BACKGROUND

To systematically evaluate and compare features of genetically solved and unsolved RP-patients.

DESIGN

Retrospective, observational study.

PARTICIPANTS

One-hundred and twelve consecutive RP-patients who underwent extensive molecular genetic analysis.

METHODS

Characterization of patients based on multimodal imaging and medical history.

MAIN OUTCOME MEASURES

Differences between genetically solved and unsolved RP-patients.

RESULTS

Compared to genetically solved patients (n = 77), genetically unsolved patients (n = 35) more frequently had an age of disease-onset above 30 years (60% vs 8%; P < 0.0001), showed atypical fundus features (49% vs 8%; P < 0. 0001) and indicators for phenocopies (eg, autoimmune diseases) (17% vs 0%; P < 0. 001). Evidence for a particular inheritance pattern was less common (20% vs 49%; P < 0. 01). The diagnostic yield was 84% (71/85) in patients with first symptoms below 30 years-of-age, compared to 69% (77/112) in the overall cohort. The other selection criteria alone or in combination resulted in limited further increase of the diagnostic yield (up to 89%) while excluding considerably more patients (up to 56%) from genetic testing.

CONCLUSIONS AND RELEVANCE

The medical history and retinal phenotype differ between genetically solved and a subgroup of unsolved RP-patients, which may reflect undetected genotypes or retinal conditions mimicking RP. Patient stratification may inform on the individual likelihood of identifying disease-causing mutations and may impact patient counselling.

Novel Predictors of Visual Outcome in Anti-VEGF Therapy for Myopic Choroidal Neovascularization Derived Using OCT Angiography

PURPOSE

To explore novel prognostic factors associated with visual function and number of anti-vascular endothelial growth factor (VEGF) treatments in eyes with active myopic choroidal neovascularization (mCNV) using OCT angiography (OCTA).

DESIGN

Prospective case series.

PARTICIPANTS

Twenty-eight treatment-naïve eyes with active mCNV from 27 consecutive patients (mean age, 64.4 ± 11.1 years).

METHODS

All eyes received through injection a single loading dose of intravitreal aflibercept (IVA), followed by additional IVA on a pro re nata (PRN) basis during the subsequent 12 months. At baseline, OCTA images of a 3 × 3-mm macular cube were acquired using an OCTA scanner. On binarized and skeletonized OCTA images of the outer retinal layer, OCTA-derived baseline parameters of mCNV-including lesion size, vessel density, vessel length density (VLD), vessel diameter index, and fractal dimension (FD)-were measured and evaluated for correlation with 12-month best-corrected visual acuity (BCVA) and number of additional injections.

MAIN OUTCOME MEASURES

The primary and secondary outcomes were BCVA 12 months after initial treatment and number of additional injections, respectively.

RESULTS

There was no significant difference between baseline and 12-month BCVA (0.37 ± 0.30 and 0.30 ± 0.35 logarithm of the minimal angle of resolution, respectively; P = 0.23). The number of additional injections was 0.93 ± 1.02 (mean ± standard deviation). Baseline VLD, FD, and BCVA were correlated with 12-month BCVA (P = 0.02, r = 0.46; P = 0.02, r = 0.46; and P = 0.02, r = 0.45, respectively), and VLD also was correlated with the number of additional injections (P = 0.03, r = 0.42).

CONCLUSIONS

Exuberant mCNV, which is characterized by high VLD and FD derived using OCTA, is a predictor of poor visual outcomes after a single IVA injection followed by a PRN regimen. Only baseline VLD was correlated with the number of additional IVA injections, which indicates that this parameter could help to determine the optimal anti-VEGF treatment regimen for individual eyes with mCNV.

Limited efficacy of adalimumab in the acute phase of serpiginous choroiditis refractory to corticosteroid and cyclosporine, a case report

BACKGROUND

The optimal treatment of serpiginous choroiditis is not established. While recent reports indicate the efficacy of adalimumab, there is limited evidence. We present a case of serpiginous choroiditis refractory to steroids, immunosuppressants, and adalimumab.

CASE PRESENTATION

An 18-year-old woman presented with severe vision loss in both eyes. A fundus examination revealed a foveal grayish-white lesion, and optical coherence tomography revealed outer retinal damage. She was diagnosed with serpiginous choroiditis and treated with steroid pulse therapy, but the disease progressed continuously. The addition of sub-Tenon's injection of triamcinolone and oral cyclosporine did not change the disease course. We also administered subcutaneous injections of adalimumab, but even with the intensive treatment, the retinal lesions and subsequent atrophy progressed. Her right and left visual acuity declined from 20/22 to 20/66 and 20/200, respectively, during the 9 months of follow-up.

CONCLUSION

Here, we report a case of serpiginous choroiditis refractory to corticosteroids, immunosuppressants, and adalimumab. Further studies are needed to establish the optimal treatment for such cases.

Four-Year Outcome of Aflibercept for Neovascular Age-Related Macular Degeneration and polypoidal choroidal vasculopathy

Intravitreal injections of anti-vascular endothelial growth factor agents such as ranibizumab and aflibercept are the first-line treatment for neovascular age-related macular degeneration (AMD). However, data about long-term outcome in real-world clinical practice is scarce. We recruited 98 AMD patients and investigated four-year visual outcome. During the four years, 25 patients dropped out. The survivors received 7.0 ± 0.1 injections during the first year and 8.0 ± 7.4 injections in the following three years. The logarithm of minimum angle of resolution (logMAR) at baseline, year one, and year four was 0.28, 0.14 (P = 0.033), and 0.22 (P = 0.697), respectively. The gain of vision was not different among AMD subtypes (typical AMD, polypoidal choroidal vasculopathy, and retinal angiomatous proliferation; P = 0.513) Among the investigated factors, the presence of external limiting membrane (ELM), the absence of vitreoretinal adhesion, and thicker choroid at baseline were associated with better logMAR values at year four (coefficient beta = -0.388, 0.201, and -0.001; P = 7.34 × 10^-6; 0.01, and 0.028, respectively). In the present study, vision was retained at baseline level after the four-year treatment with aflibercept. The status of ELM, vitreoretinal adhesion, and choroidal thickness were predictive factors for final vision.

Plasma markers of chronic low-grade inflammation in polypoidal choroidal vasculopathy and neovascular age-related macular degeneration

PURPOSE

Ageing is the strongest predictor of neovascular age-related macular degeneration (AMD), where neuroinflammation is known to play a major role. Less is known about polypoidal choroidal vasculopathy (PCV), which is an important differential diagnosis to neovascular AMD. Here, we report plasma markers of inflammation with age (inflammaging) in patients with PCV, patients with neovascular AMD and a healthy age-matched control group.

METHODS

We isolated plasma from fresh venous blood obtained from participants (n = 90) with either PCV, neovascular AMD, or healthy maculae. Interleukin(IL)-1β, IL-6, IL-8, IL-10 and tumour necrosis factor receptor 2 (TNF-R2) were measured using U-PLEX Human Assays. Routine plasma C-reactive protein (CRP) was measured using Dimension Vista 1500.

RESULTS

Patients with PCV had plasma levels of IL-1β, IL-6, IL-8, IL-10 and TNF-R2 similar to that in healthy controls. Patients with neovascular AMD had significantly higher plasma IL-1β, IL-6 and IL-10 than healthy controls, whereas no significant differences were observed for plasma IL-8 and TNF-R2. Differences between plasma IL-1β, IL-6 and IL-10 possessed a positive but weak ability in discriminating neovascular AMD from PCV. Both patients with PCV and patients with neovascular AMD had significantly higher levels of routine plasma CRP.

CONCLUSION

Patients with PCV differ from patients with neovascular AMD in terms of plasma inflammaging profile. Apart from increased CRP, no signs of inflammaging were observed in patients with PCV. In patients with neovascular AMD, we find a specific angiogenesis-twisted inflammaging profile.

Multiple subretinal fluid blebs after pars plana vitrectomy for rhegmatogenous retinal detachment repair

PURPOSE

To investigate the incidence of and clinical risk factors for multiple subretinal fluid (SRF) blebs after pars plana vitrectomy (PPV).

METHODS

This study examined patients who underwent PPV (25- or 27-gauge) to repair a primary rhegmatogenous retinal detachment (RRD). Clinical characteristics, including age, sex, axial length, symptom duration, and postoperative best-corrected visual acuity (BCVA), were compared between eyes with and without multiple SRF blebs. Intentional drainage retinotomy and cryotherapy use were also performed. Main outcome measures were the effect of these parameters on multiple SRF bleb incidence 1 month after surgery.

RESULTS

A total of 108 eyes of 106 patients (76 men and 32 women; mean age = 58.9 ± 9.0 years) were included. Multiple SRF blebs were observed in 8 eyes (7.4%). Logistic regression analysis showed that creation of intentional drainage retinotomy and 27-gauge PPV are risk factors for the development of multiple SRF blebs. The number and size of blebs spontaneously decreased over time, and SRF had completely resolved in 5 eyes (62.5%) 1 year after surgery.

CONCLUSION

Multiple SRF blebs developed even after small gauge vitrectomy. The SRF did not affect postoperative BCVA and gradually absorbed without treatment.

Time-Course Change in Eye Shape and Development of Staphyloma in Highly Myopic Eyes

Purpose

To quantitatively assess the posterior pole shape change in highly myopic eyes and to investigate the factors determining the speed of shape change.

Methods

Local curvature of the Bruch's membrane on the optical coherence tomography image was measured at intervals of 1 μm, and the mean curvature and curvature variance were calculated for 1094 eyes with an axial length of ≥26 mm. Speed of shape change was calculated using two points of mean curvature and curvature variance, and compared according to age, sex, axial length, and baseline eye shape.

Results

The posterior pole shape of females changed significantly greater than males (P < 0.01). Protruding change through the mean curvature was the greatest in the eyes with an axial length of ≥28 mm and <29 mm, while undulating change through the curvature variance became greater with axial length elongation in the eyes with an axial length of <29 mm and showed similar change in the eyes with an axial length of ≥29 mm. The eyes with a flatter shape at baseline tended to show a slow shape change, whereas those with moderate shape deformation at baseline showed faster shape change.

Conclusions

Quantitative evaluation of posterior pole eye shape clearly demonstrated significant time-dependent protruding and undulating changes in highly myopic eyes. Sex, axial length, and baseline posterior pole eye shape significantly affected speed of the posterior pole shape change. Our findings will facilitate risk assessment of staphyloma-associated complications in highly myopic eyes through measurement of speed of the posterior pole shape change.

Long-term efficacy and safety of anti-VEGF therapy in retinitis pigmentosa: a case report

Background

Retinitis pigmentosa (RP), a neurodegenerative disease, is occasionally accompanied by choroidal neovascularization (CNV) and cystoid macular oedema. It is presently treated with repeated intravitreal injections of anti-vascular endothelial growth factor (VEGF) agents. However, there are concerns regarding long-term inhibition of VEGF by the use of these agents, especially in cases involving neurodegenerative diseases, since VEGFs have a neuroprotective effect. Currently, there are no reports on the long-term safety of anti-VEGF therapy in patients with RP.

Case presentation

In this report, we describe the case of a 56-year-old female patient with CNV associated with RP who was treated with anti-VEGF therapy for 8 years. She had autosomal dominant RP with a heterozygous PRPH2 mutation (c.410G > A) and complained of metamorphopsia in her left eye. Examinations revealed CNV with serous retinal detachment. She was treated with as-needed injections for 2 years; however, she experienced a recurrence. Therefore, we switched to a bimonthly regimen that was continued for 6 years. In total, the patient received 34 injections of various types of anti-VEGFs over 8 years. No recurrences were noted during that time, and we have not detected any negative effects concerning the progression of visual field loss in comparison with the fellow eye.

Conclusions

No negative effects related to the progression of visual field loss were observed during continuous treatment with anti-VEGF agents for 8 years in our patient.

Long-term results of photodynamic therapy or ranibizumab for polypoidal choroidal vasculopathy in LAPTOP study

BACKGROUND/AIM

We previously reported that ranibizumab performed better on visual prognosis than photodynamic therapy (PDT) in a Ranibizumab (Lucentis) And Photodynamic Therapy On Polypoidal choroidal vasculopathy (LAPTOP) study. To determine if the first-choice treatment, either PDT or intravitreal ranibizumab, has a long-term effect in patients with polypoidal choroidal vasculopathy (PCV).

METHODS

We reviewed medical records of patientsrandomised to either PDT (29 eyes) or ranibizumab (27 eyes) from July 2009 to June 2011 in LAPTOP study. Retreatment or switching to other treatments were at the investigator's discretion after release from the 2-year LAPTOP study up to 5years. We evaluated visual acuity (VA), continuity of initial treatment, percentage of dry macula achievement and macular atrophy at 5 years.

RESULTS

The logarithm of minimal angle of resolution VA was 0.56 in the PDT and 0.44 in the ranibizumab groups at baseline (p=0.101) and was 0.55 and 0.28 at 5years, respectively (p<0.05). More than 70% of the patients converted to aflibercept in following years. Achievement percentages of dry macula were 74% (PDT) and 63% (ranibizumab) at 5years, and macular atrophy was detected in 78% (PDT) and 60% (ranibizumab) with a mean area of 7.7 and 3.5 mm², respectively (p=0.155).

CONCLUSIONS

The better VA in the initial ranibizumab group compared with the PDT group at 2 years was retained at the 5-year follow-up.