[OPHTHALMOLOGY - ON THE TIP OF THE SPEAR]

INTRODUCTION

Ophthalmology is a broad branch of medicine, which includes an extensive range of sub-specialties on one hand, and interfaces with other fields of medicine on the other. This issue contains papers from different sub-specialties of ophthalmology, that together cover several of the most important issues in this field. These papers present the topics in a manner compatible with the wide readership of the journal, and touch upon the most current updates and innovations. The original articles in this issue deal with treatments for the prevention of myopia progression in children, treatment of complicated cases of retinal detachment in children, ocular manifestations of vascular abnormalities in patients with coronavirus, and a series of patients with corneal damage due to ultraviolet-C (UVC) lamps intended to clear the air of this virus. The review papers describe glaucoma and the current change in its treatment paradigm, which focuses on earlier intervention, ocular manifestations of systemic autoimmune diseases, and the possibilities for artificial corneal implantation. We hope that this special issue will be of interest and clinical value to its readers.

[LOWER EYELID BLEPHAROPLASTY]

INTRODUCTION

Eyelid blepharoplasty, including lower eyelid blepharoplasty, are among the most common aesthetic surgeries recently performed. In contrast to upper eyelid blepharoplasty, lower eyelid blepharoplasty is a surgery with mostly an aesthetic indication, in which patients bear all associated costs, and their expectations rise accordingly. Nevertheless, the complexity of the anatomy, the differences in the aging processes of the face and eyelids between patients, the diversity of surgical methods, and the expectations gap make the surgery more challenging in comparison to upper eyelid blepharoplasty. A comprehensive understanding of the eyelid anatomy and the surrounding tissues, as well as matching expectations alongside with thorough preoperative evaluation, are all essential for providing a more personal adjustment of the surgical method and avoiding complications and mental distress for both patients and surgeons. This article briefly reviews the anatomy and aging processes of the lower eyelids, the main surgical approaches, and their common complications. Moreover, we present a framework for how such complications can be avoided.

Post-Intravitreal injection pain reduction using topical NSAIDS: A comparative study

PURPOSE

To compare the efficacy of two different topical non-steroidal anti-inflammatory drugs (NSAIDs) drops with versus without conservatives after intravitreal injections (IVIs).

DESIGN

Prospective, randomized, placebo-controlled, single-blinded comparative study.

PARTICIPANTS AND METHOD

A total of 308 eyes of 252 patients receiving an IVI of anti-vascular endothelial growth factor (anti-VEGF) were randomly assigned to receive either a single drop of nepafenac 0.1%, preservative-free diclofenac 0.1%, or artificial tears (control group) immediately after IVI. Primary outcome measure was pain scores immediately, six hours and twenty-four hours post- injection.

RESULTS

166 patients received one topical drop of NSAIDS, of which 90 in the diclofenac group and 76 in the nepafenac group. Additional 86 patients were included in the control group. Mean reported pain score was significantly lower at six hours after IVI in the preservative-free diclofenac group (17.1 ± 23.0) than in the nepafenac group (26.2 ± 31.9) and the control group (27.5 ± 29.2) (p = 0.03). At twenty-four hours post-injection there was no statistically significant difference between the groups. Patients reported less pain compared to previous IVIs and none referred to urgent health care, but these findings were not statistically significant.

CONCLUSIONS

The use of topical preservative-free NSAIDs may be superior to preservative- containing NSAIDs in pain relief after IVIs and may be considered as part of the treatment protocol of this population.

SYRINGE DESIGN AND FILLING TECHNIQUE AFFECT ACCURACY OF ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR INTRAVITREAL INJECTIONS

PURPOSE

To evaluate the effect of syringe design and filling technique on the accuracy of anti-vascular endothelial growth factor delivery.

METHODS

Volume output was measured with three syringe designs: a 1.0-mL slip-tip syringe, a 1.0-mL Luer-lock syringe, and a ranibizumab prefilled syringe-using two filling techniques ("upward" and "downward") and two fluids (water and bevacizumab). A total of 300 simulated injections were performed. Accuracy was determined by difference from the intended volume of 50 µ L and by mean absolute percentage error.

RESULTS

Volume outputs were significantly different between syringe designs, with mean values of 61.99 ± 4.18 µ L with the 1-mL slip-tip syringe, 57.43 ± 4.95 µ L with the Luer-lock 1-mL syringe, and 51.06 ± 4.74 µ L with the ranibizumab syringe, making the latter the most accurate syringe. There were 37 cases (12.3%) of underdosing below 50 µ L, the majority of which occurred with the ranibizumab syringe. The "downward" technique reduced the occurrence of air bubbles.

CONCLUSION

Intravitreal injections using 1.0-mL syringes are less accurate than using the ranibizumab prefilled syringe, which has a low-volume and low dead-space plunger design. The variability in volume output may result in less predictable treatment response, especially in cases of underdosing, which were more common with the ranibizumab syringe.

Assessment of long-term visual outcomes in aphakic children wearing scleral contact lenses

BACKGROUND

Timely management of aphakic children is critical for the rehabilitation of adequate visual gain. This study aims to evaluate the long-term efficacy of scleral contact lenses in terms of visual outcomes, complications, and compliance in aphakic children.

METHODS

Retrospective data review of children with congenital or acquired cataract, or subluxated crystalline lenses, who underwent lensectomy from 2004 to 2018 and who used scleral contact lenses for refractive correction. Collected data from the follow up period included recorded aphakic refraction and visual acuity, complications following scleral contact lens wear documented in the clinic and ophthalmic emergency room and compliance to lens wear according to parental feedback on every visit in the clinic.

RESULTS

76% of cases, with final best corrected visual acuity (BCVA) of 20/40 or better achieved in seventeen eyes (34%). The rate of amblyopia was 50%. Strabismus developed in 56% of children, and those had less favourable visual outcomes (0.43 ± 0.4 LogMAR without strabismus and 0.8 ± 0.5 LogMAR with strabismus, p = 0.015). No corneal infections were documented during the follow up. Main adverse effect on the ocular surface was superficial punctate keratopathy (n = 16). Compliance was good in 48 children (96%)- except for two cases, the scleral lenses were tolerated well by all children.

CONCLUSION

Scleral contact lenses are an effective means of visual rehabilitation in aphakic children after lensectomy and may be used long-term with good compliance of wear, excellent visual outcomes, and tolerable adverse events.

Polypoidal choroidal vasculopathy—characteristics and response to treatment with bevacizumab in caucasian patients

Purpose

To investigate the features and treatment response in Caucasian patients with polypoidal choroidal vasculopathy (PCV), initially treated with bevacizumab.

Methods

45 eyes of 43 treatment-naïve patients with PCV were included in this retrospective study, all uniformly initially treated with three bevacizumab injections monthly. OCT characteristics and clinical parameters were recorded and analyzed at presentation, after the initial 3 bevacizumab injections and at the final follow up period.

Results

Following 3 monthly bevacizumab injections visual acuity significantly improved with a mean gain of one line of vision. Central macular thickness (CMT) significantly improved from a mean of 402.1 ± 130.8 μm at presentation to 322.0 ± 96.8 μm (p < 0.01). Subretinal fluid, intraretinal fluid and submacular hemorrhage significantly improved. 53% were later switched to aflibercept and showed better response in the central macular thickness in comparison to those in which bevacizumab injections were continued. No correlation was found between the presence of pachyvessels or increased choroidal thickness and the improvement in VA or CMT.

Conclusion

Fixed first-line treatment with intravitreal bevacizumab monotherapy in non-Asian PCV patients achieves satisfactory visual and anatomical outcomes.

Optical Coherence Tomography Prognostic Factors in AMD Patients with Peripapillary Choroidal Neovascularization

PURPOSE

To investigate the correlation between optical coherence tomography (OCT) findings and visual acuity outcomes after treatment with intravitreal bevacizumab (IVB) injections for age related macular degeneration (AMD) patients with peripapillary choroidal neovascularization (PPCNV).

METHODS

A retrospective case series of consecutive patients diagnosed with PPCNV secondary to AMD. All patients were treated with IVB injections with a follow-up time of one year. Data collected included best corrected visual acuity (BCVA), automated and manually measured OCT parameters.

RESULTS

A total of 68 eyes were diagnosed with PPMV. Of them, 30 eyes of 30 patients aged 84.3±6.9 years of which 63.3% female gender were included. Baseline BCVA was 0.46±0.62 logMAR (Snellen 20/57), average choroidal thickness was 193.2±22 µm and mean number of IVB injections was 7.2±1.9. After one year BCVA was 0.56±0.78 logMAR (Snellen 20/72) (p=0.28). Eyes with greater central retinal thickness (r=-0.36, p=0.05), greater subretinal hyperreflective material (SHRM) area (r=-0.37, p=0.05) and greater sub retinal fluid (SRF) area (r=-0.73, p<0.001) had a significantly smaller improvement in BCVA. Eyes with pigment epithelium detachment (PED) (0.68±0.90 versus 0.21±0.12, p=0.03) had a significantly worse BCVA.

CONCLUSIONS

Our data suggests that AMD related PPCNV with greater foveal thickness, PED size, SHRM and SRF areas have worse final BCVA prognosis.

Optical Coherence Tomography Biomarkers Predicting Visual Acuity Change after Intravitreal Bevacizumab Injections for Macular Edema Secondary to Branch Retinal Vein Occlusion

PURPOSE

This study aimed to identify baseline optical coherence tomography (OCT) factors in branch retinal vein occlusion (BRVO) that predict response to bevacizumab injections.

METHODS

It is a retrospective case series of consecutive patients that underwent OCT at diagnosis, and the central macular thickness (CMT), extent of disorganized retinal inner layers, and outer retinal layers including external limiting membrane, ellipsoid zone (EZ), and cone outer segment tips (COST) were measured. Patients received 3 consecutive monthly injections of bevacizumab followed by pro re nata treatment. The main outcome measure was improvement in best-corrected visual acuity (BCVA) after 1 year. Results are expressed as mean ± SD, and p value <0.05 was considered statistically significant.

RESULTS

Overall, 66 eyes of 66 patients, with an average age of 68.5 ± 11.4 years, were included. The mean BCVA improved significantly from 0.68 logMAR at baseline to 0.50 logMAR at 1 year (p < 0.001). Baseline logMAR BCVA (r = 0.41, p < 0.001) and CMT (r = 0.23, p = 0.04) were associated with improvement while EZ (r = -0.24, p = 0.05) and COST (r = -0.32, p = 0.01) disruption with deterioration in BCVA.

CONCLUSION

In patients with naïve BRVO treated with bevacizumab, BCVA improvement at 1 year can be predicted from baseline BCVA, CMT, extent of COST disruption, and EZ disruption.

Treatment of Neovascular Age-Related Macular Degeneration: An Economic Cost-Risk Analysis of Anti-Vascular Endothelial Growth Factor Agents

PURPOSE

To find the best cost-effective neovascular age-related macular degeneration (nAMD) treatment to improve vision while avoiding complications. The model is based on a cost-risk tradeoff analysis from policymakers' perspective.

DESIGN

A powerful and flexible simulation modeled outcomes of 2 years of treatment with the 4 commonly used anti-vascular endothelial growth factor drugs (bevacizumab, ranibizumab, aflibercept, and brolucizumab) across 3 injection protocols, building on prior findings that these drugs are noninferior. The model incorporates blinding complications, their management, and associated costs to society. Each option and several what-if scenarios were simulated 1,000 times with 100,000 hypothetical patients.

PARTICIPANTS

One hundred thousand simulated patients using data from published clinical trials.

METHOD

Case- and eye-specific cost-risk economic analysis.

MAIN OUTCOME MEASURES

Costs of nAMD treatment per patient and number of eyes that become blind as a result of treatment over 2 years.

RESULTS

Using published prices and fees, the injection protocol that follows published clinical studies, results showed that the mean±standard deviation cost per patient were $16,859 ± $3.65, $32,949 ± $3.27, $39,831 ± $3.80, and $53,056 ± $2.99 for bevacizumab, brolucizumab, aflibercept, and ranibizumab, respectively. The numbers±standard deviations of treated eyes that became blind were 108 ± 10.18, 694 ± 26.66, 168 ± 12.83, and 108 ± 10.52, respectively. We further provide a lower bound (when all patients are maximally extended) and upper bound (when no patient is extended) to these numbers. For brolucizumab, the upper bound is the 2-month interval injection protocol.

CONCLUSIONS

Taking a policymaking perspective, this study suggested that bevacizumab is the preferred first-line therapy. Recommendation for second-line therapy depends on the extent of the policymaker's risk aversion because of the tradeoff between cost and risk of blindness as a result of treatment. If risk neutral, the least expensive option (brolucizumab) is preferred. But if policymakers are moderately to highly risk averse, then aflibercept or ranibizumab are preferred. Because medical advances and different costs may change our findings, we provide a free application (https://eye-inj.shinyapps.io/calc/) for readers who wish to use different cost structures. Simulating outcomes is an innovative approach, unique in ophthalmology, and presents a significant opportunity because it can be adapted easily to different settings (using different costs, risks, and protocols) and to other diseases (e.g., diabetic macular edema), to ultimately improve wide-scale decision-making and use of funds.

Detection of Intraorbital Foreign Bodies Using Magnetic Resonance Imaging and Computed Tomography

PURPOSE

We analyze the detectability of intraorbital foreign bodies (OrbFBs) of various types and sizes using computed tomography (CT) and magnetic resonance imaging using a three-Tesla machine (MRI 3 T).

METHODS

An ex vivo model of sheep eyes with preserved extraocular muscles and orbital fat tissue placed in the orbital cavity of the human skull was created for this study. Foreign bodies made of four different materials - plastic, bottle glass, stone and wood - each in three different sizes (large, intermediate and small) were inserted into the soft tissue of the orbit in the extraocular space. Each orbit was scanned by CT and MRI. Images were analyzed by a senior radiologist and underwent masked review by three oculoplastic surgeons.

RESULTS

Analysis of MRI and CT scans identified distinguishing characteristics for each of the four materials. This information was further integrated into a clinical algorithm. CT allowed easier identification of most of the embedded materials compared to MRI. Smaller OrbFB size was associated with lower detectability. Review of CT yielded 94.4% agreement between oculoplastic specialists in detecting OrbFbs using CT scans and allowed detection of most OrbFBs. In contrast, the overall agreement with MRI was lower: 66.7% with T1 MPRAGE, 50% with T1TSE, 88.9% with T2 TSE and 72.2% with T2 TSE FS. Plastic was the most difficult material to detect in all size categories.

CONCLUSIONS

CT offers a clear advantage over MRI for detecting and localizing nonmetallic OrbFBs of all sizes, except for plastic. Plastic OrbFBs can be detected with CT depending on size but are more visible in MRI scans.

The 100 most-cited papers on age-related macular degeneration: a bibliographic perspective

The 100 most-cited papers on age-related macular degeneration (AMD) were analysed using a bibliographic study. The bibliographic databases of the Institute for Scientific Information Web of Knowledge were searched, limited to research articles published between 1965 and 2020 in peer-reviewed journals. The papers were ranked in order of number of citations since publication. Five of the top 10 (and 3 of the top 4) papers reported randomised clinical trial results for either anti-vascular endothelial growth factor agents or nutritional supplements. Four of the top 10 papers reported genotype-phenotype associations between AMD and variants in Complement Factor H. This bibliographic study provides perspective and insight into many of the most influential contributions in the understanding and management of AMD and its evolution over time.

Drug Delivery via the Suprachoroidal Space for the Treatment of Retinal Diseases

The suprachoroidal space (SCS), a potential space between the sclera and choroid, is becoming an applicable method to deliver therapeutics to the back of the eye. In recent years, a vast amount of research in the field has been carried out, with new discoveries in different areas of interest, such as imaging, drug delivery methods, pharmacokinetics, pharmacotherapies in preclinical and clinical trials and advanced therapies. The SCS can be visualized via advanced techniques of optical coherence tomography (OCT) in eyes with different pathologies, and even in healthy eyes. Drugs can be delivered easily and safely via hollow microneedles fitted to the length of the approximate thickness of the sclera. SCS injections were found to reach greater baseline concentrations in the target layers compared to intravitreal (IVT) injection, while agent clearance was faster with highly aqueous soluble molecules. Clinical trials with SCS injection of triamcinolone acetonide (TA) were executed with promising findings for patients with noninfectious uveitis (NIU), NIU implicated with macular edema and diabetic macular edema (DME). Gene therapy is evolving rapidly with viral and non-viral vectors that were found to be safe and efficient in preclinical trials. Here, we review these novel different aspects and new developments in clinical treatment of the posterior segment of the eye.

The Role of Anterior Chamber Depth on Post-operative Refractive Error After Phacovitrectomy

Purpose

To investigate the effect of phacovitrectomy on the post-operative anterior chamber depth (ACD) and refractive outcomes, and to analyze the potential differences between vitreous filling with BSS, air and gas.

Methods

Patients who underwent phacovitrectomy were included in this study and invited for repeated post-operative examination including refraction and biometry at least 3 months after the surgery. Data retrieved included demographic information, indication for phacovitrectomy, surgical details, type of vitreous filling (BSS, air or gas), pre-operative and post-operative biometric data including K-readings, axial length (AL), and ACD, as well as spherical equivalent (SE) values of the target and final refraction.

Results

Forty-three eyes of 43 patients were included in this study, including 10 eyes filled with BSS, 18 with air and 15 with gas. The mean difference between the final measured spherical equivalent (SE) and the SE of the intended target refraction was 0.61±0.68 D (p = 0.019). Only 58.1% of eyes had a final SE within ±0.5D of the target refraction. Following surgery, AL remained unchanged, while mean pre-operative ACD increased significantly from 3.11±0.34 mm to 4.77±0.47 mm (p < 0.001). There was no difference in refractive error between the vitreous fillings and no correlation with AL or ACD.

Conclusions

Phacovitrectomy is associated with lower accuracy of post-operative refraction compared to cataract surgery. This may be attributed to a significant change in ACD, influencing the effective lens position of the IOL, and may require adjustment of the pre-operative calculations.

The 100 most cited papers on retinal detachment: a bibliographic perspective

The 100 most cited papers on retinal detachment (RD) were analysed using a bibliographic study. The bibliographic databases of the ISI Web of Knowledge were searched, limited to research articles published between 1965 and 2020 in peer-reviewed journals. The papers were ranked in order of number of citations since publication. Ninety of the 100 most cited papers on RD were published in 12 ophthalmology journals, with 74 of them published in American Journal of Ophthalmology (n=31), Ophthalmology (n=23), Archives of Ophthalmology (n=10) and Investigative Ophthalmology and Visual Science (n=10); the remaining 10 papers were published in 8 journals from other fields of medical research. All papers in the top 100 were published in English. The 100 most cited papers on RD originated from 12 different countries, with the majority (72 papers) originating from the USA. The 100 identified papers represent a mix of clinical trials and animal/laboratory studies. This bibliographic study provides a unique perspective and insight into some of the most influential contributions in RD understanding and management over the last 55 years.

Evaluation of Accuracy and Agreement of Optical Coherence Tomography Angiography Interpretation of Common Retinal Findings and Diagnoses

PURPOSE

To evaluate the accuracy and agreement of optical coherence tomography angiography (OCTA) interpretation in cases of common retinal findings and diagnoses, and to evaluate the effect of OCT B-scans on OCTA interpretations.

METHODS

This is a case series consisting of a questionnaire with 8 cases demonstrating common retinal conditions of normal, age-related macular degeneration (AMD) and diabetic retinopathy (DR). Each case included OCTA images, and 58 participants were asked to identify retinal findings and provide a diagnosis. Following OCTA interpretation, the corresponding OCT B-scans were revealed and the participants were asked again to identify retinal findings and provide a diagnosis. The rates of accuracy and agreement for each condition were analyzed.

RESULTS

Overall the rates of accurate diagnosis and identification of retinal findings were 37.4 and 61.6%, respectively. Following addition of the OCT B-scans, the rates increased to 61.6 and 79.4%, respectively (p < 0.001 for both). A significant improvement in correct interpretation occurred in the normal and AMD cases, but not in the DR cases. There was no correlation with length of experience or self-reported familiarity with OCTA.

DISCUSSION

Considerable variability exists in OCTA interpretation, with mediocre rates of accuracy and agreement between clinicians. Increased familiarity as well as future automation advances will be needed to improve OCTA interpretation accuracy and uniformity.

In vivo retinal imaging in translational regenerative research

Regenerative translational studies must include a longitudinal assessment of the changes in retinal structure and function that occur as part of the natural history of the disease and those that result from the studied intervention. Traditionally, retinal structural changes have been evaluated by histological analysis which necessitates sacrificing the animals. In this review, we describe key imaging approaches such as fundus imaging, optical coherence tomography (OCT), OCT-angiography, adaptive optics (AO), and confocal scanning laser ophthalmoscopy (cSLO) that enable noninvasive, non-contact, and fast in vivo imaging of the posterior segment. These imaging technologies substantially reduce the number of animals needed and enable progression analysis and longitudinal follow-up in individual animals for accurate assessment of disease natural history, effects of interventions and acute changes. We also describe the benefits and limitations of each technology, as well as outline possible future directions that can be taken in translational retinal imaging studies.

The Top 100 Most-Cited Papers on Intravitreal Injections: A Bibliographic Perspective

Purpose

To analyze the top 100 most-cited papers on pars intravitreal injections.

Methods

Literature search using the bibliographic databases of the ISI Web of Knowledge for all types of publications on intravitreal injections published between 1965 and 2019 in peer-reviewed journals.

Results

Eighty-three of the top 100 papers on intravitreal injections were published in ophthalmology journals, their majority in the top five Q1 leading journals in the field. They originated from 16 different countries, predominantly from the USA (n=52), and were all published in English. These manuscripts cover a wide spectrum of topics but were mostly focused on retinal diseases (n=60) and the use of anti-VEGF or steroid agents (n=75).

Discussion

This bibliographic study provides a unique perspective on the evolution and assimilation of intravitreal injections, from their introduction, through their present role as the most common therapeutic procedure in ophthalmology, to future developments.

Blunt ocular trauma in patients over 70: Clinical characteristics and prognosis

PURPOSE

To describe the mechanisms and outcomes of open globe injuries (OGIs) in patients 70 years or older.

METHODS

A retrospective chart review of patients from two large academic centers in Israel who were underwent surgery for OGI. Data was collected from surgical and clinic charts. Anatomical and functional results were recorded as well any additional surgeries and complications.

RESULTS

Thirty-two eyes of 32 patients were included. The mechanism of OGI consisted of blunt trauma with ocular rupture secondary to falls. All eyes underwent immediate primary closure of the corneal and scleral lacerations. Additional surgeries were performed in 34.3% of cases. In 31.2% of cases additional surgery was not required, and in 21.9% of cases the damage was so devastating that additional procedures were not recommended. Four patients (12.5%) chose not to undergo additional surgery. Mean visual acuity at presentation was 2.24 ± 0.72 logMAR and it improved to 1.92 ± 0.89 logMAR at final follow-up (p = 0.002). VA at presentation was significantly correlated to final VA (p < 0.001).

CONCLUSIONS

OGI in the elderly represents a unique group. It is mostly related to falls, with a female predominance and a poor visual prognosis. In this patient population, general health concerns and increased risks of anesthesia require special attention. Care should be taken to educate elderly patients and their caretakers on how to avoid falls.

Unique molecular signatures of microRNAs in ocular fluids and plasma in diabetic retinopathy

The main objective of this pilot study was to identify circulatory microRNAs in aqueous or plasma that were reflecting changes in vitreous of diabetic retinopathy patients. Aqueous, vitreous and plasma samples were collected from a total of 27 patients undergoing vitreoretinal surgery: 11 controls (macular pucker or macular hole patients) and 16 with diabetes mellitus(DM): DM-Type I with proliferative diabetic retinopathy(PDR) (DMI-PDR), DM Type II with PDR(DMII-PDR) and DM Type II with nonproliferative DR(DMII-NPDR). MicroRNAs were isolated using Qiagen microRNeasy kit, quantified on BioAnalyzer, and profiled on Affymetrix GeneChip miRNA 3.0 microarrays. Data were analyzed using Expression Console, Transcriptome Analysis Console, and Ingenuity Pathway Analysis. The comparison analysis of circulatory microRNAs showed that out of a total of 847 human microRNA probes on the microarrays, common microRNAs present both in aqueous and vitreous were identified, and a large number of unique microRNA, dependent on the DM type and severity of retinopathy. Most of the dysregulated microRNAs in aqueous and vitreous of DM patients were upregulated, while in plasma, they were downregulated. Dysregulation of miRNAs in aqueous did not appear to be a good representative of the miRNA abundance in vitreous, or plasma, although a few potential candidates for common biomarkers stood out: let-7b, miR-320b, miR-762 and miR-4488. Additionally, each of the DR subtypes showed miRNAs that were uniquely dysregulated in each fluid (i.e. aqueous: for DMII-NPDR was miR-455-3p; for DMII-PDR was miR-296, and for DMI-PDR it was miR-3202). Pathway analysis identified TGF-beta and VEGF pathways affected. The comparative profiling of circulatory miRNAs showed that a small number of them displayed differential presence in diabetic retinopathy vs. controls. A pattern is emerging of unique molecular microRNA signatures in bodily fluids of DR subtypes, offering promise for the use of ocular fluids and plasma for diagnostic and therapeutic purposes.

Prophylactic Circumferential Laser Retinopexy in Macular Hole and Epiretinal Membrane Surgeries

Background:

The role of PCLR in vitrectomy surgeries for macular diseases is controversial. Several studies report a reduction in post-operative RD rates, while other studies do not show such reduction. reducing complications stemming from intra- and post- operative retinal tears, especially at sclerotomy sites, are suggested as reasons for PCLR use.

Objective:

To investigate the effect of PCLR on the rate of post-operative RD in patients undergoing pars plana vitrectomy for either Macular Hole (MH) or epiretinal membrane (ERM).

Methods:

This retrospective study included 179 eyes of 170 patients who underwent vitrectomy for either MH or ERM between 2006-2012. Recorded parameters included demographic information, diagnosis, lens status, use and type of tamponade, whether PCLR was performed, follow-up period, the occurrence of RD, the cause and time of RD. Outcome and complication rates were compared between patients who received PCLR (PCLR group) and those who did not (Control group).

Results:

The study included 179 eyes of 170 patients. 126 eyes had PCLR while 53 eyes did not. Pre-operative demographics data, best-corrected visual acuity, lens status and indication for macular surgery were similar between the two groups. Post-operative RD was diagnosed in one eye (1.8%) in the control group and 5 eyes (3.9%) in the PCLR group (Kaplan-Meier survival analysis, log-rank p = 0.28).

Conclusion:

PCLR was not correlated with a decrease in RD in MH and ERM surgeries in our cohort. Intra-operative and post-operative examination for small retinal breaks is essential in all surgeries. PCLR might be unnecessary in small gauge vitrectomies.

Recent Developments in Diabetic Retinal Neurodegeneration: A Literature Review

Neurodegeneration plays a significant role in the complex pathology of diabetic retinopathy. Evidence suggests the onset of neurodegeneration occurs early on in the disease, and so a greater understanding of the process is essential for prompt detection and targeted therapies. Neurodegeneration is a common pathway of assorted processes, including activation of inflammatory pathways, reduction of neuroprotective factors, DNA damage, and apoptosis. Oxidative stress and formation of advanced glycation end products amplify these processes and are elevated in the setting of hyperglycemia, hyperlipidemia, and glucose variability. These key pathophysiologic mechanisms are discussed, as well as diagnostic modalities and novel therapeutic avenues, with an emphasis on recent discoveries. The aim of this article is to highlight the crucial role of neurodegeneration in diabetic retinopathy and to review the molecular basis for this neuronal dysfunction, its diagnostic features, and the progress currently made in relevant therapeutic interventions.

Acute angle closure in an aphakic infant: Case report and review of the literature

Purpose

Aphakic pupillary block glaucoma is a rare complication after congenital cataract surgery. We describe the case of an infant with acute angle closure in an aphakic eye following congenital cataract lensectomy with anterior vitrectomy nine months prior. Potential pathophysiology and therapeutic strategies are discussed.

Observations

A one-year-old male infant presented to our emergency unit with right eye injection and pain. At the age of six weeks he had undergone right eye lensectomy with anterior vitrectomy for congenital cataract and was left aphakic with large anterior and posterior capsulorrhexis. Examination was significant for a shallow anterior chamber centrally and iridocorneal touch of the periphery for 360° with intraocular pressure (IOP) measured at 70 mmHg. The child was diagnosed with aphakic pupillary block leading to an acute angle closure event. He underwent emergent anterior vitrectomy with surgical peripheral iridotomy (PI) performed via pars plana approach. This resulted in immediate deepening of the anterior chamber, with resolution of the pupillary block and iridocorneal touch. Thereafter, his ocular exam was normal.

Conclusions and Importance

This unusual case underscores the importance of vigilance in the postoperative management of children after congenital cataract extraction. Unexpected complications remain a threat despite the initial undertaking of preventative measures.

[INTRAVITREAL INJECTION - A SMALL PROCEDURE FOR THE EYE, A GIANT LEAP FOR OPHTHALMOLOGY]

Intravitreal injections are the most common therapeutic procedures in ophthalmology. These injections allow intraocular delivery of drugs that are highly effective for the treatment of a variety of retinal diseases. The procedure is short and simple, has an excellent local and systemic safety profile, and enables restoration and preservation of visual acuity in a large number of patients. Intravitreal injections were introduced to the routine clinical practice of ophthalmology only a little over a decade ago, but have created a therapeutic revolution due to their high efficacy, and today are an integral part of the treatment of ocular diseases. This review will cover the development of intravitreal injection treatment, describe the injected drugs, the injection technique and its possible complications, and the commonly used treatment protocols.

Novel Long-acting Pharmacotherapy for Exudative Age Related Macular Degeneration

Exudative age-related macular degeneration (AMD) is a major indication for the administration of intravitreal injections of anti-VEGF agents, which have been established as a very effective pharmacotherapy for this disease. However, treatment with anti-VEGF agents requires several patient visits for monitoring and treatment. Strategies for achieving a longer duration of pharmacological action are currently being developed. These include the development of longer-acting drugs, and of novel technologies to increase the duration of action of administered agents. This manuscript will review the novel drugs and technologies currently being developed for achieving a longer-action pharmacotherapy for exudative AMD.

Perfluorocarbon Liquid Vs. Subretinal Fluid Drainage during Vitrectomy for the Primary Repair of Rhegmatogenous Retinal Detachment: A Comparative Study

PURPOSE

To compare the anatomical and functional results achieved with subretinal fluid drainage (SRFD) and perfluorocarbon liquid (PFCL) use in patients with rhegmatogenous retinal detachment (RRD) treated by primary pars plana vitrectomy (PPV).

METHODS

The study included 162 eyes of 162 patients who underwent PPV for RRD, either with PFCL (n = 108) or SRFD (n = 54). The two groups were matched in 2:1 ratio for age, gender, and lens status. Groups were compared for rates of retinal reattachment, visual improvement, and the occurrence of recurrent RRD and any other postoperative complications.

RESULTS

Both groups had a single surgery success rate of 90.7%, and 100% of retinas were reattached by the end of follow-up. Both groups had similar final VA (0.30 ± 0.39 logMAR in the SRFD group and 0.35 ± 0.44 in the PFCL group; p = 0.48) and degrees of visual improvement (0.64 ± 0.75 logMAR in the SRFD group and 0.59 ± 0.89 in the PFC group; p = 0.71). Complication rates were also similar between groups. The rate of additional interventions was higher (although not statistically significant) in the PFCL group than the SRFD group, due to cases of PFCL retention (4.6% vs. 1.8%, respectively).

CONCLUSIONS

Both PFCL and SRFD achieved excellent results in terms of retinal reattachment and visual improvement, and have comparable safety profiles. A slightly higher rate of additional surgeries was found in the PFCL group. These findings indicate that PFCL are not necessary in routine PPV for RRD, as they do not improve the results achieved with SRFD and may be less cost-effective due to their higher price and potential for a higher rate of additional surgeries.

Benign yellow dot maculopathy

Purpose

To describe a new family with benign yellow dot maculopathy.

Observations

A young male patient was found to have bilateral multiple small yellow dots in both maculae. Visual acuity and color vision were normal, and no pathological findings were demonstrated on automated visual field, optical coherence tomography (OCT) and electrophysiological testing. Examination of his parents revealed similar findings in his mother, suggesting autosomal dominant inheritance. No deterioration of vision occurred over long term follow up. These findings are consistent with the newly described phenotype of benign yellow dot maculopathy.

Conclusions and importance

This is the first report of patients with benign yellow dot maculopathy since its original description, and the first to document it in a family of North African descent. This report will serve to raise awareness to this phenotype, which may be more common than currently known.

2018 Update on Intravitreal Injections: Euretina Expert Consensus Recommendations

Intravitreal injections (IVI) have become the most common intraocular procedure worldwide with increasing numbers every year. The article presents the most up-to-date review on IVI epidemiology and techniques. Unfortunately, important issues related to pre-, peri- and postinjection management lack randomized clinical trials for a final conclusion. Also, a great diversity of approaches exists worldwide. Therefore, expert consensus recommendations on IVI techniques are provided.

Fundus Findings in Wernicke Encephalopathy

Wernicke encephalopathy (WE) is an acute neuropsychiatric syndrome resulting from thiamine (vitamin B₁) deficiency, classically characterized by the triad of ophthalmoplegia, confusion, and ataxia. While commonly associated with chronic alcoholism, WE may also occur in the setting of poor nutrition or absorption. We present a 37-year-old woman who underwent laparoscopic sleeve gastrectomy and presented with visual disturbance with bilateral horizontal nystagmus, confusion, and postural imbalance. Fundus examination revealed bilateral optic disc edema with a retinal hemorrhage in the left eye. Metabolic workup demonstrated thiamine deficiency. Her symptoms resolved after thiamine treatment. This case raises the awareness of the possibility of posterior segment findings in WE, which are underreported in WE.

Protective Effect of Intravitreal Administration of Exosomes Derived from Mesenchymal Stem Cells on Retinal Ischemia

PURPOSE

Exosomes derived from human mesenchymal stem cells (hMSCs) cultured under hypoxic conditions contain proteins and growth factors that promote angiogenesis. This study investigated the effect of intravitreal administration of these exosomes on retinal ischemia using a murine model.

METHODS

Oxygen-induced retinopathy (OIR) was induced by exposing one-week-old male C57BL/6J mice to 5 days of 75% hyperoxic conditioning, and returning to room air. After hyperoxic conditioning, the right eye of each mouse was injected intravitreally with 1 µl saline or exosomes derived from hMSCs and compared to control mice of the same age raised in room air without OIR injected intravitreally with saline. Two weeks post-injection, fluorescein angiography (FA) and phase-variance optical coherence tomography angiography (pvOCTA) were used to assess retinal perfusion. Retinal thickness was determined by OCT. The extent of retinal neovascularization was quantitated histologically by counting vascular nuclei on the retinal surface.

RESULTS

Among eyes with OIR, intravitreal exosome treatment partially preserved retinal vascular flow in vivo and reduced associated retinal thinning; retinal thickness on OCT was 111.1 ± 7.4µm with saline versus 132.1 ± 11.6µm with exosome, p < 0.001. Retinal neovascularization among OIR eyes was reduced with exosome treatment when compared to saline-treated eyes (7.75 ± 3.68 versus 2.68 ± 1.35 neovascular nuclei per section, p < 0.0001). No immunogenicity or ocular/systemic adverse effect was associated with intravitreal exosome treatment.

CONCLUSIONS

Intravitreal administration of exosomes derived from hMSCs was well tolerated without immunosuppression and decreased the severity of retinal ischemia in this murine model. This appealing novel non-cellular therapeutic approach warrants further exploration.

Intravitreal Administration of Human Bone Marrow CD34+ Stem Cells in a Murine Model of Retinal Degeneration

Purpose

Intravitreal murine lineage-negative bone marrow (BM) hematopoietic cells slow down retinal degeneration. Because human BM CD34+ hematopoietic cells are not precisely comparable to murine cells, this study examined the effect of intravitreal human BM CD34+ cells on the degenerating retina using a murine model.

Methods

C3H/HeJ^rd1/rd1 mice, immunosuppressed systemically with tacrolimus and rapamycin, were injected intravitreally with PBS (n = 16) or CD34+ cells (n = 16) isolated from human BM using a magnetic cell sorter and labeled with enhanced green fluorescent protein (EGFP). After 1 and 4 weeks, the injected eyes were imaged with scanning laser ophthalmoscopy (SLO)/optical coherence tomography (OCT) and tested with electroretinography (ERG). Eyes were harvested after euthanasia for immunohistochemical and microarray analysis of the retina.

Results

In vivo SLO fundus imaging visualized EGFP-labeled cells within the eyes following intravitreal injection. Simultaneous OCT analysis localized the EGFP-labeled cells on the retinal surface resulting in a saw-toothed appearance. Immunohistochemical analysis of the retina identified EGFP-labeled cells on the retinal surface and adjacent to ganglion cells. Electroretinography testing showed a flat signal both at 1 and 4 weeks following injection in all eyes. Microarray analysis of the retina following cell injection showed altered expression of more than 300 mouse genes, predominantly those regulating photoreceptor function and maintenance and apoptosis.

Conclusions

Intravitreal human BM CD34+ cells rapidly home to the degenerating retinal surface. Although a functional benefit of this cell therapy was not seen on ERG in this rapidly progressive retinal degeneration model, molecular changes in the retina associated with CD34+ cell therapy suggest potential trophic regenerative effects that warrant further exploration.

Evaluation of a Portable Artificial Vision Device Among Patients With Low Vision

IMPORTANCE

Low vision is irreversible in many patients and constitutes a disability. When no treatment to improve vision is available, technological developments aid these patients in their daily lives.

OBJECTIVE

To evaluate the usefulness of a portable artificial vision device (OrCam) for patients with low vision.

DESIGN, SETTING, AND PARTICIPANTS

A prospective pilot study was conducted between July 1 and September 30, 2015, in a US ophthalmology department among 12 patients with visual impairment and best-corrected visual acuity of 20/200 or worse in their better eye.

INTERVENTIONS

A 10-item test simulating activities of daily living was used to evaluate patients' functionality in 3 scenarios: using their best-corrected visual acuity with no low-vision aids, using low-vision aids if available, and using the portable artificial vision device. This 10-item test was devised for this study and is nonvalidated. The portable artificial vision device was tested at the patients' first visit and after 1 week of use at home.

MAIN OUTCOMES AND MEASURES

Scores on the 10-item daily function test.

RESULTS

Among the 12 patients, scores on the 10-item test improved from a mean (SD) of 2.5 (1.6) using best-corrected visual acuity to 9.5 (0.5) using the portable artificial vision device at the first visit (mean difference, 7.0; 95% CI, 6.0-8.0; P < .001) and 9.8 (0.4) after 1 week (mean difference from the first visit, 7.3; 95% CI, 6.3-8.3; P < .001). Mean (SD) scores with the portable artificial vision device were also better in the 7 patients who used other low-vision aids (9.7 [0.5] vs 6.0 [2.6], respectively; mean difference, 3.7; 95% CI, 1.5-5.9; P = .01).

CONCLUSIONS AND RELEVANCE

When patients used a portable artificial vision device, an increase in scores on a nonvalidated 10-item test of activities of daily living was seen. Further evaluations are warranted to determine the usefulness of this device among individuals with low vision.

Diabetic Macular Edema: Emerging Strategies and Treatment Algorithms

Diabetic macular edema (DME) is the most common cause of vision loss in diabetic patients, and its management is often a long process requiring frequent monitoring and therapeutic interventions. During the past several decades, numerous treatments have been developed for the treatment of DME. Although many of them have been found to be effective and safe, there is relatively little comparative data, and no established guidelines for the optimal treatment approach exist. In this chapter, the evolution of DME therapies is reviewed, and the current common practice patterns are discussed. Available data from clinical trials on the commonly used agents, as well as comparative studies and combination therapies are reviewed. Additionally, recent advances and novel treatment options that are currently being investigated are also discussed.

Drug Delivery to the Posterior Segment of the Eye

Drug delivery into the posterior segment of the eye is complicated by the existence of the blood-ocular barrier. Strategies for delivering drugs to the posterior segment include systemic administration, modification of the barrier, and local drug delivery (including transcorneal, transscleral, and intravitreal). The most commonly used method for drug delivery into the posterior segment is by intravitreal injection. Other routes that can be used to achieve therapeutic drug levels in the posterior segment include topical, iontophoretic, and juxtascleral delivery. Extended-release intravitreal drug delivery systems can achieve sustained therapeutic levels with the goal of providing a prolonged clinical benefit with significantly fewer interventions.

Management of Diabetic Macular Edema

Diabetic macular edema is a common condition frequently encountered by ophthalmologists. In this piece we briefly review its definition, pathogenesis, clinical aspects, imaging, and treatment.

Advances in bone marrow stem cell therapy for retinal dysfunction

The most common cause of untreatable vision loss is dysfunction of the retina. Conditions, such as age-related macular degeneration, diabetic retinopathy and glaucoma remain leading causes of untreatable blindness worldwide. Various stem cell approaches are being explored for treatment of retinal regeneration. The rationale for using bone marrow stem cells to treat retinal dysfunction is based on preclinical evidence showing that bone marrow stem cells can rescue degenerating and ischemic retina. These stem cells have primarily paracrine trophic effects although some cells can directly incorporate into damaged tissue. Since the paracrine trophic effects can have regenerative effects on multiple cells in the retina, the use of this cell therapy is not limited to a particular retinal condition. Autologous bone marrow-derived stem cells are being explored in early clinical trials as therapy for various retinal conditions. These bone marrow stem cells include mesenchymal stem cells, mononuclear cells and CD34+ cells. Autologous therapy requires no systemic immunosuppression or donor matching. Intravitreal delivery of CD34+ cells and mononuclear cells appears to be tolerated and is being explored since some of these cells can home into the damaged retina after intravitreal administration. The safety of intravitreal delivery of mesenchymal stem cells has not been well established. This review provides an update of the current evidence in support of the use of bone marrow stem cells as treatment for retinal dysfunction. The potential limitations and complications of using certain forms of bone marrow stem cells as therapy are discussed. Future directions of research include methods to optimize the therapeutic potential of these stem cells, non-cellular alternatives using extracellular vesicles, and in vivo high-resolution retinal imaging to detect cellular changes in the retina following cell therapy.

Phase I/II Randomized Study of Proton Beam with Anti-Vascular Endothelial Growth Factor for Exudative Age-Related Macular Degeneration: One-Year Results

OBJECTIVE

To assess the safety and efficacy of proton beam therapy (PBT) as an adjunct to intravitreal anti-vascular endothelial growth factor (VEGF) for the treatment of exudative age-related macular degeneration.

DESIGN

Phase I/II, interventional, prospective, randomized, sham-controlled double-blinded study.

PARTICIPANTS

Eyes with newly diagnosed exudative age-related macular degeneration with vision between 20/40 and 20/400 were included. Exclusion criteria included diabetes or other ocular comorbidities affecting vision.

METHODS

Eyes were randomized to receive either 16 GyE, 24 GyE, or sham PBT. All eyes had 3 monthly intravitreal anti-VEGF treatments, followed by monthly visits with treatments as needed.

MAIN OUTCOME MEASURES

Mean change in best-corrected visual acuity (BCVA), mean number of anti-VEGF injections, proportion of eyes with >15 letters BCVA decrease, proportion of eyes developing radiation retinopathy or papillopathy, proportion of eyes with cataract progression, and mean changes central retinal thickness on OCT and lesion size on angiography at 1 year.

RESULTS

Of 30 enrolled eyes, 22 completed follow-up monthly for 12 months for analysis. The BCVA improved by a mean of 8 letters (0.48±0.36 logarithm of the minimum angle of resolution) overall from baseline. Overall, central retinal thickness decreased from 340±155 to 246±48 (P = 0.008) at 12 months. The mean change in BCVA and central retinal thickness was not different among the 3 study groups. The mean number of anti-VEGF injections at 12 months was 6.13 for sham irradiation arm, 5.52 in the 16 GyE arm, and 3.83 for the 24 GyE arm (P = 0.004 between sham and 24 GyE). No eye had severe visual loss, radiation retinopathy, or papillopathy.

CONCLUSIONS

No safety issue was noted associated with combining 16 GyE or 24 GyE PBT with intravitreal anti-VEGF therapy in eyes with exudative age-related macular degeneration. Overall improvements in BCVA and imaging parameters were not affected by the addition of PBT, but the number of anti-VEGF treatments needed was significantly lower with the addition of 24 GyE PBT.

Repeatability of Choroidal Thickness Measurements on Enhanced Depth Imaging Optical Coherence Tomography Using Different Posterior Boundaries

PURPOSE

To assess the reliability of manual choroidal thickness measurements by comparing different posterior boundary definitions of the choroidal-scleral junction on enhanced depth imaging optical coherence tomography (EDI-OCT).

DESIGN

Reliability analysis.

METHODS

Two graders marked the choroidal-scleral junction with segmentation software using different posterior boundaries: (1) the outer border of the choroidal vessel lumen, (2) the outer border of the choroid stroma, and (3) the inner border of the sclera, to measure the vascular choroidal thickness (VCT), stromal choroidal thickness (SCT), and total choroidal thickness (TCT), respectively. Measurements were taken at 0.5-mm intervals from 1.5 mm nasal to 1.5 mm temporal to the fovea, and averaged continuously across the central 3 mm of the macula. Intraclass correlation coefficient (ICC) and coefficient of reliability (CR) were compared to assess intergrader and intragrader reliability.

RESULTS

Choroidal thickness measurements varied significantly with different posterior boundaries (P < .001 for all). Intergrader ICCs were greater for SCT (0.959-0.980) than for TCT (0.928-0.963) and VCT (0.750-0.869), even in eyes where choroidal-scleral junction visibility was <75%. Intergrader CRs were lower for SCT (41.40-62.31) than for TCT (61.13-74.24) or VCT (72.44-115.11). ICCs and CRs showed greater reliability for averaged VCT, SCT, or TCT measurements than at individual locations. Intragrader ICCs and CRs were comparable to intergrader values.

CONCLUSIONS

Choroidal thickness measurements are more reproducible when measured to the border of the choroid stroma (SCT) than the vascular lumen (VCT) or sclera (TCT).

Role of Tractional Forces and Internal Limiting Membrane in Macular Hole Formation: Insights from Intraoperative Optical Coherence Tomography

We report the case of a 69-year-old patient who underwent vitrectomy for vitreomacular traction (VMT) and developed a postoperative macular hole that was observed 1 week after surgery. The hole did not close by in-office fluid-gas exchange alone, but was achieved after repeat surgery with internal limiting membrane (ILM) peeling. Intraoperative OCT (iOCT) images from the first surgery revealed an occult macular hole that formed after VMT release. We discuss how iOCT findings provide insight into the role of the ILM in macular hole formation and emphasize the importance of carefully inspecting iOCT images in real time to avoid missing small but important findings.