Chorioretinal Atrophic Lesions Evolution in Patients with Quiescent Myopic Choroidal Neovascularization Followed for More Than 10 Years

Purpose

To evaluate the progression of chorioretinal atrophic areas associated with myopic choroidal neovascularization (CNV) in high myopic patients followed by a minimum period of 10 years.

Patients and Methods

Patients with myopic CNV lesions that achieved clinical and structural remissions over 10 years of follow-up were included. Medical records were reviewed for CNV characterization and treatment, best-corrected visual acuity at baseline (BCVA0), immediately after the last treatment (BCVA1) and at the latest visit (BCVA2). Fundus autofluorescence (FAF) was used to quantify the amount of atrophic area increase per year associated with the treated myopic CNV lesion. The first FAF performed after treatment suspension (FAF1) was compared with the most recent exam (FAF2).

Results

Thirty-six eyes from 36 patients were included. Mean total follow-up was 12.38 ± 2.68 years. Mean number of intravitreal injections (IVI) was 12.50 ± 12.40 and 25% of the eyes had previous treatment with photodynamic therapy (PDT). Mean improvement between BCVA0 and BCVA1 was 5.58 ± 15.98 letters (p < 0.001). However, a drop of 8.03 ± 12.25 letters was noticed between BCVA1 and BCVA2. FAF1 was 6.34 ± 4.92mm2 and increased to 9.88 ± 7.56mm2 (3.54 ± 3.79mm2 variation p < 0.001). The mean growth rate of the atrophic area was 0.89 ± 0.84mm2 per year. BCVA2 negatively correlated with FAF2 (k = -0.498, p = 0.002) being worse in patients with higher atrophic area growth rate (k = -0.341, p = 0.042). Eyes treated with PDT needed less IVI (5.89 ± 5.21 vs 14.70 ± 13.36, p = 0.008) but had larger FAF1 (9.80 ± 5.33 vs 5.19 ± 4.27, p = 0.013) and FAF2 (16.05 ± 7.10 vs 7.83 ± 6.63, p = 0.003). Hypothyroidism was associated with higher atrophy growth rate (1.55 ± 1.15 vs 0.73 ± 0.67, p = 0.016).

Conclusion

This research demonstrates the importance of chorioretinal atrophy progression after myopic CNV lesions regression and its impact on visual prognosis, reporting a mean yearly growth of 0.89 mm2 in atrophic areas. Previous treatment with PDT and hypothyroidism were identified as risk factors associated with larger atrophic areas and worse visual outcomes.

Ocular Complications of COVID-19 Patients Admitted to Intensive Care in Portugal

N/a.

Intravitreal Fluocinolone Acetonide Implant (FAc, 0.19 mg, ILUVIEN®) in the Treatment of Patients with Recurrent Cystoid Macular Edema After Pars Plana Vitrectomy

INTRODUCTION

Postoperative cystoid macular edema (PCME) is a complication of several ocular procedures, including pars plana vitrectomy (PPV), due to the activation of the inflammatory cascade. The purpose of this case series is to evaluate the effectiveness and safety of fluocinolone acetonide intravitreal implant (FAc, 0.2 μg/day; ILUVIEN®) in the treatment of refractory PCME after successful PPV.

METHODS

This retrospective observational case series includes consecutive eyes of patients with recurrent PCME after PPV and treated with a single FAc implant at Centro Hospitalar Universitário de São João, Porto, Portugal. Previous treatments, best-corrected visual acuity (BCVA, ETDRS letters), central macular thickness (CMT, μm), intraocular pressure (IOP, mmHg), and IOP-lowering medication needed were recorded at baseline and during follow-up. Total macular edema resolution was defined as CMT less than 300 μm or a reduction of greater than 20%, and partial macular edema resolution was defined as a reduction of greater than 10%.

RESULTS

Nine eyes from nine patients were included. Before FAc implant, all eyes received intravitreal short-action corticosteroids (triamcinolone and dexamethasone implant), with a good response but relapse 1-5 months later. At baseline, BCVA was 55.0 ± 10.6 letters, CMT was 514.9 ± 165.6 μm, and IOP was 15.4 ± 2.4 mmHg with four eyes under IOP-lowering medication. After FAc implant, all eyes achieved edema resolution (eight total and one partial) with a peak gain of 17.2 letters and a maximum decrease of 208.2 μm in CMT. During follow-up (44.0 ± 14.8 months), 66.7% of the eyes kept their macula dry and three showed recurrence after 11, 14, and 28 months, respectively. The maximum IOP registered was 17.0 ± 6.0 mmHg. IOP-lowering regimen was increased in one eye and two additional eyes started hypotensive drops.

CONCLUSION

FAc implant can be considered a therapeutic alternative in PCME refractory to other therapies in vitrectomized eyes, reducing the need for repeated treatments.

Terson Syndrome - Clinical Presentation, Management, and Visual Outcomes in a Tertiary Centre

Purpose

The purpose of this study was to characterize the clinical presentation, management strategy and visual outcomes of patients diagnosed with Terson syndrome and followed in a tertiary centre in Portugal.

Patients and Methods

A single-centre retrospective study was performed, based on the survey review of the medical records of every consecutive patient diagnosed with Terson syndrome and followed from January 2018 to August 2021. The change in best-corrected visual acuity (BCVA) from baseline to the final evaluation was the primary outcome.

Results

Fifteen eyes from 8 patients (50% female) were included. The mean age at diagnosis was 55±7 years. The neurological event was traumatic brain injury in 37.5% (n=3) and subarachnoid haemorrhage in 62.5% of the patients (n=5). Bilateral intraocular haemorrhage occurred in 875% (n=7) of the patients. Vitreous and preretinal haemorrhages occurred each in 66.7% (n=10), intraretinal in 30% (n=3) and subretinal in 13.3% (n=2) of the eyes. In 40% of the eyes (n=6), spontaneous resolution of intraocular haemorrhage occurred, while PPV was performed in the remaining 60% (n=9). Ocular haemorrhage detection occurred 58.47 ± 40.94 days after the neurological event (range 11 to 121 days). Baseline BCVA was 1.11 ± 1.01 logMAR and improved to 0.32 ± 0.69 logMAR in the follow-up period (p=0.004). A positive correlation was found between initial and final BCVA (Spearman's rho = 0.643, p=0.01). Baseline BCVA of eyes undergoing PPV was lower than of those conservatively managed (1.84±0.72 vs 0.20±0.28 logMAR, p<0.001). However, there were no statistically significant differences in final BCVA after surgery or observation (0.56 ± 0.90 vs 0.04 ± 0.04 logMAR, p=0.149). Longer periods between the neurological and the ophthalmological diagnosis were correlated with worse final BCVA (Spearman's rho = 0.688, p=0.005).

Conclusion

Terson syndrome is a potential cause of irreversible visual loss. Diagnosis delay may affect visual prognosis. PPV is indicated when intraocular haemorrhage is dense and does not resolve spontaneously or when visual acuity at presentation is low, allowing for good visual outcomes with minimal complications.

Two-Step Iridocorneal Endothelial Syndrome Management: Endocapsular Intraocular Lens and Artificial Iris Followed by Descemet's Stripping Automated Endothelial Keratoplasty

A 54-year-old female presented with complaints of glare and progressive visual loss OS with a corrected distance visual acuity (CDVA) OS of 20/100. The patient had grade 1 corneal edema with a "beaten bronze" appearance on specularly reflected light, pseudopolycoria, and a nuclear sclerotic cataract. The diagnosis of nuclear cataract and progressive iris atrophy iridocorneal endothelial (ICE) syndrome was made, and the patient underwent uneventful phacoemulsification with capsular bag placement of an AcrySof SA60AT intraocular lens combined with pseudopolycoria repair using an endocapsular Model A REPER artificial iris. Six months later, the patient was submitted to a Descemet's stripping automated endothelial keratoplasty (DSAEK) procedure, and 6 months after that the CDVA was 20/32 with no corneal edema and normal intraocular pressure. This two-step surgical approach, combining phacoemulsification and endocapsular foldable iris prosthesis placement followed by DSAEK, may be considered a promising option to successfully treat progressive iris atrophy ICE syndrome patients.

Best Fit Sphere Back and Adjusted Maximum Elevation of Corneal Back Surface as Novel Predictors of Keratoconus Progression

Purpose

We evaluated the Maximum Elevation of Corneal Back Surface adjusted to the same Best Fit Sphere Back (BFSB) between timeline measurements (AdjEleBmax) and the BFSB radius (BFSBR) itself as new tomographic parameters for documentation of ectasia progression and compare them with the most recent and reliable parameters used on keratoconus (KC) progression.

Results

We evaluated the performance and the ideal cutoff point of Kmax, D-index, posterior radius of curvature from the 3.0 mm centered on the thinnest point (PRC), EleBmax, BFSBR, and AdjEleBmax as isolated parameters to document KC progression (defined as a significant change in two or more variables), we found a sensitivity of 70%, 82%, 79%, 65%, 51%, and 63% and a specificity of 91%, 98%, 80%, 73%, 80%, and 84% to detect KC progression. The area under the curve (AUC) for each variable was 0.822, 0.927, 0.844, 0.690, 0.695, 0.754, respectively.

Conclusion

AdjEleBmax presented a greater specificity, larger AUC, and better performance compared to EleBmax without any adjustment, with similar sensitivity. Although AdjEleBmax and BFSB demonstrated smaller AUC and specificities comparing with Kmax and D-Index, AdjEleBmax still presented a good performance with a reasonable AUC. Since the shape of the posterior surface, more aspheric and curved than the anterior, may facilitate detection of change, we suggest the inclusion of AdjEleBmax in the evaluation of KC progression in conjunction with other variables to increase the reliability of our clinical evaluation and early detection of progression.

Hypotony Maculopathy Related to Anti-VEGF Intravitreal Injection

Purpose

To describe a case of hypotony maculopathy following anti-VEGF intravitreal injection (IVI) in a patient with pseudoxanthoma elasticum (PE).

Methods

Clinical case report.

Results

A 52-year-old male complained of right eye (OD) vision loss 2 days after an uncomplicated anti-VEGF IVI for the treatment of choroidal neovascularization secondary to angioid streaks. Relevant medical history included PE, pathologic myopia, and a previous pars plana vitrectomy (PPV) due to a retinal detachment. OD best-corrected visual acuity (BCVA) dropped from 6/12 to 6/18 after the IVI. Intraocular pressure (IOP) was 3 mmHg and chorioretinal folds were evident in the posterior pole. Topical dexamethasone and atropine were prescribed, and full recovery was noticed after 3 days. Four months later, the patient developed a new episode of vision loss after another IVI. His BCVA was counting fingers, IOP was 2mmHg, and more noticeable chorioretinal folds were found. This time, an open scleral wound at the injection site was evident and a scleral suture was necessary. Once again, the patient recovered well.

Conclusion

Hypotony maculopathy following intravitreal injection is a rare condition. However, the described patient presented several conditions which could be related with poor scleral wound closure: intrinsic scleral fragility due to myopia and pseudoxanthoma elasticum; repeated IVI procedures; and absence of vitreous in the posterior segment due to prior vitrectomy. Despite the good outcome, hypotony maculopathy may be a sight-threatening condition, and special attention is necessary for specific patients with risk factors.

Prevalence and Area of Retinal Pigment Epithelium and Outer Retinal Atrophy in Eyes with Non-Exudative Macular Neovascularization

PURPOSE

The objective of this study wasto assess the prevalence of complete retinal pigment epithelium (RPE) and outer retinal atrophy (cRORA) in patients with unilateral exudative age-related macular degeneration (AMD) of the fellow eye and establish if the presence of non-exudative macular neovascularization (NE-MNV) influences the prevalence of RPE and outer retinal atrophy in eyes with AMD.

METHODS

This is an observational cross-sectional study of 68 patients with unilateral exudative AMD. Demographic and clinical data were collected, and multimodal retinal imaging was performed in all patients. Two groups of patients were defined according to the presence (NE-MNV) or absence (no NE-MNV) of NE-MNV in the study eye. We compared the prevalence of tomographic cRORA and fundus autofluorescence (FAF) geographic atrophy (GA) and differences in cRORA greatest linear diameter (GLD) and GA area between groups.

RESULTS

Globally, cRORA was present in 11 eyes (16.2%), FAF GA was present in 10 eyes (14.7%), and NE-MNV was present in 10 eyes (14.7%) of patients with unilateral exudative AMD of the fellow eye. The overall cRORA GLD was 1,950.64 ± 1,428.31 μm, and the mean area of GA was 9.25 ± 7.50 mm2. Regarding comparisons between groups, cRORA was present in 9 eyes (15.5%) without NE-MNV and in 2 eyes (20%) with NE-MNV (p = 0.66). Tomographic signs of atrophy were more frequent in eyes with NE-MNV (50% vs. 24.1% in eyes without NE-MNV; p = 0.008). No significant differences were found in cRORA GLD (p = 0.30) between groups. Eyes with NE-MNV and eyes without NE-MNV had a similar prevalence of FAF GA (2 eyes out of 10 and 8 eyes out of 58, respectively; p = 0.64). Eyes with NE-MNV had a smaller mean area of GA (2.07 ± 0.24 mm2 vs. 11.05 ± 7.34 mm2; p = 0.01).

CONCLUSION

In our study, the presence of NE-MNV was not associated with the prevalence of cRORA and/or FAF GA. Nonetheless, eyes with NE-MNV presented smaller areas of GA, which suggests that this type of neovascularization may prevent the progression of RPE and outer retinal atrophy. Longitudinal studies are required to confirm these preliminary results.

Bilateral Episcleral Corkscrew Vessels: Expedition into the Unknown – Case Report

We aim to report a case of a middle-aged woman with bilateral idiopathic elevated episcleral venous pressure (IEEVP) and its difficulties in the diagnostic approach. Particularly in this case, the atypical feature of ocular hypertension without glaucomatous optic nerve damage may be misleading. We present a 66-year-old woman with longstanding bilateral “red eyes.” Clinical findings included bilateral episcleral vessel engorgement and tortuosity and raised intraocular pressure with open iridocorneal angles. Despite ocular hypertension, glaucomatous neuropathy was absent and confirmed by normal structural (optical coherence tomography) and functional (standard automated perimetry) tests. The systemic workup was unremarkable. Magnetic resonance angiography showed bilateral dilated superior ophthalmic veins. Cerebral digital subtraction angiography was requested, and no carotid-cavernous fistula (or other significant vascular findings) was identified. The diagnosis of IEEVP was assumed. In conclusion, our case highlights the systematic investigation necessary in cases of bilateral episcleral vessel engorgement and tortuosity and the possible differential diagnosis to be considered to rule out life-threatening causes of elevated episcleral venous pressure. It is important for clinicians to be aware of IEEVP even in patients with atypical features that despite significative ocular hypertension had no glaucomatous damage.

Covid-19 Impact on Macular Neovascularization and Retinal Vein Occlusion Treatment: Single-Center Experience

Purpose

The aim of this study was to evaluate whether the coronavirus disease 19 (COVID-19) pandemic resulted in undertreatment and subsequent loss of visual acuity (VA) in patients with macular neovascularization (MNV) or retinal vein occlusion (RVO) regularly treated with intravitreal antivascular endothelial growth factor injections.

Methods

Single-center, retrospective study of patients scheduled for treatment between March 19 and June 1, 2020, the national mandatory quarantine period. Patients' demographics, VA, and scheduled treatment during this period were reviewed via medical records. All patients were analyzed regarding treatment attendance rates. The visual impact of COVID-19 was assessed in patients who had been treated and presented a stable VA for >6 months before the beginning of the quarantine.

Results

This study included 927 eyes from 769 patients. The attendance rate increased throughout the study timeframe (p < 0.001) and correlated negatively with higher patient's age (r = -0.142; p = 0.005). Patients with age-related macular degeneration (67.6%) had lower attendance rates (p = 0.007) and were older (p < 0.001). The visual impact analysis included 400 eyes from 325 patients. The average VA variation throughout this period was -1.7 ± 8.4 ETDRS letters and was similar in different retinal pathologies (p = 0.334). VA variation did not correlate with the number of missed treatments per patient (r = 0.100; p = 0.150). The prevalence of subretinal fluid and intraretinal fluid, as well as central retinal thickness decreased significantly throughout the study period (p values of <0.001, <0.001, and 0.032, respectively).

Conclusion

The COVID-19 pandemic had a significant impact on the attendance rate of patients with MNV or RVO to their scheduled treatments, which was higher in the first week of mandatory quarantine. Nevertheless, VA did not decrease significantly during this period, with a limited VA variation regardless of primary retinal disorder and morphological parameters even improved in the eyes included in the visual impact analysis.

Gut microbiota and age-related macular degeneration: A growing partnership

Age-related macular degeneration (AMD) is a leading cause of severe, irreversible vision impairment in developed countries, and its prevalence is rising all over the world, increasing sharply with age. AMD represents an acquired degeneration of the retina that causes significant central visual impairment through a combination of noneovascular and neovascular derangement. The main risk factors for the development of advanced AMD are increasing age, genetic factors, and cigarette smoking; however, the exact pathophysiology of AMD is yet relatively poorly understood. In recent years, the gut microbiota has been intensively studied and linked to several pathologic processes, including ocular diseases. In this sense, the aim of this review is to gather published evidence about the relationship between gut microbiota and AMD.

Two Novel Disease-Causing Variants in the PDE6C Gene Underlying Achromatopsia

We report the clinical phenotype and genetic findings of two variants in PDE6C underlying achromatopsia (ACHM). Four patients with the variant c.1670G>A in exon 13 of the PDE6C gene were identified. Additionally, one had compound heterozygous genotype, with two variants in the PDE6C gene, a variant of c.2192G>A in exon 18 and c.1670G>A in exon 13. All patients presented the symptomatic triad of decreased visual acuity, severe photophobia, and colour vision disturbances. SD-OCT showed an absence of the ellipsoid zone, creating an optically empty cavity at the fovea in three patients. The patient with the compound heterozygous genotype presented a more severe subfoveal outer retina atrophy. ERG recordings showed extinguished responses under photopic and 30-Hz flicker stimulation, with a normal rod response. We identified two new variants in the PDE6C gene that leads to ACHM.

Increased Choroidal Thickness in Morquio Syndrome

The purpose of this clinical case report is to describe a case of mucopolysaccharidosis type IVA (MPS IVA), or Morquio syndrome, with increased choroidal thickness in enhanced-depth imaging optical coherence tomography (EDI-OCT) which can represent choroidal deposition of glycosaminoglycans (GAGs). A 21-year-old male with genetically confirmed diagnosis of MPS IVA was examined at our Pediatric Ophthalmology clinic as part of our follow-up protocol for MPS patients. His best-corrected visual acuity was 4/10 in his right eye (OD) and 6/10 in the left eye (OS). Mild diffuse corneal opacification was evident. Intraocular pressure was within normal range. Fundus examination and color fundus photography revealed no abnormalities. EDI-OCT revealed significantly increased choroidal thickness in his right eye and in his left eye, suggesting the presence of choroidal deposition of GAGs, despite absence of retinal or optic disc GAG deposition or other chorioretinal involvement. To our knowledge, this is the first case of MPS IVA described in the literature with suspected choroidal deposition of GAGs. With improved control of systemic features of MPS IVA, life expectancy of these patients has increased, allowing for more ocular manifestations to develop. The parallel development of technology in ophthalmology, such as the EDI-OCT, further contributes to the detection of these unprecedented ocular features in MPSs.

Corneal structure and endothelial morphological changes after uneventful phacoemulsification in type 2 diabetic and nondiabetic patients

PURPOSE

The aim of this study was to compare corneal structure and endothelial morphological changes after uneventful phacoemulsification cataract surgery between type 2 diabetic and nondiabetic patients and to determine the preoperative and intraoperative factors that may predict greater endothelial cell density loss.

METHODS

Forty-five diabetic pa-tients (45 eyes) and 43 controls (43 eyes) with age-related cataract were enrolled in this prospective observational study. Corneal (thickness and volume) and anterior segment parameters were measured by Scheimpflug tomography; endothelial cell density and morphology (coefficient of variation of cell size, hexagonal cells) were recorded using noncontact specular microscopy. Patients were evaluated preoperatively and at one and six months after surgery. Univariate and multivariate linear regression analyses were performed to evaluate the relationship between demographic, clinical, ocular, and intraoperative parameters and postoperative endothelial cell density changes at six months.

RESULTS

Significant postoperative endothelial cell loss occurred one month after surgery in both groups (p<0.001), which remained stable until month 6; there were no differences between patients with and without diabetes mellitus at any time point. The mean postoperative central corneal thickness at one and six months did not change significantly from the mean preoperative value in either group (p>0.05). Multivariate linear regression analysis showed that older age (p=0.042) and higher cataract grades (p=0.001) were significantly associated with greater endothelial cell density reduction at six-month follow-up.

CONCLUSION

This study showed that older age and denser cataracts might be associated with greater endothelial cell density reduction after cataract surgery. Other factors, such as diabetes mellitus and preoperative anterior segment parameters, did not influence postoperative changes in endothelial cell density.

Long-term progression of geographic atrophy in age-related macular degeneration does the phakic status matter?

PURPOSE

To assess the long-term risk of geographic atrophy (GA) progression after cataract surgery.

METHODS

Subjects with GA secondary to AMD followed for at least 1 year with fundus autofluorescence imaging and with at least two visits at our centre were included. Patients with wet AMD, disciform scar, past history of intravitreal injections or laser treatment, other maculopathies and with poor quality images were excluded. GA area at baseline and at follow-up visit was measured. Three study groups were defined according to their phakic status: (A) pseudophakia, (B) phakic and (C) phacoemulsification surgery performed during the study. Differences of GA area progression were compared between these study groups. In addition, comparison between GA progression rate in group (C) before and after the surgery was performed. The enlargement rate (ER) was calculated for lesion size after transforming the measurements to the square-root scale.

RESULTS

A total of 92 eyes of 92 patients were enrolled. Median follow-up time was 4 [1-10] years. Regarding the eye's phakic status, 29 (31.5%) were pseudophakic and 63 (68.5%) were phakic; of these, 22 underwent phacoemulsification during the study. Overall, the median baseline and follow-up area of GA were 1.42 [0.04-32.10] mm² and 6.48 [0.25-47.40] mm², respectively. The ER was similar between phakic and pseudophakic eyes (0.18 [0.01-1.03] vs 0.15 [0.01-0.65] mm/year, p = 0.62). In patients that underwent cataract surgery during the study, the GA ER remained stable (0.13 [0.01-0.92] vs 0.14 [0.01-0.63] mm/year, p = 0.43).

CONCLUSION

These results suggest that cataract surgery does not increase the risk of pre-existing GA progression. Therefore, cataract surgery seems safe and a potential therapeutic weapon to improve visual acuity and consequently quality of life in GA patients.

Foveal and Extrafoveal Effects of Half-Dose Photodynamic Therapy in Chronic Central Serous Chorioretinopathy: A Cohort Study

PURPOSE

To compare the efficacy and safety of foveal and extrafoveal half-dose photodynamic therapy (HD-PDT) for chronic Central Serous Chorioretinopathy (cCSC).

METHODS

This retrospective, cohort study included cCSC eyes submitted to HD-PDT on foveal (F) or extrafoveal (E) areas. Patients were evaluated at baseline and 12 weeks after treatment for best corrected visual acuity (BCVA) and the following spectral-domain optical coherence tomography (SD-OCT) subfoveal parameters: central macular thickness (CMT), outer nuclear layer, external limiting membrane, ellipsoid zone, interdigitation zone, choroidal thickness and subretinal fluid (SRF).

RESULTS

F group comprised 33 eyes (47.1%) and E group comprised 37 eyes (52.9%). Both groups showed an improvement of BCVA after HD-PDT with no significant differences in final BCVA (p = .41). CMT and SRF showed a significant improvement after HD-PDT in both groups, but the rate of disruption of the external retinal layers remained stable. During follow-up, SD-OCT parameters and the rate of anatomical success showed no significant differences regarding the treatment location. No major sequelae were noticed.

CONCLUSION

Foveal and extrafoveal applications of HD-PDT for cCSC showed comparable efficacy and safety.

Predicting retinal pigment epithelium remodelling and its functional impact

PURPOSE

To identify predictive factors for RPE tear remodelling and its correlation with functional and morphological outcomes.

METHODS

Retrospective longitudinal study of patients with retinal pigment epithelium (RPE) tears secondary to age-related macular degeneration (AMD). Imaging was performed using spectral-domain optical coherence tomography (SD-OCT) and fundus autofluorescence (FAF). RPE layer integrity in the RPE-denuded area was examined with SD-OCT, and variation in the RPE-denuded homogeneous hypofluorescent area was examined with FAF over time for each case (eye). Patients were divided in two groups, according to the presence (Rem) or absence (No Rem) of evidence of RPE tear remodelling. Data were collected at three different time points: at baseline (at diagnosis of exudative AMD), at RPE tear diagnosis, and at the last available follow-up. Using SD-OCT, the following parameters were evaluated: type of CNV, type of PED and its dimensions, presence of subretinal (SRF) or intraretinal (IRF) fluid, central retinal thickness (CRT), presence and location of hyperreflective dots, and dimension and location of RPE tear.

RESULTS

This study included 32 eyes from 31 patients (19 female and 12 male), with RPE tears secondary to AMD. RPE remodelling after tear development was evident in 17 (53.1%) eyes after 7 [1-59] months. Anatomical recovery was associated with a younger age at RPE tear diagnosis (73 ± 7 vs. 81 ± 7 years old, p=0.01), smaller and narrower retinal pigment epithelial detachment (PED) at tear diagnosis (height 369 vs. 602 μm, p=0.02; width 2379 vs. 3378 μm, p=0.04), and the presence of SRF at tear diagnosis (94% vs. 53%, p=0.02). After adjusting for other covariates, a younger age at RPE tear diagnosis maintained significant association with RPE tear remodelling. RPE tear remodelling did not correlate with a better visual outcome at last follow-up (43 ± 22.8 vs. 34 ± 23.8 ETDRS letters, p=0.30). Final VA was directly proportional to VA at tear diagnosis (r= 0.654; p<0.001) and correlated negatively with PED width at tear diagnosis (r = -0.388; p=0.03).

CONCLUSION

RPE remodelling was evident in half of our sample and was associated with a younger age, smaller and narrower PED at RPE tear diagnosis, and presence of SRF also at tear diagnosis. Nevertheless, this structural recovery did not result in a better functional outcome.

Gastric Bypass Improves Microvascular Perfusion in Patients with Obesity

PURPOSE

Basic science research has shown that obesity is associated with microvascular endothelial dysfunction. However, whether bariatric surgery impacts the microvascular networks has yet to be explored. This study sought to evaluate the impact of gastric bypass in the retinal microvasculature.

METHODS

Patients with obesity (BMI ≥ 35 kg/m²) scheduled to gastric bypass were consecutively recruited and included in the study. Patients were evaluated before surgery and 6-12 months after the intervention. Macular microvascular properties were evaluated using optical coherence tomography (OCT) angiography. Foveal avascular zone area, perimeter, circularity, and foveal and perifoveal vascular density (in both superficial and deep vascular plexus) were computed.

RESULTS

In total, 40 eyes from 20 patients were included (30% male, mean BMI 43.4 ± 4.5 kg/m² (range 35.7-51.4). From these, 45% were diabetic before bariatric surgery. After surgery, there was a significant increase in foveal avascular zone circularity (from 0.85 ± 0.09 to 0.92 ± 0.07, p = 0.001) and vascular density in perifoveal deep vascular plexus (from 0.69 ± 0.12 to 0.73 ± 0.12; p = 0.04), whereas foveal avascular zone perimeter decreased (from 2.34 ± 0.37 to 2.20 ± 0.35 mm, p = 0.007). Preoperative diabetic status was not a predictor of microvascular retinal changes after bariatric surgery. However, after multivariate adjustments, the increased drop in HbA1c after the surgery remained associated with the increase in perifoveal vascular density in the deep vascular plexus (B = 0.05; 95% CI 0.05-0.10; p = 0.03).

CONCLUSIONS

Gastric bypass improves retinal microvascular perfusion as demonstrated by the increased parafoveal vascular density in the deep vascular plexus, increased foveal avascular zone circularity, and decreased foveal avascular zone perimeter.

Ocular findings in metabolic syndrome: a review

Metabolic syndrome (MetS) has emerged as a worldwide health hazard of the modern lifestyle, representing a cluster of metabolic abnormalities and a risk factor for cardiovascular disease. Eye diseases, such as diabetic retinopathy, central retinal artery occlusion, cataract, age-related macular degeneration, glaucoma, and dry eye syndrome have been linked with many of MetS components. Their relationship with MetS itself is, however, a recent topic of investigation. This review aims to gather published evidence supporting associations between ocular findings and MetS and to explore the related physiopathological processes that congregate in this syndrome and lead to these diseases. Despite compiling interesting and compelling evidence, it raises awareness to the need of further studies in this field to keep solidifying these associations and unveiling the pathological processes that support them. It ultimately targets MetS patients as a population of individuals who are at increased risk of developing age-related eye diseases and vision loss.

Increased choroidal thickness is not a disease progression marker in keratoconus

The recent findings of increased Choroidal Thickness (CT) in Keratoconus (KC) patients raised the question of whether CT could be an indicator of progressive KC. To test this hypothesis, we evaluated and compared the choroidal profile in progressive and non-progressive KC. We ran a cross-sectional observational study in 76 patients diagnosed with KC, age 14–30, to assess KC progression. Progression was defined as when at least two of the studied variables confirmed progression (Kmax, Km, PachyMin, D-Index, Astig, K2, 3 mm PCR). Included patients performed a Spectralis Optical Coherence Tomography (OCT) with enhanced depth image (EDI) technology to evaluate choroidal profile. Choroidal measurements were taken subfoveally and at 500 µm intervals from the fovea, in 7 different locations, and compared between groups. Multivariate linear regression analyses were also performed to assess the influence of CT in KC progression. Thirty-six eyes (47.4%) were classified as KC progressors. The mean subfoveal CT observed in the total sample was 382.0 (± 97.0) μm. The comparison between groups (progressive and non-progressive KC) showed no differences in the locations evaluated (mean subfoveal CT difference between groups was 2.4 μm, p = 0.915). In the multivariate analysis CT seems not be influenced by KC progression (B = 6.72 μm, 95% CI − 40.09 to 53.53, p = 0.775). Assessment of choroidal profile does not appear to be a useful tool to differentiate progressive and non-progressive KC. Further research is needed in order to better understand the role of choroid in KC.

Evaluation of the different thresholding strategies for quantifying choriocapillaris using optical coherence tomography angiography

Background

In this paper, we evaluate the different thresholding strategies that have been used for the quantification of the choriocapillaris (CC) and explore their repeatability and the interchangeability of the measurements resulting from its application.

Methods

Observational study. Eighteen eyes from nine healthy volunteers aged >18 years were imaged four consecutive times with a SD-OCTA system (Heidelberg Engineering, Germany) using a 10°×10° high-resolution protocol centered on the fovea. Projection artifacts were removed, and the CC was bracketed between 10 and 30 µm below Bruch's membrane. For the quantification of CC, we used four flow deficits (FD) parameters: FD number, mean FD size, total FD area and FD density. We performed a systematic review of literature to collect the thresholding methods that have been used for the quantification of CC. The CC quantification parameters were then evaluated after applying each of the thresholding strategies. Intraclass correlation coefficient (ICC) and Pearson's correlation analysis were used to compare the repeatability and interchangeability among the different thresholding strategies for quantifying the CC.

Results

A total of 72 optical coherence tomography angiography (OCTA) examinations were considered. The systematic review allowed us to conclude that three local thresholding strategies (Phansalkar, mean and Niblack) and three global thresholding strategies (mean, default, Otsu) have been used for CC quantification. These strategies were evaluated in our observational study. We found a high agreement within the same method in the quantification of FD number, mean FD size, total FD area and FD density but a poor agreement with different strategies. Local strategies achieved a significantly superior ICC than global ones in CC quantification.

Conclusions

In conclusion, the interchangeability of the CC quantification using different thresholding strategies is low, and direct comparisons should not be performed. Local thresholding strategies are significantly superior to global ones for quantifying CC and should be preferred. There is an unmet need for a uniform strategy to quantify CC in future studies.

Longitudinal Retinal Changes Induced by Hydroxychloroquine in Eyes without Retinal Toxicity

INTRODUCTION

This study aimed to evaluate the longitudinal changes in retinal layer thickness in patients treated with hydroxychloroquine without retinal toxicity.

METHODS

This is a longitudinal retrospective study of patients taking hydroxychloroquine followed in a hydroxychloroquine retinal toxicity screening program of a tertiary hospital between January 2010 and April 2019. Patients who performed 2 optical coherence tomography (OCT) scans at least 1 year apart were included. All subjects with hydroxychloroquine suspected or confirmed retinal toxicity, glaucoma, retinal pathology, or poor segmented images were excluded. Spectral-domain optical coherence tomography (Spectralis HRA-OCT, Heidelberg) was used to evaluate the macular area. Automatically segmented ETDRS retinal thickness maps were compared between the first and the last OCT evaluation available. Full retina (FR), inner retina (IRL), ganglion cells (GCL), inner nuclear (INL), and outer retina (ORL) layer thicknesses were measured in the foveolar, paracentral, and peripheral area.

RESULTS

The population included 144 eyes of 144 patients. The mean interval between OCT scans was 38.1 ± 18.4 months, and the mean cumulative dose was 406.9 ± 223.9 g. Foveolar (p = 0.040, p = 0.006, and p = 0.001, respectively) and paracentral (p = 0.006, p = 0.001, and p = 0.005, respectively) FR, IRL, and GCL decreased overtime. No differences were found in INL or ORL. A very weak correlation was found between age and foveal IRL change overtime (p = 0.037; R = 0.175), as well as between the hydroxychloroquine time of use and foveal GCL variation (p = 0.032; R = 0.179).

CONCLUSION

Hydroxychloroquine was found to cause progressive thinning of the inner retinal layers, specifically in the GCL of the foveolar and paracentral areas, but no changes were observed in the outer retina.

SARS-COV-2 in Ophthalmology: Current Evidence and Standards for Clinical Practice

INTRODUCTION

COVID-19 is caused by the coronavirus SARS-CoV-2. Ocular manifestations have been reported including conjunctivitis and retinal changes. Therefore, it is of the utmost importance to clarify eye involvement in COVID-19 in order to help with its diagnosis and to further prevent its transmission. The purpose of this review is to describe the structure and transmission of SARS-CoV-2, reported ocular findings and protection strategies for ophthalmologists.

MATERIAL AND METHODS

Literature search on PubMed for relevant articles using the keywords 'COVID-19', 'coronavirus', and 'SARS-CoV-2' in conjunction with 'ophthalmology' and 'eye'. Moreover, official recommendations of ophthalmological societies were reviewed.

RESULTS

Although the conjunctiva is directly exposed to extraocular pathogens, and the mucosa of the ocular surface and upper respiratory tract are connected by the nasolacrimal duct, the eye is rarely involved in human SARS-CoV-2 infection and the SARS-CoV-2 RNA positive rate by RT-PCR test in tears and conjunctival secretions from patients with COVID-19 is also extremely low.

DISCUSSION

The eye can be affected by SARS-CoV-2, which is supported by some reports of conjunctivitis and retinal changes, but its role in the spread of the disease is still unknown.

CONCLUSION

Given the current scarce evidence, more research is needed to clarify the relationship between SARS-CoV-2 and the eye.

Bariatric Surgery Induces Retinal Thickening Without Affecting the Retinal Nerve Fiber Layer Independent of Diabetic Status

PURPOSE

Obese patients have neurodegeneration of the optic nerve demonstrated by decreased peripapillary nerve fiber layer. Whether bariatric surgery reverses this neurodegenerative process has not been explored. We aimed to evaluate the impact of bariatric surgery in the structure of the retina and optic nerve.

METHODS

Multicentric observational study. Obese patients scheduled for bariatric surgery were consecutively recruited and included in the study and evaluated before and 6-12 months after the intervention. The retinal structure was evaluated as retinal thickness in the different retinal layers in the foveal, perifoveal, and parafoveal regions using optical coherence tomography. Choroidal thickness and optic nerve retinal nerve fiber layer thickness were also evaluated.

RESULTS

Eighty eyes from 40 participants were included. Globally, we found a significant thickening of the retina after bariatric surgery (foveal: 273.5 (21.5) μm vs 280.0 (28.8) μm, p < 0.001; parafoveal 332.4 ± 17.8 μm vs 336.6 ± 15.9 μm, p = 0.003; perifoveal: 293.4 ± 13.8 μm vs 295.7 ± 14.9 μm; p = 0.001), whereas no significant differences were found for the ganglion cell layer, choroid, or peripapillary nerve fiber layer thickness. The retinal thickening was confined to inner retinal layers and was independent of the diabetic status of the patients. After multivariate adjustment, HbA1c variation, preoperative C-peptide, preoperative hypertension, preoperative OSA, and preoperative LDL and TG levels seem to be clinical predictors of retinal thickening.

CONCLUSIONS

We found a significant thickening of the retina after bariatric surgery that was independent of the diabetic status. The thickening was confined to inner retinal layers and may represent and improve perfusion. The peripapillary nerve fiber layer remained unchanged after the surgery.

Evaluation of Corneal Structure and Endothelial Morphological Characteristics in Type 2 Diabetic and Non-Diabetic Patients

Purpose

To compare corneal structure and endothelial morphological features between patients with type 2 diabetes mellitus (DM) and non-diabetic patients; and determine if the DM duration, glycated hemoglobin (HbA1c) levels, and diabetic retinopathy (DR) stage affect corneal morphological properties.

Patients and Methods

Sixty diabetic patients and 47 age- and sex-matched controls were enrolled in this cross-sectional study. DM group was analyzed according disease duration, HbA1c levels, and presence of retinopathy. Endothelial cell density (ECD) and morphology (average and coefficient of variation [CV] of cell size, percentage of hexagonal cells) were recorded using non-contact specular microscopy. Central corneal thickness (CCT) and corneal volume were measured by scheimpflug tomography. Univariate and multivariate linear regression analyses were performed to evaluate the relationship between demographical, clinical, and ocular variables with CCT and ECD.

Results

There were no statistically significant differences in the endothelium cell density or morphology between DM and non-DM groups (p>0.05). Also, there was no statistical difference between groups for CCT or corneal volume (p>0.05). Multivariate linear regression analysis showed that older age (p=0.028) was significantly associated with lower ECD; CCT was found to be significantly greater in males (p<0.001) and positively associated with corneal volume (p<0.001).

Conclusion

The present study did not find any statistically significant differences between the corneal structural and endothelial characteristics of diabetic and non-diabetic subjects; other demographical parameters, such as age and gender, seem to be more determinant for the corneal properties.

Nonexudative Macular Neovascularization - A Systematic Review of Prevalence, Natural History, and Recent Insights from OCT Angiography

PURPOSE

To review the available literature on the prevalence, incidence, natural history, and exudative conversion rates of subclinical (treatment-naïve) nonexudative macular neovascularization (MNV) in patients with age-related macular degeneration (AMD).

CLINICAL RELEVANCE

Nonexudative MNV is now known to be more prevalent in patients with AMD than initially thought and is bringing new insights into both the natural history and management of this very prevalent disease.

METHODS

We conducted a literature search on PubMed, Scopus, and Web of Science, along with a manual search, from January 2014 to June 2019. We included studies that used optical coherence tomography angiography (OCTA) as a primary diagnostic tool to evaluate subclinical (treatment-naïve), nonexudative, neovascular AMD.

RESULTS

Of the 258 screened articles, 12 were included. The prevalence of subclinical nonexudative neovascular AMD in the fellow eyes of patients with unilateral exudative AMD ranged from 6.25% to 27%. Although these lesions were not associated with a significant decrease in visual acuity, the presence of nonexudative MNV seems to be an important predictor of exudative disease. Incidence of exudation in the reviewed studies ranged from 20% to 80% (follow-up 6 months to 2 years). There is some evidence that nonexudative MNV may slow down the growth of adjacent geographic atrophy (GA). As long as exudation does not occur, it appears that subclinical nonexudative MNV is not responsible for the deterioration of visual function.

CONCLUSIONS

Nonexudative MNV is an asymptomatic condition. Although nonexudative MNV seems to be a precursor for the formation of exudative neovascular AMD, there is evidence suggesting a protective effect in slowing the progression of GA. Early detection of nonexudative MNV before exudation develops should result in better monitoring of patients who are at high risk of conversion to exudative AMD. Though no controlled clinical trial has been performed to provide definitive recommendations, the authors of the studies included in this review agree that nonexudative lesions should not be treated until symptomatic exudation develops. Moreover, the existence of a nonexudative form of neovascular AMD would suggest that the term "neovascular AMD" should be preceded by either "exudative" or "nonexudative" when describing this neovascular stage of AMD.

Association between Serum Vitamin D and Diabetic Retinopathy in Portuguese Patients with Type 1 Diabetes

INTRODUCTION

Recently, vitamin D has gained importance as a diabetes risk modifier. Our aim was to assess the association between serum vitamin D levels and the prevalence of diabetic retinopathy in patients with type 1 diabetes.

MATERIAL AND METHODS

Retrospective review of a population of patients with type 1 diabetes followed in a Portuguese tertiary center. Patients were included if they had an ophthalmological evaluation and a serum 25-hydroxyvitamin D level determination within the same year. Logistic regression analysis was used to adjust for possible confounders.

RESULTS

We included 182 patients (47% male), and 57% (n = 103) had signs of diabetic retinopathy. We found a significant association between lower circulating levels of 25-hydroxyvitamin D levels and a greater prevalence of diabetic retinopathy after adjusting for confounders (duration of diabetes, estimated glomerular filtration rate, age, sex, metabolic control, season, dyslipidemia and hypertension) (OR = 0.94; 95% CI 0.90 - 0.99, p = 0.023). Longer duration of diabetes and worse metabolic control also remained associated with diabetic retinopathy in the multivariate analysis (OR = 1.20; 95% CI 1.13 - 1.27, p < 0.001 and OR = 4.13; 95% CI 1.34 - 12.7, p = 0.013, respectively).

CONCLUSION

Lower levels of vitamin D were associated with an increased prevalence of diabetic retinopathy in patients with type 1 diabetes, after adjusting for possible confounders. Future controlled studies may elucidate the molecular routes for this association as well as the role of supplementation in the prevention of diabetes microvascular complications.

Agreement between IOLMaster® 500 and Pentacam® HR for keratometry assessment in type 2 diabetic and non-diabetic patients

AIM

To evaluate inter-device agreement of anterior keratometry obtained by the IOLMaster^® 500 and Pentacam^® HR in type 2 diabetic and non-diabetic patients.

METHODS

Corneal measurements were sequentially performed in 60 diabetes mellitus (DM) and 48 age and sex-matched controls undergoing cataract surgery. Variables recorded included flat and steep keratometry, mean keratometry (K_m), astigmatism magnitude, axis location, J0 and J45 components. Bland-Altman plots and intraclass correlation coefficients were used for examination of agreement. Subgroup analyses were performed for astigmatism magnitude, diabetes duration, hemoglobin A1c (HbA1c) levels and diabetic retinopathy (DR) stage.

RESULTS

Agreement for K_m and astigmatism magnitude were considered good and moderate, with 95% limits of agreement (LoA) of -1.09 to 1.23 diopters (D) and -0.83 to 0.86 D in DM group, respectively; and -0.59 to 0.72 D and -0.98 to 0.75 D in non-DM group, respectively. In contrast, the 95% LoA for corneal axis exceeded the clinically relevant margins in both groups. In the total sample, only 41 eyes (38%) had a smaller than 5-degree difference. Diabetes duration, HbA1c levels and DR stage were not found to significantly affect agreement. Logistic regression showed that higher corneal power (P=0.021) and astigmatism magnitude (P=0.011) were associated with a decreased risk of having a difference in axis location greater than 10-degrees.

CONCLUSION

In both groups, IOLMaster and Pentacam agree well for corneal power and moderately for astigmatism. However, axis location disagreement is frequent in eyes with flatter corneas and small amounts of astigmatism.

Baseline visual acuity and interdigitation zone as predictors in idiopathic epiretinal membranes: A retrospective cohort study

OBJECTIVE

Determine which functional and anatomical characteristics may be predictors of final visual acuity in patients with idiopathic ERM (iERM) submitted to pars plana vitrectomy (PPV) with ERM and internal and internal limiting membrane (ILM) peeling.

DESIGN

Retrospective cohort study.

SUBJECTS

Patients with iERM submitted to PPV between 2016 and 2017.

METHODS

Data regarding the best-corrected visual acuity (BCVA) and the characteristics of the retinal layers observed in SD-OCT were collected preoperatively and until 12 months postoperatively. Central macular thickness (CMT), disorganization of the retinal inner layers (DRIL), outer nuclear layer (ONL) thickness, integrity of subfoveal external limiting membrane (ELM), ellipsoid zone (EZ), and interdigitation zone (IZ) were evaluated.

RESULTS

A total of 128 eyes with iERM from 121 patients were included. BCVA improved significantly (p < 0.001). Significant improvement of BCVA, CMT, DRIL, ONL, ELM, and EZ were obtained. The final IZ was not different from baseline until the end of the study. A significant correlation was observed between the baseline BCVA, EZ, IZ, and the postoperative BCVA (p < 0.001). However, only the baseline BCVA and the integrity of the subfoveal baseline IZ were predictive factors for final BCVA (p < 0.005 and p < 0.001, respectively).

CONCLUSION

PPV provides a significant improvement of BCVA and retinal anatomy recovery in iERM eyes. Baseline IZ didn't change during the 12 months following surgery. Baseline BCVA and subfoveal IZ at baseline were prognostic factors for the final BCVA.

Effectiveness of treat-and-extend versus pro re nata regimens in the treatment of Neovascular Age Macular Degeneration: A Real World Comparison

PURPOSE

Evaluate and compare the visual and morphological results of Pro re nata (PRN) and treat-and-extend (T&E) treatment regimens at 3 years in real world clinical practice.

METHODS

Retrospective study of patients with neovascular age macular degeneration (AMD) treated with anti-VEGF with 3 years of continuous follow-up and no previous anti-VEGF treatment. Best corrected visual acuity (BCVA), central foveal thickness (CFT) and number of intravitreal injections outcomes were tested for statistical differences between the two groups at baseline and during follow-up.

RESULTS

A total of 240 eyes were included in the study, 170 in the PRN group and 70 in the T&E group. At 12 months, mean BCVA (ETDRS letters) gain from baseline was at its highest point in the T&E group (+6.38±13.32; p=0.25). In the PRN group, BCVA peaked at 3 months and slowly decreased until end of follow-up. With both regimens, from baseline, CFT continued to decrease until the second year (PRN -138.81 [-846.7 to +162.77] and T&E -81 [-604 to +100] μm, p=0.06). After that, T&E group maintained this tendency, reaching the lowest CFT value at 36 months, whereas PRN group showed an increased in CFT values (PRN -104 [-807.7 to +297] μm and T&E -103 [-575 to +244], μm p=0.63). Patients treated with T&E regimen received a significantly higher number of injections (PRN 16.3±7.6 vs T&E 23.9 ±9.4, p<0.01).

CONCLUSION

Our results demonstrated a trend towards for T&E to achieve higher marks in BCVA, peaking at 12 months, and lower CFT thickness at the end of three years. Despite the higher number of injections performed in the T&E group the mean BCVA reverts to baseline values at 3 years.

Retinal Nerve Fiber Layer Thickness Decrease in Obesity as a Marker of Neurodegeneration

BACKGROUND

Idiopathic intracranial hypertension (IIH) is a serious condition that is frequently associated with irreversibly vision loss, having a higher incidence among obese women. Our aims were to screen subclinical IIH in obese patients scheduled to bariatric surgery using peripapillary retinal nerve fiber layer (RNFL) thickness and to evaluate if the findings demand the possible need of a preoperative evaluation in this population.

METHODS

This study included 111 eyes from 36 obese patients (86% female, body mass index > 35 kg/m²) scheduled to bariatric surgery and 20 non-obese (body mass index < 25 kg/m²) age-matched controls. We measured sectorial and mean RNFL thickness in a 3.5-mm-diameter circular scan centered on the optic nerve head, using optical coherence tomography (Heidelberg Spectralis SD-OCT) in all participants. Multivariate linear regression was used for adjustments.

RESULTS

No patient had subclinical IIH corresponding to increased RNFL thickness. However, in obese individuals, global peripapillary RNFL was thinner than in controls (104 ± 6 μm versus 99 ± 12 μm, p = 0.005). Overall, RNFL thickness was superior in the control group for all sectors. The differences reached significance for the nasal, temporal, superior temporal, and inferior temporal sectors. These differences remained even after adjusting for possible confounders (hypertension, dyslipidemia, diabetes, age, sleep apnea syndrome, and sex).

CONCLUSIONS

Routine screening asymptomatic obese patients undergoing bariatric surgery for IIH using RNFL thickness was not clinically relevant in our study. However, we found that severe obesity is associated with neurodegeneration independently of the other components of the metabolic syndrome, what may justify future investigation on the need of monitoring these patients.

A New Approach for Diabetic Macular Edema Treatment: review of clinical practice results with 0.19 mg fluocinolone acetonide intravitreal implant including vitrectomized eyes

PURPOSE OF REVIEW

Fluocinolone acetonide is a synthetic fluorinated glucocorticoid. It has selective and potent agonist properties by binding to the cytosolic glucocorticoid receptor with high affinity; it is devoid of mineralocorticoid activity. Two extended-release (i.e. lasting up to 3 years) drug delivery systems containing fluocinolone acetonide (FAc) have been approved by the FDA for intravitreal use: Retisert ® (Bausch&Lomb, New Jersey, USA) and Iluvien ® (Alimera Sciences, Atlanta, USA). The former contains 0.59 mg of FAc, which is approved for the treatment of chronic noninfectious posterior segment uveitis. The latter contains a dose of 0.19 mg of FAc and is approved for the treatment of diabetic macular edema and here we review the results published in the clinical literature relating to its use in the treatment of diabetic macular edema (DME).

RECENT FINDINGS

The 0.19 mg FAc implant (Iluvien®) is a new approved treatment approach for DME. It is a non-biodegradable implant that continuously releases a microdose of FAc into the vitreous cavity for up to three years. It is effective in chronic DME with the added value of decreasing the treatment burden of multiple intravitreal injections. Recently, clinical practice studies are reporting its efficacy and safety profile (intra-ocular pressure rise and cataract), as well as its use in clinical setting not included in clinical trial such as vitrectomized eyes.

SUMMARY

The FAc implant has demonstrated in clinical practice results that mirror the results of the clinical trials efficacy wise. Regarding its safety profile, cataract is a common complication, however, intra-ocular pressure rises may be lower than the ones reported in trials. The implant has shown effectiveness in vitrectomized eyes. An increasing evidence of real-world studies have supported utility of the implant in DME patients. It's extended-release format for up to 3 years benefits to the patient and carer as it means fewer injections and visits to the clinic.

532-nm Subthreshold Micropulse Laser for the Treatment of Chronic Central Serous Retinopathy

Introduction

Subthreshold micropulse laser treatment with a 532 nm (532-SML) wavelength has been suggested as a treatment option for the treatment of chronic central serous retinopathy (cCSR). The objective is to present its effects and complications.

Methods

We present a retrospective cohort study of cCSR patients submitted to 532-SML. Best-corrected visual acuity (BCVA) and spectral-domain optical coherence tomography (SD-OCT) parameters – central macular thickness, subfoveal outer nuclear layer, external limiting membrane, ellipsoid band, interdigitation band, subretinal fluid and choroidal thickness – were evaluated before and 12 weeks after treatment. A power of 50%, a duty cycle of 5%, exposure time of 200 ms and a spot size of 160 µm were the applied laser parameters.

Results

We included 26 eyes. Overall there were no significant changes in visual acuity (median 0.20 (IQR 0) logMAR before and after treatment) or SD-OCT parameters. However, visual benefits occurred in 42.3% (n=11) of the patients and in half of the cases, subretinal fluid was completely reabsorbed. There were no complications.

Conclusion

In this study, 532-SML was overall ineffective on cCSR as it did not lead to significant changes in the overall median visual acuity and SD-OCT parameters. However, some patients may have benefited functionally and anatomically from the treatment; further investigation is necessary to understand the potential of 532-SML.

Quantitative Optical Coherence Tomography Angiography Biomarkers in a Treat-and-Extend Dosing Regimen in Neovascular Age-Related Macular Degeneration

Purpose

To evaluate the association between quantitative optical coherence tomography angiography (OCT-A) parameters and clinical outcomes in treatment-naïve neovascular age-related macular degeneration (nAMD) patients treated with a treat-and-extend dosing regimen on a 12-month follow-up interval.

Methods

Observational, prospective study of consecutive patients. The treatment protocol was based on a loading dose of three anti-vascular endothelial growth factor (VEGF) intravitreal injections (IVI) followed by a treat-and-extend regimen. Eyes were evaluated by swept-source OCT-A at baseline, 1 month after the loading dose and at 12 months. A quantitative analysis was issued for fractal dimension (FD), lacunarity index (LAC), blood flow surface area (SA), and vessel density (VD). An association of these parameters with the anatomic response and functional responses, and IVI number at 12 months of follow-up was assessed. A level of significance α = 0.05 was considered.

Results

Sixty-four patients were included, 52 of whom (81%) completed the 12-month study protocol. The median number of injections at 12 months was 7 (P₂₅-P₇₅: 6-12). FD and SA were reduced 1 month after the loading dose of anti-VEGF (P < 0.001). The generalized linear models using baseline FD and baseline SA achieved the best performance in discriminating a lower treatment burden (area under the curve [AUC] = 0.78; 95% confidence interval [CI]: 0.64-0.91 and AUC = 0.76; 95% CI: 0.63-0.90, respectively).

Conclusions

Baseline OCT-A may provide useful biomarkers for the treatment burden in nAMD.

Translational Relevance

The application of fractal dimension and automatic blood flow area algorithms to OCT-A data can distinguish patients with distinct treatment burdens in the first year of nAMD.

Incidence of endophthalmitis after intravitreal injection with and without topical antibiotic prophylaxis

PURPOSE

The purpose was to compare the incidence of endophthalmitis after intravitreal injection with and without topical antibiotic prophylaxis.

METHODS

This is a single-center, retrospective case-control study. All patients treated with intravitreal injection of ranibizumab, bevacizumab, aflibercept, or corticosteroids for a variety of retinal vascular diseases between 1 October 2014 and 30 November 2018 were included. The total number of patients and injections were determined from a review of billing code and practice management records. Endophthalmitis cases were determined from billing records and then confirmed with chart review. A 24-month period when topical antibiotics were prescribed after intravitreal injection was compared with a 24-month period when topical antibiotics were not prescribed.

RESULTS

Between 1 October 2014 and 30 November 2018, a total of 33,515 intravitreal injections were performed and 13 cases of post-intravitreal injection endophthalmitis were identified (incidence rate of 0.0388%; 95% confidence interval, 0.0217%-0.0644%) or approximately 1 case for every 2578 intravitreal injections. Between 1 October 2014 and 31 October 2016, while topical antibiotic prophylaxis was used postoperatively, 14,828 intravitreal injections were performed and 5 cases of endophthalmitis were reported (0.0337%; 95% confidence interval, 0.0129%-0.0739%). Between 1 November 2016 and 30 November 2018, while no prophylaxis was used, 18,687 intravitreal injections were performed and 8 cases of endophthalmitis were identified (0.0428%; 95% confidence interval, 0.0202%-0.0808%). There were no statistical differences in the incidence rates between the two groups (p = 0.675).

CONCLUSION

The incidence rate of endophthalmitis in the group with topical antibiotic prophylaxis after intravitreal injection was similar to the group with no prophylaxis. Changing the current clinical practice to no antibiotic prophylaxis had no effect on the incidence of endophthalmitis.

Changing trends in the prevalence of diabetic retinopathy in type 1 diabetes mellitus from 1990 to 2018: A retrospective study in a Portuguese population

PURPOSE

To estimate the prevalence of diabetic retinopathy /(DR) in a Portuguese population with type 1 diabetes (T1DM).

METHODS

Retrospective review of all patients with T1DM, whose reference center was Centro Hospitalar de São João, a tertiary center in Portugal, who were diagnosed between 1990 and 2018. DR was classified based on fundus examination in medical records as (0) no evidence of retinopathy, (1) mild non-proliferative retinopathy (NPDR); (2) moderate to severe non-proliferative retinopathy (NPDR) and (3) proliferative retinopathy (PDR). Patients were classified according to the eye with a worse retinopathy stage. Follow-up was considered as time between the diagnosis of diabetes and the last funduscopic evaluation.

RESULTS

233 patients met the inclusion and exclusion criteria. The prevalence of any DR at less than 5, 10, 15, 20 and more than 20-years of DM was 1.8%, 10.4%, 34.8%, 54.1% and 71.2% respectively. The overall prevalence of DR was 43.3% (n = 101). At the last observation, 43 patients (18.5%) had mild NPDR, 34 patients (14.6%) had moderate to severe NPDR and 24 patients (10.3%) had PDR. The longer the disease duration, the higher the number of patients with DR.

CONCLUSION

The prevalence of DR in our cohort was 34.8% after 15 years of systemic disease and 54.1% after 20 years, which is lower than what has been reported in the literature. Further multicentric prospective studies, are needed to clarify changes in the epidemiology of DR in type 1 diabetics.

Impact of Intravitreal Ranibizumab Therapy on Vision Outcomes in Diabetic Macular Edema Patients: A Meta-Analysis

PURPOSE

Evaluation of the impact of the injection frequency of ranibizumab on best-corrected visual acuity (BCVA) outcomes in patients with diabetic macular edema (DME).

METHODS

A meta-analysis of randomized controlled trials (RCTs) and real-world studies was performed to quantify the effect of ranibizumab treatment on BCVA and central foveal thickness (CFT) in DME as well as the relationship between the number of injections and the change in BCVA/CFT.

RESULTS

All combined sources (29 RCTs and 11 real-life studies) showed a significant increase in BCVA from baseline following anti-vascular endothelial growth factor (VEGF) treatment (8.2, 9.4, and 10.3 ETDRS letters gained after 12, 24, and 36 months of ranibizumab treatment, respectively). The largest changes in BCVA were observed in RCTs and the smallest in real-life studies at 12 months. A significant relationship was found between the number of injections and change in BCVA at 12 months.

CONCLUSIONS

Inferior vision outcomes were observed in clinical practice compared with RCTs and might be partly attributable to administration of fewer anti-VEGF injections. Physicians should be aware that early and appropriate anti-VEGF treatment regimens are necessary to obtain the results reported in RCTs and help prevent irreversible vision loss in DME patients.

Risk factors for prevalent diabetic retinopathy and proliferative diabetic retinopathy in type 1 diabetes

PURPOSE

Age at diagnosis of type 1 diabetes (DM1) has been implied as an important factor associated with the development of the microvascular complications. Our aim was to identify factors associated with prevalent diabetic retinopathy (DR) and proliferative diabetic retinopathy (PDR) in DM1 people with early and late-onset.

METHODS

We reviewed medical records from all DM1 people from the reference area of a tertiary center (about 340,000 persons). Univariate and multivariate logistic regression were used to assess the relationship between potential risk factors (sociodemographic, diabetes-related, co-morbidities, and laboratory parameters) and prevalent DR/PDR. We performed an analysis comparing patients diagnosed before (early-onset) and after (late-onset) 18 years of age.

RESULTS

We included 140 patients in early-onset DM1 group and 169 in late-onset DM1 group. Longer duration of diabetes and HbA1c remained associated with prevalent DR in both groups after adjusting for potential risk factors. Nephropathy was associated with prevalent DR in the late-onset group but not in the early-onset group. Peripheral neuropathy remained associated with prevalent PDR when modeled together in the multivariate model. High BMI demonstrated a significative association with PDR in early but not in the late-onset DM1 group.

CONCLUSIONS

Although previous reports suggest that age at DM1 diagnosis may have a role in DR prevalence, the risk factors for DR in early and late-onset DM1 were similar for both groups. Duration of disease and lifelong metabolic control were the major predictors for DR in both groups. Nephropathy was associated with DR in patients with late-onset disease. Neuropathy was associated with PDR occurrence in both groups. BMI was associated with PDR early-onset DM1 group.

Transepithelial accelerated versus conventional corneal collagen crosslinking in patients with keratoconus: a comparative study

Purpose

To systematically compare the efficacy of transepithelial accelerated corneal collagen crosslinking (TE-ACXL) with conventional corneal collagen crosslinking (C-CXL) in patients with progressive keratoconus.

Methods

Eyes of patients with progressive keratoconus who were treated with C-CXL (3 mW/cm² for 30 minutes) were compared with those who underwent TE-ACXL (6 mW/cm² for 15 minutes). Best-corrected visual acuity (BCVA), keratometry values, corneal thickness, and topometric indexes were compared before CXL, and at 2 months, 6 months, and 12 months postoperatively.

Results

The study enrolled 26 eyes of which 16 had TE-ACXL and 10 had C-CXL. Both groups were comparable at baseline and 12 months in terms of BCVA (P=0.16 and P=0.57), Kmax (maximum keratometry) (P=0.31 and P=0.73), pachymetry (P=0.75 and P=0.37), index of surface variance (ISV) (P=0.45 and P=0.86), index of vertical asymmetry (IVA) (P=0.26 and P=0.61), and index of height decentration (IHD) (P=0.27 and P=0.86, respectively). We did not observe significant differences between preoperative and 12-month postoperative readings in within-group analysis: ΔKmax (TE-ACXL, −2.13±5.41, P=0.25 vs C-CXL, 0.78±1.65, P=0.17), Δpachymetry (TE-ACXL, 4.10±14.83, P=0.41 vs C-CXL, −8.90±22.09, P=0.24), ΔISV (TE-ACXL, −8.50±21.26, P=0.24 vs C-CXL, 3.80±12.43, P=0.36), ΔIVA (TE-ACXL, −0.12±0.31, P=0.26 vs C-CXL, 0.03±0.18, P=0.61), and ΔIHD (TE-ACXL, −0.03±0.07, P=0.18 vs C-CXL, −0.01±0.03, P=0.88).

Conclusion

Both TE-ACXL and C-CXL were similarly effective. Further follow-up is required to determine whether these techniques are comparable in the long-term.

Spectral Domain-Optical Coherence Tomography As a New Diagnostic Marker for Idiopathic Normal Pressure Hydrocephalus

PURPOSE

Characterized by a progressive onset of gait disturbances, dementia, and urinary incontinence, idiopathic normal pressure hydrocephalus (iNPH) is considered a rare, but under-diagnosed disease. Non-invasive diagnostic markers are still insufficient to enable the diagnosis of iNPH with certainty and yet early treatment with ventriculoperitoneal (VP) shunting can reverse symptoms and stop disease progression. Vascular circulation abnormalities in iNPH may be reflected by changes in subfoveal and peripapillary choroidal thickness (PPChT). This study uses spectral domain-optical coherence tomography (SD-OCT)-based measures of retinal and choroidal thickness to test this hypothesis and to assess ophthalmological non-invasive markers for iNPH.

METHODS

Twelve patients who displayed neurological and neuroradiological characteristics of iNPH were subject to a full ophthalmological examination including enhanced depth imaging (EDI) SD-OCT. Of the 12 included iNPH patients, 6 had undergone VP shunting with beneficial outcome. Parameters studied with EDI SD-OCT were macular retinal thickness (MT), subfoveal choroidal thickness (SFChT), retinal nerve fiber layer thickness (RNFL), and PPChT. Results were compared with 13 healthy, age-matched controls.

RESULTS

Macular thickness and RNFL and MT values of iNPH patients did not reflect atrophy. Non-shunted iNPH patients showed significantly lowered median PPChT and SFChT values compared to healthy controls. Shunted iNPH patients displayed a significantly higher median PPChT and SFChT compared to non-shunted iNPH patients. SFChT and PPChT values in shunted patients were not significantly different to values in healthy controls.

CONCLUSION

Although limited by small sample size, SD-OCT measures in this study reveal significant changes of choroidal thickness and support the hypothesis of choroidal susceptibility to hemodynamic alterations in iNPH. Non-shunted iNPH patients in this study show choroidal thinning in combination with normal RNFL and MT values. In addition to neurological and neuroradiological exams, this pattern may aid in the challenging diagnosis of iNPH.