Long-Standing Macula-Involving Diabetic Tractional Retinal Detachments with Good Visual Acuity: How Should We Manage These Patients?

Purpose

We assess the merits of pars plana vitrectomy (PPV) in subjects with good visual acuity (VA) and a chronic macula-involving tractional retinal detachment (TRD) secondary to proliferative diabetic retinopathy (PDR).

Methods

A retrospective review of medical records was undertaken. Subjects were divided into 1) a Study Group of subjects who underwent prompt PPV and 2) a Control Group of subjects in which PPV was deferred in favor of less invasive treatment options or observations. Both study and control subjects had a baseline Snellen VA of ≥20/50 and a PDR-associated macula-involving TRD of >6 months duration with a minimum follow-up of 12-months.

Results

There were 58 patients analyzed over an average follow-up period of 27.6 (±7.1) months. The change in VA was similar in the Study Group compared to the Control Group (p=0.94) with both groups losing about three lines of VA during the study period (-0.30 ±0.52 logMAR). Although the rates of maintaining ≥20/200 Snellen VA and ≥20/50 Snellen VA were similar in the Study Group compared to the Control Group (p=0.55 and p=0.28, respectively), the Study Group had more subjects gaining ≥2 lines of VA during the study period (p=0.002).

Conclusion

Patients presenting with good VA and a PDR-associated macula-involving TRD of >6 months were more likely to gain ≥2 lines of VA when PPV was performed at baseline compared to PPV deferral until further deterioration occurred.

Topography-Guided LASIK: A Prospective Study Evaluating Patient-Reported Outcomes

Purpose

To evaluate patient-reported outcomes with a validated patient questionnaire following topography-guided LASIK (TG-LASIK).

Methods

Patients undergoing TG-LASIK using Phorcides analytic software were prospectively enrolled to receive an adapted Patient-Reported Outcomes with LASIK Symptoms and Satisfaction (PROWL) questionnaire before and 26-weeks after treatment. The main study outcome was the change in the Global Vision Satisfaction Index from the PROWL questionnaire.

Results

Forty-six patients underwent treatment and completed the modified PROWL questionnaire before and 26-weeks after TG-LASIK. The Global Vision Satisfaction Index from the modified PROWL questionnaire improved from 4.07 (3.87-4.26) to 5.00 (4.81-5.19) after the TG-LASIK treatment (p < 0.0001). The study population's binocular uncorrected distance visual acuity was 20/16, 20/12.5, and 20/10 or better in 100%, 87.0%, and 15.2% at 26 weeks post TG-LASIK, respectively.

Conclusion

Patient satisfaction as assessed with the modified PROWL questionnaire is very high after undergoing TG-LASIK using Phorcides analytic software. Patient-reported outcomes add another dimension when assessing treatment efficacy beyond change in visual acuity and corneal architecture, and specialists may consider incorporating such assessments into the consenting process and patient education at large.

INTERNAL LIMITING MEMBRANE PEELING IN PATIENTS UNDERGOING VITRECTOMY FOR TRACTIONAL RETINAL DETACHMENT SECONDARY TO DIABETIC RETIONPATHY

PURPOSE

To assess the merits of internal limiting membrane (ILM) peeling during pars plana vitrectomy in subjects with a tractional retinal detachment secondary to proliferative diabetic retinopathy.

METHODS

One hundred and ninety-one proliferative diabetic retinopathy subjects undergoing pars plana vitrectomy for the principal indication of tractional retinal detachment were enrolled into this randomized controlled trial. Study subjects were intraoperatively randomized into one of the following treatment groups: Cohort A patients underwent ILM peeling, whereas Cohort B patients did not undergo ILM peeling. The main outcome was postsurgical epiretinal membrane development at 6 months. The secondary outcome was attainment of ≥ 20/50 visual acuity (Snellen) at 6 months.

RESULTS

One hundred and thirty-nine subjects underwent randomization and completed the study's 6-month trial period. Cohort A had 3.1% (2 of 64) of subjects developing an epiretinal membrane postoperatively, whereas Group B had 26.7% (20 of 75) of subjects developing an epiretinal membrane postoperatively at 6 months ( P < 0.001). Attainment of ≥ 20/50 visual acuity (Snellen) at 6 months was found in 21.9% (14 of 64) of subjects in Cohort A and 9.3% (7 of 75) of subjects in Cohort B ( P = 0.039).

CONCLUSION

Proliferative diabetic retinopathy patients undergoing pars plana vitrectomy for tractional retinal detachment have a lower frequency of postsurgical epiretinal membrane formation and a greater likelihood of attaining ≥20/50 Snellen visual acuity at 6 months when ILM peeling is conducted. Specialists may consider peeling of the ILM during pars plana vitrectomy an important surgical maneuver in this patient population.

Timing of the Initial Postoperative Care After Cataract Surgery: A Patient's Perspective

Purpose

To evaluate patient preferences in regards to the timing of the initial postoperative examination after undergoing cataract surgery.

Methods

A retrospective, consecutive case series analysis from a single private practice institution was performed using a standardized phone survey on patients who underwent cataract surgery. Subjects were classified into one of two possible study groups according to the timing of their initial postoperative cataract surgery examination: Group A received the initial postoperative cataract surgery examination on the same day as the surgery, whereas Group B received the initial postoperative cataract surgery examination on the day following the operation.

Results

There were 80 subjects contacted for the phone survey of which 70 (35 in each study group) completed the survey and therefore were included in the analysis. Group A subjects responded favorably in regards to preference and realizing reduced time and cost savings compared to Group B (p < 0.0001 for both). There were no subjects in Group A who would have preferred next-day initial postoperative care, whereas 31.4% of subjects in Group B would have preferred same-day care if given the opportunity.

Conclusion

Patients undergoing cataract surgery both prefer and report time and cost savings with same-day initial postoperative care compared to next-day initial postoperative care. Patient preferences regarding their postoperative care should be one of the many factors that a surgeon ought to take into consideration when providing follow-up care after cataract surgery.

Intravitreal Faricimab for Aflibercept-Resistant Neovascular Age-Related Macular Degeneration

PURPOSE

To evaluate the short-term effects of intravitreal faricimab (IVF) in treatment-resistant neovascular age-related macular degeneration (nAMD) subjects previously treated with intravitreal aflibercept (IVA).

METHODS

A retrospective review was conducted on nAMD patients undergoing IVA therapy at a single private practice institution. Subjects were divided into Study and Control groups. Both Study and Control subjects had undergone ≥6 IVA treatments during the previous 12 months, ≥4 IVA treatments during the previous 6 months, had a central macular thickness (CMT) on optical coherence tomography (OCT) of ≥300 microns, and had observable intraretinal and/or subretinal fluid on OCT prior to group assignment. Study subjects were switched from IVA to IVF and received 3 treatments within 4 months. Control subjects remained on IVA during the same time period and received 3 treatments within 4 months.

RESULTS

There were a total of 55 subjects analyzed. There were 39.3% (11/28) in the Study Group and 7.4% (2/27) in the Control Group attaining a CMT of less than 300 microns without retinal fluid on OCT at the end of the 4-month study period (p = 0.004). There were 35.7% (10/28) in the Study Group and 7.4% (2/27) in the Control Group gaining 2 or more lines of visual acuity at the end of the 4-month study period (p = 0.008).

CONCLUSION

IVF can improve the visual and anatomic outcomes in a significant minority of treatment-resistant nAMD subjects previously managed with IVA. A greater follow-up period is needed to determine if such improvements can be maintained.

Faricimab for Treatment-Resistant Diabetic Macular Edema

Purpose

To assess the short-term outcomes in treatment-resistant diabetic macular edema (DME) patients changed from intravitreal aflibercept (IVA) to intravitreal faricimab (IVF).

Methods

A retrospective review was undertaken on DME subjects receiving IVA therapy at a single private practice. Patients were separated into study and control cohorts. Both study and control patients had received more than or equal to six IVA injections during the preceding 12 months, more than or equal to four IVA injections during the preceding 6 months, had a central macular thickness (CMT) on optical coherence tomography (OCT) of ≥300 µm, and had retinal fluid on OCT before cohort assignment. Study patients were switched to IVF and underwent three injections within 4 months, whereas control patients stayed on IVA during the same period and received three injections within 4 months.

Results

There were 51 patients analyzed. There were 37.5% (9/24) in the study group and 3.7% (1/27) in the control group who achieved a CMT of less than 300 µm without retinal fluid on OCT at the end of the 4-month study (p=0.001). There were 41.7% (10/24) in the study group and 11.1% (3/27) in the control group who had gained two or more lines of visual acuity at the end of the 4-month study (p=0.01).

Conclusion

For a significant minority, IVF can improve the short-term visual and anatomic outcomes in treatment-resistant DME patients formerly managed with IVA. Longer follow-up is needed to determine if such improvements can be preserved.

Patient Attitudes and Desirability Regarding Immediate Sequential Bilateral Cataract Surgery

Purpose

To analyze patient attitudes and desirability regarding routine immediate sequential bilateral cataract surgery (ISBCS).

Methods

This study was conducted as a prospective, consecutive survey-based case series from a single private practice institution serving a mostly rural population. A standardized phone survey assessing patient perspectives on ISBCS was administered to patients before and after routine delayed sequential bilateral cataract surgery (DSBCS) was performed. Subject responses were analyzed, including a subset analysis on patient responses under a variety of circumstances.

Results

There were 61 patients enrolled into the study and 47 completed the surveys before and after routine DSBCS (77.0% completion rate). Thirty-nine (83.0%) of respondents had a favorable outlook of ISBCS preoperatively, whereas 36 (76.6%) had a favorable outlook of ISBCS postoperatively (p>0.05). On the postoperative questionnaire, twenty-five (53.2%) of respondents were willing to accept additional surgical risk if necessary to receive ISBCS, and this finding was significant between the subgroup of patients with systemic health co-morbidities compared to those without systemic health co-morbidities (p=0.05).

Conclusion

Most patients had a favorable outlook of ISBCS before and after undergoing DSBCS. Patients with underlying systemic health co-morbidities were most likely to accept additional surgical risk if necessary to receive ISBCS. From a patient’s perspective, ISBCS may be an acceptable option to routinely implement when cataract surgery is required for both eyes.

OUTCOMES IN PATIENTS RESUMING INTRAVITREAL ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY FOLLOWING TREATMENT DELAY DURING THE CORONAVIRUS-19 PANDEMIC

PURPOSE

To evaluate the outcomes of delay in care secondary to the coronavirus pandemic in patients requiring intravitreal anti-vascular endothelial growth factor therapy.

METHODS

A retrospective review was performed, and subjects were divided into two groups: 1) a study group of patients who experienced a treatment delay of ≥6 weeks from the intended follow-up during the coronavirus pandemic and resumed treatment with ≥2 anti-vascular endothelial growth factor injections over 6 months following treatment delay, and 2) a control group of patients who received regular care throughout the coronavirus pandemic.

RESULTS

Totally, 234 subjects were analyzed. The mean treatment delay from the intended follow-up in the study group was 11.8 (±4.0) weeks. Visual acuity and central macular thickness worsened from baseline to 6 months after resuming anti-vascular endothelial growth factor therapy in the study group (P < 0.0001 and P = 0.001, respectively). Visual acuity and central macular thickness were better in the control group compared with the study group at the end of the 6-month study period (P < 0.0001 for both).

CONCLUSION

Treatment delay in subjects undergoing anti-vascular endothelial growth factor therapy for retina disease during the coronavirus pandemic had worse visual and anatomical outcomes despite reinitiating treatment over 6 months compared with a control group, suggesting irreversibility and permanence of outcomes.

Corneal Epithelial Stem Cell Supernatant in the Treatment of Severe Dry Eye Disease: A Pilot Study

PURPOSE

To report the subjective assessment of topical self-administered, cadaver-derived corneal epithelial stem cell supernatant for treatment of severe dry eye disease (DED).

METHODS

Thirty-four eyes of 17 patients with advanced DED as defined by Standardized Patient Evaluation of Eye Dryness (SPEEDTM) questionnaire ≥14, Ocular Surface Disease Index (OSDI©) score ≥40 and documented attempt of at least six conventional dry eye therapies were enrolled into a prospective clinical trial at a single private practice institution. Treatment consisted of patient self-administered topical instillation of the corneal epithelial stem cell-derived product four times daily in both eyes for 12 weeks. Patient-reported outcome measures (PROMs) were taken with the SPEEDTM questionnaire (the main outcome variable), OSDI© score and visual analog score (VAS; UNC Dry Eye Management Scale©), and objective clinical measurements were taken with best-corrected visual acuity (BCVA), corneal topographic index measurements and tear film osmolarity. These measurements were compared at baseline versus the endpoint at completion of the 12-week treatment.

RESULTS

All 34 eyes tolerated the treatment without any adverse events or significant side effects. Compared with baseline, both the SPEEDTM questionnaire and the VAS significantly improved at the conclusion of the 12-week treatment (p = 0.0054 and p = 0.0202, respectively). The OSDI© improved by an average of 10.9 points after the treatment but was not statistically significant (p = 0.1409). There were no significant changes in any of the objective clinical measurements. None of the study subjects failed to complete the treatment course, experienced decrease in any of the PROMs or lost one or more lines of BCVA during the follow-up period.

CONCLUSION

Topical corneal epithelial stem cell-derived supernatant that can be self-administered by the patient shows promise at improving patient symptoms and quality of life in the setting of severe DED that is unresponsive to conventional therapies.

Pars Plana Vitrectomy with Internal Limiting Membrane Peeling for Treatment-Naïve Diabetic Macular Edema: A Prospective, Uncontrolled Pilot Study

Purpose

To report the outcomes in subjects undergoing pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling for the management of treatment-naïve diabetic macular edema (DME).

Methods

Ten treatment-naïve subjects with non-proliferative diabetic retinopathy prospectively underwent PPV with ILM peeling for the treatment of DME at a single university-affiliated institution. The preoperative features, intraoperative details and postoperative outcomes were collected and analyzed.

Results

All 10 subjects underwent PPV with ILM peeling without significant intraoperative or postoperative complications at 6 months follow-up. Visual acuity improved from a baseline of 0.74 (95% CI: 0.48–1.0) logMAR (Snellen 20/110) to 0.46 (95% CI: 0.3–0.62) logMAR (Snellen 20/58) at 6 months follow-up (p=0.045). Optical coherence tomography central macular thickness reduced from a baseline of 456 (95% CI: 394.7–516.4) microns to 316.8 (95% CI: 275.9–357.7) microns at 6 months follow-up (p < 0.001).

Conclusion

This pilot study suggests that PPV with ILM peeling may be a viable treatment option for the management of treatment naïve DME in subjects with non-proliferative diabetic retinopathy. Development of a randomized controlled trial may be justified to validate the results of this study.

Clinicaltrials.gov Identifier #

NCT03660345.

Femtosecond-Assisted Laser in situ Keratomileusis with de novo Flap Creation Following Previous Microkeratome Laser in situ Keratomileusis

Purpose

To report the outcomes of laser in situ keratomileusis (LASIK) in patients with previous microkeratome LASIK using a femtosecond laser platform to create a de novo flap.

Methods

The charts of 17 patients that underwent femtosecond-assisted LASIK with de novo flap creation for consecutive refractive error following previous microkeratome LASIK were retrospectively reviewed at a single private practice institution. The baseline characteristics, intraoperative findings and postoperative outcomes were analyzed.

Results

All 17 eyes underwent femtosecond-assisted LASIK with de novo flap creation without significant intraoperative or postoperative complications. Uncorrected visual acuity improved postoperatively (p<0.0001) and remained stable at 6 months follow-up. None of the subjects lost any lines of best spectacle corrected visual acuity or developed epithelial ingrowth during the postoperative period.

Conclusion

The femtosecond laser technique described in this report can provide a safe and effective method to deliver LASIK following previous microkeratome LASIK. Future investigations are required to further validate the findings in this study.

Optical Coherence Tomography-Guided Femtosecond LASIK in the Setting of Corneal Scarring

Purpose

To report the outcomes of femtosecond-assisted laser in situ keratomileusis (LASIK) in patients with previous corneal scarring using optical coherence tomography (OCT) imaging to determine flap depths.

Methods

The charts of 11 eyes of 9 patients with previous off-visual axis corneal scarring that underwent femtosecond LASIK using OCT guidance for flap depth determination were retrospectively reviewed at a single private practice institution. The baseline characteristics, intraoperative findings and postoperative outcomes were analyzed.

Results

All 11 eyes underwent femtosecond laser flap creation and LASIK without any significant intraoperative complications. Uncorrected visual acuity improved postoperatively (p<0.0001) and remained stable at 3 months follow-up. None of the subjects lost any lines of best spectacle corrected visual acuity or developed any flap complications during the postoperative period.

Conclusion

The OCT-guided femtosecond laser technique described in this report can provide a safe and effective method to deliver LASIK in the setting of previous corneal scarring. Future investigations are required to further validate the findings in this study.

Ziv-aflibercept versus bevacizumab administration prior to diabetic vitrectomy: a randomised and controlled trial

Purpose

To compare the effectiveness of intravitreal ziv-aflibercept (IVZ) to intravitreal bevacizumab (IVB) administered preoperatively to patients undergoing pars plana vitrectomy (PPV) for severe manifestations of proliferative diabetic retinopathy (PDR).

Design

Randomised clinical trial (RCT).

Methods

Two hundred and six patients with PDR-related complications requiring PPV were randomised into one of two treatment groups: Group A received IVZ (1.25 mg/0.05 mL) 1–10 days before PPV, while Group B received IVB (1.25 mg/0.05 mL) 1–10 days before PPV. The primary outcome was best-corrected visual acuity (BCVA) at 6 months follow-up. Secondary outcome measures were perioperative tractional retinal detachment (TRD) rates, surgical times, intraoperative and postoperative complications and incidence of unplanned PPV during the 6 month study interval.

Results

One hundred and seventy three subjects underwent PPV and completed the 6-month follow-up interval. Group A subjects had better BCVA at 6 months (p=0.0035), shorter surgical times (p=0.0013) and were less likely to have a recurrence of vitreous haemorrhaging in the postoperative period (p=0.0101) when compared with subjects in Group B. There were no significant differences among the treatment groups with regards to baseline characteristics, perioperative TRD development, intraoperative complications and incidence of unplanned PPV during the 6 month study interval.

Conclusions

This RCT demonstrated better final visual outcomes, shorter operating times and less vitreous haemorrhage recurrences in the postoperative period when subjects received IVZ compared to IVB prior to PPV for the treatment of PDR-related complications.

Bevacizumab before Diabetic Vitrectomy: A Clinical Trial Assessing 3 Dosing Amounts

PURPOSE

To evaluate the optimal dosing of preoperative intravitreal bevacizumab (IVB) in patients undergoing pars plana vitrectomy (PPV) for manifestations of proliferative diabetic retinopathy (PDR).

DESIGN

Randomized clinical trial.

PARTICIPANTS

Two hundred six patients with severe manifestations of PDR underwent PPV at a single university-based hospital.

METHODS

Patients were randomized into 1 of 3 treatment groups: group A received 0.625 mg IVB (0.025 ml) 1 to 10 days before PPV, group B received 1.25 mg IVB (0.05 ml) 1 to 10 days before PPV, and group C received 2.5 mg IVB (0.1 ml) 1 to 10 days before PPV.

MAIN OUTCOME MEASURES

The primary outcome was best-corrected visual acuity (BCVA) at 6 months. Secondary outcome measures were rates of perioperative tractional retinal detachment (TRD) development, intraoperative and postoperative complications, and incidence of unplanned PPV at 6 months.

RESULTS

One hundred sixty-seven patients underwent PPV and completed 6 months of follow-up. There were no significant differences between treatment groups regarding baseline characteristics, final BCVA, intraoperative complications, postoperative complications, or unplanned PPV rates. There were no patients in group A (0.0%), 3 patients in group B (7.0%), and 5 patients in group C (8.5%) who demonstrated perioperative TRD after IVB administration, but before PPV (P = 0.0283). This difference was significant between groups A and B (P = 0.0494) and between groups A and C (P = 0.0080).

CONCLUSIONS

This randomized clinical trial demonstrated that patients receiving the 0.625-mg dose of IVB before PPV for the treatment of PDR-related manifestations showed similar visual acuity, but a lower incidence of perioperative TRD development compared with patients receiving the 1.25-mg and 2.5-mg doses. Clinicians should consider adopting the lowest effective dose, 0.625 mg, into clinical practice. The current study is limited by the lack of a control group receiving no IVB before PPV.

Preoperative Bevacizumab Administration in Proliferative Diabetic Retinopathy Patients Undergoing Vitrectomy: A Randomized and Controlled Trial Comparing Interval Variation

PURPOSE

To assess the optimal interval of preoperative intravitreal bevacizumab (IVB) administration in diabetic subjects undergoing pars plana vitrectomy (PPV) for severe manifestations of active proliferative diabetic retinopathy (PDR).

DESIGN

Randomized clinical trial.

METHODS

One hundred and fifty-six patients with PDR-related complications requiring PPV were prospectively randomized into 1 of 2 treatment groups: Group A received IVB (2.5 mg/0.1 mL) 1-3 days before PPV, while Group B received IVB (2.5 mg/0.1 mL) 5-10 days before PPV. The primary outcome was best-corrected visual acuity (BCVA) at 6 months follow-up. Secondary outcome measures were intraoperative surgery time, intraoperative complications, postoperative complications, and incidence of unplanned PPV at 6 months follow-up.

RESULTS

One hundred and twenty-five subjects underwent PPV and completed the 6-month follow-up interval. Group B patients had better final BCVA (P = .033) and were less likely to have a postoperative complication (P = .018) when compared to Group A patients. The mean difference in final BCVA between groups was 0.22 logMAR (95% confidence interval: 0.02-0.43, P = .017). Group A was 3.90 (95% confidence interval: 1.08-17.31, P = .046) times more likely to have a loss of 1 or more logMAR lines of final BCVA when compared to Group B. There were no significant differences among the treatment groups with regard to baseline features, intraoperative surgery time, intraoperative complications, and incidence of unplanned PPV during the study interval.

CONCLUSIONS

This randomized clinical trial demonstrated better postoperative outcomes at 6 months when subjects received preoperative IVB 5-10 days before PPV compared to 1-3 days for the treatment of PDR-related complications.

One-Year Outcomes of Femtosecond Laser-Assisted LASIK Following Previous Radial Keratotomy

PURPOSE

To report the 1-year outcomes of LASIK in patients with previous radial keratotomy using a novel femtosecond laser platform.

METHODS

The charts of 27 eyes of 18 patients who underwent femtosecond laser-assisted LASIK with the WaveLight FS200 laser (Alcon Laboratories, Inc., Fort Worth, TX) for consecutive hyperopia following previous radial keratotomy were retrospectively reviewed at a single private practice location. The preoperative characteristics, intraoperative details, and postoperative results were evaluated.

RESULTS

All 27 eyes had successful femtosecond laser flap creation without significant intraoperative or postoperative complications. Uncorrected visual acuity significantly improved postoperatively to 0.13 ± 0.13 logMAR at 12 months of follow-up (P < .0001). Postoperative spherical equivalent averaged 0.11 ± 0.53 diopters. None of the patients lost any lines of corrected distance visual acuity during the postoperative period.

CONCLUSIONS

The femtosecond laser technique described by this study resulted in a safe and effective way to deliver LASIK following previous radial keratotomy. Future investigations are needed to further validate the outcomes of this study.

Epithelium-off versus transepithelial corneal collagen crosslinking for progressive corneal ectasia: a randomised and controlled trial

AIM

To compare the outcomes of corneal collagen crosslinking (CXL) for the treatment of progressive corneal ectasia using a standard epithelium-off technique versus a transepithelial technique with enhanced riboflavin solution.

METHODS

One hundred and forty-four eyes with progressive corneal ectasia were prospectively randomised into a transepithelial CXL study arm or an epithelium-off CXL control arm. Follow-up examinations were set at 3, 6, 12 and 24 months. The primary outcome measure was change in the maximum simulated keratometry value (K_steep) after 24 months of follow-up. The secondary outcome measure was change in the best spectacle-corrected visual acuity (BSCVA) after 24 months follow-up.

RESULTS

One hundred and thirty-one eyes completed the 24-month follow-up interval. Change in K_steep was -1.52±0.66 dioptres (D) for the control group versus -0.54±0.58 D for the study group at 24 months of follow-up (p=0.0320). Change in BSCVA was -0.18±0.09 logMAR for the control group versus -0.14±0.08 logMAR for the study group at 24 months of follow-up (p=0.4978). Two eyes in the control group had minor postoperative complications that did not affect the final visual acuity, and one eye in the control group underwent keratoplasty during the study interval.

CONCLUSIONS

At 24 months of follow-up, subjects in the epithelium-off CXL group demonstrated a greater improvement in K_steep compared with subjects in the transepithelial CXL group, but no statistically significant difference in BSCVA was found between groups.

TRIAL REGISTRATION NUMBER

NCT01708538; pre-results.

Ranibizumab Versus Bevacizumab for Neovascular Age-Related Macular Degeneration With an Incomplete Posterior Vitreous Detachment

PURPOSE

The aim of this study was to compare the effects of ranibizumab to those of bevacizumab during the treatment of neovascular age-related macular degeneration (AMD) with an incomplete posterior vitreous detachment.

DESIGN

A retrospective chart review.

METHODS

A retrospective chart review was performed on treatment-naive neovascular AMD subjects with an incomplete posterior vitreous detachment treated with either ranibizumab or bevacizumab over a 12-month period.

RESULTS

One hundred thirty subjects were analyzed. There were 49 subjects determined to have vitreous attachment to the fovea. Subjects with vitreous attachment to the fovea required a significantly greater number of injections during the study interval compared with those without (10.2 ± 0.75 vs 7.8 ± 0.62) (P < 0.0001). In subjects with vitreous attachment to the fovea, the ranibizumab cohort had a greater improvement in visual acuity (0.18 ± 0.1 vs 0.04 ± 0.11 logMAR) (P = 0.0176) and a greater reduction in macular thickness (93.4 ± 32.2 μm vs 30.3 ± 28.3 μm) (P = 0.0064) compared with the bevacizumab cohort.

CONCLUSIONS

Neovascular AMD patients with vitreous attachment to the fovea may have better visual and anatomic outcomes when treated with ranibizumab compared with bevacizumab.

Predictability of Recurrent Exudation and Subretinal Hemorrhaging in Neovascular Age-Related Macular Degeneration With Indocyanine Green Angiography

BACKGROUND AND OBJECTIVE

To report the predictability of recurrent exudation and subretinal hemorrhaging after treatment extension in neovascular age-related macular degeneration (AMD) through assessment of interval changes in choroidal neovascularization (CNV) size on indocyanine green (ICG) angiography.

PATIENTS AND METHODS

The charts of patients with neovascular AMD who underwent bevacizumab therapy using a treat-and-extend protocol were retrospectively reviewed over a 12-month period.

RESULTS

An increase of 33% or more in CNV surface area on ICG angiography from 4 to 6 weeks, 6 to 8 weeks, and 8 to 10 weeks was observed in patients whose treatment interval could not be extended from 6 to 8 weeks, 8 to 10 weeks, and 10 to 12 weeks, respectively, and this was significant compared to patients whose treatment interval was successfully extended during those respective intervals (P < .0001, P = .0002, P = .0004, respectively).

CONCLUSION

CNV size change on ICG angiography can predict which patients are likely to experience recurrent exudation and/or subretinal hemorrhaging after treatment extension using treat-and-extend bevacizumab.

Corneal Epithelial Thickness Measured by Manual Electronic Caliper Spectral Domain Optical Coherence Tomography: Distributions and Demographic Correlations in Preoperative Refractive Surgery Patients

PURPOSE

The aim of this study was to report the distributions and demographic correlations of corneal epithelial thickness measured by manual electronic caliper spectral domain optical coherence tomography in preoperative refractive surgery patients.

DESIGN

This was a retrospective review.

METHODS

The charts of 218 consecutive patients (413 eyes) who presented for refractive surgery evaluation from April 2013 through September 2013 were retrospectively reviewed.

RESULTS

The mean corneal epithelial thickness was 51.0 μm with a range of 43 to 61 μm. Corneal epithelial thickness was significantly correlated with sex (P < 0.0001), corneal keratometry (P = 0.01), and underlying corneal thickness excluding the epithelium (P = 0.0268). No significant associations were identified in which corneal epithelial thickness correlated with either age (P = 0.0760) or existing refractive status of the eye (P = 0.5135).

CONCLUSIONS

Corneal epithelial thickness measured by manual electronic caliper optical coherence tomography in preoperative refractive surgery patients is comparable with the findings for the general population using other measurement techniques, the awareness of which may be useful in the preoperative assessment of these patients.

Femtosecond Laser Flap Creation for Laser In Situ Keratomileusis in the Setting of Previous Radial Keratotomy

PURPOSE

The aim of the study was to report the outcomes of laser in situ keratomileusis (LASIK) in subjects with previous radial keratotomy (RK) using a novel femtosecond laser setting on a proprietary femtosecond laser platform.

DESIGN

This was a retrospective, consecutive chart review of patients at a single private practice institution.

METHODS

The medical records of 16 eyes of 8 subjects who underwent femtosecond-assisted LASIK for consecutive hyperopia after RK were retrospectively reviewed. The preoperative characteristics, intraoperative details, and postoperative outcomes were analyzed.

RESULTS

All 16 eyes had successful femtosecond laser flap creation without significant intraoperative or postoperative complications. Uncorrected visual acuity significantly improved postoperatively (P = 0.0142) and remained stable through the final follow-up interval at 9 to 12 months postoperatively. None of the subjects lost any lines of best spectacle-corrected visual acuity in the postoperative period.

CONCLUSIONS

The novel femtosecond laser technique described in this study can provide a safe and effective method for patients undergoing LASIK after previous RK. Future investigations are required to further validate the findings reported in this study.

Predictability of Recalcitrance in Neovascular Age-Related Macular Degeneration With Indocyanine Green Angiography

PURPOSE

This study aimed to evaluate the utility of indocyanine green (ICG) angiography in predicting recalcitrance in neovascular age-related macular degeneration (nAMD).

DESIGN

A retrospective case series.

METHODS

The charts of treatment-naive subjects with nAMD undergoing anti-vascular endothelial growth factor (anti-VEGF) therapy during a 6-month period were retrospectively reviewed. The study group consisted of subjects with persistent retinal edema on optical coherence tomography (OCT) despite 6 consecutive monthly anti-VEGF injections. The control group was age-matched to the study group and consisted of subjects who demonstrated complete resolution of retinal edema on OCT after 3 or fewer monthly anti-VEGF injections.

RESULTS

There were 42 study cases and 42 controls included in the analysis. The baseline visual acuity, central macular thickness on OCT, and choroidal neovascularization (CNV) surface area on ICG angiography were statistically similar between the study and control groups. The CNV surface area on ICG angiography 2 months after starting consecutive monthly anti-VEGF injections increased from a baseline of 1.78 ± 0.86 to 2.66 ± 0.92 mm2 in the study group (P = 0.008) and decreased from a baseline of 1.94 ± 0.97 to 1.12 ± 0.05 mm2 in the control group (P = 0.04); this change in CNV size on ICG angiography from baseline to 2-month follow-up was statistically significant between the study and control groups (P < 0.0001).

CONCLUSIONS

Change in CNV surface area on ICG angiography can predict which subjects with nAMD are likely to have persistent retinal edema on OCT after 6 or more consecutive monthly anti-VEGF injections.

Evaluation of choroidal neovascularization with indocyanine green angiography in neovascular age-related macular degeneration subjects undergoing intravitreal bevacizumab therapy

PURPOSE

To report the clinical implications of interval changes in choroidal neovascularization (CNV) size measured by indocyanine green (ICG) angiography in neovascular age-related macular degeneration (AMD) patients undergoing intravitreal bevacizumab therapy.

DESIGN

Retrospective, consecutive chart review.

METHODS

The charts of neovascular AMD patients who underwent intravitreal bevacizumab therapy using a treat-and-extend dosing schedule were reviewed. ICG angiographic CNV surface areas were measured at baseline, 2 months, 6 months, and 12 months in each subject. The primary outcome was change in CNV size. Secondary outcomes included the correlation of change in CNV surface area with change in best-corrected visual acuity (BCVA), change in central macular thickness on optical coherence tomography (OCT), and the number of injections delivered over the 12-month study interval.

RESULTS

A total of 123 subjects were included in the analysis. The baseline CNV size was 1.9 mm2±2.5 mm2. CNV size was 1.66 mm2±2.11 mm2 at 2 months, 1.60 mm2±2.23 mm2 at 6 months, and 1.50 mm2±2.12 mm2 at 12 months. The change in CNV size from baseline was not statistically significant at any of the follow-up intervals. A decrease in CNV size of 33% or more at 2 months was associated with a significant decrease in CNV size at 12 months (P=.0096), complete resolution of CNV at 12 months (P=.0013), and a decrease in the number of injections delivered over the study interval (P=.0165). Complete resolution of CNV at 12 months occurred in 7.3% of subjects. Subjects that had complete resolution of CNV at 12 months were significantly more likely to gain 3 more lines of BCVA at the end of the study interval (P=.0131). No significant correlation was found between CNV size and change in central macular thickness on OCT.

CONCLUSIONS

Our study suggests that change in CNV size on ICG angiography may help the clinician predict the clinical course of neovascular AMD subjects undergoing intravitreal bevacizumab therapy using a treat-and-extend dosing schedule.

Optical coherence tomography-guided transepithelial phototherapeutic keratectomy for the treatment of anterior corneal scarring

PURPOSE

To report the visual and anatomic outcomes of a novel technique for the management of anterior corneal scarring using optical coherence tomography (OCT)-guided transepithelial phototherapeutic keratectomy (transepithelial PTK).

DESIGN

Retrospective, consecutive case series.

METHODS

The charts of 22 patients with anterior corneal scarring associated with irregularities in the Bowman layer who had undergone transepithelial PTK according to a novel protocol were reviewed. The protocol consisted of a preoperative OCT-measured depth-of-treatment calculation, followed by a dual excimer laser treatment profile set to achieve the desired refractive outcome while eliminating or reducing corneal scarring. The primary outcomes were change in best spectacle-corrected visual acuity (BSCVA) and change in corneal topography indices at 4 months after ablation.

RESULTS

BSCVA (in logMAR) improved from a mean of 0.82 (0.61-1.02; 95% confidence interval) preoperatively to a mean of 0.40 postoperatively (0.19-0.61) (P = 0.0070). All patients gained a minimum of 1 line of BSCVA postoperatively. Preoperative and postoperative corneal topographic indices showed significant improvement in corneal cylinder (P = 0.0173) and projected visual acuity (P = 0.0261) but not in the surface asymmetry index (P = 0.0849) or the surface regularity index (P = 0.0543). Postoperative spherical equivalent averaged 0.78 diopters (0.49-1.07) of error from the intended target refractive outcome. No complications were associated with the treatment, and no patients required or desired subsequent treatment with either repeat PTK or with more invasive surgery such as lamellar or penetrating keratoplasty.

CONCLUSIONS

OCT-guided transepithelial PTK using a dual ablation excimer laser profile can provide favorable results as well as predictable refractive outcomes in the treatment of corneal scarring associated with Bowman layer irregularities. Future investigations are warranted to further validate the technique reported in this study.

Conversion of superoxide generated by polymorphonuclear leukocytes to hydroxyl radical: a direct spectrophotometric detection system based on degradation of deoxyribose

Hydroxyl radical is produced secondarily after phagocytic cells have been stimulated to generate superoxide anion. The systems used most commonly for detection of cell-generated hydroxyl radical are often inconvenient for routine biomedical research. We have modified an assay used heretofore in cell-free systems, that is, the degradation of deoxyribose, and adapted it for use with neutrophils. The time and dose responses of the system, requirement for chelated iron, inhibition profiles with various scavengers, and correlation with superoxide production have been ascertained. The method correlated strongly with a standard but more cumbersome technique. Values for a normal population are provided. The method can readily be used to study the parameters of superoxide-hydroxyl radical conversion by cells in various disease or treatment states.

Inhibition of epiphyseal cartilage collagenase by tetracyclines in low phosphate rickets in rats

Drugs in the tetracycline family can inhibit mammalian tissue collagenase both in vitro and in vivo by a mechanism that is independent of antibiotic action. The epiphyseal cartilages of rachitic rats contain extremely high levels of collagenase (CGase), and we have used this model to study further the phenomenon of tetracycline inhibition of tissue CGase. Rickets was induced in rats by phosphate/vitamin D deficiency and parameters of gross bone morphology, bone chemistry, and serum chemistry were evaluated in both rachitic and nonrachitic animals with and without treatment with oral tetracyclines (TETs). Minocycline (or doxycycline) partially suppressed the appearance of many of the expected changes in the rachitic animals, including gross bone hardness, growth plate widening, long bone length, suppression of weight gain, and decreased bone ash content. The effects were dose dependent and were associated with marked suppression of the enhanced CGase activity. Examination of collagen breakdown products by SDS-PAGE documented that the rachitic enzyme behaved like other mammalian collagenases including in vitro inhibition with minocycline 10-20 micrograms/ml and with a nonantibiotic tetracycline. No evidence of TET osseous toxicity was noted, and, in fact, administration of TET to nonrachitic animals had a mildly favorable effect on growth and development. TET suppression of CGase can be demonstrated in a well defined model system and this form of pharmacologic enzyme inhibition can be a useful probe for delineating the role of the enzyme in connective tissue pathology.