International Classification System for Ocular Complications of Anti-VEGF Agents in Clinical Trials

PURPOSE

Complications associated with intravitreal anti-VEGF therapies are reported inconsistently in the literature, thus limiting an accurate evaluation and comparison of safety between studies. This study aimed to develop a standardized classification system for anti-VEGF ocular complications using the Delphi consensus process.

DESIGN

Systematic review and Delphi consensus process.

PARTICIPANTS

Twenty-five international retinal specialists participated in the Delphi consensus survey.

METHODS

A systematic literature search was conducted to identify complications of intravitreal anti-VEGF agent administration based on randomized controlled trials (RCTs) of anti-VEGF therapy. A comprehensive list of complications was derived from these studies, and this list was subjected to iterative Delphi consensus surveys involving international retinal specialists who voted on inclusion, exclusion, rephrasing, and addition of complications. Furthermore, surveys determined specifiers for the selected complications. This iterative process helped to refine the final classification system.

MAIN OUTCOME MEASURES

The proportion of retinal specialists who choose to include or exclude complications associated with anti-VEGF administration.

RESULTS

After screening 18 229 articles, 130 complications were categorized from 145 included RCTs. Participant consensus via the Delphi method resulted in the inclusion of 91 complications (70%) after 3 rounds. After incorporating further modifications made based on participant suggestions, such as rewording certain phrases and combining similar terms, 24 redundant complications were removed, leaving a total of 67 complications (52%) in the final list. A total of 14 complications (11%) met exclusion thresholds and were eliminated by participants across both rounds. All other remaining complications not meeting inclusion or exclusion thresholds also were excluded from the final classification system after the Delphi process terminated. In addition, 47 of 75 proposed complication specifiers (63%) were included based on participant agreement.

CONCLUSIONS

Using the Delphi consensus process, a comprehensive, standardized classification system consisting of 67 ocular complications and 47 unique specifiers was established for intravitreal anti-VEGF agents in clinical trials. The adoption of this system in future trials could improve consistency and quality of adverse event reporting, potentially facilitating more accurate risk-benefit analyses.

FINANCIAL DISCLOSURE(S)

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

Non-nasal, atypical retinochoroidal coloboma in pediatric patients: Case series and review

Purpose

To report 2 cases of atypically located, non-nasal colobomas in the pediatric population.

Observations

A 3-week-old female neonate with no known past ocular or medical history was diagnosed with temporal iris and chorioretinal coloboma with tractional membranes upon examination under anesthesia and imaging. A 9-year-old female with a history of bilateral sensorineural hearing loss and left mild hydronephrosis presented with a temporal chorioretinal coloboma associated with retinal detachment.

Conclusions and importance

Very few cases of atypically located, non-nasal pediatric colobomas have been reported, and they lack a clear cause or mechanism of formation. Continued documentation of their occurrence and research into their formation at a molecular and embryological level are warranted to better understand their pathogenesis.

Optical coherence tomography angiography in pediatric ocular cutis marmorata telangiectatica congenita: A case series

Purpose

To report 2 cases of enlarged foveal avascular zone (FAZ) on optical coherence angiography (OCTA) imaging in pediatric patients with cutis marmorata telangiectatica congenita (CMTC).

Observations

A 10-week-old female and a 3-year-old male diagnosed with CMTC presented for retinal examination. Both had peripheral avascularity on fluorescein angiography (FA) and enlargement of the FAZ on OCTA in both eyes.

Conclusions and Importance

Pediatric patients with CMTC should undergo ocular evaluation with not only FA, but also OCTA to more robustly evaluate the affected retina in this rare disease.

Avascular Peripheral Retina in Infants

Avascular peripheral retina in an infant is a common characteristic of numerous pediatric retinal vascular disorders and often presents a diagnostic challenge to the clinician. In this review, key features of each disease in the differential diagnosis, from retinopathy of prematurity, familial exudative vitreoretinopathy, Coats disease, incontinentia pigmenti, Norrie disease, and persistent fetal vasculature, to other rare hematologic conditions and telomere disorders, will be discussed by expert ophthalmologists in the field.

Variability in Plus Disease Diagnosis using Single and Serial Images

PURPOSE

To assess changes in retinopathy of prematurity (ROP) diagnosis in single and serial retinal images.

DESIGN

Cohort study.

PARTICIPANTS

Cases of ROP recruited from the Imaging and Informatics in Retinopathy of Prematurity (i-ROP) consortium evaluated by 7 graders.

METHODS

Seven ophthalmologists reviewed both single and 3 consecutive serial retinal images from 15 cases with ROP, and severity was assigned as plus, preplus, or none. Imaging data were acquired during routine ROP screening from 2011 to 2015, and a reference standard diagnosis was established for each image. A secondary analysis was performed using the i-ROP deep learning system to assign a vascular severity score (VSS) to each image, ranging from 1 to 9, with 9 being the most severe disease. This score has been previously demonstrated to correlate with the International Classification of ROP. Mean plus disease severity was calculated by averaging 14 labels per image in serial and single images to decrease noise.

MAIN OUTCOME MEASURES

Grading severity of ROP as defined by plus, preplus, or no ROP.

RESULTS

Assessment of serial retinal images changed the grading severity for > 50% of the graders, although there was wide variability. Cohen's kappa ranged from 0.29 to 1.0, which showed a wide range of agreement from slight to perfect by each grader. Changes in the grading of serial retinal images were noted more commonly in cases of preplus disease. The mean severity in cases with a diagnosis of plus disease and no disease did not change between single and serial images. The ROP VSS demonstrated good correlation with the range of expert classifications of plus disease and overall agreement with the mode class (P = 0.001). The VSS correlated with mean plus disease severity by expert diagnosis (correlation coefficient, 0.89). The more aggressive graders tended to be influenced by serial images to increase the severity of their grading. The VSS also demonstrated agreement with disease progression across serial images, which progressed to preplus and plus disease.

CONCLUSIONS

Clinicians demonstrated variability in ROP diagnosis when presented with both single and serial images. The use of deep learning as a quantitative assessment of plus disease has the potential to standardize ROP diagnosis and treatment.

The Prevalence of Retinal Disease and Associated CNS Disease in Young Patients with Incontinentia Pigmenti

PURPOSE

To evaluate the prevalence of retinal disease on fluorescein angiography (FA) in patients with incontinentia pigmenti (IP) and to compare the severity of retinal disease in those with and without known central nervous system (CNS) disease.

DESIGN

Multi-institutional consecutive retrospective case series.

SUBJECTS

New patients with a diagnosis of IP were seen at the Casey Eye Institute at the Oregon Health and Science University (OHSU), Moran Eye Center, University of Utah, or Bascom Palmer Eye Institute, University of Miami from December 2011 to September 2018.

METHODS

Detailed ophthalmoscopic examination and FA were recommended for all new patients and performed on every patient who had parental consent. Ophthalmoscopic findings and FA images were graded for severity by 2 masked graders on a 3-point scale: 0 = no disease, 1 = vascular abnormalities without leakage, 2 = leakage or neovascularization, and 3 = retinal detachment. The presence of known CNS disease was documented. Additional cases were obtained from a pediatric retina listserv for examples of phenotypic variation.

MAIN OUTCOME MEASURES

The proportion of eyes noted to have disease on ophthalmoscopy compared with FA and the severity of retinal disease in those with and without known CNS disease.

RESULTS

Retinal pathology was detected in 18 of 35 patients (51%) by indirect ophthalmoscopy and 26 of 35 patients (74%) by FA (P = 0.048) in a predominantly pediatric population (median age, 9 months). Ten patients (29%) had known CNS disease at the time of the eye examination. A Wilcoxon rank-sum test indicated that the retinal severity scores for patients with CNS disease (median, 2) were significantly higher than the retinal severity scores for patients without CNS disease (median, 1), z = -2.12, P = 0.034.

CONCLUSIONS

Retinal disease is present in the majority of patients with IP, and ophthalmoscopic examination is less sensitive than FA for detection of disease. There may be a correlation between the severity of retinal and CNS disease.

Paradoxical Exudative Retinopathy and Macular Star Formation After Treatment Initiation in Coats Disease

Purpose: This work describes a unique clinical feature in Coats disease. Methods: A retrospective series of 2 cases is reported. Results: Two pediatric patients receiving treatment for Coats disease were included. In both cases, vision worsened secondary to paradoxically increased exudation and macular star formation following standard treatment with intravitreal bevacizumab, sub-Tenon triamcinolone acetonide, and laser photocoagulation. After serial treatments under general anesthesia, the exudates in both cases consolidated. Conclusions: A paradoxical exudative retinopathy can occur in some patients when initiating standard treatment of Coats disease. Longitudinal follow-up with continued intravitreal antivascular endothelial growth factor agents, laser photocoagulation, and corticosteroids might help control persistent exudation in these cases.

International Classification of Retinopathy of Prematurity, Third Edition

PURPOSE

The International Classification of Retinopathy of Prematurity is a consensus statement that creates a standard nomenclature for classification of retinopathy of prematurity (ROP). It was initially published in 1984, expanded in 1987, and revisited in 2005. This article presents a third revision, the International Classification of Retinopathy of Prematurity, Third Edition (ICROP3), which is now required because of challenges such as: (1) concerns about subjectivity in critical elements of disease classification; (2) innovations in ophthalmic imaging; (3) novel pharmacologic therapies (e.g., anti-vascular endothelial growth factor agents) with unique regression and reactivation features after treatment compared with ablative therapies; and (4) recognition that patterns of ROP in some regions of the world do not fit neatly into the current classification system.

DESIGN

Review of evidence-based literature, along with expert consensus opinion.

PARTICIPANTS

International ROP expert committee assembled in March 2019 representing 17 countries and comprising 14 pediatric ophthalmologists and 20 retinal specialists, as well as 12 women and 22 men.

METHODS

The committee was initially divided into 3 subcommittees-acute phase, regression or reactivation, and imaging-each of which used iterative videoconferences and an online message board to identify key challenges and approaches. Subsequently, the entire committee used iterative videoconferences, 2 in-person multiday meetings, and an online message board to develop consensus on classification.

MAIN OUTCOME MEASURES

Consensus statement.

RESULTS

The ICROP3 retains current definitions such as zone (location of disease), stage (appearance of disease at the avascular-vascular junction), and circumferential extent of disease. Major updates in the ICROP3 include refined classification metrics (e.g., posterior zone II, notch, subcategorization of stage 5, and recognition that a continuous spectrum of vascular abnormality exists from normal to plus disease). Updates also include the definition of aggressive ROP to replace aggressive-posterior ROP because of increasing recognition that aggressive disease may occur in larger preterm infants and beyond the posterior retina, particularly in regions of the world with limited resources. ROP regression and reactivation are described in detail, with additional description of long-term sequelae.

CONCLUSIONS

These principles may improve the quality and standardization of ROP care worldwide and may provide a foundation to improve research and clinical care.

Macular Retinal Pigment Epithelial Clumping Leading to a Diagnosis of FEVR

Familial exudative vitreoretinopathy (FEVR) is a rare hereditary disorder characterized by abnormal or incomplete retinal angiogenesis. The peripheral avascularity, irregular neovascularization, and vascular leakage seen in FEVR are similar to changes that may be seen in retinopathy of prematurity (ROP). The authors report a case of atypical macular pigment clumping leading to the diagnosis of ROPER (ie, ROP vs FEVR) in a premature infant born at 23 weeks of gestation with a birth weight of 451 grams, who presented with atypical aggressive posterior ROP and a heterozygous variant in the LRP5 gene. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:505-508.].

SEOM clinical guideline for the management of cutaneous melanoma (2020)

Melanoma affects about 6000 patients a year in Spain. A group of medical oncologists from Spanish Society of Medical Oncology (SEOM) and Spanish Multidisciplinary Melanoma Group (GEM) has designed these guidelines to homogenize the management of these patients. The diagnosis must be histological and determination of BRAF status has to be performed in patients with stage ≥ III. Stage I–III resectable melanomas will be treated surgically. In patients with stage III melanoma, adjuvant treatment with immunotherapy or targeted therapy is also recommended. Patients with unresectable or metastatic melanoma will receive treatment with immunotherapy or targeted therapy, the optimal sequence of these treatments remains unclear. Brain metastases require a separate consideration, since, in addition to systemic treatment, they may require local treatment. Patients must be followed up closely to receive or change treatment as soon as their previous clinical condition changes, since multiple therapeutic options are available.

Representation of Women in Vitreoretinal Meeting Faculty Roles from 2015 through 2019

PURPOSE

To describe the proportion of female faculty presenting or moderating at vitreoretinal meetings from 2015 through 2019.

DESIGN

Retrospective trend study.

SUBJECTS

6 highly attended annual national vitreoretinal meetings from 2015 to 2019 (30 total meetings) METHODS: Conference programs were acquired either through online search or directly from meeting organizers and were reviewed and analyzed. Genders of program committee members, first author main podium presenters of papers and nonpaper presenters, main podium panelists, and main podium moderators were recorded. A χ² analysis was performed to compare the proportion of women with podium roles in 2015 and those in each subsequent year until 2019.

MAIN OUTCOME MEASUREMENTS

change in proportion of women filling faculty roles in 2015 versus those in 2019.

RESULTS

A total of 4,521 faculty roles were included for analysis. Women filled 22.1% of those roles and were more likely to be included as invited moderators or panelists (25.0%) than as paper (21.4%) or non-paper (19.8%) presenters. Meetings with at least one female program committee member were significantly more likely to include female non-paper presenters (P = .02), moderators or panelists (P = .02), and total women faculty (P < .001). Although there were no significant changes in the proportion of women when comparing consecutive years, the overall trend was for an increased proportion of women faculty, with a significant increase from 19.6% in 2015 to 25.5% in 2019 (P = .002). When the types of faculty roles filled by women were examined, there was a statistically significant increase from 2015 to 2019 in the proportion of abstract presentations (19.7% vs. 25.2%, respectively; P = .045) but a nonstatistically significant increase in invited presentations and moderator or panelist roles.

CONCLUSIONS AND RELEVANCE

Women filled less than one-fourth of the main podium faculty roles at vitreoretinal meetings included for analysis over a 5-year period, although there was a significant increase in female representation when 2015 and 2019 participation were compared. Meetings with at least 1 female program committee member filled non-paper podium faculty roles with a significantly greater proportion of women.

Peters plus syndrome and Chorioretinal findings associated with B3GLCT gene mutation - a case report

Background

Peters plus syndrome (PPS) is a combination of congenital Peters anomaly and systemic abnormalities. It is inherited most commonly in an autosomal recessive pattern with homozygous B3GLCT mutations. Ocular findings consist predominantly anterior segment abnormalities without posterior segment involvement.

Case presentation

In this presentation, we report a case of PPS with homozygous pathogenic variant in B3GLCT who presented with classic anterior segment findings, systemic abnormalities, as well as atypical bilateral chorioretinal atrophy. The chorioretinal findings were characterized with spectral-domain optical coherence tomography.

Conclusions

Our report expands the phenotypic descriptions of PPS by characterizing posterior segment findings.

Leukocoria in a 2-Year-Old Patient With Atypical Optic Nerve Fiber Layer Myelination

Myelinated retinal nerve fiber layer is a benign retinal condition that is usually an incidental finding in a healthy patient. Visual acuity is typically not compromised, but some cases have other associated ocular conditions that can affect vision. Diagnosis in challenging atypical cases requires imaging studies to rule out other pathologies. The authors describe the case of a 2-year-old girl who presented with atypical optic nerve fiber myelination. [J Pediatr Ophthalmol Strabismus. 2020;57:e56-e58.].

THU0186 CLINICAL EVALUATION OF THE IMMUNOGENICITY TO CT-P13 FOR SUBCUTANEOUS USE IN PATIENTS WITH ACTIVE RHEUMATOID ARTHRITIS: 1-YEAR CLINICAL RESULTS FROM A MULTICENTER, RANDOMIZED CONTROLLED PIVOTAL TRIAL

Background:

Novel subcutaneous infliximab (CT-P13 SC) was developed to augment the flexibility in therapeutic use of infliximab and noninferiority (NI) of CT-P13 SC versus CT-P13 intravenous (IV) was demonstrated for efficacy in patients with rheumatoid arthritis (RA) [1]. CT-P13 SC 120mg biweekly showed consistent higher therapeutic trough levels during the treatment period, which helps in maintaining efficacy over time. Since immunogenicity has clinical importance in patients using anti-TNF alpha agents and there is a general presumption that SC route is more immunogenic than IV route, this needs careful assessment.

Objectives:

Immunogenicity assessment of CT-P13 SC with further impact analysis has been performed on the pivotal data set [1] to determine whether there was any correlation between the magnitude of anti-drug antibody (ADA) positivity and clinical outcomes in RA patients.

Methods:

The immune response against CT-P13 in human serum was detected using an electrochemiluminescence (ECL) platform with an Affinity Capture Elution (ACE) step. An ADA ECL ACE assay showed ability to detect ADA at low levels in all samples regardless of residual drug in serum (25 ng/mL ADA in the presence of 80 μg/mL of CT-P13 in RA serum). To investigate the impact of ADA titer on PK, efficacy and safety, key clinical parameters were assessed by visit based ADA titer quartile. All patients who had ‘Positive’ ADA status result at each visit were included in the analysis and categorized into 4 groups using the 25th, 50th, 75th percentiles of ADA titer result, respectively.

Results:

The four subgroups categorized by quartiles at each visit from week 22 to week 54 were: 1st (ADA titer ≤ 3), 2nd (3 < ADA titer ≤ 9), 3rd (9 < ADA titer ≤ 27) and 4th (27 < ADA titer). There was a trend for pre-dose concentration to decrease as ADA titer increases for both CT-P13 SC and CT-P13 IV arms as expected (Figure 1). Patients in the 1st and 2nd subgroup maintained the sufficient therapeutic drug concentration level. Figure 2 shows the correlation between ADA titer and efficacy outcomes where the change from baseline of DAS28 (CRP) and the proportion of patients achieving ACR20 were lower in the 3rd and 4th subgroups. The ADA impact was especially apparent in the 4th subgroup where the mean pre-dose concentration of the patients was below the therapeutic drug concentration level (1 μg/mL), which led to worse efficacy outcomes in both arms, IV as well as SC. Nevertheless, no impact of ADA on safety profile in both arms was observed. A neutralizing antibody (NAb) method with enhanced drug tolerance but limited performance was also developed and clinical consequences of NAb titer in terms of PK, efficacy and safety were not different from the results with ADA.

Conclusion:

The analysis of both ADA positivity and titer is clinically meaningful in the prediction of PK profile and clinical response. CT-P13 SC administration did not result in a greater incidence of ADA compared to the CT-P13 IV and there were no clinical differences depending on the formulation.

References:

[1]Westhovens R, et al. Annals of the Rheumatic Diseases 2019;78:1158-1159.

Disclosure of Interests:

Rene Westhovens Grant/research support from: Celltrion Inc, Galapagos, Gilead, Consultant of: Celltrion Inc, Galapagos, Gilead, Speakers bureau: Celltrion Inc, Galapagos, Gilead, DaeHyun Yoo Grant/research support from: Celltrion, Inc, Consultant of: Celltrion, Inc, Speakers bureau: Celltrion Healthcare, Inc, Piotr Wiland Grant/research support from: Celltrion, Inc, Speakers bureau: Novartis, Pfizer, Abbvie, Gedeon-Richter, Lilly, Roche, Sandoz, Marek Zawadzki Grant/research support from: Celltrion, Inc, Delina Ivanova Grant/research support from: Celltrion, Inc, Alfredo Berrocal Grant/research support from: Celltrion, Inc, Speakers bureau: Pfizer, Elias Chalouhi Grant/research support from: Celltrion, Inc, Éva Balázs Grant/research support from: Celltrion, Inc, Consultant of: Amgen, Sergii Shevchuk Grant/research support from: Celltrion, Inc, Sang Joon Lee Shareholder of: Celltrion, Inc, Employee of: Celltrion, Inc, Sung Hyun Kim Shareholder of: Celltrion, Inc, Employee of: Celltrion, Inc, JeeHye Suh Employee of: Celltrion, Inc, Chankyoung Hwang Employee of: Celltrion, Inc, Dae Seok Choi Shareholder of: Celltrion, Inc, Employee of: Celltrion, Inc

Pathological Findings of Synchysis Scintillans Secondary to Familial Exudative Vitreoretinopathy With Chronic Exudative Retinal Detachment

Purpose:

We describe a unique case of synchysis scintillans in a 23-year-old woman with a history of chronic exudative retinal detachment in the setting of familial exudative vitreoretinopathy.

Methods:

Fundus and slit-lamp photographs were obtained at presentation, and pathological studies were performed on the enucleated specimen to confirm the diagnosis.

Results:

Synchysis scintillans is a degenerative condition of cholesterol deposition that affects severely damaged eyes, often as a result of chronic vitreous hemorrhage or retinal detachment. In this case, synchysis scintillans presented as crystals in the anterior chamber in the setting of a chronic retinal detachment. After enucleation, there were noted to be cholesterol slits on pathological correlation, confirming the diagnosis.

Conclusions:

This case demonstrates the importance of clinical pathological correlation in the diagnosis of synchysis scintillans migrating into the anterior chamber.

Oral acetazolamide as a medical adjuvant to retinal surgery in optic disc pit maculopathy in a pediatric patient

Purpose

To describe a novel combination of surgical and medical management for the treatment of optic disc pit maculopathy.

Observations

A 12-year-old obese girl with bilateral optic disc pits presented with decreased vision in the left eye (20/400). On dilated fundus examination, she was found to have a macula-involving serous retinal detachment. Pars plana vitrectomy, posterior hyaloid peel, internal limiting membrane peel, fluid-air exchange, temporal juxtapapillary endolaser, and C₃F₈ tamponade were performed. Postoperatively, there was persistence of subretinal fluid, so oral acetazolamide and a weight loss regimen were started. After 3 months of medical treatment, the subretinal fluid decreased significantly and visual acuity improved to 20/60.

Conclusion and Importance

Currently, the mechanisms leading to optic disc pit maculopathy remain a topic of debate. As optic disc pits may provide a conduit between the subarachnoid and subretinal spaces, the reduction of intracranial pressure with the use of systemic carbonic anhydrase inhibitors may play a role in decreasing the subretinal fluid associated with select cases of optic disc pit maculopathy.

SEOM clinical guideline for the management of immune-related adverse events in patients treated with immune checkpoint inhibitors (2019)

The use of immune checkpoint inhibitors has emerged as an effective treatment option for patients with several tumor types. By increasing the activity of the immune system, they can induce inflammatory side effects, which are often termed immune-related adverse events. These are pathophysiologically unique toxicities, compared with those from other anticancer therapies. In addition, the spectrum of the target organs is very broad. Immune-inflammatory adverse events can be life threatening. Prompt diagnosis and pharmacological intervention are instrumental to avoid progression to severe manifestations. Consequently, clinicians require new skills to successfully diagnose and manage these events. These SEOM guidelines have been developed with the consensus of ten medical oncologists. Relevant studies published in peer-review journals were used for the guideline elaboration. The Infectious Diseases Society of America grading system was used to assign levels of evidence and grades of recommendation.

A Multicenter Study of Pediatric Macular Holes: Surgical Outcomes With Microincisional Vitrectomy Surgery

Purpose:

Pediatric macular holes occur often related to trauma and rarely require surgical intervention. The purpose of the present study was to evaluate outcomes of microincisional vitrectomy surgery.

Methods:

A multicenter retrospective consecutive case series was conducted of pediatric patients undergoing surgery for macular hole repair.

Results:

A total of 31 eyes from 8 centers were included in this study. The mechanism of macular hole development was blunt trauma in 30 eyes (97%) and industrial laser in 1 eye (3%). The rate of anatomic closure after primary vitrectomy was 81% (25 eyes); the final anatomic closure rate after a secondary vitrectomy was 94% (29 eyes). There was a statistically significant improvement in visual acuity from initial presentation (20/164) to final follow-up (20/100) ( P = .009).

Conclusions:

Microincisional vitrectomy surgery for pediatric macular holes results in substantial anatomic success and modest improvement in visual acuity.