Association between the patterns of diabetic macular edema and photoreceptors' response after intravitreal ranibizumab treatment: a spectral-domain optical coherence tomography study

PURPOSE

To analyze photoreceptors' condition after intravitreal ranibizumab treatment according to the pattern of diabetic macular edema (DME) on spectral-domain optical coherence tomography (SD-OCT).

METHODS

Retrospective study includes 58 treatment naïve patients with DME, treated with intravitreal ranibizumab injections and followed up for at least 12 months. Patients were classified based on DME morphology on SD-OCT into: diffuse macular edema, cystoid macular edema (CME) and serous retinal detachment with CME (SRD/CME). The DME morphology was analyzed, while quantitative measurement of ellipsoid zone (EZ) defect, as well as qualitative assessment of the condition of external limiting membrane (ELM) and interdigitation zone (IZ) at foveal area, was taken before and after treatment.

RESULTS

Before treatment, patients with CME presented worse ELM and IZ condition and greater EZ defect than patients with diffuse macular edema or SRD/CME. After treatment, the restoration of EZ defect and IZ was more evident in patients with CME than in diffuse macular edema or SRD/CME.

CONCLUSION

Patients with DME presented significant photoreceptors' restoration after intravitreal ranibizumab injections at the 12-month follow-up. The improvement in EZ defect size and IZ was dependent on the pattern of DME on SD-OCT.

Thoughts and Challenges for the Current Treatment of Optic Disc Pit Maculopathy

PURPOSE

The present review describes the procedures that intervene directly in covering and stuffing the optic disc pit (ODP).

METHODS

We made a comprehensive review of the literature regarding the new treatment modalities for the treatment of ODP maculopathy, mainly concentrated on covering and stuffing of the ODP. We presented the anatomical and functional outcomes of these techniques in patients with ODP maculopathy, while potential risks and complications of these techniques are also discussed.

RESULTS

The most commonly used treatment alternative for ODP maculopathy is vitrectomy, which seems to be more successful if it is associated with the covering of the ODP by internal limiting membrane (ILM) inverted flapping. The results of the procedure are successful, if the origin of the fluid comes from the vitreous cavity. Another new procedure aims at the stuffing of the ODP by rolled ILM-flap, autologous scleral tissue or human amniotic membrane, providing promising anatomical results. The so far anatomical and functional results are discussed in detail. The literature, however, is limited regarding these techniques and based mainly on case reports with short-term follow-up. Additionally, the stuffing technique is possible to provoke further damage of optic nerve tissue and remain challenging in its use.

CONCLUSIONS

Both covering and stuffing techniques of the ODP seem to have promising results, when used as adjunct to vitrectomy. One should take into account special considerations and possible further complications for their use in the treatment of ODP maculopathy.

Pre-operative intravitreal dexamethasone implant in patients with refractory diabetic macular edema undergoing cataract surgery

To examine preoperative use of intravitreal dexamethasone implant in patients with refractory diabetic macular edema (DME) undergoing cataract surgery. Participants in this study were 17 patients with DME refractory to previous treatment with anti-vascular endothelial growth factor agents or dexamethasone implant, and co-existent cataract. All participants received intravitreal dexamethasone implant at baseline and underwent phacoemulsification within one month after its insertion. Best-corrected visual acuity (BCVA) and central subfield thickness (CST) changes between baseline, time of cataract surgery and postoperative months 1, 2 and 3 were evaluated. At month 1 after surgery, BCVA improved significantly from 42.3 ± 9.6 to 58.7 ± 11.9 letters compared to baseline (p < 0.001) and the improvement was sustained at month 2 and month 3 postoperatively. One month postoperatively, CST improved significantly compared to baseline (p < 0.001) and the improvement was sustained at month 2 (p < 0.001), while at month 3 CST started to increase, but remained significantly lower than baseline (p = 0.003). At month 3 postoperatively, 35.3% of patients presented recurrence of ME. Patients with refractory DME and cataract can safely undergo phacoemulsification when dexamethasone implant is inserted one month prior to surgery to ensure adequate control of postoperative inflammation and prevent deterioration of ME.

The Effect of Diabetes Mellitus on Corneal Endothelial Cells and Central Corneal Thickness: A Case-Control Study

PURPOSE

The aim of this study was to evaluate the characteristics of corneal endothelial cells and central corneal thickness (CCT) in patients with diabetes mellitus (DM), comparing them with those of healthy subjects (controls) and to determine potential factors affecting the corneal parameters in patients with DM.

METHODS

Participants in this study were 72 patients with DM and 88 healthy controls. Diabetic patients were further classified into groups depending on the severity of diabetic retinopathy (no retinopathy, mild, moderate, severe non-proliferative diabetic retinopathy, and proliferative diabetic retinopathy). All participants underwent non-contact specular microscopy to evaluate corneal endothelium parameters and CCT, while factors affecting endothelial cell density and CCT in patients with DM were also analyzed.

RESULTS

Patients with DM presented significantly decreased endothelial cell density compared to controls (2,297.9 ± 311.3 and 2,518.3 ± 243.7 cells/mm2, respectively; p < 0.001), while the two groups did not differ significantly in any other measured corneal parameter. In the diabetic group, the multivariate analysis showed a significant association between decreased endothelial cell density and increased HbA1c (p < 0.001), longer DM duration (p = 0.003), and more severe diabetic retinopathy status (p = 0.008).

CONCLUSION

DM seems to affect the corneal endothelium, since endothelial cell density was decreased in the diabetic group, while duration of disease, HbA1c levels, and severity of retinopathy were significantly associated with changes in endothelial cell density and should be taken into account.

Widefield Optical Coherence Tomography Angiography in Diabetic Retinopathy

PURPOSE

To summarize the role of widefield optical coherence tomography angiography (WF-OCTA) in diabetic retinopathy (DR), extending from the acquisition strategies to the main clinical findings.

METHODS

A PubMed-based search was carried out using the terms "Diabetic retinopathy", "optical coherence tomography angiography", "widefield imaging", and "ultra-widefield imaging". All studies published in English up to August 2020 were reviewed.

RESULTS

WF-OCTA can be obtained with different approaches, offering advantages over traditional imaging in the study of nonperfusion areas (NPAs) and neovascularization (NV). Quantitative estimates and topographic distribution of NPA and NV are useful for treatment monitoring and artificial intelligence-based approaches. Curvature, segmentation, and motion artifacts should be assessed when using WF-OCTA.

CONCLUSIONS

WF-OCTA harbors interesting potential in DR because of its noninvasiveness and capability of objective metrics of retinal vasculature. Further studies will facilitate the migration from traditional imaging to WF-OCTA in both the research and clinical practice fields.

Efficacy of intravitreal dexamethasone implant for the treatment of macular oedema after pars plana vitrectomy for rhegmatogenous retinal detachment: long-term outcomes

Purpose: To investigate the efficacy and safety of intravitreal dexamethasone implant as initial and only treatment for macular oedema after pars plana vitrectomy (PPV) for rhegmatogenous retinal detachment (RRD).Methods: This study included 14 patients, who were diagnosed with macular oedema after PPV for RRD and who were treated with intravitreal dexamethasone implant. Patients were examined at the time of macular oedema diagnosis (baseline) and 1, 6 and 12 months after treatment, using best corrected visual acuity (BCVA) measurement and optical coherence tomography (OCT).Results: The mean BCVA at baseline was 0.72 ± 0.29 logMAR and improved significantly to 0.37 ± 0.21, 0.42 ± 0.19 and 0.35 ± 0.22 logMAR at month 1, 6 and 12 after treatment with dexamethasone implant. The mean central retinal thickness (CRT) was 623 ± 142 μm at baseline and decreased significantly to 339 ± 163 μm, 428 ± 131 μm and 356 ± 147 μm at month 1, 6 and 12 after treatment. Total resolution of macular oedema was observed in 10 out of 14 patients (71.4%) at month 12. Ellipsoid zone was intact in 71.4% of patients at the end of the follow-up, while 71.4% of patients received only one implant until the end of the 12-month follow-up. No adverse events were observed.Conclusions: Intravitreal dexamethasone implant was found to be effective and safe as initial treatment for macular oedema after PPV for RRD.

Macular Edema after Successful Pars Plana Vitrectomy for Rhegmatogenous Retinal Detachment: Factors Affecting Edema Development and Considerations for Treatment

Purpose: To investigate the incidence of macular edema after pars plana vitrectomy (PPV) for rhegmatogenous retinal detachment (RRD) repair, the factors affecting its development and the efficacy of intravitreal dexamethasone implant for its treatment.Methods: Participants in this study 86 patients with RRD. All patients were examined postoperatively and those with macular edema were treated with intravitreal dexamethasone implant and were followed-up for 12 months.Results: 14 out of 86 patients presented macular edema post PPV for RRD repair. Patients with preoperative macula off RRD, duration of RRD >1 week and proliferative vitreoretinopathy were more prone to develop macular edema. There was a statistically significant improvement in best corrected visual acuity and central retinal thickness at month 12 post intravitreal dexamethasone implant compared to baseline.Conclusions: The incidence of macular edema post PPV for RRD repair was found to be 16.3%. Intravitreal dexamethasone implant seemed to be safe and effective in cases with post-PPV macular edema after RRD repair.

New Observations regarding the Assessment of Cilioretinal Arteries Coexistence with Optic Disc Pit

Purpose: To investigate the coexistence of cilioretinal arteries (CRAs) with optic disc pit (ODP), and to delineate the characteristics of CRAs related to their number, location of their emergence and their association with the size of ODP. Methods: 47 patients (49 eyes) with ODP were diagnosed and followed-up between 1997 and 2017, using slit-lamp biomicroscopy, color fundus photographs, fluorescein angiography and indocyanine green angiography. The presence of CRAs was recorded in association with the size of the ODP, along with their number and location of emergence. The fellow normal eyes of patients were also analyzed. Results: 42 out of 49 eyes with ODP (85.7%) presented CRAs. In 35 out of 42 eyes (83.3%) CRAs emerged from the pit, either from bottom or from its margin. In 7.1% of cases, CRAs were emerged outside the ODP, while in 9.6% of cases, the type of CRA emergence could be characterized as mixed. The number of CRAs, that ranged from 1 to 4, was positively associated with ODP size. In the fellow normal eyes, CRAs was found in 22.2% of cases, difference which was significant compared to patients with ODP. Conclusion: Based on the high percentage of CRAs coexistence with ODP and the excessive frequency of their emergence from ODP (83.3%), it is supported that ODP as a developmental disorder could go along with further anatomic peculiarities, that also include the presence of multiple CRAs.

The Role of Disorganization of Retinal Inner Layers as Predictive Factor of Postoperative Outcome in Patients with Epiretinal Membrane

PURPOSE

The purpose of this retrospective study was to evaluate the disorganization of the retinal inner layers (DRIL) as a potential predictive factor of postoperative visual outcome in patients with idiopathic epiretinal membrane (iERM), treated with pars plana vitrectomy (PPV).

METHODS

Participants in the study were 46 consecutive patients diagnosed with iERM, who underwent PPV. Best corrected visual acuity (BCVA) measurement and spectral-domain optical coherence tomography (SD-OCT) were performed at baseline (preoperatively), and at months 3 and 6 postoperatively. DRIL and additional OCT parameters were assessed at 1-mm-wide foveal centered area.

RESULTS

DRIL was observed in 47.8% of patients at baseline. There was statistically significant improvement in BCVA and central retinal thickness (CRT) between baseline and months 6 and 12 in all patients. There was a statistically significant difference in BCVA and CRT change between patients with and without DRIL at months 6 and 12 compared to baseline, showing that there was a correlation between change in BCVA or CRT and baseline DRIL. Ellipsoid zone and external limiting membrane were intact in 91.3 and 95.7%, respectively, not affecting our results.

CONCLUSIONS

Baseline DRIL has been shown to be predictive of postoperative visual outcome in patients with iERM, treated with PPV.

Treatment of Macular Edema after Pars Plana Vitrectomy for Idiopathic Epiretinal Membrane Using Intravitreal Dexamethasone Implant: Long-Term Outcomes

PURPOSE

The aim of this study was to investigate the efficacy and safety of intravitreal dexamethasone implant for the treatment of macular edema after pars plana vitrectomy (PPV) for epiretinal membrane (ERM) removal.

METHODS

This prospective study included 27 patients who were diagnosed with macular edema after PPV for ERM removal and who were treated with either intravitreal dexamethasone implant (n = 15) or were observed without intervention (n = 12). Changes in best-corrected visual acuity (BCVA) and central retinal thickness (CRT) were assessed 1, 6, and 12 months -after treatment.

RESULTS

Patients treated with intravitreal dexamethasone implant showed significant improvement in BCVA and reduction in CRT at months 1, 6, and 12 after treatment, while patients in the control group showed improvement that did not reach statistical significance. The two groups differed significantly in terms of BCVA and CRT at all time points of the follow-up period, in favor of the dexamethasone implant group. Eighty percent of the patients treated with intravitreal dexamethasone needed only one implant until month 12, while no serious adverse events were noticed in any group.

CONCLUSIONS

Intravitreal dexamethasone implant was found to be effective and safe for the treatment of macular edema after PPV for ERM removal.

Ocular Manifestations of Granulomatosis with Polyangiitis: A Review of the Literature

Granulomatosis with polyangiitis (GPA) is a rare systemic autoimmune disease of unknown etiology that is characterized by granulomatous inflammation, tissue necrosis, and vasculitis in small- and medium-sized vessels. Ocular and orbital manifestations are common in almost half of patients with GPA, affecting every structure of the eye, from the eyelid and orbit to the retina, the choroid, and the optic nerve, with a wide range of severity. Since imaging findings are not always specific for the diagnosis of GPA, biopsy is useful to confirm the diagnosis. Regarding treatment, a localized pharmaceutical and surgical approach may be helpful to achieve remission, while immunosuppressive therapy, corticosteroids, and cyclosporine are also useful. In any case, multidisciplinary intervention is required to reduce the rates of relapse and morbidity in patients with GPA.

XEN Implant for Glaucoma Treatment: A Review of the Literature

PURPOSE

The purpose of this review is to summarize current knowledge on XEN implant for the treatment of glaucoma.

METHODS

A comprehensive literature review has been performed regarding XEN implant and its use on glaucoma management. Forty-two articles were checked and 37 were found to be relevant. Out of them, 21 were excluded as being case reports and reviews and the remaining 16 were eligible for the purpose of our review.

RESULTS

There was a significant reduction in intraocular pressure as well as in the number of medications needed in glaucoma patients treated with XEN implant either alone or combined with cataract surgery. In addition, combination of XEN implant with Baerveldt tubes has been shown to be beneficial in cases of refractory glaucoma, although complications may be present in this technique. Moreover, uveitic glaucoma may be a potential application of XEN implant.

CONCLUSIONS

XEN implant devices have been developed as a surgical alternative for glaucomatous patients and are expected to play an important role in the management of glaucoma in the future.

Evolution of fundus autofluorescence patterns over time in patients with chronic central serous chorioretinopathy

PURPOSE

To determine the evolution of fundus autofluorescence (FAF) patterns in chronic central serous chorioretinopathy (CSCR) over time.

METHODS

We retrospectively studied the changes in FAF patterns over time in 157 eyes of 112 patients with chronic CSCR using the Heidelberg Retina Angiography with a 488-nm excitation light and a 500-nm cutoff barrier filter.

RESULTS

The mean duration of follow-up was 37.2 months. The most common baseline pattern was that of granular hypoautofluorescence (51.0%). The earliest change in chronic CSCR is diffuse hyperautofluorescence and it occurs approximately 4 months after the reported first episode. The most common change observed at this stage is a change within areas of hyperautofluorescence where hyper-reflective dots appeared or disappeared. Change in FAF patterns from areas of hyperautofluorescence to hypoautofluorescence was slow. Only 25% of eyes showed such a change in pattern by 36 months. It takes an average of 24 months for granular hypoautofluorescent pattern to develop confluent hypoautofluorescence. There were no predictive patterns for the development of confluent CSCR.

CONCLUSION

Fundus autofluorescence (FAF) changes in CSCR evolve very gradually and so is not a good outcome measure for clinical trials.

Eplerenone in the treatment of central serous chorioretinopathy: a review of the literature

Purpose

The purpose of this review is to examine the role of eplerenone in the treatment of central serous chorioretinopathy (CSCR).

Methods

A comprehensive search of the PubMed database has been conducted regarding eplerenone for CSCR, while studies using spironolactone were excluded. Articles and book chapters cited in the reference lists of articles obtained by this method were reviewed and included when considered appropriate, while the retrieved articles were filtered manually to exclude duplicates.

Results

Oral eplerenone at a dose of 25–50 mg/day has been found to be effective and well-tolerated for the treatment of chronic CSCR. The published studies have shown significant improvement in visual acuity and decrease or total absorption of subretinal fluid in patients with CSCR treated with oral eplerenone. However, it should be noted that the majority of studies were retrospective with limited number of patients and short follow-up. On the other hand, patients presenting widespread retinal pigment epithelium changes are less likely to benefit from eplerenone treatment, which may argue for an earlier intervention.

Conclusions

CSCR is a challenging disease to understand and treat, since its pathogenesis remains elusive and multifactorial. Pharmacologic approaches, like eplerenone, are intriguing, as they target several pathophysiological pathways and may lead to visual acuity improvement and more rapid recovery.

Optic disk pit maculopathy: current management strategies

Introduction

Optic disk pit (ODP) is a rare congenital abnormality of the optic nerve head and can lead to visual impairment when macular detachment occurred. Recent advances in retinal imaging brought new insights into the pathophysiology of the disease, while new therapeutic options have been also described.

Methods

We made a comprehensive search of the literature regarding the current treatment modalities for the treatment of ODP maculopathy.

Results

Although there have been reported some cases of spontaneous resolution, current management of ODP maculopathy involves several surgical approaches. The most commonly used treatment alternative for ODP maculopathy management is vitrectomy, either alone or in combination with other treatment modalities, such as gas tamponade or laser photocoagulation. Other options, such as scleral buckling and inner fenestration, are also used, based on the recent findings about pathophysiology of the disease.

Conclusion

The management of ODP maculopathy remains challenging. Even though there are further advances in the understanding of the disease pathophysiology, the applied treatment is not single and therapeutic modalities differ in the success rate, related to the anatomical and functional results.

Editorial - Suboptimal response to intravitreal anti-VEGF treatment for patients with diabetic macular edema: is there any point in switching treatment?

To investigate if there is any point in switching treatment in patients with diabetic macular edema (DME) showing suboptimal response to anti-vascular endothelial growth factor (anti-VEGF) treatment. The standard of care for DME is anti-VEGF agents. Although anti-VEGF agents seem to be effective for the treatment of DME, there is a proportion of patients, showing a suboptimal response to anti-VEGF treatment. In such patients, switching treatment to another anti-VEGF agent or to intravitreal dexamethasone implant may provide favorable anatomical and functional results. However, without a control group, it is impossible to compare the effect of switching treatment with the effect of continuing the original administered treatment. Switching treatment in patients with DME remains challenging. Further studies with a control group are needed to reach a safe conclusion.

Chronic Central Serous Chorioretinopathy-Like Maculopathy as Atypical Presentation of Chorioretinal Folds

Purpose

The purpose of this case report was to present the clinical data and management of a 69-year-old female patient with chorioretinal folds who developed chronic central serous chorioretinopathy-like maculopathy.

Case Presentation

A 69-year-old female patient presented with a recent-onset slight decrease in visual acuity in her left eye. Her past ocular history was clear. Regarding her medical history, she had only hypertension, treated with per os medications. The patient underwent a complete ophthalmological examination. At presentation, the visual acuity was 6/6 in the right eye and 6/7.5 in the left eye. Intraocular pressure was 16 mm Ηg in both eyes. On fundoscopy, chorioretinal folds were noticed in the left eye. Spectral-domain optical coherence tomography, fluorescein angiography, and indocyanine green angiography confirmed the diagnosis of chronic central serous chorioretinopathy-like maculopathy in the left eye, since other causes of chorioretinal folding were excluded. The right eye was normal. No treatment was given to the patient, and at the 6-month follow-up there was improvement in visual acuity, which was 6/6, and decreased subretinal fluid.

Conclusions

Central serous chorioretinopathy-like maculopathy should be taken into account for the differential diagnosis of patients with chorioretinal folds.

Dexamethasone Intravitreal Implant in Diabetic Macular Edema: Real-Life Data from a Prospective Study and Predictive Factors for Visual Outcome

INTRODUCTION

The purpose of the study was to evaluate the long-term anatomical and functional outcomes in patients with diabetic macular edema (DME) treated with intravitreal dexamethasone implant and to determine the predictive factors for the final visual outcome.

METHODS

The study included 54 patients with DME refractory to previous antivascular endothelial growth factor (anti-VEGF) who were treated with intravitreal dexamethasone implant. Predictive factors for visual outcome were assessed. In addition, the change in best-corrected visual acuity (BCVA) and the percentage of patients with edema resolution were evaluated.

RESULTS

At the end of the 12-month follow-up, patients with DME gained + 5.2 letters (about 1 Snellen line), while 57.4% of patients presented total resolution of macular edema. Negative predictive factors for the final visual outcome were found to be increasing age, increasing macular thickness, phakic status, the presence of intraretinal fluid, hyperreflective foci, hard exudates, as well as external limiting membrane and ellipsoid zone disruption. The mean number of injections was 2.1.

CONCLUSIONS

The various predictive factors that determine the visual outcome and possibly define patient prognosis after dexamethasone intravitreal implant in DME cases have been studied. The long follow-up showed that dexamethasone intravitreal implant seems to be a safe and effective treatment for this disease, requiring a limited number of injections.

Refractive changes after intravitreal ranibizumab injections for diabetic macular oedema

PURPOSE

The purpose of this study was to evaluate refractive changes after intravitreal ranibizumab injections for the treatment of diabetic macular oedema.

METHODS

Participants in this retrospective study were 35 patients (35 eyes) with diabetic macular oedema, who received intravitreal ranibizumab injections. Spherical equivalent refractive power was evaluated before treatment and at least one month after the last injection where no fluid existed. Demographic characteristics, visual acuity, central retinal thickness and the number of injections were recorded and analysed.

RESULTS

The spherical equivalent refractive power did not differ significantly pre- or post-injections. Changes in visual acuity and central retinal thickness were statistically significant before and after injections.

CONCLUSIONS

Intravitreal ranibizumab injections did not seem to affect the refractive power of patients with diabetic macular oedema. Therefore, appropriate spectacle correction can be prescribed any time during ongoing treatment with ranibizumab injections.

The Impact of Epiretinal Membrane in Neovascular Age-Related Macular Degeneration Treatment: A Spectral-Domain Optical Coherence Tomography Study

PURPOSE

The purpose of this prospective study was to evaluate the impact of epiretinal membrane (ERM) on anatomical and functional results in patients with wet age-related macular degeneration (AMD) treated with intravitreal anti-vascular endothelial growth (anti-VEGF) injections.

METHODS

Participants in the study were 48 patients with either wet AMD alone (AMD group, n = 27) or AMD and ERM (AMD/ERM group, n = 21). All patients received intravitreal anti-VEGF injections (three monthly injections and PRN thereafter) and were followed up for at least 12 months. All participants had best-corrected visual acuity (BCVA) measurement and spectral domain-optical coherence tomography (SD-OCT) at each visit, while fluorescein angiography was performed at baseline and then at the discretion of the physician.

RESULTS

There was a statistically significant improvement in BCVA at month 12 compared to baseline in each group (p < 0.001 for both groups), while the two groups did not differ significantly regarding BCVA at the end of the follow-up (p = 0.056). Additionally, there was a statistically significant reduction in CRT in both groups at month 12 (p < 0.001 for AMD group and p = 0.004 for AMD/ERM group) with no statistically significant difference between the groups (p = 0.183). Patients in the AMD group had a lower percentage of subretinal fluid (25.9%) than patients in the AMD/ERM group (52.4%) at the end of the follow-up, while ellipsoid zone disruption was found to be more profound in the AMD/ERM group (38.1%) than in the AMD group (18.5%). Patients in the AMD/ERM group needed more injections (7.1 ± 2.0 injections) than patients in the AMD group (4.8 ± 1.7 injections).

CONCLUSIONS

Patients in the AMD/ERM group had a higher percentage of subretinal and intraretinal fluid and ellipsoid zone interruption during the follow-up period. Anti-VEGF treatment appeared to have a beneficial effect in both groups, although the AMD/ERM group needed more injections compared to the AMD group.

Location of submacular hemorrhage as a predictor of visual outcome after intravitreal ranibizumab for age-related macular degeneration

Purpose

To evaluate the anatomical and functional outcomes in patients with submacular hemorrhage (SMH) due to age-related macular degeneration (AMD) treated with ranibizumab, and to evaluate the potential role of the SMH location in the final outcome after treatment.

Methods

Participants in this study were 12 treatment-naïve patients with SMH due to neovascular AMD who were treated with intravitreal ranibizumab and had at least 12 months’ follow-up. All patients underwent best-corrected visual acuity measurement and optical coherence tomography at baseline and at every visit posttreatment, while fluorescein angiography was done at baseline and at the discretion of the physician thereafter.

Results

Of the patients, 83.4% showed improvement or stabilization in best-corrected visual acuity after treatment at the 12-month follow-up, with a mean number of 7.3±2.9 injections. Patients with SMH surrounding the foveal area in 360° presented worse anatomical and functional outcomes compared to those with SMH adjacent to the fovea.

Conclusion

Intravitreal ranibizumab seems to be safe and effective, either improving or stabilizing visual acuity, in patients with SMH due to wet AMD. The location of the SMH may predict the final outcome after treatment.

Eccentric Macular Hole after Pars Plana Vitrectomy for Epiretinal Membrane Without Internal Limiting Membrane Peeling: A Case Report

Introduction

Postoperative eccentric macular hole formation is an uncommon complication after pars plana vitrectomy (PPV) without internal limiting membrane (ILM) peeling for the treatment of epiretinal membrane (ERM). We present a case of eccentric macular hole formation after PPV for ERM without ILM peeling.

Case report

A 68-year-old male patient presented with ERM and visual acuity of 6/24 in his left eye. He underwent 23-gauge PPV without ILM peeling for treatment of ERM. One week postoperatively the retina was attached and the epiretinal membrane was successfully removed, while visual acuity was 6/9. One month after PPV, a single eccentric retinal hole below the macula was detected using fundoscopy and subsequently confirmed by optical coherence tomography. At this time the visual acuity was 6/9 and the patient reported no symptoms. No further intervention was attempted and at the 9-month follow-up, the visual acuity and the size of the eccentric macular hole remained stable.

Conclusion

Eccentric macular holes can be developed after PPV even without ILM peeling and are usually managed conservatively by observation.

Optical Coherence Tomography Evolution in a Case of X-Linked Juvenile Retinoschisis: 15 Years of Follow-Up

PURPOSE

We present the evolution of X-linked juvenile retinoschisis (XLRS) in a male patient using optical coherence tomography (OCT) with a long-term follow-up time of 15 years.

CASE DESCRIPTION

A 10-year-old male patient presented at the Medical Retina Department of our hospital complaining for blurred vision in both eyes. At the initial presentation in 2001, his best corrected visual acuity (BCVA) was 6/12 in both eyes on the Snellen chart. Based on clinical and OCT findings, the diagnosis of XLRS was made, and it was confirmed by genetic testing. No treatment was performed, but the patient was regularly examined. His BCVA and OCT findings remained relatively stable from 2001 to 2012, when BCVA decreased to 6/18 and 6/24 in the right and left eye, respectively. In 2016, his BCVA was 6/24 and 6/36 in right and left eye, respectively, while OCT depicted significant macular thinning, accompanied by irregularities of the foveal contour in both eyes.

CONCLUSION

Patients with XLRS should be monitored regularly to evaluate the progression of the disease and manage the potential complications.

BAX and BCL2 Gene Polymorphisms in Rhegmatogenous Retinal Detachment

PURPOSE

The purpose of this study was to investigate the potential association between rhegmatogenous retinal detachment (RRD) and BAX and BCL2 polymorphisms.

METHODS

This is a case control study of 99 patients with RRD and 120 healthy control subjects of Greek origin, surveyed for BAX and BCL2 polymorphisms (rs2279115 and rs4645878) and a potential correlation to RRD.

RESULTS

The rs4645878 AA genotype was found to be significantly associated with RRD (p = 0.003; OR: 6.89, 95% CI: 1.76-26.93), while the rs2279115 CC genotype as well as the C allele was not found in patients with RRD.

CONCLUSIONS

This is the first study evaluating the potential relationship between BCL2 and BAX gene polymorphisms and RRD in a Greek population, showing a significant association between BAX rs4645878 polymorphism and RRD susceptibility. This finding suggests that an apoptotic mechanism is implicated in the pathogenesis of RRD.

Choriocapillaris' alterations in the presence of reticular pseudodrusen compared to drusen: study based on OCTA findings

PURPOSE

To evaluate the qualitative changes of choriocapillaris in the presence of reticular pseudodrusen (RPD) and compare them with conventional small drusen due to dry age-related macular degeneration (AMD).

PROCEDURES

Participants in this study were 59 patients with non-neovascular AMD, presenting either RPD (23 patients) or drusen (36 patients) of similar size. All patients underwent best-corrected visual acuity, slit-lamp examination, spectral domain optical coherence tomography (SD-OCT) and optical coherence tomography angiography.

RESULTS

The morphology of RPD in SD-OCT was depicted either as conical or as amorphous in shape. Both types were found to affect the ellipsoid zone. The presence of RPD was associated with choriocapillaris' reduced blood flow signal (non-perfusion), while the same but less intense choriocapillaris' non-perfusion appearance was noticed in the presence of drusen of the same size. In 13% of patients with RPD, ghost-like vessels were observed in the non-perfusion area of choriocapillaris, while in none patients with drusen ghost vessels were present. In all 23 patients with RPD, the choriocapillaris non-perfusion was correspondent to the location of RPD. Additionally, in about 35% of them, choriocapillaris' impairment was also observed, covering areas outside RPD.

CONCLUSIONS

Morphological impairment of choriocapillaris was more intense in patients with RPD than in those with conventional drusen of the same size. The existence of ghost vessels in the area of choriocapillaris' density defect suggested that choriocapillaris' alterations may occur in patients with RPD.

Model for Risk-Based Screening of Diabetic Retinopathy in People With Newly-Diagnosed Type 2 Diabetes Mellitus

Purpose

The purpose of this study was to evaluate the role of inflammatory/lipid markers and potential risk factors for diabetic retinopathy (DR) development in newly diagnosed patients with type 2 diabetes mellitus (T2DM).

Methods

Participants in this study were 1062 patients with newly diagnosed T2DM. Demographic and clinical data of patients were collected. Assessment of DR status was performed using digital two-field photography. In addition, HbA1c (%), lipid profile, and urinary albumin were measured at recruitment. The following inflammatory markers were also measured: serum C-reactive protein, white blood cells, platelet, adiponectin, IL-4, IL-6, IL-10, vascular endothelial growth factor, tumor necrosis factor-α (TNF-α), IL-1b, IL-1 receptor antagonist (IL-1RA), and monocyte chemotactic protein-1. Univariate and multivariate analyses of the association of various potential risk factors and DR were conducted.

Results

Univariate analysis showed that male sex, any cardiovascular event, and HbA1c were positively associated with DR, while IL-1RA, IL-1b, IL-6, and TNF-α were significantly negatively associated with presence of DR in the cohort. Risk factors that remained significantly associated with DR presence at the multivariate analysis were male sex, any cardiovascular event, HbA1c, and IL-1RA.

Conclusions

Our study demonstrated that HbA1c levels, male sex, and previous cardiovascular events were risk factors for presence of DR in people with newly diagnosed T2DM, while IL-1RA seemed to have a protective role. The prevalence of DR in our population was 20.2%, reflecting current practice. Our findings may contribute to future risk-based modelling of screening for DR.

Full-thickness macular hole formation following anti-VEGF injections for neovascular age-related macular degeneration

PURPOSE

Macular hole (MH) is part of a group of age-related degenerative diseases characterized by pathology of vitreomacular interface. Similarly, neovascular age-related macular degeneration (nAMD) affects older patients and is a leading cause of irreversible visual loss. The purpose of this case series is to describe the development of full-thickness MH in patients with nAMD, following antivascular endothelial growth factor (anti-VEGF) treatment.

METHODS

Participants in this case series were four patients with nAMD, who received anti-VEGF injections with variable therapeutic response to treatment. Patients were examined at baseline (when AMD was diagnosed) and monthly thereafter. The examination included visual acuity measurement, slit-lamp biomicroscopy, and optical coherence tomography.

RESULTS

All patients were found to develop full-thickness MH within 1-4 months after the last anti-VEGF injection, even in the absence of pre-existing vitreomacular interface abnormalities in some cases. The median number of injections before the MH formation was 3.

CONCLUSION

MH formation may represent an adverse effect of anti-VEGF treatment in patients with nAMD and could be also coexisting pathology with nAMD in older individuals.

Eccentric Macular Hole after Pars Plana Vitrectomy for Idiopathic Macular Hole: A Case Report

Introduction

Postoperative eccentric macular hole (MH) formation is an uncommon complication after pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling for epiretinal membrane or MH treatment. Herein, we present a case of eccentric MH formation after PPV with ILM peeling for MH.

Case Description

A 72-year-old female patient underwent 23-gauge PPV with ILM peeling for idiopathic MH in her right eye. The visual acuity was 6/24 in the right eye. One week postoperatively the retina was attached and the MH seemed to be closed, while visual acuity was 6/12. One month after PPV, there was a single eccentric retinal hole below the macula, which was detected at the fundoscopy and was confirmed by OCT. The visual acuity was 6/9 and the patient referred no symptoms. No further intervention was attempted, and at the 6-month follow-up the visual acuity and the size of the eccentric MH remained stable.

Conclusions

Eccentric MHs can develop after PPV and are usually managed conservatively by observation.

Receptor of Advanced Glycation End Products Gene Polymorphism and Primary Open-Angle Glaucoma

PURPOSE

The purpose of this study was to investigate the potential association between primary open-angle glaucoma and receptor of advanced glycation end products (AGER) polymorphisms in a Greek population.

METHODS

This is a case-control study of 106 patients with primary open-angle glaucoma and 120 healthy control subjects of Greek origin surveyed for AGER polymorphisms (rs1051993 and rs2070600) and a potential correlation to primary open-angle glaucoma.

RESULTS

AGER polymorphisms showed no statistically significant difference between patients with primary open-angle glaucoma and healthy controls.

CONCLUSIONS

Our study did not find any significant association between AGER polymorphism and primary open-angle glaucoma. Since we cannot reject the possibility that oxidative stress is a crucial factor for the development of primary open-angle glaucoma, further studies may be needed to confirm the importance of the AGER gene in the glaucoma pathogenesis.

Risk Factors for Central Serous Chorioretinopathy: Multivariate Approach in a Case-Control Study

PURPOSE

The purpose of this prospective study was to investigate the potential risk factors associated independently with central serous retinopathy (CSR) in a Greek population, using multivariate approach.

MATERIALS AND METHODS

Participants in the study were 183 consecutive patients diagnosed with CSR and 183 controls, matched for age. All participants underwent complete ophthalmological examination and information regarding their sociodemographic, clinical, medical and ophthalmological history were recorded, so as to assess potential risk factors for CSR. Univariate and multivariate analysis was performed.

RESULTS

Univariate analysis showed that male sex, high educational status, high income, alcohol consumption, smoking, hypertension, coronary heart disease, obstructive sleep apnea, autoimmune disorders, H. pylori infection, type A personality and stress, steroid use, pregnancy and hyperopia were associated with CSR, while myopia was found to protect from CSR. In multivariate analysis, alcohol consumption, hypertension, coronary heart disease and autoimmune disorders lost their significance, while the remaining factors were all independently associated with CSR.

CONCLUSIONS

It is important to take into account the various risk factors for CSR, so as to define vulnerable groups and to shed light into the pathogenesis of the disease.

Ranibizumab versus aflibercept for macular edema due to central retinal vein occlusion: 18-month results in real-life data

PURPOSE

The objective of this study was to compare the anatomical and functional outcomes of ranibizumab versus aflibercept for the treatment of macular edema due to central retinal vein occlusion (CRVO) in routine clinical practice.

METHODS

Participants in this observational study included 62 treatment-naïve patients with CRVO who received intravitreal injections of either ranibizumab or aflibercept. The demographic data, best-corrected visual acuity (BCVA) and spectral-domain optical coherence tomography (SD-OCT) characteristics were evaluated at baseline and at months 1, 2, 3, 6, 12 and 18 post-treatment.

RESULTS

At month 18, the mean BCVA of ranibizumab-treated eyes increased 7.9 letters, compared to 7.4 letters for eyes receiving aflibercept, with a similar number of injections. There was no statistically significant difference between the two groups in letters or in central subfield thickness at month 18. At the end of the follow-up, 50% of patients in the ranibizumab group and 42.9% in the aflibercept group showed complete resolution of macular edema.

CONCLUSIONS

Ranibizumab and aflibercept demonstrated similar anatomical and functional outcomes over 18-month follow-up in patients with macular edema due to CRVO, with a similar number of injections.

Gas Tamponade for Retinectomy in PVR-Related Retinal Detachments: A Retrospective Study

Introduction

The purpose of the study was to evaluate the anatomical and functional results in patients with proliferative vitreoretinopathy (PVR) treated with retinectomy and perfluoro-octane gas (C₃F₈) as a tamponade agent.

Methods

12 patients with inferior and anterior complicated PVR-related retinal detachment, who were treated with retinectomy, where C₃F₈ was used as the tamponade agent were examined. Primary outcome was the anatomical success, while visual acuity, existence of an epiretinal membrane (ERM) and intraocular pressure (IOP) postoperatively were secondary outcomes.

Results

The primary success rate was 75% (mean follow-up of 9.8 months). Reoperation was needed on 25% of patients after the retinectomy procedure. Preoperative best corrected visual acuity (BCVA) was poor due to macular involvement in all cases. BCVA was improved in three patients (25%), remained stable in 25% and deteriorated in 16.7%. Two patients were lost during the follow-up period. Postoperative ERM formation was noted in 33.3% of patients. One patient developed hypotony, while no other complications were observed.

Conclusion

Retinectomy with C₃F₈ as the tamponade agent provides anatomical and functional restoration at a 75% primary success rate in PVR-related retinal detachment.

Causes and management of small pupil in patients with cataract

BACKGROUND

The purpose of the study was to present the causes and management of small pupil (<6 mm) in Greek patients with cataract.

METHODS

About 1144 consecutive patients with cataract comprised the study group. The pupil size was measured after maximal dilation by means of Rosenbaum cards and Colvard pupillometer. Dilation regimen included phenylephrine 10%, tropicamide 1%, cyclopentolate 1%, and ketorolac trometamol 0.5% administered 3 times at 5 min intervals starting 1 h before surgery. The presence of possible risk factors for small pupil was recorded. The need of additional maneuvers and devices to dilate the pupil during cataract surgery was examined, and the complication rate in cases with small pupils was recorded.

RESULTS

Small pupil was observed in 78 out of 1144 eyes (6.8%, 95% confidence interval = 5.2%-8.8%). Nine eyes had pupil size <4 mm (0.78%) preoperatively. Six cases (0.52%) developed intraoperative pupillary miosis. The major cause of small pupil was pseudoexfoliation (PEX) in 47.4% (37/78) of patients. No significant associations were observed regarding age, gender, history of diabetes mellitus, the maturity of cataract, and phacodonesis. Techniques for small pupil management included pupil stretching in 14 cases (17.9%), use of iris hooks in 6 cases (7.7%), iris sphincter cuts in 2 cases (2.6%), and placement of a Malyugin Ring in 4 cases (5.1%). Seven eyes (9%) with small pupil had capsular rupture versus 16 eyes (1.5%) with normal dilation (P < 0.001).

CONCLUSIONS

Small pupil is not very common in Greek population, is mostly caused by PEX, and it is associated with increased complication rate.

Health-related quality of life, visual function and treatment satisfaction following intravitreal dexamethasone implant for diabetic macular edema

PURPOSE

The aim of this study was to explore and describe quantitatively patient-reported outcome measures (PROMs), ie, health-related quality of life (QoL), visual function and treatment satisfaction, in patients with diabetic macular edema (DME) receiving two different regimens of Ozurdex (intravitreal dexamethasone implant).

METHODS

In this multicenter, prospective study, 100 patients with center-involving refractory DME were randomized 1:1 to either five monthly fixed dosing or optical coherence tomography (OCT)-guided pro re nata (PRN) regimen of dexamethasone intravitreal implant therapy. The primary outcome was the difference between arms in change in PROMs and health-related QoL from baseline to 12 months, as measured by the Retinopathy-Dependent Quality of Life (RetDQoL) questionnaire, Visual Function Questionnaire-25 (VFQ-25) and Retinopathy Treatment Satisfaction Questionnaire (RetTSQ).

RESULTS

There was no statistically significant difference in the RetDQoL score and VFQ-25 score at month 12 compared to those at baseline, whereas the total mean RetTSQ score increased significantly at the exit visit. The two treatment arms did not differ significantly regarding the change in PROMs and health-related QoL questionnaires. Logistic regression analysis showed that visual acuity (VA) of ≥55 letters, central foveal thickness <300 μm and macular volume <9.2 mm³ at the exit visit (month 12) predicted a higher change in RetTSQ.

CONCLUSION

This study showed that there is a statistically significant improvement in treatment satisfaction, as measured by RetTSQ, in patients with DME treated with dexamethasone intravitreal implant, independent of the dose regimen, namely, fixed or PRN. However, it should be noted that the clinically meaningful change could not be assessed accurately, since no thresholds for clinically meaningful change currently exist for the RetTSQ. On the other hand, there was no significant change in health-related QoL, as measured using VFQ-25 and RetDQoL. Factors affecting the patients' treatment satisfaction were the final VA, the central foveal thickness and the macular volume.

Thyroidopathy and Age-Related Macular Degeneration: Is There Any Correlation

Purpose

The purpose of this study was to evaluate whether inherent sociodemographic parameters, lifestyle features, as well as medical data may be potential risk factors for the presence of age-related macular degeneration (AMD).

Methods

Participants in our study were 114 patients with AMD, 63 males and 51 females, and 100 control subjects without any ocular disease. Demographic data, lifestyle data, medical history, and comorbidities were recorded and analyzed as potential risk factors for the presence of AMD.

Results

There was no statistically significant difference between patients and controls regarding age, gender, smoking, alcohol consumption, walking, exercise, presence of hypertension, diabetes mellitus, myoskeletal problems, migraine, and cancer. Marital status, higher educational level, cardiovascular disorders, and thyroidopathy were found to be significantly associated with AMD.

Conclusions

Apart from already reported risk factors for AMD, thyroidopathy was associated with AMD.