Anatomical-functional concordance of microperimetry and the simplified age-related macular degeneration study classification: A pilot study

PURPOSE

The principal aim of this pilot study was to investigate the concordance between the different stages of Age-Related Macular Degeneration (AMD), as determined by the simplified classification of the Age Related Eye Disease Study Group (AREDS), and new evaluation criteria using a microperimetry system.

METHODS

A complete eye examination and a microperimetry MAIATM (Macular Integrity Assessment, CenterVue, Padova, Italy) examination was performed on 59 eyes with early, intermediate or advanced AMD. We analysed 19 evaluation criteria for every clinical group category.

RESULTS

There were 20 female and 12 male participants included with a median age of 74 years (min: 54, max: 87). Thirteen eyes (22%) were classified as category 1, 11 eyes (18.6%) as category 2, 17 eyes (28.8%) as category 3 and 18 eyes (30.6%) as category 4 AMD.All evaluated microperimetry criteria related to retinal sensitivity were found to have a statistically significant difference among the stages (p < 0.05). Fixation stability was unstable in 55.6% of the eyes classified as stage 4 (p = 0.001). The analysis of the distance between the two PRLs - PRL_initial and PRL_final was larger for the stage 4 (p = 0.0258). The mean sensitivity in stages 2 and 3 correlated with the presence or not of reticular pseudodrusen (p = 0.0137).

CONCLUSIONS

The mean sensitivity and the categorized sensitivity (set to 25, 15 and 5 dB), the five higher and lower stimuli sensitivity appeared to be the most sensitive criteria to differentiate the four AMD categories. Microperimetry provides a new reproducible method of anatomical-functional macular analysis.

Optical coherence tomography analyses based segmentation and relative intensity evaluation of outer retinal layers in patients affected with X-linked juvenile retinoschisis

PURPOSE

We aim to provide a description of the optical coherence tomography findings in the outer macula hyperreflective bands of our patients with X-linked juvenile retinoschisis. Also to categorize these changes and to quantitatively and qualitatively correlate their reflectivity levels with visual function.

METHODS

We manually segmented the borders, and depicted relative intensity of the inner segment ellipsoid band, and quantified the volume of edema.

RESULTS

The average relative intensity of the ellipsoid zone, ISe band, for the control subject was 14.864, our patient's, with the mild disease was, 28.238 and 34.943 in OD and OS, respectively, and for the patient with severe disease was, 44.442 and 40.154 for OD and OS respectively. Thresholding showed a significant difference in edema volume between mild disease (~20%), and severe form (~50%). Relative intensity analyses are indicative of homogeneity variability. High standard deviation value illustrates the high dispersion of data values and is a safe marker of ellipsoid zone homogeneity.

CONCLUSION

Data suggested that both anatomic and functional characteristic of outer macula hyperreflective bands were notably associated with the pathogenesis cascade in the photoreceptor cells. External limiting membrane line disruption is initiated by the volume of macular edema and followed by disorganization of the three lines in a stepwise pattern, first at the ellipsoid zone, followed by the cone outer segment tips zone and finally at the External limiting membrane.

Multimodal imaging of two cases of retinal vein occlusion secondary to Waldenstrom macroglobulinemia

PURPOSE

To report multimodal imaging characteristics of two cases of retinal vein occlusion (RVO) secondary to Waldenstrom macroglobulinemia (WM).

CASE REPORT

Case 1: An 82-year-old woman presented with vision loss. She had a history of WM. Best-corrected visual acuity (BCVA) was 20/100 Snellen equivalent in the right eye (OD) and 20/63 in the left eye (OS). Fundoscopy showed bilateral hemorrhages in posterior pole and along superotemporal arcade. Fluorescein angiography illustrated no macular leakage. Optical coherence tomography (OCT) revealed macular edema (ME). Optical coherence tomography angiography (OCTA) demonstrated abnormalities in choriocapillaris. A diagnosis of bilateral branch RVO was made and ME was treated with intravitreal dexamethasone, achieving stability. Case 2: A 65-year-old man presented with venous dilation, tortuosity, and intraretinal hemorrhages. BCVA was 20/20 in both eyes (OU). OCT showed ME and hyperreflective dots in choroid. A diagnosis of bilateral central RVO was made. Laboratory evaluation and bone narrow biopsy confirmed a diagnosis of WM. After that, our patient consulted because of vision loss. BCVA was 20/400 in OU. Fundoscopy and OCT demonstrated a worsening of the intraretinal hemorrhages and the ME. OCTA showed damage of choriocapillaris. Thus, intravitreal dexamethasone and plasmapheresis was advised. Two months after, BCVA was 20/40 in the OD and 20/32 in the OS. Also, fundoscopy and OCT improved.

CONCLUSION

Early treatment of WM is truly important, with the aim of achieving a decrease in IgM levels in order to avoid toxic effect over the RPE that results in refractory ME.

Natural course of acquired vitelliform lesions associated with pigment epithelial detachments in dry age related macular degeneration

PURPOSE

To describe the natural history of acquired vitelliform lesions (AVLs) associated with different types of pigment epithelial detachments (PEDs) in dry age-related macular degeneration.

METHODS

A retrospective review of clinical examination and multimodal imaging data of patients with AVLs associated with PED(s) was performed.

RESULTS

This study included 25 eyes of 17 patients. The mean age of patients was 67.2 ± 9.7 (47-83) years. The mean follow-up time was 32.6 ± 16.2 (12-66) months, excluding four patients (five eyes) that were lost to follow-up. The mean logMAR BCVA was 0.21 ± 0.16 at baseline and 0.38 ± 0.28 at final visit (p = 0.016). At the end of the follow-up period, PEDs enlarged in eight eyes (40%) and were unchanged in two eyes (10%). Spontaneous resolution of the central PED(s) with AVLs was seen in four (20%) eyes. Rupture of the PED(s) occurred in four eyes (20%), with two developing central foveolar atrophy afterwards. Overall, central foveolar atrophy was seen ultimately in four eyes (20%).

CONCLUSION

It seems that high PED size may be a risk factor for PED rupture during follow-up. 1/3 of the eyes ended up with unfavorable anatomical outcome.

The effect of insulin pump therapy in retinal vasculature in type 1 diabetic patients

BACKGROUND/OBJECTIVES

Continuous subcutaneous insulin infusion (CSII) is a treatment for type 1 diabetes that improves metabolic control and reduces micro and macrovascular complications. The aim of this study was to compare the effect of CSII versus traditional multiple daily injections (MDI) therapy on retinal vasculature.

METHODS

We performed a prospective study with type 1 diabetic patients with no prior history of ocular pathology other than mild diabetic retinopathy. The patients were divided into two groups according to their therapeutic modality (CSII vs MDI). The retinal nerve fiber layers thickness and vascular densities were compared between groups in both macula and optic disc. The correlations between vascular density and clinical features were also determined. Statistical significance was defined as p < 0.05.

RESULTS

The study included 52 eyes, 28 in the insulin CSII group. The mean age was 36.66 ± 12.97 years, with no difference between groups (p = 0.49). The mean glycated hemoglobin (HbA1c) was found to be lower in the CSII group (7.1% ± 0.7 vs 7.5% ± 0.7 p < 0.01). The parafoveal vascular density was found to be higher in the CSII group (42.5% ± 0.4 vs 37.7% ± 0.6, p < 0.01). We found an inverse correlation between HbA1c value and parafoveal vascular densities (p < 0.01, r = -0.50).

CONCLUSION

We found that CSII provided better metabolic control than MDI and this seemed to result in higher parafoveal vascular density. As lower vascular density is associated with an increased risk of diabetic retinopathy, these results suggest that CSII could be the safest therapeutic option to prevent retinopathy.

Long-term macular vascular density measured by OCT-A in children with retinopathy of prematurity with and without need of laser treatment

PURPOSE

To assess long-term vascular density measured by optical coherence tomography angiography (OCT-A) in former preterm children with history of retinopathy of prematurity (ROP) with and without need of laser treatment.

METHODS

This observational study included former preterm children that developed ROP stage 2 or 3. Infants were divided in two groups according to previous need of laser treatment, and underwent a complete ophthalmologic evaluation, including assessment of macular morphologic and vascular parameters by OCT-A.

RESULTS

Fifteen eyes were included in group 1 (laser-requiring ROP) and 19 in group 2 (non-treated ROP). Group 1 had lower mean gestational age and birth weight values than group 2 (p < 0.001 and p < 0.001, respectively). Best corrected visual acuity (BCVA) was lower in group 1 (0.08 ± 0.04 logMAR vs 0.04 ± 0.07 logMAR, p = 0.03). Laser-requiring ROP had lower vascular parameters, especially of central and internal vascular density (9.15 ± 2.75 vs 10.52 ± 0.86 mm^-1, p = 0.05; 13.74 ± 1.00 vs 15.86 ± 0.64 mm^-1, p = 0.05; respectively), and lower avascular zone circularity (0.58 ± 0.06 vs 0.76 ± 0.02, p < 0.001). Mean macular thickness was higher in group 1 (300.50 ± 10.50 vs 281.11 ± 2.50 μm, p = 0.05). Best corrected visual acuity (BCVA) was correlated with superficial vascular density (p < 0.05).

CONCLUSION

Laser-requiring ROP seems to result in a decrease of long-term BCVA, which is at least partially attributed to a decrease in superficial macular vascular density. However, prematurity degree was more pronounced in children that required treatment, which might have influenced our results.

Swept source OCT-Angiography assessing a case of aneurysmal type 1 neovascularization secondary to high-myopic posterior staphyloma

AIM

To report an uncommon case of aneurysmal type 1 neovascularization (polypoidal choroidal vasculopathy) secondary to high-myopic staphyloma in a Caucasian patient, assessed with multimodal imaging including swept source OCT-Angiography.

METHODS

Observational case report.

RESULTS

About 73-year-old Caucasian male patient with high myopia (axial length = 27.24 mm). Fundus examination showed a myopic conus and a deep orange-brownish nodular lesion at the edge of a deep haemorrhage and connected to a large choroidal vessel. ICGA showed a circular hyperfluorescent lesion in mid-phase, without any branching vascular network. OCT-Angiography could detect the aneurysmal lesion non-invasively as a small circular high-flow lesion in the outer retina slab, with a shadowing in the choriocapillaris slab. At the level of the aneurysmal lesion, structural OCT showed a high bilobed PED, without any subretinal fluid. A vascular flow was noted within the PED on cross-sectional OCT-A, confirming the vascular aneurysmal nature of this lesion. Additionally, swept source OCT highlighted the presence of an abrupt change in choroidal thickness, from 62 µm in the peripapillary area to 120 µm underneath the polypoidal lesion, with dilated choroidal vessels.

CONCLUSION

To our knowledge, this is the first report of OCT-A findings in aneurysmal (polypoidal) dilation secondary to high-myopic staphyloma. We could demonstrate the usefulness of OCT-A detecting non-invasively the aneurysmal dilation and the usefulness of swept source OCT assessing the choroidal structure to better understand the pathophysiology of this uncommon finding.

OCTA-guided navigated laser therapy for advanced macula neovascularization secondary to age related macular degeneration

INTRODUCTION

To evaluate the effects of the Navilas system guided by optical coherence tomography angiography for advanced macular neovascularization (MNV) secondary to age-related macular degeneration (AMD).

METHODS

Prospective case-series including nine eyes presenting with advanced MNV with persistence of exudative signs, no longer responding to anti-VEGF therapy, best-corrected visual acuity at least of 1.3 logMar. All patients were treated with Navilas guided by overlaid optical coherence tomography angiography (OCTA) images at the site of branching large neovascular trunks.

RESULTS

Occlusion of large neovascular trunks successfully occurred in all nine included patients. OCTA analysis revealed, at 1 month follow up, MNV total area decreasing from 6.2 ± 3.1 to 2.6 ± 3.4 mm². At 6 months follow up, mean MNV area was 3.3 ± 3.4 mm² (p = 0.008).

CONCLUSION

This preliminary study showed that Navilas treatment guided by OCTA may represent an attractive therapeutic option in advanced neovascular lesions secondary to AMD.

Irregular vascular network identified with OCT-A in angioid streaks: A probable predictor of active choroidal neovascularization (case series)

PURPOSE

To evaluate the risk of active choroidal neovascularization (CNV) in presence of deep irregular vascular network (IVN) in eyes with angioid streaks (AS).

METHODS

Observational case series including three treatment-naive eyes with angioid streaks and IVN, without CNV. Patients were followed-up during 18 months with multimodal imaging including structural optical coherence tomography (OCT) and OCT Angiography (OCT-A) to detect possible neovascular complication.

RESULTS

On OCT-A, IVN was detected as a peripapillary and/or macular high-flow lesion, filling the spaces between the angioid streaks in the outer retina slab. Repeated OCT-A could detect an active CNV emerging from the IVN, as a high-flow rich anastomotic vascular network with a perilesional dark halo. Patient was treated with intravitreal injections of Bevacizumab on a Pro Re Nata regimen, with a decreased CNV area and lower vascular density on control OCT-A.

CONCLUSION

OCT-A shown to be helpful in detecting the presence of IVN in asymptomatic eyes with AS during a routine examination. In our series, the IVN seems to be predictor of active CNV, needing a close surveillance and frequent follow-up to allow early treatment upon CNV activation.

Multimodal imaging of a vascularized idiopathic epiretinal membrane

PURPOSE

To report a case of vascularized idiopathic epiretinal membrane including the multimodal imaging.

METHODS

Findings on clinical examination, color fundus photography, spectral-domain optical coherence tomography, optical coherence tomography angiography, and fluorescein angiography.

RESULTS

Sixty-three-year-old woman with a previous rhegmatogenous retinal detachment (RRD) who presented with an asymptomatic idiopathic neovascular complex below an epiretinal membrane. It was assessed with fluorescein angiography, OCT and OCT-A. The vascularized ERM was already present previously to the retinal detachment.

CONCLUSION

Our case report describes an example of idiopathic epiretinal membrane complicated by neovascularization; we hypothesized hypertension could be one of the factors in this case, as it may lead to decreased retinal perfusion and upregulation in vascular endothelial growth factor (VEGF). Multimodal imaging can help in detecting neovascularized ERM.

OCT angiography analysis in acute non-arteritic anterior ischemic optic neuropathy: The importance of segmentation

BACKGROUND

In non-arteritic anterior ischemic optic neuropathy (NAION), optical coherence tomography angiography (OCTA) shows changes in peripapillary vascularization. However, the presence of an optic disc edema may induce artifacts that prevent visualizing the peripapillary network. The aim of this study was to evaluate the peripapillary vascularization in acute NAION using swept-source OCTA algorithms allowing segmenting only the retinal nerve fiber layer (RNFL).

METHODS

Retrospective analysis of 15 eyes with acute NAION of 15 patients. The optic nerve head was imaged using swept-source OCTA. Morphological and quantitative analyzes were performed. The capillary flux index (CFI), defined as the total weighted area of perfused vasculature per unit area, and the capillary perfusion density (CPD), defined as the total area of perfused microvasculature per unit area, were quantified. Each NAION eye was compared to the unaffected fellow eye using a Wilcoxon test for matched samples.

RESULTS

After segmentation at the RNFL, the morphological analysis showed less vascular dropout and more vascular tortuosity than the analysis of a larger segmentation. The quantitative analysis showed that the mean CFI and the CFI in the four quadrants were significantly higher in NAION eyes compared to healthy eyes (p = 0.0002 and p < 0.01). The mean CPD and the CFD in the inferior quadrant were lower in NAION eyes (p = 0.03 and p = 0.0054, respectively).

DISCUSSION

The RNFL segmentation allowed better visualizing the peripapillary network because the edema related darkening was reduced. The increased CFI suggests an autoregulatory phenomenon to compensate the ischemic process at the ciliary vasculature.

Serpiginous choroiditis presenting after SARS-CoV-2 infection: A new immunological trigger?

INTRODUCTION

To report the first case of a serpiginous choroiditis presenting after SARS-CoV-2 infection in a previously healthy young woman.

CASE DESCRIPTION

A 41-year-old woman reported blurry vision OS 1 month after a mild SARS-CoV-2 infection. Left eye fundus examination revealed multiple peripapillary atrophic lesions, adjacent to a larger diffuse, ill-defined, yellow-whitish deep amoeboid-like patch, involving the peripapillary region and extending temporally to the fovea. Multimodal imaging including fluorescein angiography, indocyanine-green angiography, fundus autofluorescence and optical coherence tomography was consistent with serpiginous choroiditis. A complete systemic work-up was performed to exclude potential infectious or inflammatory etiologies. The active choroidal lesions responded to high dose corticosteroids, with functional improvement. Immunomodulatory therapy with methotrexate was initiated for long-term management.

CONCLUSION

Serpiginous choroiditis is a rare but important sight-threatening condition that has been previously associated to viral infections, which seem to have a role in the induction and/or perpetuation of choroidal inflammation. SARS-CoV-2 infection appears to have played a role as a possible trigger for intraocular inflammation in this case. Therefore, COVID-19 patients reporting visual symptoms should be carefully evaluated in order to obtain adequate ophthalmological management to avoid irreversible visual damage.

Functional and morphological outcomes after surgery in lamellar macular holes versus epiretinal membrane foveoschisis

PURPOSE

To compare the clinical findings and outcomes of vitrectomy for lamellar macular holes (LMH) versus epiretinal membrane foveoschisis (ERMF).

MATERIALS AND METHODS

This retrospective study enrolled 36 eyes of 35 patients with a minimum follow-up of 6 months. Spectral domain optical coherence tomography (SD-OCT) parameters and best-corrected visual acuity (BCVA) were analyzed preoperatively and postoperatively.

RESULTS

The 19 (52.8%) ERMF and 17 (47.2%) LMH were included. Preoperatively, eyes with LMH were characterized by a lower central foveal thickness (CFT) (102.18 ± 31.44 µm vs 159.37 ± 25.25 µm, p < 0.001) and a greater incidence of outer retinal disruption (p < 0.001). Primary anatomical success was achieved in 34/36 eyes (94.4%). Preoperative BCVA was better in ERMF (0.16 - IQR 0.09 - logarithm of the minimal angle of resolution (LogMAR) - 20/28 Snellen) than LMH (0.40 - IQR 0.30 - LogMAR, 20/50 Snellen) (p = 0.008). At 6 months after surgery, BCVA significantly improved in the ERMF group (p < 0.001), but showed insignificant change in LMH (p = 0.125). Two cases, both in the LMH group, developed full thickness macular hole after surgery.

CONCLUSION

Eyes with LMH showed visual stabilization after surgery, whereas the eyes in the ERMF group were susceptible to functional improvement. These differences in BCVA outcomes may be the consequence of a higher damage in the outer retina in the LMH group; an accurate SD-OCT examination is a fundamental step when deciding to proceed or not to the surgery.

Fovea-sparing coats disease: A rare clinical entity

PURPOSE

To evaluate the rarity, clinical features and management of Coats disease characterized by fovea-sparing enhancing the importance of pediatric retinal screening and early management to maintain a good visual acuity.

METHODS

Retrospective analysis of approximately 40 patients affected by Coats disease between 2000 and 2020 at the Retinoblastoma Referral Center and Ophthalmology unit of the University of Siena in Italy.

RESULTS

Two patients with fovea sparing Coats disease were included. Both presented an extrafoveal Coats disease (stage 2A by Shields classification) when they were 5 and 6 years old respectively.They had no anterior findings and a presenting visual acuity of 20/20 reflecting the early stage and a milder phenotype of the disease which are indeed more likely to be found in patients older than 3 years at presentation.Both presented telangiectasia and retinal exudation in the affected eye. Standard Argon laser photocoagulation and subsequently Cryotherapy were performed in the telangiectatic retinal periphery of both patients obtaining an excellent control and regression of the disease.

CONCLUSIONS

Careful pediatric retinal screening and early management are crucial to ensure a good visual prognosis in such an early feature of Coats disease as fovea sparing since this condition unfortunately tends to recall the physician's attention in more advanced stages.Due to the extremely poor number of articles regarding such a rare feature of Coats disease like fovea sparing, we report our experience.

Validation of mobile-based funduscope for diabetic retinopathy screening in Estonia

AIM

To validate mobile-based funduscope for diabetic retinopathy screening in Estonia.

METHODS

Quality validation comparison of HEINE^® iC2 funduscope and Zeiss Visucam camera with image scoring and diagnostic test accuracy measurement by sensitivity and specificity. Study took place from January 2020 until March 2020 in East-Tallinn Central Hospital's eye clinic.

RESULTS

Based on 90 patients, the Zeiss Visucam showed 35.6% DR prevalence while iC2 had 18.9% for images and 17.8% for videos. The average Likert score was 4.7 for Zeiss Visucam and 2.4 for both iC2 images and iC2 videos. The sensitivity of iC2 images was 72.7% (95%CI 49.6-88.4) for grader 1 and 61.9% (95%CI 38.7-81.0) for grader 2, iC2 video sensitivity was 57.1% (95%CI 37.4-75.0) and 65.4% (95%CI 44.4-82.1), respectively. The grader-based specificity for iC2 images was 96.7% (95%CI 80.9-99.8) and 93.5% (95%CI 77.2-98.9). iC2 videos had a 100% (95%CI 91.7-1.0; 92.0-1.0) specificity by both graders. Cohen's kappa agreement was 0.82 and 0.96 for images and videos.

CONCLUSION

Mobile-based funduscope iC2 is not valid for DR screening with non-dilated pupils and thus not suitable for clinics that do not have experienced specialist present. Moreover, the screening specialist needs to be experienced fundus photographer with extra multiple day training for funduscope use. As main resolution, mobile-based funduscope was not validated for DR screening in Estonia based on pre-set study criteria. Additional research and development of funduscope algorithm for image stripping from videos is needed for validation as iC2 benefits do not offset the gold standard at the moment.

Use of ultra-wide field retinal imaging and optical coherence tomography angiography in the diagnosis of incomplete Susac syndrome

PURPOSE

To describe clinical findings through ultra-wide field (UWF) images and optical coherence tomography angiography (OCT-A), in Susac's syndrome (SS).

METHODS

SS patients were retrospectively analyzed in a single center. Clinical features, ultra-wide-field retinographies (UWF-PR), UWF fluorescein angiographies (UWF-FA), and optical coherence tomography angiography & en face (OCT-A/EF) were reviewed.

RESULTS

Twelve eyes from six patients with a mean follow-up of 35.66 months ± SD 36.88 were included. UWF-PR showed areas of retinal whitening and cotton-wool spots in all the eyes after acute attack. Segmentary mid peripheral arteriolitis could be observed in five eyes by UWF-FA in acute and convalescent stages. OCT-A revealed capillary density changes in all of the affected eyes. During the acute phase there was a well-preserved superficial capillary network, while deep retinal plexus showed a lower density in the affected areas. OCT-A/EF revealed deep retinal plexus drop-out and surrounding edematous retina in acute attacks, becoming atrophic over time. Conversely, superficial plexus was much less affected. Perifoveal reperfusion was seen in seven eyes after the acute attack.

CONCLUSIONS

UWF-PR/FA and OCT-A/EF might be helpful to stablish an early diagnosis and to monitor SS progression.

What can visual caregivers expect with patients treated for SARS-CoV-2? An analysis of ongoing clinical trials and ocular side effects

Within the COVID-19 pandemic context, the WHO has proposed a list of medicines to treat patients with severe acute respiratory syndrome (SARS-CoV-2). An analysis of their ocular side effects was performed. Only chloroquine and hydroxychloroquine were found to have an ocular impact in the medium and long-term. Detailed search strategies were performed in EMBASE, MEDLINE, SCOPUS and WOS Core Collection. Additionally, the worldwide ongoing clinical trials including chloroquine or hydroxychloroquine were evaluated, and their proposals of drug administration and exclusion criteria analyzed. In general, high maximum cumulative doses of chloroquine or hydroxychloroquine are being used for a short period in 135 currently underway clinical trials (to 21st April 2020). Typically, the doses were 2 to 5 times greater than the AAO recommendation (adjusted to weight) to avoid toxic retinopathy, the most undesirable ocular side effect. Maximum cumulative doses up to 12,000 mg for chloroquine and 18,000 mg for hydroxychloroquine were found. In prophylaxis clinical trials, 72,000 mg and 22,500 mg were the maximum cumulative doses for hydroxychloroquine and chloroquine respectively. Only 48% of the clinical trials considered retinal impairment as an exclusion criterion, and just one referred to an ophthalmic examination previous to study inclusion. How chloroquine and hydroxychloroquine treatment affect patients with a previous retinal condition is still poorly understood. A comprehensive ophthalmological examination 6 months after treatment is recommended in this subgroup. This review provides an overview of this topic and sheds light on the challenges visual caregivers may face regarding these repurposed drugs.

TriPla Regimen: A new treatment approach for patients with neovascular age-related macular degeneration in the COVID-19 "era"

In the last months, a rapidly increasing number of people have been infected with severe acute respiratory syndrome coronavirus 2, the virus causing coronavirus disease 2019 (COVID-19). Due to the risk of cross-infections, the number of visits and injections was dramatically reduced in the last months, and the time between visits has been rescheduled from every 15 to 45 min, significantly impairing the total number of available visits. Although continuity of care has been allowed, a series of measures to diminish the risk of contamination need to be adopted until the end of this pandemic outbreak, which may persist until the development of an effective vaccine. For these reasons, we have introduced a new treatment regimen that is aimed at reducing the number of in-person visits and achieving continuity of treatment. This regimen is named "Triple and Plan" (TriPla). The main advantage of the TriPla regimen is to reduce the number of visits of patients in comparison to the pro re nata and treat and extend regimen. Using the TriPla regimen, the risk of contamination would be reduced. Furthermore, by reducing the number of scheduled visits, physicians could guarantee an adequate number of examinations for each patient, lengthening the interval between visits, and reducing the risk of cross-infections.

Analysis of intravitreal bevacizumab treatment for macular oedema due to retinal vein occlusion

PURPOSE

Our aim was to analyse the clinical effect of intravitreal bevacizumab treatment for macular oedema due to central/branch retinal vein occlusion (CRVO/BRVO). The end points were final best-corrected visual acuity (BCVA), BCVA improvement, final central 1-mm macular subfield thickness (CST) and change in CST.

METHODS

Our study included 34 CRVO and 25 BRVO patients. Patients received intravitreal bevacizumab (IVB) treatment at our department. Our control group consisted of 50 CRVO and 30 BRVO patients, who had not received this treatment because their disease developed before the anti-VEGF treatment became available. For statistical analysis, two-sample t-test, Pearson's correlation, and ANOVA were used. The level of significance was defined at p < 0.05.

RESULTS

With the two-sample t-test we found significant improvement of BCVA in the IVB-treated group (CRVO: 0.171 ± 0.270, p1 = 3.25×10-4; BRVO: 0.215 ± 0.282, p2 = 5.52×10-4). The difference in BCVA improvement was also significant compared to the control group (CRVO: p1 = 3.46×10-4; BRVO: p2 = 0.003). Significant decrease was observed in the CST in the treated group (CRVO: -345.114 ± 280.577, p1 = 6.94×10-9; BRVO: -151.875 ± 174.341, p2 = 1.67×10-4). In case of BRVO patients the final BCVA was significantly better in the treated group (0.617 ± 0.334) compared to the control group (0.406 ± 0.357), p = 0.016.

CONCLUSION

IVB treatment results in significantly better final visual acuity and leads to significantly increased BCVA improvement compared to patients with RVO-induced macular oedema receiving no treatment.

Multimodal imaging of chorioretinal folds induced by orbital vascular malformation in two cases

PURPOSE

To investigate the alterations in the retinal pigment epithelium (RPE) in the crest and trough portions of chorioretinal folds (CRFs) induced by an orbital vascular tumor.

METHODS

Review of multimodal imaging in two eyes of two patients with globe compression and CRFs from an orbital vascular tumor.

RESULTS

Fundus photography demonstrated obliquely extending CRFs with alternating hyperpigmented and hypopigmented linear alterations in both eyes. Fundus autofluorescence (AF) imaging showed obliquely oriented hypoAF lines, incompletely alternating with hyperAF lines. In Case 1, the hyperAF lines had interspersed hypoAF segments and Case 2 had peripapillary mottling of AF. Fluorescein angiography (FA) showed alternating hyper and hypofluorescent lines in the late phase in Case 1. Optical coherence tomography (OCT) documented relative thinning of RPE at the folded crests in Case 1 and preservation of RPE in Case 2. Swept-source OCT angiography (SS-OCTA) demonstrated oblique hyporeflective lines in the outer retina and choriocapillaris layers in Case 2. These findings suggest that the crest of a CRF represents thinned or rarified RPE with hypoAF, transmission hyperfluorescence (FA), partially attenuated RPE layer (OCT), and isoreflectivity (SS-OCTA) while the trough represents compressed RPE with irregular hyperAF, transmission hypofluorescence (FA), thickened RPE layer (OCT), and hyporeflectivity (SS-OCTA).

CONCLUSION

The anatomic and functional status of the RPE in CRFs based on multimodal imaging reveals normal to attenuated RPE with hypofunctionality at the fold crest and compacted, thickened RPE at the trough with segmental functional impairment on AF imaging. Anatomic information regarding CRFs is evident on OCT, FA, and SS-OCTA while the functional status is depicted on AF.

OCT based interpretation of the optic nerve head anatomy in young adults with retinal vascular occlusions and ischemic optic neuropathy

PURPOSE

To examine optic nerve head (ONH) anatomy in young adults with central retinal vein occlusion (CRVO), branch retinal vein occlusion (BRVO), central retinal artery occlusion (CRAO), branch retinal artery occlusion (BRAO) or nonarteritic anterior ischemic optic neuropathy (NA-AION) in order to look for associated, potentially predisposing anomalies.

METHODS

Cross-sectional study including 54 patients (ages 16-50 years) diagnosed from 2009 to 2018 with CRVO, BRVO, CRAO, BRAO, or NA-AION. Using Optical Coherence Tomography the presence of optic disc drusen (ODD), prelaminar hyperreflective lines and peripapillary hyperreflective ovoid mass-like structures (PHOMS), and determination of scleral canal size, retinal nerve fiber layer thickness (RNFLT) and macular ganglion cell layer thickness (GCLT) was obtained. Data for retinal vascular occlusion patients were grouped and analyzed together.

RESULTS

ODD were found in 13% of all patients, 2% of retinal vascular occlusion patients and 67% of NA-AION patients (p < 0.0001). Prelaminar hyperreflective lines were found in 35% of all patients, 24% of retinal vascular occlusion patients and 89% of NA-AION patients (p = 0.0005). PHOMS were found in 20% of all patients, 13% of retinal vascular occlusion patients and 56% of NA-AION patients (p = 0.012). RNFLT was decreased in ODD patients compared to patients without ODD (p = 0.01). Scleral canal diameter and GCLT was not correlated with ODD, prelaminar hyperreflective lines or PHOMS.

CONCLUSION

ODD, prelaminar hyperreflective lines and PHOMS were more frequent in NA-AION patients compared to retinal vascular occlusion patients. The prevalence of ODD in retinal vascular occlusion patients was similar to the reported prevalence in the general population.

Direct and transsynaptic retrograde degeneration and optic nerve head microvascular changes in patients with hemianopia

PURPOSE

To investigate optic nerve head (ONH) microvascular changes secondary to transsynaptic retrograde degeneration (TRD), comperatively with direct retrograde degeneration and healthy controls.

METHODS

Patients with hemianopia due to intracranial lesion included in the study. Intracranial lesion was categorized by location: postgeniculate (causing TRD), chiasmal (causing direct retrograde degeneration). For the postgeniculate lesions, the eye on the same side of the lesion was defined as the ipsilateral eye and the eye on the opposite side as the contralateral eye. Optic disc microvasculature was evaluated with the help of optic coherence tomography angiography.

RESULTS

Sixteen eyes of 16 patients with chiasmal lesion, 28 eyes of 14 patients with postgeniculate lesion, and 30 eyes of 30 healthy subjects were included in the study. Ipsilateral eyes of the patients with postgeniculate lesion had decreased vessel density at the temporal sectors compatible with the affected nasal side of the visual field. Contralateral eyes showed no reduction of the vessel density at the affected nasal sectors. The eyes with chiasmal lesions had decreased vessel density at the peripapillary region and nasal half of the ONH compatible with temporal hemianopia. Vascular changes in the chiasmal lesion were more prominent than those of the postgeniculate lesion. Retinal nerve fiber layer and ganglion cell complex thickness were reduced.

CONCLUSION

Vessel density of ONH was reduced in patients with homonymous hemianopia, providing evidence for TRD secondary to acquired postgeniculate lesion. Direct retrograde degeneration was more prominent in affected sectors when compared to TRD.

Comparison between two fast threshold strategies: SPARK and SITA in normal subjects

BACKGROUND

Numerous fast threshold strategies have been developed in perimetry which use maximum likelihood approaches to estimate the threshold. A recent approach to threshold estimation has been developed estimating the threshold from a limited number of test points which further reduces examination time. This strategy, SPARK, has not been compared to the SITA strategy. The aim of this study was to compare SPARK with SITA in a normal cohort to evaluate within and between strategy agreement in threshold estimates.

METHODS

A total of 83 normal subjects each underwent two visual field examinations with SITA and SPARK on two separate occasions on a randomly selected eye. The eye examined and the order of strategy examined first was randomised but remained constant over the two perimetry visits.

RESULTS

Visual field examination with SPARK Precision was on average 33% faster than SITA Standard. A positive correlation between group mean sensitivities of SITA Standard and SPARK Precision (rho = 0.713, p < 0.001) was found. In total, 95% of stimulus locations were located within the 95% limits of agreement and linear regression on the differences in sensitivities showed no statistically significant proportional bias (t = 1.713, p = 0.09). Pointwise analysis showed SITA Standard had significantly larger variability for individual stimulus locations examined over two visits when compared to SPARK (t = 9.175, p < 0.001).

CONCLUSION

The clinical examination of SPARK yields a sensitivity profile similar to SITA but in a faster examination time. The lower threshold variability of SPARK may be as a result of data smoothing in the threshold estimation process.

Optical coherence tomography angiography markers associated with treatment response in neovascular age-related macular degeneration

PURPOSE

To investigate whether qualitative and quantitative features of choroidal neovascular membranes are associated with anti-vascular endothelial growth factor treatment response in patients with neovascular age-related macular degeneration.

METHODS

A total of 41 eyes were included in this cross-sectional observational study and divided into "good responders" and "poor responders" based on the long-term functional changes, frequency of recurrent choroidal neovascular activity, and injection need. Enface optical coherence tomography angiography images were obtained and qualitative features of choroidal neovascular membranes were described based on vessel network density. Then, quantitative measurements including vessel area, vessel length, junction density, and lacunarity were calculated using validated software (ImageJ and AngioTool). Chi-square tests, t-test, or Mann-Whitney U tests were used for group comparisons, and intraclass correlation coefficients were calculated for reliability assessment of quantitative analyses.

RESULTS

Twenty-two eyes treated by a median of 9 (3-24) anti-vascular endothelial growth factor injections at a median follow-up of 41 (12-89) months were categorized as good responders, 19 treated by a median of 26 (11-46) injections at a median follow-up of 44.5 (12-84) months as poor responders. Good responder group mostly had loose network (45.5%), and poor responders mostly had dense network (47.7%). The difference was not statistically significant (p = 0.25). The size of the lesion was 2.7 times greater at baseline (p = 0.04) and 1.7 times greater at final examination in the poor responder group (p = 0.04). Lacunarity index, showing lesion heterogeneity, was higher in good responders (p = 0.018) than poor responders. Other quantitative vascular features did not significantly differ between the groups (p > 0.05).

CONCLUSION

Long-term remodeling of chronically treated choroidal neovascular may be non-invasively and reproducibly investigated using optical coherence tomography angiography. Quantitative analysis and lacunarity index, in particular, may be used as a measure of vessel maturation and guide treatment strategies in neovascular age-related macular degeneration.

Foveal thickness, foveal microvasculature, and refractive error in children with asymmetric involvement of retinopathy of prematurity

OBJECTIVE

To evaluate foveal thickness, foveal microvasculature, and refractive error in children with asymmetric involvement of retinopathy of prematurity who had laser treatment in one eye and spontaneously regressed retinopathy of prematurity in the fellow eye.

METHODS

Totally, 17 children (34 eyes) with a history of asymmetric course of acute Zone II retinopathy of prematurity were assessed. Data on best-corrected visual acuity, refractive status, axial length, anterior chamber depth, and optical coherence tomography angiography findings were analyzed between treated and non-treated fellow eyes.

RESULTS

Treated eyes were more myopic than non-treated eyes (mean, -0.09 ± 1.86 diopters vs mean, 0.07 ± 0.98 diopters, p = 0.026). Compared to non-treated eyes, treated eyes had shallower anterior chamber depth (mean, 3.27 ± 0.24 mm vs mean, 3.55 ± 0.19 mm, p = 0.02). No significant difference was observed regarding optical coherence tomography angiography parameters between two eyes of the children. The mean central foveal thickness was found to be higher in treated eyes than in non-treated eyes (297.46 ± 22.03 vs 275.55 ± 18.45, p = 0.009). Higher number of laser spots were associated with decreased parafoveal superficial capillary plexus vessel density (r = -0.56, p = 0.02) and increased central foveal thickness (r = 0.62, p = 0.008).

CONCLUSION

Our results revealed no difference in optical coherence tomography angiography parameters between laser-treated and non-treated eyes in children with asymmetric involvement of Zone II retinopathy of prematurity except for a higher central foveal thickness in laser-treated eyes. Treated eyes were more myopic than the non-treated eyes. Number of laser applications during treatment had an impact on parafoveal superficial capillary plexus vessel density.