Pegcetacoplan in the treatment of geographic atrophy

Geographic atrophy (GA) secondary to age-related macular degeneration is a leading cause of visual deterioration in the global elderly population, often causing a decreased quality of life. Perifoveal atrophy can significantly affect reading, low-light vision and driving. Similarly, foveal atrophy can cause defects in central visual acuity. While the complement cascade has been implicated as playing a pivotal role in disease pathogenesis, no approved treatment for GA currently exists. Two concurrent phase III trials, DERBY and OAKS, assessed pegcetacoplan (Apellis Pharmaceuticals, MA, USA), a selective complement component C3 inhibitor, with regard to reduction in GA progression. This article reviews the available clinical trial data relating to the efficacy and safety of pegcetacoplan in the treatment of GA secondary to age-related macular degeneration.

High Variation in Inner Retinal Reflectivity Predicts Poor Visual Outcome in Patients With Central Retinal Vein Occlusion: SCORE2 Report 21

Purpose

To assess the association of a novel spectral domain optical coherence tomography biomarker with 6-month visual acuity in in the Study of COmparative Treatments for REtinal Vein Occlusion 2.

Methods

Spectral domain optical coherence tomography volume scans were evaluated for inner retinal hyperreflectivity, quantified by optical intensity ratio (OIR) and OIR variation. Baseline visual acuity letter score (VALS), baseline OCT biomarkers, and month 1 OIR were correlated with VALS at month 6. Regression trees, a machine learning technique yielding readily interpretable models, were used to assess for variable interaction.

Results

Only baseline VALS correlated positively with month 6 VALS in multivariate regression. Regression trees detected a novel functional and anatomical interaction in a subgroup. Among patients with a baseline VALS worse than 43, those with an OIR variation at month 1 of more than 0.09 had a mean of 13 fewer letters of vision at 6 months compared with patients with an OIR variation of 0.09 or less.

Conclusions

Baseline VALS was the strongest predictor of month 6 VALS. Regression tree analysis detected an interaction effect, in which higher OIR variation at month 1 predicted worse 6-month VALS in patients with low VALS at baseline. OIR variation may serve as a predictor for poor visual outcome despite treatment of macular edema secondary to retinal vein occlusion in patients with poor vision at baseline.

Translational Relevance

Pixel heterogeneity in three-dimensional OCT data may serve as measure of disruption of the retinal laminations, and this factor may carry visually prognostic value.

Fabrication of thin Molybdenum backed target using rolling method

A successful attempt was made to fabricate a thin foil of natural Mo target on a thick Au backing with Indium in between to improve adhesion between the foils. Rolling at elevated temperature was considered to fabricate Mo foil while gold foil was fabricated employing conventional rolling technique. The heating of Mo foil under natural environment lead to the oxidation or carbonization on foil surface which was confirmed through Energy Dispersive X-ray Spectroscopy (EDS) measurements. Indium of thickness ∼86μg/cm² was evaporated on Mo foil to improve adhesion between Mo and Au foils. The characterization of fabricated thin Mo foil was done using the Energy Dispersive X-ray Spectroscopy (EDS) and the Scanning Electron microscope (SEM) techniques. Thickness measurement of the target (Mo-Au) was done using Energy Dispersive X-ray Fluorescence (EDXRF) technique, in the measurements the thickness of the Mo foil and of gold backing are found out to be 1.3 mg/cm² and 9 mg/cm² respectively.

Risk of New Retinal Vascular Occlusion After mRNA COVID-19 Vaccination Within Aggregated Electronic Health Record Data

Importance

New-onset retinal vascular occlusion (RVO) occurring acutely after messenger RNA (mRNA) COVID-19 vaccination has been described in recent literature. Because RVO can cause vision loss or blindness, an epidemiologic investigation evaluating this potential association is of great importance to public health.

Objective

To investigate how often patients are diagnosed with new RVO acutely after the mRNA COVID-19 vaccine compared with influenza and tetanus, diphtheria, pertussis (Tdap) vaccines.

Design, Setting, and Participants

A retrospective population-based cohort design using the TriNetX Analytics platform, a federated, aggregated electronic health record (EHR) research network containing the deidentified EHR data of more than 103 million patients, was used to examine aggregate EHR data. Data were collected and analyzed on October 20, 2022. Data on patients within the TriNetX Analytics platform were searched for the presence of vaccination Common Procedural Technology codes, and instances of newly diagnosed RVO within 21 days of vaccination were recorded and reported. Propensity score matching based on demographic characteristics (age, sex, race and ethnicity) and comorbidities (diabetes, hypertension, and hyperlipidemia) was performed between vaccination groups for evaluation of relative risks (RRs).

Main Outcomes and Measures

The appearance of a new-encounter diagnosis of RVO within 21 days of the mRNA COVID-19 vaccination was the primary outcome. Historical comparison cohorts of patients receiving influenza and Tdap vaccinations allowed for evaluation of the RRs for RVO.

Results

Of 3 108 829 patients (mean [SD] age at vaccination, 50.7 [20.4] years; 56.4% women) who received the mRNA COVID-19 vaccine, 104 (0.003%; 95% CI, 0.003%-0.004%) patients had a new diagnosis of RVO within 21 days of vaccination. After propensity score matching, the RR for new RVO diagnosis after the first dose of COVID-19 vaccination was not significantly different from that after influenza (RR, 0.74; 95% CI, 0.54-1.01) or Tdap (RR, 0.78; 95% CI, 0.44-1.38) vaccinations, but was greater when compared with the second dose of the COVID-19 vaccination (RR, 2.25; 95% CI, 1.33-3.81).

Conclusions and Relevance

The findings of this study suggest that RVO diagnosed acutely after mRNA COVID-19 vaccination occurs extremely rarely at rates similar to those of 2 different historically used vaccinations, the influenza and Tdap vaccines. No evidence suggesting an association between the mRNA COVID-19 vaccination and newly diagnosed RVO was found.

Characterizing and Predicting Limited Early Response in Eyes With Retinal Vein Occlusion Using Machine Learning in Routine Clinical Practice

OBJECTIVE

To characterize and predict limited early responders (LER) in eyes with retinal vein occlusion (RVO) treated with anti-vascular endothelial growth factor (anti-VEGF).

PATIENTS AND METHODS

This retrospective cohort study of 116 eyes with edema secondary to RVO characterized early responders (ER) and LER 3 months after initiating anti-VEGF treatment. Baseline characteristics and 12-month outcomes were compared. A machine learning (ML) algorithm was developed to predict LER.

RESULTS

At baseline, LER had higher best-corrected visual acuity (BCVA) than ER (P< 0.0001) and lower central subfield thickness (CST) than ER (P< 0.01). At 12 months, change in BCVA was + 0.8 and + 21.4 letters, and change in CST was -104.4 and -187.1 μm for LER and ER, respectively (P < 0.0001, P < 0.05). The ML algorithm achieved area under the receiver operating characteristic curve = 0.73.

CONCLUSION

ER eyes experienced greater functional and anatomical improvements at 12 months in routine clinical practice than LER. The ML algorithm achieved moderately high performance predicting LER. [Ophthalmic Surg Lasers Imaging Retina 2023;54:231-237.].

Meta-Analyses of Two Treatment Regimens for Retinal Vein Occlusion

BACKGROUND AND OBJECTIVES

To pool available data on the change in best-corrected visual acuity (BCVA), central retinal thickness (CRT), and number of injections as reported by treat and extend (T&E) and pro re nata (PRN) regimens for retinal vein occlusion (RVO).

MATERIALS AND METHODS

After PubMed was queried, separate random effect models were fitted to the data extracted and the Wald test was used to compare the estimates of the two independent meta-analyses.

RESULTS

Fourteen T&E and 29 PRN studies were included in two independent meta-analyses. No significant difference was observed in BCVA (+14.74 [+11.52, +17.96] in T&E vs +15.90 [+14.24, + 17.56] in PRN, P = 0.530) or CRT improvements (-259.56 [-189.02, -330.09] in T&E vs -256.58 [-226.57, -286.48] in PRN, P = 0.939). More injections over 12 months were observed in T&E regimens (7.48 [6.32, 8.65] vs 5.13 [4.20, 6.06] in PRN, P = 0.002).

CONCLUSION

Although more injections may be required, T&E achieves similar functional and anatomic benefits as compared to PRN regimens. [Ophthalmic Surg Lasers Imaging Retina 2023;54:244-250.].

Long-Term Visual Outcomes in Neovascular Age-Related Macular Degeneration Eyes With Baseline Macular Atrophy on Anti-Vascular Endothelial Growth Factor Treatment

BACKGROUND AND OBJECTIVE

This study explores the connection between macular atrophy (MA) status at baseline and best visual acuity (BVA) after 5 to 7 years of anti-vascular endothelial growth factor (anti-VEGF) injections on eyes with neovascular age-related macular degeneration (nAMD).

PATIENTS AND METHODS

This retrospective study included patients with neovascular age-related macular degeneration receiving anti-VEGF injections at least twice-yearly for 5+ years at Cole Eye Institute. Analyses of variance and linear regressions explored the connection between MA status, baseline MA intensity, and 5-year BVA change.

RESULTS

Of 223 included patients, 5-year BVA change was not statistically significant between MA status groups or from baseline. The population's average 7-year BVA change was -6.3 Early Treatment Diabetic Retinopathy Study letters. Type and frequency of anti-VEGF injections were comparable between MA status groups (P > .05).

CONCLUSION

Regardless of MA status, 5- and 7-year BVA change lacked clinical relevance. If receiving regular treatment for 5+ years, patients with baseline MA achieve comparable visual outcomes to those without MA, with similar treatment and visit burdens. [Ophthalmic Surg Lasers Imaging Retina 2023;54(X):X-X.].

Perioperative COVID-19 Screening at a Tertiary Ophthalmic Institution

Purpose: To characterize the rate of COVID-19 positivity during presurgical screening and the surgical outcomes of ophthalmic patients who were positive for COVID-19 and to report the overall cost. Methods: This retrospective study included patients 18 years or older who had ophthalmic surgical procedures at a tertiary institution between May 11, 2020, and December 31, 2020. Patients without a valid presurgical COVID-19 test within 3 days before their scheduled procedure, who had incomplete or mislabeled visits, or who had incomplete or missing data in their file were excluded. COVID-19 screening was completed using a polymerase chain reaction (PCR) kit. Results: Of the 3585 patients who met the inclusion criteria, 2044 (57.02%) were women; the mean age was 68.2 years ± 12.8 (SD). Thirteen asymptomatic patients (0.36%) tested positive for COVID-19 via PCR screening. Three patients had a known positive COVID-19 infection within the 90 days before surgery; thus, 10 patients (0.28%) were found to have asymptomatic naïve COVID-19 infection via PCR testing. Testing was associated with a total charge of US $800 000. Five of the 13 patients (38.46%) who tested positive for COVID-19 experienced a delay in their surgery; the mean delay was 17.23 ± 22.97 days. Conclusions: Asymptomatic ophthalmic surgical patients had a low positivity rate with a limited impact on surgery scheduling at a significant cost. Further studies would be valuable in evaluating a targeted presurgical screening population as opposed to universal testing.

Baseline Diabetic Retinopathy Severity and Time to Diabetic Macular Edema Resolution with Ranibizumab Treatment: A Meta-Analysis

OBJECTIVE

Having a better understanding of how long diabetic macular edema (DME) takes to resolve in patients with diabetic retinopathy (DR) after treatment with ranibizumab, and the factors affecting this outcome, would be of benefit to physicians and patients alike. The objective of this analysis was to evaluate the time to first DME resolution and the impact of baseline DR severity on this outcome in patients treated with ranibizumab in phase III clinical trials.

DESIGN

Meta-analysis of data from the phase III trials, RIDE (NCT00473382) and RISE (NCT00473330), and DR Clinical Research Network protocols I (NCT00444600), S (NCT01489189), and T (NCT01627249).

PARTICIPANTS

Patients with DME (central subfield thickness [CST] > 250 μm) and DR with Diabetic Retinopathy Severity Scale (DRSS) score between 35 and 85.

INTERVENTION

Intravitreal injection of ranibizumab.

MAIN OUTCOME MEASURES

The time to first DME resolution (defined as CST ≤ 250 μm) within 24 months was evaluated overall and by baseline DR severity category per the DRSS (35 of 43 [mild or moderate nonproliferative DR], 47-53 [moderately severe or severe nonproliferative DR], 60 [mild proliferative DR], and 61-85 [moderately severe to severe proliferative DR]).

RESULTS

There were 777 patients included in the meta-analysis. The overall mean (95% confidence interval) time to first DME resolution, adjusted for baseline CST, was 6.0 (5.6-6.4) months. The mean (95% CI) time to first DME resolution was 7.1 (6.2-7.9), 5.9 (5.2-6.6), 6.0 (4.8-7.2), and 4.5 (3.5-5.5) months for the 35 of 43, 47 to 53, 60, and 61 to 85 baseline DRSS categories, respectively (overall P = 0.002). By month 24, the proportion of eyes with DME resolution was 74.9% (221 of 295), 77.5% (299 of 386), 69.4% (109 of 157), and 78.7% (148 of 188) for the 35 of 43, 47 to 53, 60, and 61 to 85 baseline DRSS categories, respectively (overall P = 0.17).

CONCLUSIONS

This meta-analysis of data from patients treated with ranibizumab showed that DME resolution was faster in patients with more severe DR at baseline. However, by month 24, a similar proportion of patients achieved DME resolution, regardless of baseline DR severity. These findings may guide treatment decisions and inform patient expectations in clinical practice.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Consequences of anti-vascular endothelial growth factor treatment lapse in patients with retinal vein occlusion

BACKGROUND

Anti-vascular endothelial growth factor (VEGF) treatments are the first-line treatment for Retinal Vein Occlusion (RVO). Although effectiveness and safety of these treatments is well documented, knowledge regarding the effect of lapses in anti-VEGF treatment among RVO patients is lacking. The purpose of this study is to analyse the anatomic and visual outcomes from a lapse in anti-VEGF treatment in patients with RVO.

METHODS

This retrospective case-control study evaluated 136 patients diagnosed with RVO and treated with anti-VEGF between January 2012 and June 2020 at Cole Eye Institute, Cleveland Clinic. Patients were divided into two cohorts: RVO patients with no lapse in anti-VEGF treatment (control group) and RVO patients with a lapse ≥3 months (lapse group). Central subfield thickness (CST) and best corrected visual acuity (BCVA) were collected pre-lapse, the first appointment post-lapse, and at 3-, 6-, and 12-month follow-up appointments.

RESULTS

Lapse patients (n = 68) and control patients (n = 68) had similar pre-lapse CST (p = 0.466) and BCVA (p = 0.303). Lapse patients experienced a significant increase in CST after discontinuing anti-VEGF therapy (lapse: 400.6 ± 192.1 µm, control: 333.0 ± 111.1 µm, p = 0.024). This persisted 12 months post-lapse after re-initiation of anti-VEGF agents (lapse: 381.6 ± 161.1 µm, control: 307.5 ± 95.4 µm, p = 0.030). Lapse patients also experienced a decrease in BCVA after lapse (lapse: 54.3 ± 25.1 ETDRS, control: 64.4 ± 17.8 ETDRS, p < 0.001) that recovered after 6 months of anti-VEGF treatment.

CONCLUSIONS

RVO patients with any lapse of anti-VEGF treatment are at risk for poorer anatomic and visual outcomes. Though BCVA normalizes upon treatment resumption, patients experience a statistically significant increase in CST that does not recover.

Characterization of ophthalmology virtual visits during the COVID-19 pandemic

OBJECTIVES

To characterize the use of virtual visits, as well as compare the characteristics to in-person visits during the pandemic period.

METHODS

This retrospective study included patients who had virtual and in-person ophthalmology visits from March 19, 2020, to July 31, 2020, in a large multispecialty ophthalmic center. Exclusion criteria included patients aged less than 18 years old; canceled, incomplete, mislabelled, and duplicated visits. 2943 virtual and 56,174 in-person visits were identified. A random sample of 3000 in-person visits was created. Each visit was analyzed as an individual data point.

RESULTS

2,266 virtual visits (2,049 patients, 64.3% female, mean [SD] age 64.3 [16.6] years old) and 2590 in-person visits (2509 patients, 59.5% female, 65.9 [15.8] years old) were included. Most virtual visits were classified as comprehensive ophthalmology (34.6%), optometry-related (19.5%), and oculoplastics (13.0%). For in-person visits, the most common specialties were optometry (29.8%), comprehensive ophthalmology (23.9%), and retina and uveitis (17.3%). The most common diagnoses in the virtual group were from the eyelids, lacrimal system, and orbits group (26.9%), while in the in-person groups were choroid and retina conditions (19.3%).

CONCLUSIONS

Numerous ocular conditions were evaluated and managed through virtual visits, and external complaints and oculoplastic consults appear to be well-suited to the virtual format. Further studies focusing on visual outcomes and patient experience will be beneficial.

Functional Imaging of Mitochondria in Age-Related Macular Degeneration Using Flavoprotein Fluorescence

PURPOSE

Oxidative stress-induced mitochondrial dysfunction is implicated in the pathogenesis of age-related macular degeneration (AMD). Oxidized mitochondrial flavoprotein fluorescence (FPF) may serve as a quantifiable biomarker of oxidative stress, reported as either mean score for the entire image (intensity) or variability (heterogeneity). This study examines FPF intensity and heterogeneity across a large patient cohort of various Beckman stages of AMD.

METHODS

This study enrolled patients with isolated AMD and healthy control patients with no retinopathy between 2018 and 2021. Multivariate logistic regression analysis included stage of AMD, age, gender, ethnicity, and smoking status. Analysis of Variance test compared mean FPF intensity and heterogeneity between disease states.

RESULTS

Four hundred fifty-six eyes (228 AMD eyes, 228 age-matched control eyes) were included in the final multivariate analysis. Intermediate, geographic atrophy (GA), and neovascular AMD correlated with significantly increased FPF intensity (P < 0.001, respectively), while all AMD stages correlated with increased FPF heterogeneity (P < 0.001, respectively). FPF intensity and heterogeneity were significant negative predictors of visual acuity (P = 0.018 and 0.024, respectively).

CONCLUSIONS

This prospective observational study further implicates mitochondrial damage in AMD pathophysiology. Long-term clinical trials will be needed to examine the predictive role of FPF imaging in patients over time. [Ophthalmic Surg Lasers Imaging Retina 2023;54:24-31.].

Time to Resolution of Diabetic Macular Edema after Treatment with Intravitreal Aflibercept Injection or Laser in VISTA and VIVID

OBJECTIVE

To assess the relationship between baseline factors and time to diabetic macular edema (DME) resolution.

DESIGN

Post hoc analysis of VISTA and VIVID.

PARTICIPANTS

Eyes with baseline central subfield thickness (CST) of ≥ 290 μm.

INTERVENTION

Eyes were treated with intravitreal aflibercept injection (IAI) 2 mg (n = 558; every 4 weeks or every 8 weeks after 5 monthly doses) or laser control (n = 274). The effect of baseline factors on the time to DME resolution (CST < 290 μm) was assessed in univariable and multivariable models and further evaluated by the Kaplan-Meier method.

MAIN OUTCOME MEASURES

Time to and cumulative incidence of DME resolution.

RESULTS

Eyes treated with IAI had a 2.5-fold higher DME resolution rate, with median time of 33.0 weeks (95% confidence interval [CI], 28.1-40.0), compared with DME resolution not being achieved in 50% of eyes treated with laser control. Multivariable analysis demonstrated that a lower DME resolution rate was associated with a thicker baseline CST (hazard ratio [HR] [95% CI] per 100-μm CST increase, 0.79 [0.72-0.86]) and better baseline best-corrected visual acuity (BCVA) (HR [95% CI] per 5-letter increase, 0.87 [0.83-0.92]) with IAI. Tertiles of increasing CST (T1_CST ≤ 419 μm; T2_CST > 419 to ≤ 541; T3_CST > 541) were associated with longer median times to DME resolution (20.1, 39.1, and 49.1 weeks, respectively; P < 0.001 for T2_CST and T3_CST versus T1_CST) and lower cumulative incidence of events (HR, 1.0, 0.6, and 0.6, respectively; P < 0.001 for T2_CST and T3_CST versus T1_CST) with IAI. Tertiles of increasing BCVA (T1_BCVA ≤ 57 letters; T2_BCVA > 57 to ≤ 66; T3_BCVA >66) were associated with longer median times to DME resolution (28.4, 31.7, and 44.1 weeks, respectively; P < 0.05 for T3_BCVA versus T1_BCVA) and lower cumulative incidence of events (HR, 1.0, 0.9, and 0.8, respectively; P < 0.05 for T3_BCVA versus T1_BCVA) with IAI. No other baseline factor was associated with the time to DME resolution.

CONCLUSIONS

The median time to DME resolution was 33 weeks among IAI-treated eyes. A thicker baseline CST and better baseline BCVA in the IAI group were associated with a longer time to and a lower rate of DME resolution.

Visual Acuity in Patients Requiring Intravitreal Injections: Short-Term and Long-Term Effects of Delay in Care

Purpose: To assess the short-term and long-term effects of a delay in care on visual acuity (VA) in patients requiring intravitreal injections. Methods: This retrospective cohort study comprised patients with neovascular age-related macular degeneration (nAMD), diabetic macular edema (DME), or retinal vein occlusion (RVO) receiving intravitreal injections. The visual and anatomic outcomes at the next completed visit and at the 1-year follow-up were studied. Results: Of 1172 patients, 38% had a delay in care (mean 5.7 weeks). Compared with baseline, these patients lost VA (Early Treatment Diabetic Retinopathy Study letters) (mean −2.13 ± 0.49 SE) in the short-term ( P = .0003) and had a thicker central subfield. Patients with no delay in care had a net VA gain (0.97 ± 0.39) ( P = .0067). There was no difference in VA between 1 year and the baseline in either group. Long term, patients with nAMD in both groups had VA loss (no delay in care: −1.76 ± 0.60; delayed care: −2.44 ± 0.78) ( P = .0005 and P = .0114, respectively). Patients with DME and no delay in care maintained gains in vision (4.68 ± 1.86) but those with delayed care did not (1.72 ± 2.24) ( P = .0202 and P = .3756, respectively). In both groups, patients with RVO had no significant difference in vision from baseline. Conclusions: In patients requiring intravitreal injections, a delay in care of 5.7 weeks affected vision outcomes in the short term but not the long term.

Five-Year Visual Acuity Outcomes of Fovea-Involving Rhegmatogenous Retinal Detachments Following Pars Plana Vitrectomy (PPV) or Combined PPV/Scleral Buckle

BACKGROUND AND OBJECTIVE

Macular involvement is considered a poor prognostic factor for visual recovery after rhegmatogenous retinal detachment (RRD) repair. Few prior studies report outcomes longer than 2 years after repair with pars plana vitrectomy (PPV) or combined PPV/scleral buckle (SB). The purpose of this study is to evaluate long-term (at least 5 years) visual outcomes following fovea-involving RRD repair with PPV or PPV/SB.

PATIENTS AND METHODS

This retrospective case series evaluated eyes that underwent fovea-involving RRD repair with PPV or PPV/SB. Eyes with single surgery anatomic success and 5 years or more of follow-up were included. Eyes with other ophthalmic pathology affecting central vision were excluded. Paired analysis compared changes in best visual acuity (BVA) between two timepoints.

RESULTS

Fifty-one eyes were included. Median (interquartile range, IQR) time to final follow-up was 7 (IQR: 3) years. Median pre-operatively BVA was 19.95 (IQR: 41.25) letters and improved to 80.15 (IQR:15.05) letters and 80.16 (IQR: 8.80) letters at the 1-year and final follow-up, respectively (P < 0.001). Thirteen of 45 eyes (28.89%) had an improvement in BVA of at least 10 letters from the 1-year to the final follow-up. Average BVA was 20/40 or better in 35/45 eyes (75.56%) at 1-year and 45/51 eyes (88.24%) at final follow-up. No eye had an average BVA of 20/200 or worse at final follow-up.

CONCLUSIONS

Patients with fovea-involving RRD successfully repaired with PPV or PPV/SB have favorable long-term visual acuity outcomes. BVA may continue to significantly improve even beyond 1 year after surgery. The majority of patients have a BVA of 20/40 or better 5 years after surgery. [Ophthalmic Surg Lasers Imaging Retina 2022;53:674-680.].

The Impact of Travel Distance on Rhegmatogenous Retinal Detachment Presentation and Outcomes

BACKGROUND AND OBJECTIVE

Rhegmatogenous retinal detachment (RRD) requires urgent surgical intervention. The effect of travel distance on RRD outcomes is unclear.

PATIENTS AND METHODS

This retrospective cohort study included 642 patients who underwent RRD repair at Cole Eye Institute from 2012 to 2020. Google Maps was used to calculate the travel distance in miles from the residential zip code to the presenting and surgery location addresses. Multivariable logistic and bivariate linear regressions were used to compare macula-off status and best-corrected visual acuity (BCVA) in ETDRS letters at presentation and at 6-month follow-up, with patient travel distance divided into < 25 miles, 25 to 50 miles, and > 50 miles.

RESULTS

Four hundred sixty-two patients were examined in the final cohort. The retinal reattachment rate was 94.3% for less than 25 miles, 96.3% for 25 to 50 miles, and 95.9% for greater than 50 miles (P = 0.63). In multivariable analysis, distance to presenting location was not associated with macula-off status (P = 0.69) or BCVA at follow-up (P = 0.27). Oneway analysis of distance and time from presentation to surgery in days revealed that distance to surgical site was associated with longer time to surgery (P = 0.003). Subset analysis of patients with income less than $25,520 (n = 18) revealed greater distance to presenting and surgical location was associated with longer time to surgery (P < .0001), but was not associated with BCVA at follow-up (P = 0.53).

CONCLUSIONS

This data suggests that patients who live further from the hospital achieve equivalent outcomes from RRD repair, despite delays in surgery. [Ophthalmic Surg Lasers Imaging Retina 2022;53:666-672.].

Functional imaging of mitochondria in genetically confirmed retinal dystrophies using flavoprotein fluorescence

BACKGROUND

Whether by indirect oxidative stress or direct genetic defect, various genetic retinal dystrophies involve mitochondrial stress. Mitochondrial flavoprotein fluorescence (FPF), reported as either average signal intensity or variability (heterogeneity), may serve as a direct, quantifiable marker of oxidative stress.

MATERIALS AND METHODS

This observational study enrolled patients with genetically confirmed retinal dystrophies between January and December 2021. Patients with concomitant maculopathy and ocular hypertension were excluded. Patients were FPF imaged with OcuMet Beacon_® third generation device during routine outpatient visit.

RESULTS

The final analysis cohort included 242 images from 157 patients. Mean FPF intensity was significantly increased between age matched controls and patients with confirmed rod-cone dystrophy, Stargardt disease, Bardet-Biedl syndrome (BBS), and Mitochondrial ATP synthase mutation (P ≤ 0.007). Mean FPF heterogeneity was significantly increased between age matched controls and patients with confirmed rod-cone dystrophy, Stargardt disease, and BBS (P ≤ 0.011). FPF lesions were noted to correlate with Fundus Autofluorescence (FAF) lesions in diseases examined.

CONCLUSIONS

FPF intensity and heterogeneity significantly increased in patients with retinal dystrophies. The correlation of FPF lesions with FAF lesions implies FPF may be a clinically useful biomarker in patients with IRDs.

Characterizing Early Residual Fluid in Neovascular Age-Related Macular Degeneration using Machine Learning in Routine Clinical Practice

PURPOSE

Neovascular age-related macular degeneration (nAMD) often requires intensive therapy with anti-VEGF injections. In prior post hoc studies, early residual fluid (ERF) after the loading phase was associated with poorer treatment outcomes. This retrospective study examined the impact of ERF on vision using machine learning (ML) methods in routine clinical practice.

DESIGN

Retrospective cohort.

PARTICIPANTS

This study included treatment-naïve patients with nAMD who were initiated on anti-VEGF between 2012 and 2018, with at least 1 year of follow-up.

METHODS

Overall, 286 patients with nAMD were included. An ML algorithm quantified intraretinal fluid (IRF), subretinal fluid (SRF), and total retinal fluid from OCTs. The ERF group included those with fluid at week 12 and was further stratified by fluid subtype. Paired t tests and analysis of variance compared best visual acuity (BVA) and fluid among subgroups, and a quartile analysis correlated fluid volumes to week 52 BVA. The risk of ERF was predicted from baseline factors using 3 ML methods: Ridge logistic regression, k nearest neighbors classification, and support vector classification.

MAIN OUTCOME MEASURES

Mean change in BVA from baseline to week 52 according to week 12 fluid status.

RESULTS

At week 12, 58.4% of patients had ERF. The breakdown of those in the ERF group included SRF-only (45.5%), IRF-only (21.6%), and IRF and SRF (32.9%). The ERF and ERF-free groups had similar BVA gains from baseline to week 52 (+5.7 ± 15.4 vs. +4.9 ± 18; P = 0.69). Examining specific ERF subgroups revealed no significant differences among the IRF-only (+4.6 ± 16.4), SRF-only (+5.6 ± 12.5), and IRF and SRF (+6.6 ± 18.5, P = 0.93) groups. Quartile analysis of week 12 fluid revealed no predictive pattern for BVA gains. Three ML methods were developed to predict those at risk for ERF achieved equivalent performance, with F1 score of 0.73 to 0.76.

CONCLUSIONS

These results diverge from prior post hoc studies, in that there was no significant difference in long-term BVA gains between ERF and ERF-free cohorts, as well as between the week 12 fluid subgroups.

Anti-Vascular Endothelial Growth Factor Treatment Patterns and Outcomes in Retinal Vein Occlusion in Routine Clinical Practice

BACKGROUND AND OBJECTIVE

To characterize treatment patterns for retinal vein occlusion (RVO)-related macular edema (ME) in routine clinical practice and its impact on long-term best-corrected visual acuity (BCVA) and central subfield thickness (CST).

PATIENTS AND METHODS

Retrospective study of 365 eyes with branch RVO (BRVO) or central/hemi-RVO (CRVO/HRVO)-related ME between 2003 and 2020. Regression analysis identified factors associated with maintenance injection interval (MII). Subgroup analysis compared outcomes between different MIIs.

RESULTS

51.3% of BRVO patients received injections ≤q8 weeks, 26.4% received injections q8-12 weeks, and 22.3% received injections >q12 weeks. 45.2% of CRVO/HRVO patients received injections ≤q8 weeks, 32.1% received injections q8-12 weeks, and 22.6% received injections >q12 weeks. Age, diabetes, and baseline CST were found to predict MII. There was no significant difference in BCVA and CST at baseline, 12, or 24 months in all MII groups in BRVO and CRVO/HRVO.

CONCLUSION

There exists a significant heterogeneity in anti-VEGF treatment frequency for RVO-associated ME in routine clinical practice. [Ophthalmic Surg Lasers Imaging Retina 2022;53:626-633.].

Predictors of limited early response to anti-vascular endothelial growth factor therapy in neovascular age-related macular degeneration with machine learning feature importance

PURPOSE

Patients with neovascular age-related macular degeneration (nAMD) have varying responses to anti-vascular endothelial growth factor injections. Limited early response (LER) after three monthly loading doses is associated with poor long-term vision outcomes. This study predicts LER in nAMD and uses feature importance analysis to explain how baseline variables influence predicted LER risk.

METHODS

Baseline age, best visual acuity (BVA), central subfield thickness (CST), and baseline and 3 months intraretinal fluid (IRF) and subretinal fluid (SRF) for 286 eyes were collected in a retrospective clinical chart review. At month 3, LER was defined as the presence of fluid, while early response (ER) was the absence thereof. Decision tree classification and feature importance methods determined the influence of baseline age, BVA, CST, IRF, and SRF, on predicted LER risk.

RESULTS

One hundred and sixty-seven eyes were LERs and 119 were ERs. The algorithm achieved area under the curve = 0.66 in predicting LER. Baseline SRF was most important for predicting LER while age, BVA, CST, and IRF were somewhat less important. Nonlinear trends were observed between baseline variables and predicted LER risk. Zones of increased predicted LER risk were identified, including age <74 years, and CST <290 or >350 μm, IRF >750 nL, and SRF >150 nL.

CONCLUSION

These findings explain baseline variable importance for predicting LER and show SRF to be the most important. The nonlinear impact of baseline variables on predicted risk is shown, increasing understanding of LER and aiding clinicians in assessing personalized LER risk.

Visual, Anatomic Outcomes, and Natural History of Retinal Nerve Fiber Layer Schisis in Patients Undergoing Epiretinal Membrane Surgery

PURPOSE

To evaluate the anatomic and visual outcomes of patients with idiopathic epiretinal membranes (ERMs) complicated by schisis of the retinal nerve fiber layer (sRNFL) in routine clinical practice.

DESIGN

Retrospective case-control study.

PARTICIPANTS

Patients undergoing idiopathic ERM surgery at Cole Eye Institute from 2013 to 2021.

METHODS

Patients were grouped by the presence or absence of sRNFL before surgery. Preoperative and postoperative data were collected regarding visual acuity (VA), changes in central subfield thickness (CST) over time, and presence of cystoid macular edema.

MAIN OUTCOME MEASURES

Frequency of sRNFL in patients undergoing idiopathic ERM surgery.

RESULTS

Overall, 48 (53.9%) of 89 patients presented with sRNFL. Schisis of the retinal nerve fiber layer patients presented with significantly decreased VA compared with those without (58.63 ± 12.48 vs. 67.68 ± 7.84 ETDRS letters, P < 0.001, respectively). At the final follow-up after ERM removal, there was no significant difference in final VA in patients with sRNFL compared with those without (71.16 ± 2.93 vs. 74.11 ± 2.76, P = 0.467). At presentation, patients with sRNFL had greater CST than those without (454 ± 10.01 vs. 436 ± 0.23, P = 0.23). This difference persisted at the 90-day follow-up after ERM removal (402 ± 8.08 vs. 375 ± 10.19 μm, P = 0.043). The resolution of sRNFL was reported at postoperative week 1 in 30 (96.7%) of 31 cases.

CONCLUSIONS

Schisis of the retinal nerve fiber layer is a microstructural feature in > 50% of idiopathic ERMs in routine clinical practice and carries visual significance on presentation and anatomic significance postoperatively.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

The Impact of Early Residual Fluid After Anti-Vascular Endothelial Growth Factor Initiation in Patients With Neovascular Age-Related Macular Degeneration: A Meta-Analysis Review

Fluid in neovascular age-related macular degeneration is often used to assess patient response to anti-vascular endothelial growth factor therapy. Various studies theorize that early residual fluid (ERF), noted as persistence of intraretinal fluid and subretinal fluid after the anti-vascular endothelial growth factor loading phase (LP), may be predictive of visual outcomes. This meta-analysis examined the existing literature on the relationship between ERF and long-term visual acuity (VA) and found that those who were fluid-free after the LP tended to have the highest VA gains overall. Early intraretinal fluid appeared to be associated with reduced VA gains, whereas the impact of early sub-retinal fluid was more debated. For those with ERF, monthly or more frequent dosing regimens following the LP appeared most optimal for VA. As most studies in this review were post hoc analyses, this highlights the need for real-world studies investigating ERF and its effect on visual outcomes in neovascular age-related macular degeneration. [Ophthalmic Surg Lasers Imaging Retina 2022;53:506-513.].

Opioid Prescription in Ophthalmology and the Impact of a Decision Support Tool in Reducing Excess Dosing

PURPOSE

To characterize opioid prescribing in ophthalmology and to determine the impact of an alert system on opioid prescription patterns.

DESIGN

Retrospective pre- and post-implementation study METHODS: : The study population included individuals over the age of 18 that received opioids written by ophthalmologists within a tertiary care center between January 3, 2015 and November 3, 2021, in the context of an opioid alert system. Mean morphine equivalent daily dose (MEDD) per prescription was compared before and after implementation of the opioid alert system. Additionally, mean MEDD per prescription was compared based on patient demographics and diagnoses.

RESULTS

A total of 8,014 individual patients were included in this study. The study population received a total of 9,055 prescriptions, seventy seven percent of which were written for pain management related to an ophthalmic surgery. Mean MEDD per prescription decreased by 15.17 after implementation of the alert system (p < 0.001). A higher mean MEDD per prescription was observed among males (33.53 MEDD; p < 0.001). Black individuals received a higher mean MEDD per prescription (33.93 MEDD) compared to white individuals (32.80 MEDD; p = 0.03). Opioids written for disorders of the eyelid, lacrimal system, and orbit constituted 57.4% of total prescriptions.

CONCLUSIONS

Prescription patterns based on patient demographics and diagnoses can provide foci for opioid prescription reform in ophthalmology. The observed decrease in opioid dosage may indicate realization of the alert system.