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.

Fluctuations in macular thickness in patients with diabetic macular oedema treated with anti-vascular endothelial growth factor agents

PURPOSE

To evaluate retinal thickness fluctuations in patients with diabetic macular oedema (DMO) treated with anti-vascular endothelial growth factor (anti-VEGF) injections.

METHODS

Visual acuity (VA) and central subfield thickness (CST) were collected at baseline, 3, 6, 9 and 12 months. Retinal thickness fluctuation was quantified by standard deviation (SD) of CST across 12 months. A mixed effects regression model evaluated the relationship between CST SD and VA at 12 months. Multiple linear regression analysis was performed to investigate predictors of CST SD.

RESULTS

Mean baseline and 12-month VAs were 63.5 ± 15.7 and 69.0 ± 13.8 Early Treatment of Diabetic Retinopathy Study (ETDRS) letters (change = +5.1 ± 16.1 letters, p < 0.001). Mean baseline and 12-month CSTs were 396.9 ± 109.7 and 337.7 ± 100.7 μm (change = -59.2 ± 114.8 μm, p < 0.001). Retinal thickness variability across the first 12 months was 59.4 ± 43.6 μm. Stratification of patient eyes by CST SD demonstrated 9.7 letters difference in 12-month VA between first and fourth quartiles. Significant predictors of CST SD include baseline CST, injection type, laser treatment, and DR stage.

CONCLUSIONS

Larger retinal thickness fluctuations are associated with poorer visual outcomes in eyes with DMO treated with anti-VEGF injections. Retinal thickness variability may be an important prognostic biomarker for DMO patients.

Association of Socioeconomic Health Care Disparities With Use of Anti-Vascular Endothelial Growth Factor and Visual Acuity Outcomes in Patients With Diabetic Macular Edema

BACKGROUND AND OBJECTIVE

This study characterizes the impact of race, ethnicity, insurance status, and geographic location on anti-vascular endothelial growth factor (VEGF) use for the treatment of diabetic macular edema (DME).

PATIENTS AND METHODS

This study is a retrospective cohort study. The American Academy of Ophthalmology Intelligent Research in Sight Registry was queried for patients diagnosed with DME who received at least one anti-VEGF injection between 2012 and 2020 (n = 203,707). Multivariate regression analyses investigated associations between race, ethnicity, insurance status, and geographic location and anti-VEGF use and visual outcomes.

RESULTS

White race, non-Hispanic/Latino ethnicity, and private insurance were associated with higher use of anti-VEGF injections during a 60-month period (incidence rate ratio, 1.2, 1.25, and 1.17, respectively; P < .01). Furthermore, being of non-Hispanic/Latino ethnicity and having private health insurance were associated with higher longitudinal visual acuity (odds ratio, 1.44 [P = .02] and odds ratio, 1.43 [P < .01], respectively).

CONCLUSION

Ethnicity and insurance status are associated with anti-VEGF use and visual acuity outcomes in DME. [Ophthalmic Surg Lasers Imaging Retina 2022; 53:380-391.].

Biochemical and molecular insights on the bioactivity and binding interactions of Bacillus australimaris NJB19 L-asparaginase

L-asparaginase, an antileukemic enzyme, is indispensable to the treatment of Acute Lymphoblastic Leukemia (ALL). However, the intrinsic glutaminase activity entails various side effects to the patients; thus, an improved version of the enzyme lacking glutaminase activity would be a requisite for effective treatment management of ALL. The present study highlights the biochemical and molecular characteristics of the recombinant glutaminase-free L-asparaginase from Bacillus australimaris NJB19 (BaAsp). Investigation of the active site architecture of the protein unraveled the binding interactions of BaAsp with its substrate. Comparative analysis of the L-asparaginase sequences revealed few substitutions of key amino acids in the BaAsp that could construe its substrate selectivity and specificity. The purified heterologously expressed protein (42 kDa) displayed maximum L-asparaginase activity at 35-40 °C and pH 8.5-9, with no observed L-glutaminase activity. The kinetic parameters, Km and Vmax, were determined as 45.6 μM and 0.16 μmoles min^-1, respectively. Furthermore, in silico analysis revealed a conserved zinc-binding site in the protein, which is generally implicated in inhibiting the L-asparaginase activity. However, BaAsp was not inhibited by zinc at 1 mM concentration. Therefore, the findings provide insights on the biochemical and molecular details of BaAsp, which could be valuable in formulating it for alternate antileukemic drug therapy.

Racial, Ethnic, and Gender Disparities in Diabetic Macular Edema Clinical Trials

Subjects in diabetic macular edema clinical trials in the United States are disproportionately White and male, compared with the population undergoing treatment for diabetic macular edema.

Influence of Race, Ethnicity, and Socioeconomic Factors in Idiopathic Macular Hole Presentation and Surgical Outcomes

BACKGROUND AND OBJECTIVE

To characterize the influence of race, ethnicity, and socioeconomic factors on idiopathic macular hole (IMH) presentation and surgical outcomes.

PATIENTS AND METHODS

This retrospective cohort study of patients diagnosed with IMH who underwent surgical repair collected IMH data from optical coherence tomography scans as well as demographic information. Univariate and multivariate regression models interrogated relevant relationships.

RESULTS

Of 292 eyes analyzed, 223 (76.4%) patients were White and 53 (18.2%) were Black. Mean income was $57,076.9 ± 17,794.7. Black patients presented with 0.05 mm² larger IMH area (95% CI, 0.01 to 0.09; P = .01) and 69.07 µm wider minimum linear diameter (95% CI, 15.05 to 123.10; P = .01). Patients with higher income presented with 3.76 µm narrower base diameter (95% CI, -6.42 to -1.09; P = .006).

CONCLUSIONS

Black patients were associated with larger IMH at presentation, and higher income patients were associated with smaller IMH. [Ophthalmic Surg Lasers Imaging Retina 2022;53(6): 333-344.].

Evaluation of the Content of Ophthalmology Fellowship Program Web sites

Purpose To assess the availability and content of fellowship program Web sites (FPWs) among ophthalmology subspecialties.

Design This is a cross-sectional study.

Subjects Web sites of all Association of University Professors of Ophthalmology-accredited fellowship programs in five subspecialties (i.e., surgical retina and vitreous; cornea, external disease, and refractive surgery; glaucoma; neuro-ophthalmology; and pediatric ophthalmology).

Methods FPWs were assessed for the presence of 26 key content criteria encompassing program demographics (n = 13), features (n = 10), and social life (n = 3). The presence of each content criterion as well as the content criteria groups were compared across subspecialties.

Main Outcome Measures The main outcome measured is the average percentage of key content criteria present among ophthalmology fellowship Web sites.

Results Among 266 accredited fellowship programs, 240 (90.2%) had Web sites. On average, Web sites reported 14.9 of 26 key content criteria (57.2%), 8.29 of 13 demographic criteria (63.8%), 5.84 of the 10 program features criteria (58.4%), and 0.705 of the 3 social life criteria (23.5%). Significant differences were identified among subspecialties in the presence of program description (p = 0.046), hospital affiliation (p < 0.001), names of current fellows (p = 0.004), case diversity (p = 0.001), and surgical statistics (p = 0.015). The average number of key criteria differed between subspecialties (p < 0.001).

Conclusion There is significant heterogeneity in program fellowship Web site content among ophthalmology subspecialties. Information regarding social life, such as wellness programs and community information, was largely absent across all disciplines. Addressing missing information on ophthalmology FPWs may help optimize program-applicant fit.

Impact of Persistent Retinal Fluid in Patients with Neovascular Age-Related Macular Degeneration in Routine Clinical Practice

BACKGROUND AND OBJECTIVE

To determine whether quantification of intraretinal fluid (IRF) and subretinal fluid (SRF) can be used as a biomarker for predicting visual prognosis in routine clinical practice.

PATIENTS AND METHODS

Retrospective, nonrandomized cohort study review of patients with neovascular age-related macular degeneration from January 1, 2012, to March 1, 2018.

RESULTS

In the 286-patient cohort, the mean baseline, 6-month, and 12-month best-corrected visual acuity (BCVA) was 60.24 ± 18.63, 65.57 ± 16.56, and 65.61 ± 17.37 Early Treatment Diabetic Retinopathy Study (ETDRS) letters, respectively (P < .001). The regression coefficient in the linear mixed effects regression model quantifying the association between eyes in the fourth and first quartile of IRF and 12-month BCVA was -4.14 (95% CI, -6.65 to -1.63) (P = .001) ETDRS letters. The regression coefficient quantifying the association between eyes in the fourth and first quartile of SRF and 12-month BCVA was -0.7 (95% CI, -3.07 to 1.27) (P = .56) ETDRS letters.

CONCLUSION

IRF and SRF are valuable biomarkers for BCVA outcomes in treatment-naïve neovascular age-related macular degeneration in routine clinical practice. [Ophthalmic Surg Lasers Imaging 2022;53:317-324.].

Impact of an Electronic Decision Support Tool to Improve Ophthalmic Safety in Hydroxychloroquine Prescribing Practices

BACKGROUND AND OBJECTIVE

The purpose of this study was to implement a clinical decision support tool (CDS) and assess its impact on adherence to 2016 American Academy of Ophthalmology (AAO) hydroxychloroquine dosing recommendations.

PATIENTS AND METHODS

This retrospective, interventional study implemented an automated alert to calculate maximum daily hydroxychloroquine dose based on 2016 AAO recommendations and flag noncompliant orders. Prevalence of excessive dosing after CDS implementation was assessed.

RESULTS

A total of 7,417 patients met inclusion criteria. After intervention, prevalence of excessive dosing decreased from 27.4% to 21.1% (P < .001) among all prescriptions and from 26.8% to 16.2% (P < .001) among new prescriptions. Daily doses exceeding 400 mg decreased from 0.8% to 0.02% (P < .001). Risk factors for excessive dosing included low weight (odds ratio, 75.6 [95% CI, 54.0 to 105.8]) and nonrheumatologist prescriber (odds ratio, 1.60 to 3.63; all P < .005).

CONCLUSIONS

This study highlights the efficacy of a CDS in reducing excessive hydroxychloroquine dosing and improving adherence to AAO ophthalmic safety guidelines. [Ophthalmic Surg Lasers Imaging 2022;53:310-316.].

Brolucizumab for the treatment of diabetic macular edema

PURPOSE OF REVIEW

To review the available data supporting the use of brolucizumab in the treatment of diabetic macular edema (DME).

RECENT FINDINGS

Brolucizumab is a humanized single- chain variable antibody fragment (scFv), the smallest functional subunit of an antibody approved for intravitreal use. Three phase III studies demonstrate that at 52 weeks, brolucizumab has statistically superior anatomical outcomes of reducing retinal thickness (54.0-57.5% of brolucizumab treated eyes achieved central subfield thickness <280 μm compared to 40.1 - 41.4% of aflibercept treated eyes) and retinal fluid (present in 54.2-60.3% of brolucizumab treated eyes compared to 72.9-78.2% of aflibercept treated eyes). Brolucizumab also demonstrated a prolonged durability up to 16 weeks, thus reducing treatment burden. The visual outcomes appear noninferior to current anti-VEGF agents with an increased risk for intraocular inflammatory events (0.3-4.7% compared to 0.6-1.7%).

SUMMARY

Results from recent phase III trials showing the efficacy and safety of brolucizumab presents an additional therapeutic option in the DME treatment landscape. It can reduce treatment burden in DME with increased inter-treatment intervals while conferring efficacy in both functional and anatomical outcomes. Caution should be taken regarding the risks of intraocular inflammation, retinal vasculitis, and retinal vascular occlusion.

Impact of retinal fluid in patients with diabetic macular edema treated with anti-vascular endothelial growth factors in routine clinical practice

OBJECTIVE

This study aims to determine the effect of intraretinal (IRF) and subretinal (SRF) fluid on visual outcomes for diabetic macular edema (DME) patients treated with anti-vascular endothelial growth factor (anti-VEGF) in routine clinical practice.

DESIGN

Optical coherence tomography scans were analyzed with a deep-learning artificial intelligence software to quantify IRF, SRF, and total retinal fluid (TRF) at baseline and at 3, 6, and 12 months. Predictive variables for best-corrected visual acuity (BCVA) were evaluated with linear mixed-effects regression models.

PARTICIPANTS

A total of 220 DME eyes of 220 patients from the Cole Eye Institute at Cleveland Clinic.

METHODS

Retrospective, nonrandomized cohort study.

RESULTS

BCVA improved from baseline to 12 months (63.36 ± 14.72 to 68.49 ± 13.14 Early Treatment Diabetic Retinopathy Study letters, p < 0.001, respectively). Central subfield thickness improved from baseline to 12 months (411.74 ± 129.7 to 335.94 ± 116.91 mm, p < 0.001, respectively). Injection frequency per patient was 8.25 ± 2.5 injections over 12 months. The linear mixed-effects regression model in the foveal region for TRF, IRF, and SRF volume at the fourth quartile showed BCVA losses of -8.29 letters (range, -10.96 to -5.62 letters, p < 0.001), -7.52 letters (range, -10.3 to -4.74 letters, p < .001), and -6.93 letters (range, -10.54 to -3.41 letters, p < .001), respectively.

CONCLUSIONS

The highest quartile of TRF, IRF, and SRF volumes led to worse visual outcomes after 12 months of anti-VEGF treatment in patients with DME. Further studies designed to investigate the effect of anti-VEGF treatment on retinal fluid morphology could provide greater insight into individualized DME treatment.

Progression to Vision-Threatening Retinopathy Complications Following Panretinal Laser for Proliferative Diabetic Retinopathy

BACKGROUND AND OBJECTIVE

To report the time in which patients with panretinal photocoagulation (PDR) progress to vision-threatening retinopathy (VTR) complications after receiving PRP, and risk factors in routine clinical practice.

PATIENTS AND METHODS

Records of patients with complete PRP for PDR were retrospectively reviewed for up to 3.5 years after PRP. Two hundred twenty eyes were selected.

RESULTS

Time from PRP to VTR was 1.25 ± 0.82 years. Age, Black race, neovascularization of the disc on examination, diabetic foot disease (DFD), and high-risk PDR characteristics on fluorescein angiography were identified as significant risk factors. Half of patients with DFD on examination developed a VTR within 1.5 years after PRP (P < .001).

CONCLUSION

In clinical practice, providers may consider DFD and Black race as predictors of time to VTR event within 4 years after PRP in patients with PDR. [Ophthalmic Surg Lasers Imaging Retina. 2022;53(4):186-193.].