Posterior vitreomacular adhesion and risk of exudative age-related macular degeneration: paired eye study

Paired-eye comparison of endothelial cell density and vault height after implantable collamer lens implantation

In clinical practice, the effect of a high vault on corneal endothelial cells after implantable collamer lens (ICL) implantation remains unclear. Many clinicians theoretically assume that a high postoperative vault leads to rapid endothelial damage, but no study has yet proven this hypothesis. We conducted a paired-eye study to compare changes in corneal endothelial cell density (ECD) between high and low postoperative vault groups. This retrospective study included 150 eyes of 75 patients with bilateral postoperative vault levels differing by more than 200 μm after ICL implantation. Patients were followed up for 7 years with ECD measurements, and changes in ECD were assessed between 6 months and 7 years post-surgery. Over the 7-year follow-up period, the percentage of ECD loss was 15.04% and 14.45% in the high- and low-vault groups, respectively. The bilateral paired-eye comparison revealed a significant reduction in ECD in the high-vault group at 3, 5, and 7 years postoperatively (P-value < 0.001). In this paired-eye comparison of long-term observations, a higher vault was associated with greater ECD loss. Our study confirms that a high vault level may be an important risk factor for ECD loss following ICL implantation.

Hyalocytes-guardians of the vitreoretinal interface

Originally discovered in the nineteenth century, hyalocytes are the resident macrophage cell population in the vitreous body. Despite this, a comprehensive understanding of their precise function and immunological significance has only recently emerged. In this article, we summarize recent in-depth investigations deciphering the critical role of hyalocytes in various aspects of vitreous physiology, such as the molecular biology and functions of hyalocytes during development, adult homeostasis, and disease. Hyalocytes are involved in fetal vitreous development, hyaloid vasculature regression, surveillance and metabolism of the vitreoretinal interface, synthesis and breakdown of vitreous components, and maintenance of vitreous transparency. While sharing certain resemblances with other myeloid cell populations such as retinal microglia, hyalocytes possess a distinct molecular signature and exhibit a gene expression profile tailored to the specific needs of their host tissue. In addition to inflammatory eye diseases such as uveitis, hyalocytes play important roles in conditions characterized by anomalous posterior vitreous detachment (PVD) and vitreoschisis. These can be hypercellular tractional vitreo-retinopathies, such as macular pucker, proliferative vitreo-retinopathy (PVR), and proliferative diabetic vitreo-retinopathy (PDVR), as well as paucicellular disorders such as vitreo-macular traction syndrome and macular holes. Notably, hyalocytes assume a significant role in the early pathophysiology of these disorders by promoting cell migration and proliferation, as well as subsequent membrane contraction, and vitreoretinal traction. Thus, early intervention targeting hyalocytes could potentially mitigate disease progression and prevent the development of proliferative vitreoretinal disorders altogether, by eliminating the involvement of vitreous and hyalocytes.

Vitreomacular interface abnormalities in the Ghanaian African

BACKGROUND/OBJECTIVE

Describe vitreomacular interface abnormalities (VMIA) using spectral-domain optical coherence tomography (SD-OCT), and correlations with age-related macular degeneration (AMD) grade in Ghanaian Africans.

SUBJECTS/METHODS

Prospective, cross-sectional study of adults aged ≥50 years recruited in Ghana AMD Study. Participant demographics, medical histories, ophthalmic examination, digital colour fundus photography (CFP) were obtained. High-resolution five-line raster OCT, Macular Cube 512 × 128 scans, and additional line scans in areas of clinical abnormality, were acquired. SD-OCT VMI features classified by International Vitreomacular Traction Study Group system and relationships to AMD grade were evaluated.

OUTCOMES

VMIA prevalence, posterior vitreous detachment (PVD), vitreomacular adhesions (VMA), vitreomacular traction (VMT), epiretinal membranes (ERM), correlations with AMD grade.

RESULTS

The full Ghana AMD cohort included 718 participants; 624 participants (1248 eyes) aged ≥50 years (range = 50-101, mean = 68.8), 68.9% female were included in this analysis. CFP with OCT scans were available for 776 eyes (397 participants); 707 (91.1%) had gradable CFP and OCT scans for both AMD and VMI grading forming the dataset for this report. PVD was absent in 504 (71.3%); partial and complete PVD occurred in 16.7% and 12.0% respectively. PVD did not increase with age (p = 0.720). VMIA without traction and macular holes were observed in 12.2% of eyes; 87.8% had no abnormalities. VMIA was not significantly correlated with AMD grade (p = 0.819).

CONCLUSIONS

This provides the first assessment of VMIA in Ghanaian Africans. VMIA are common in Africans; PVD may be less common than in Caucasians. There was no significant association of AMD grade with VMIA.

Prevalence and Associations of Epiretinal Membranes in an Elderly English Population: The Bridlington Eye Assessment Project

Purpose: To determine the prevalence and risk factors of epiretinal membranes (ERMs) in an adult English population. Methods: The Bridlington Eye Assessment Project is a population-based study of eye disease among residents aged 65 years or older. Comprehensive interviews and ophthalmic examinations were conducted to assess potential risk factors. Digital mydriatic nonstereoscopic 30° colour fundus photography (CFP) was performed. ERMs were classified as primary/idiopathic or secondary on the basis of findings from the ocular examination and the structured questionnaire. Logistic regression models were used to determine the independence of potential risk factors for idiopathic ERMs. Results: In a comprehensive screening of 3588 patients aged over 65, we identified an eye-based prevalence of ERMs of 4.26% and a subject-based prevalence of ERMs of 6.88%. The majority of these cases were idiopathic in nature (90.7%), while 9.3% were secondary ERMs; predominantly, there was a history of cataract surgery (43.5%). No significant correlation between idiopathic ERMs and factors such as age, gender, diabetes, hypertension, a history of stroke, or the presence of AMD was found. Conclusions: The prevalence of ERMs in an elderly English population and the proportion of idiopathic and secondary ERMs are similar to previous reports. However, in elderly patients aged over 65 years, age is not a risk factor for the presence of idiopathic ERMs. The presence of diabetes, hypertension, a history of stroke, and AMD of any grade was not associated with ERMs.

[Role of vitreous in the pathogenesis of neovascular age-related macular degeneration]

Age-related changes in vitreous molecular and anatomic morphology begin early in life and involve two major processes: vitreous liquefaction and weakening of vitreo-retinal adhesion. An imbalance in these two processes results in anomalous posterior vitreous detachment (PVD), which comprises, among other conditions, vitreo-macular adhesion (VMA) and traction (VMT). VMA is more common in patients with neovascular age-related macular degeneration (nAMD) than age-matched control patients, with the site of posterior vitreous adherence to the inner retina correlating with location of neovascular complexes. The pernicious effects of an attached posterior vitreous on age-related macular degeneration (AMD) progression involve mechanical forces, enhanced fluid influx and inflammation in and between the retinal layers, hypoxia leading to an accumulation of vascular endothelial growth factor (VEGF) and other stimulatory cytokines, and probably an infiltration of hyalocytes. It has been shown that vitrectomy not only mitigates progression to end-stage AMD, but existing choroidal neovascularization regresses after surgery. Thus, surgical PVD induction during vitrectomy or by pharmacologic vitreolysis may be considered in non-responders to anti-VEGF treatment with concomitant VMA.

Comparison of implantation of posterior chamber phakic IOL implantation and laser vision correction in terms of corneal endothelial cells: 3-year observational paired-eye study

PURPOSE

To compare the postoperative endothelial cell counts of EVO-implantable collamer lenses (ICLs) with a central hole (V4c and V5) and laser vision correction surgery (laser in situ keratomileusis or photorefractive keratectomy).

SETTING

B&VIIT Eye Center, Seoul, South Korea.

DESIGN

Retrospective observational and paired contralateral study.

METHODS

62 eyes of 31 patients who underwent EVO-ICLs with a central hole implantation in one eye (phakic intraocular lens [pIOL] group) and laser vision correction in the contralateral eye (LVC group) to correct refractive errors were retrospectively reviewed. Central endothelial cell density (ECD), percentage of hexagonal cells (HEX), coefficient of variation (CoV) in cell size, and adverse events were evaluated for at least 3 years. The endothelial cells were observed using a noncontact specular microscope.

RESULTS

All surgeries were performed, without complications during the follow-up period. The mean ECD loss values compared with the preoperative measurements were 6.65% and 4.95% during the 3 years after pIOL and LVC, respectively. There was no significant difference in ECD loss compared with the preoperative values (paired t test, P = .188) between the 2 groups. No significant loss in ECD was observed at any timepoint. The pIOL group showed higher HEX ( P = .018) and lower CoV ( P = .006) values than the LVC group at the last visit.

CONCLUSIONS

According to the authors' experience, the EVO-ICL with a central hole implantation was a safe and stable vision correction method. Moreover, it did not induce statistically significant changes in ECD at 3 years postoperatively compared with LVC. However, further long-term follow-up studies are required to confirm these results.

Prognostic factors associated with the course of vitreomacular traction in eyes with age-related macular degeneration

CLINICAL RELEVANCE

Vitreomacular traction(VMT) is a clinical syndrome that can cause decreased vision and may affect the treatment response in cases of age-related macular degeneration(AMD). Factors affecting the course of VMT in AMD cases will guide the clinician in terms of patient management.

BACKGROUND

The aim of this study was to determine the prevalence of VMT in patients with AMD, to evaluate the natural course of VMT, and to investigate factors associated with the prognosis of VMT in eyes with AMD.

METHODS

This retrospective case series was conducted with 55 eyes of 46 patients who were diagnosed as having AMD accompanying with VMT. Demographic data, complete ophthalmologic examination findings, type of AMD, receiving an intravitreal injection(IVI), number of IVIs, and the presence of complete spontaneous release were obtained from the medical records of the patients. The horizontal length of VMT(HLVMT), central macular thickness(CMT), the horizontal length of choroidal neovascularization(HLCNV) were evaluated from spectral-domain optical coherence tomography(SD-OCT) images.

RESULTS

Spontaneous release was observed in 7(28%) eyes of the exudative AMD group and 10(33.3%) eyes of the nonexudative AMD group. On the last visit, the HLVMT was increased in 22(40%) of the eyes and a decrease in HLVMT was observed in 8(14.5%) of the eyes. In the remaining 12(21.8%) eyes had unchanged HLVMT. In all eyes with CNV, the area of VMT corresponded in 100% with localization of the CNV complex. No significant difference was found between the eyes with spontaneous release and persistent traction in terms of the type of AMD, IVI, HLVMT, age, gender, and crystalline lens status.

CONCLUSION

In this study, VMT was observed at higher rates in eyes with exudative AMD compared to the eyes with nonexudative AMD. However, spontaneous release rates were found close to those with idiopathic VMT independently of the type of AMD, HLVMT, and IVI.

Visual Outcome after Vitrectomy with Subretinal tPA Injection to Treat Submacular Hemorrhage Secondary to Age-Related Macular Degeneration or Macroaneurysm

Purpose

To determine the efficacy and safety of 23G transconjunctival sutureless vitrectomy, subretinal injection of tissue plasminogen activator using the EVA Surgical System, and pneumatic displacement with air to treat submacular hemorrhages.

Methods

Retrospective analysis of 93 eyes surgically treated for submacular hemorrhage caused by neovascular AMD or retinal macroaneurysms. Main Outcome Measures. Postoperative visual acuity and surgical complications.

Results

After surgery, visual acuity improved after 6 weeks but decreased again at the final postoperative visit at 8 months due to progression of the underlying disease. Complications consisted of 2 cases of retinal pigment epithelial tear, 7 vitreous hemorrhages, 4 hyphema, 6 cases of retinal detachment, and 2 subchoroidal hemorrhages during the follow-up period.

Conclusions

This study suggests that a surgical approach with 23G vitrectomy, subretinal tPA injection, and pneumatic displacement using air may be an effective procedure for submacular hemorrhage displacement in patients with AMD and retinal macroaneurysms. However, visual outcome is limited by the underlying macular pathology. Larger multicenter randomized controlled studies are warranted to determine the therapeutic effect of this surgical approach.

The prevalence of vitreomacular adhesion in eyes with macular oedema secondary to retinal vein occlusion selected for intravitreal injections

PURPOSE

To assess the prevalence of vitreomacular adhesion (VMA) in consecutive naïve eyes diagnosed with macular oedema (ME) secondary to retinal vein occlusion (RVO) and to longitudinally evaluate the incidence of vitreomacular interface changes over time and the influence on response to treatment.

DESIGN

Retrospective cross-sectional analysis and longitudinal cohort study conducted at two Italian tertiary referral centres.

METHODS

A total of 295 eyes, treated with intravitreal ranibizumab and/or dexamethasone for ME secondary to RVO between June 2008 and May 2018, were enrolled in the study. 280 fellow eyes met the inclusion criteria and were included as control group. The vitreomacular interface status was evaluated by spectral domain optical coherence tomography (OCT) and graded according to the OCT-based International Classification System developed by the International Vitreomacular Traction Study (IVTS) group.

RESULTS

At baseline, VMA was present in 130 (44.07%) RVO eyes and 142 (50.7%) control eyes (no statistically significant difference was found; p = 0.455). Mean follow-up (FU) was 35.98 months (min 6 - max 112). Throughout the FU, the incidence of spontaneous release of VMA (RVMA) in RVO eyes was significantly higher in comparison with that of the control group [59 (41.84%) RVO eyes versus 18 (12.33%) control eyes; p < 0.0001]. The number of injections in VMA+ eyes was significantly higher when compared with VMA- eyes. No significant difference was found between VMA+ and VMA- eyes regarding their mean best-corrected visual acuity (BCVA) at baseline and at each annual time point (p = 0.2). Differences in central macular thickness (CMT) were significant only at the baseline evaluation (p = 0.0303).

CONCLUSIONS

Vitreomacular adhesion (VMA) was not found to be more prevalent in eyes with RVO compared to healthy fellow eyes, and RVO, in turn, did not result in a higher persistence of VMA over time. This suggests that VMA and RVO might be two independent retinal phenomena, with no mutual pathogenetic influence. Vitreomacular adhesion (VMA) might have an impact on the response to treatment, since it was found to result in a more intensive treatment regimen; however, it did not affect visual and anatomic outcomes. These results do not support vitrectomy or PVD induction in the prevention, nor the treatment, of RVO.

OCT Biomarkers in Neovascular Age-Related Macular Degeneration: A Narrative Review

Age-related macular degeneration (AMD) is the leading cause of legal blindness in elderly people. Neovascular AMD (nAMD) is responsible for the majority of cases of severe visual loss in eyes with AMD. Optical coherence tomography (OCT) is the most widely used technology for the diagnosis and follow-up of nAMD patients, which is widely used to study and guide the clinical approach, as well as to predict and evaluate treatment response. The aim of this review is to describe and analyze various structural OCT-based biomarkers, which have practical value during both initial assessment and treatment follow-up of nAMD patients. While central retinal thickness has been the most common and one of the first OCT identified biomarkers, today, other qualitative and quantitative biomarkers provide novel insight into disease activity and offer superior prognostic value and better guidance for tailored therapeutic management. The key importance of retinal fluid compartmentalization (intraretinal fluid, subretinal fluid, and subretinal pigment epithelium (RPE) fluid) will be discussed firstly. In the second part, the structural alterations of different retinal layers in various stages of the disease (photoreceptors layer integrity, hyperreflective dots, outer retinal tubulations, subretinal hyperreflective material, and retinal pigment epithelial tears) will be analyzed in detail. The last part of the review will focus on how alterations of the vitreoretinal interface (vitreomacular adhesion and traction) and of the choroid (sub-RPE hyperreflective columns, prechoroidal clefts, choroidal caverns, choroidal thickness and choroidal volume, and choroidal vascular index) interact with nAMD progression. OCT technology is evolving very quickly, and new retinal biomarkers are continuously described. This up-to-date review article provides a comprehensive description on how structural OCT-based biomarkers provide a valuable tool to monitor the progression of the disease and the treatment response in nAMD patients. Thus, in this perspective, clinicians will be able to allocate hospital resources in the best possible way and tailor treatment to the individual patient's needs.

Prevalence of Vitreoretinal Interface Disorders in an Australian Population

Purpose

To describe the prevalence, risk factors, and associations of vitreoretinal interface (VRI) abnormalities in a population-based study of older adults.

Design

Cross-sectional analysis of cohort study participants.

Participants

Of the 1149 participants (mean age, 76.1 ± 6.9 years) in the 15-year Blue Mountains Eye Study follow-up examination from 2007 through 2009, 905 (1791 eyes) had gradable time-domain or spectral-domain OCT scans of the macula from at least 1 eye.

Methods

OCT scans were graded according to the International Vitreomacular Traction Study Group classification system of VRI abnormalities. Best-corrected visual acuity (BCVA) was recorded.

Main Outcome Measures

Prevalence of VRIs.

Results

Overall, 451 participants showed any VRI abnormality (49.8%). Prevalence of VRI abnormality by person was: vitreomacular adhesion (VMA), 33.6%; vitreomacular traction (VMT), 1.6%; epiretinal membrane (ERM), 21.4%; full-thickness macular hole (FTMH), 0.7%; and lamellar macular hole (LMH), 0.7%. Twenty-two percent of VMAs were focal, and 78% were broad based; 76% of VMTs were focal, and 24% were broad based. All FTMHs observed were large (>400 μm), with mean aperture size of 573 μm (range, 459–771 μm). Increased age was associated with higher ERM and lower VMA prevalence (P < 0.001 for both). Pseudophakia and myopia were associated with ERM (age- and sex-adjusted odds ratios [ORs], 1.48 [95% confidence interval (CI), 1.01–2.17] and 1.72 [95% CI, 1.05–2.81], respectively). Moderate or severe ERM and FTMH were associated with worse BCVA of 9.2 Early Treatment Diabetic Retinopathy Study (ETDRS) letters (95% CI, 3.4–15.0 ETDRS letters; P = 0.008) and 26.0 ETDRS letters (95% CI, 10.9–41.1 ETDRS letters; P = 0.001), respectively.

Conclusions

The prevalence of VRI abnormalities is high in older individuals. Epiretinal membrane was associated with increasing age, pseudophakia, and myopia. Epiretinal membrane and FTMH may account for significant visual loss in the affected eye. This study provided useful population-based data on the prevalence of VRI abnormalities in older individuals.

Vitreomacular interface after anti-VEGF injections in diabetic macular edema

Background

The purpose of this study was to evaluate the incidence of vitreomacular adhesion (VMA) release after anti-VEGF therapy for the treatment of diabetic macular edema (DME) and to evaluate further changes in outcome.

Methods

This was a retrospective study that enrolled 66 eyes of 66 patients with DME who presented with VMA diagnosed by spectral-domain optical coherence tomography (OCT) at baseline. VMA was classified as focal (attachment: ≤ 1500 μm) or broad (attachment: > 1500 μm). All patients received at least three monthly intravitreal injections of an anti-VEGF agent. Follow-up visits were performed 1 month after each injection to evaluate the incidence of VMA release.

Results

The mean patient age was 61.4 years (range: 29 to 78 years), and 72.7 % were male. The mean best-corrected visual acuity was 0.62 logMAR, and the mean central retinal thickness (CRT) was 473 μm at baseline. The mean length of follow-up was 18.5 months, and the mean number of injections was 5.8. The intravitreal drugs used were aflibercept (40.9 %), ranibizumab (37.9 %) and bevacizumab (21.2 %). Forty-seven eyes had broad VMA, and 19 had focal VMA. Twenty-two eyes (33.3 %) developed VMA release following a mean of 5.7 injections (range: 3–13). Sixteen eyes (72.7 %) with focal VMA and 6 eyes (27.3 %) with broad VMA at baseline developed VMA release. Twenty-one eyes that developed VMA release showed an improvement in CRT following VMA release (mean: -106 μm; range: 22 to 289 μm).

Conclusions

VMA release occurs in approximately 1/3 of patients with DME following anti-VEGF therapy. Most of them show a short-term decrease in CRT.

AFLIBERCEPT AFTER RANIBIZUMAB INTRAVITREAL INJECTIONS IN EXUDATIVE AGE-RELATED MACULAR DEGENERATION: The ARI2 Study

Treatment-resistant pigment epithelial detachments can be effectively treated with aflibercept switch therapy. Patients were treated with 3 monthly intravitreal injections and then a Q6 regimen. Mean pigment epithelial detachment height and volume were statistically reduced after the switch at primary endpoint (12 weeks), and best-corrected visual acuity also improved steadily throughout the duration of the study.

Purpose:

To analyze the efficacy of aflibercept switch treatment for regression of pigment epithelial detachment (PED) in patients previously treated with ranibizumab.

Methods:

Multicenter, prospective, nonrandomized clinical trial. One eye of patients presenting neovascular age–related macular degeneration with PED of more than 250 μm in height, with persistent fluid, was included. Patients had to have received at least six ranibizumab intravitreal injections during the 12 months before enrollment. Patients were switched from ranibizumab pro re nata to aflibercept (fixed regimen, 3 monthly intravitreal injections, and then Q6). Main outcome measure was change in PED height from baseline to Week 12 after switch. Secondary outcomes were best-corrected visual acuity and PED volume changes.

Results:

Eighty four patients were included. Mean delay between last ranibizumab intravitreal injection and switch was 44.7 days. Mean maximal PED height at baseline visit was 347 μm (±109) and reduced to a mean of 266 μm (±114) at Week 12 (P < 0.001) and 288.2 μm at Week 32 (P < 0.001). Mean PED volume was reduced from 1.3 mm³ to 0.98 mm³ at Week 12 (P < 0.001). Best-corrected visual acuity improved by 3.3 Early Treatment Diabetic Retinopathy Study letters at Week 32 (P = 0.003).

Conclusion:

Aflibercept switch therapy seems to be effective on large PED in patients previously treated with pro re nata ranibizumab.

The role of posterior vitreous detachment on the efficacy of anti-vascular endothelial growth factor intravitreal injection for treatment of neovascular age-related macular degeneration

Purpose:

A prospective cohort study investigating the effect of posterior vitreous detachment (PVD) on the efficacy of intravitreal bevacizumab for exudative age-related macular degeneration (AMD), in view of evidence that the vitreoretinal interface impacts the severity of the disease.

Methods:

Treatment-naïve AMD eyes with (+) complete PVD and without (−) PVD on ultrasonography received three monthly and then pro re nata bevacizumab injections. Best-corrected visual acuity (BCVA) on Snellen charts and optical coherence tomography (OCT) findings were recorded for 12 months. Secondary analysis included PVD definition and group allocation according to OCT baseline scan.

Results:

Forty-one eyes of 34 patients met the inclusion criteria. At 12 months, median BCVA improved by 0.12 logMAR in the PVD+ group [interquartile range (IQR) −0.52, 0.03, P = 0.140] and remained the same in the PVD− group (IQR −0.12, 0.15, P = 0.643). Median central retinal thickness improved by 43.5 μm and 43 μm in the PVD+ (IQR −143, 3, P = 0.016) and PVD− group (IQR −90, −14, P = 0.008), respectively. All parameters were similar in the two groups at final follow up (P > 0.05). The secondary analysis included 32 eyes of 26 patients and showed no significant differences between the groups at the 12 months endpoint (P > 0.05).

Conclusion:

Our findings show no significant impact of PVD as assessed by ultrasound or by OCT on visual and anatomical outcomes in exudative AMD treated with bevacizumab.

Influence of the Vitreoretinal Interface on the Treatment with Anti-VEGF for Exudative Age-Related Macular Degeneration

PURPOSE

To investigate the influence of the vitreoretinal interface on the outcomes of different ranibizumab regimens for exudative age-related macular degeneration.

METHODS

We conducted a retrospective subanalysis of 2 prospective clinical trials. Patients were treated with ranibizumab for 12 months according to 3 different regimens: pro-re-nata (PRN), treat and extend (T&amp;E), and monthly. Vitreoretinal interface was assessed for absence (group ON) or presence (group OFF) of posterior vitreous detachment (PVD).

RESULTS

We included 64 eyes from 64 patients. Visual improvement was poorer for group ON (0.3 ± 10.7 letters) than for group OFF (9.2 ± 13.3; p = 0.007). A significant difference in letters of improvement between groups was observed in the PRN cohort (ON: -5.0 ± 12.9; OFF: 11.4 ± 11.9; p = 0.003), but not in the cohorts with monthly (ON: 5.7 ± 7.8; OFF: 7.9 ± 15.2; p = 0.735) or T&amp;E (ON: 4.3 ± 4.3; OFF: 7.8 ± 11.1; p = 0.424) treatment.

CONCLUSION

The negative impact of absence of PVD is regimen dependent, with monthly dosing providing similar outcomes to PVD patients. In the absence of PVD (group ON), PRN should be avoided, and T&amp;E might be an alternative.

Baseline Predictors of Visual Acuity Outcome in Patients with Wet Age-Related Macular Degeneration

Age-related macular degeneration (AMD) is one of the leading causes of severe vision loss in people over 60 years. Wet AMD (wAMD) causes more severe visual acuity (VA) loss compared with the dry form due to formation of choroidal neovascularization (CNV). Antivascular endothelial growth factor (anti-VEGF) agents such as ranibizumab and aflibercept are now the standard of care treatment for wAMD. Unfortunately, up to a quarter of anti-VEGF-treated wAMD patients might not fully benefit from intravitreal injections and CNV activity may not respond to the treatment and these patients are called anti-VEGF nonresponders. This article aims to discuss the baseline factors associated with VA outcome such as age, initial VA, lesion types, disease duration, optical coherence tomography (OCT) features, fundus autofluorescence findings, and the presence of particular genotype risk alleles in patients with wAMD. Recommendations are provided regarding when to consider discontinuation of therapy because of either success or futility. Understanding the predictive factors associated with VA outcome and treatment frequency response to anti-VEGF therapy may help retina specialists to manage patients' expectations and guide treatment decisions from the beginning of treatment on the basis of “personalized medicine.”

ASSOCIATION BETWEEN THE VITREOMACULAR INTERFACE AND OPTICAL COHERENCE TOMOGRAPHY CHARACTERISTICS IN WET AGE-RELATED MACULAR DEGENERATION

PURPOSE

To study the effect of the vitreomacular interface on various wet age-related macular degeneration (AMD) characteristics including the size and type of choroidal neovascularization (CNV), choroidal thickness, and activity of the CNV.

METHODS

This was a retrospective observational cross-sectional study. The study included 43 patients (51 eyes) with treatment-naive age-related macular degeneration. Twenty-six patients with wet AMD in one eye and dry AMD in the other eye were included in a paired-eye analysis. Patients underwent optical coherence tomography examination using Heidelberg Spectralis (spectral domain optical coherence tomography) at presentation to determine the type of CNV and the vitreomacular status. In addition, various parameters were measured including the choroidal thickness and horizontal width and vertical height measurements of the CNV.

RESULTS

There was no correlation between the height, width, activity or type of the CNV, and the presence or absence of vitreomacular adhesion. The mean choroidal thickness (using enhanced depth imaging) in cases with vitreomacular adhesion was 272.57 μm compared with 197.32 μm in cases with no vitreomacular adhesion, a statistically significant difference (P = 0.003). In the paired-eye study (21 patients), there was no significant difference between the eyes with wet AMD and dry AMD with regard to vitreomacular status or the choroidal thickness. In a subgroup analysis, patients with Type 1 CNV had a significantly higher percentage of vitreomacular adhesion compared with the other eye with dry AMD (P = 0.034).

CONCLUSION

In conclusion, the vitreomacular interface does seem to be associated with an increased choroidal thickness in cases of wet AMD. Furthermore, the association between the vitreomacular interface and wet AMD is more significant for Type 1 CNV.

The effect of vitreomacular adhesion in exudative age-related macular degeneration on the results of ranibizumab intravitreal injection

PURPOSE

To investigate whether vitreomacular adhesion (VMA) affects the outcome of anti-vascular endothelial growth factor (VEGF) therapy for the treatment of exudative age-related macular degeneration (AMD) in Japanese patients.

SUBJECTS AND METHODS

Of 88 Japanese AMD patients (28 men and 60 women, mean age: 72.7±7.5 years) who underwent intravitreal injection of ranibizumab for 3 years from 2010 to 2013, this study involved 12 eyes of 12 patients (10 men and two women) in whom VMA was observed based on optical coherence tomography (OCT) findings (VMA [+] group) and 17 eyes of 16 patients (seven men and nine women, control group) in whom no VMA was observed (VMA [-] group). In all enrolled patients, ranibizumab was administered monthly for 3 months, and then administered as needed (ie, pro re nata) when deterioration was observed. The two groups were then compared in regard to changes in visual acuity (VA) and the frequency of ranibizumab administration over a 1-year period.

RESULTS

No significant difference was found between the two groups in regard to the transformation of the mean logarithm of the minimum angle of resolution VA change after the first visit. Over the 1-year treatment, the mean frequency of ranibizumab administration for the VMA (+) group was 5.6±2.5 times and for the VMA (-) group was 3.8±1.1 times, thus illustrating a significant difference between the two groups (Mann-Whitney's U-test: P<0.05).

CONCLUSION

Our findings show that the mean frequency of ranibizumab administration for the VMA (+) group was higher than that in the VMA (-) group, thus indicating that VMA might possibly be involved in the progress of AMD pathology.

Vitreomacular adhesion or vitreomacular traction may affect antivascular endothelium growth factor treatment for neovascular age-related macular degeneration

OBJECTIVE

The aim of this review is to determine whether vitreomacular adhesion (VMA) or vitreomacular traction (VMT) has an influence on the outcomes of antivascular endothelium growth factor (anti-VEGF) treatment neovascular age-related macular degeneration (nAMD).

METHODS

A systematic literature search was performed in Pubmed.gov, Cochrane Library, Web of Science, China National Knowledge Infrastructure, Wanfang, SinoMed and ClinicalTrials.gov up to 30 June 2016 to identify eligible studies.

RESULTS

Nine studies and 2212 participants were finally identified. At month 6, the mean improvement in best-corrected visual acuity (BCVA) and mean decline in central retinal thickness (CRT) of the VMA/VMT(+) group was less than that of the VMA/VMT(-) group (95% CI -3.05 to -0.96 letters, p=0.0002; 15.53 to 32.98 μm, p<0.00001; respectively); at month 12, there was a small or only marginally significant difference (-0.01 to 2.00 letters, p=0.05; 0.17 to 23.7 μm, p=0.05; respectively) between the groups. During the 12 months, however, the VMA/VMT(+) group required more injections ((0.25 to 0.95), p=0.0008).

CONCLUSIONS

In using anti-VEGF drugs to treat nAMD, clinicians should take into account the fact that concurrent VMA or VMT might antagonise the efficacy of anti-VEGF drugs during the early stage of treatment.

The vitreomacular interface in different types of age-related macular degeneration

AIM

To evaluate the vitreomacular interface in cases with wet age-related macular degeneration (AMD) and to compare them to eyes with dry AMD and normal eyes.

METHODS

This was a cross-sectional comparative study that included 87 eyes with wet AMD, 42 eyes with dry AMD and 40 eyes without AMD as a control group. Optical coherence tomography (OCT) examination was performed for all patients to assess the vitreomacular interface.

RESULTS

In the wet AMD group, 34.5% of cases had vitreomacular adhesion (VMA). Only 14.3% of dry AMD cases and 10% of control cases had VMA. There was a significant difference between the control group and the wet AMD group (P=0.004) as well as the dry and wet AMD group (P=0.017). There was also a significant difference between the incidence of VMA in patients with subretinal choroidal neovascularization (CNV, type 1) and intraretinal CNV (type 2 or type 3) (P=0.020).

CONCLUSION

There is an association between posterior vitreous attachment and AMD. There is also an increased incidence of VMA with intra-retinal CNV.

Vitreomacular Adhesion and the Risk of Neovascular Age-Related Macular Degeneration

PURPOSE

To assess the prevalence of vitreomacular adhesion (VMA) in consecutive naïve eyes diagnosed with exudative age-related macular degeneration (AMD) in comparison with eyes with nonexudative AMD and age-matched controls, and to evaluate prospectively the incidence of vitreomacular interface changes over time and their influence on choroidal neovascularization (CNV) development.

DESIGN

Retrospective cross-sectional analysis and longitudinal cohort study conducted at Sacrocuore Hospital, Negrar, Verona, Italy.

PARTICIPANTS

A total of 1067 eyes examined at Sacrocuore Hospital between August 2008 and June 2015 met the inclusion criteria and were evaluated in this study.

METHODS

Eyes were classified into 3 groups: 403 eyes of 364 patients (mean [standard deviation; SD] age 77.8 [8.0] years) affected by exudative AMD; 350 eyes of 298 subjects (mean [SD] age 78.1 [8.2] years) with nonexudative AMD; and 314 eyes of 214 subjects (mean [SD] age 74.2 [8.2] years) with no signs of AMD enrolled as the control group. The vitreomacular interface status was evaluated by spectral-domain optical coherence tomography (OCT) and was graded according to the OCT-based International Classification System developed by the International Vitreomacular Traction Study Group by 2 independent masked observers.

RESULTS

VMA was present in 101 (25.1%) eyes with exudative AMD, 84 (24.0%) eyes with nonexudative AMD, and 84 (26.8%) eyes with no signs of AMD (no statistical difference was found; P = 0.3384). Spontaneous release of VMA (RVMA) was found in 15 (15.3%) eyes with exudative AMD, 21 (28.0%) eyes with nonexudative AMD, and 10 (24.4%) eyes with no signs of AMD over a mean follow-up of 25.5, 25.9, and 24.1 months, respectively. The incidence of RVMA in exudative AMD eyes was significantly lower compared with nonexudative (P = 0.0207) and lower, but not statistically significant, with respect to eyes with no signs of AMD (P = 0.1013). In eyes with nonexudative AMD, de novo development of CNV occurred in 91 eyes (30.6%). There was no significant difference regarding the rate of CNV development in the presence or absence of VMA (P = 0.0966).

CONCLUSIONS

The present study found no significant difference in the prevalence of VMA in eyes affected by AMD compared with age-matched controls and no difference in the rate of de novo CNV development in eyes with or without VMA. Conversely, a lower incidence of RVMA over time was found in eyes affected by exudative AMD. The results of this study suggest that VMA might be a consequence rather than a causative factor in the development of CNV.

Multimodal imaging and diagnosis of myopic choroidal neovascularization in Caucasians

Purpose

To investigate myopic choroidal neovascularization (mCNV) by fluorescein angiography (FA), spectral-domain optical coherence tomography (SD-OCT), near-infrared (NIR) reflectance, and autofluorescence (AF).

Methods

This retrospective study included 65 eyes of 62 Caucasian patients with a mean age of 66.72 years (95% confidence interval [CI] 63–70 years) and a mean refraction of −9.72 diopters (95% CI −8.74 to −10.70 diopters).

Results

Most of the mCNV cases were foveal-juxtafoveal (60/65, 92.3%), with thickening of the corresponding retina (62/65, 95.3%) and leakage on FA (44/65, 67.6%). No retinal fluid was detectable in 32 (49.2%) eyes and there was no hemorrhage in 25 (38.4%) eyes. Papillary chorioretinal atrophy was evident in 58 (89.2%), a shadowing effect in 48 (73.8%), and an epiretinal membrane in 38 (58.4%) eyes. If an area of macular chorioretinal atrophy was present, mCNV frequently developed adjacent to it and was hyperfluorescent rather than with leakage (P⩽0.001). In eyes with edema or hemorrhage, hyper-reflective foci were more frequent (P⩽0.005). NIR and AF features were indeterminable in 19 (29.2%) and 27 (41.5%) eyes, respectively. The predominant feature was black or grayish on NIR (34/65, 52.3%) and patchy (hypo- and hyperfluorescence was observed) on AF (25/65, 38.4%). FA and SD-OCT correctly detected mCNV in 49 (75.3%) and 48 (73.8%) eyes, respectively, whereas NIR and AF exhibited limited diagnostic sensitivity. Doubtful diagnosis was associated with hyperfluorescent mCNV (P⩽0.001), absence of retinal fluid and epiretinal membrane (P⩽0.05), and presence of macular chorioretinal atrophy (P⩽0.01).

Conclusion

Tomographic, angiographic, AF, and NIR features of mCNV are described in this study. Combination of SD-OCT and FA is recommendable for diagnosis.

EPIRETINAL MEMBRANES IN NEOVASCULAR AGE-RELATED MACULAR DEGENERATION: Effect on Outcomes of Anti-vascular Endothelial Growth Factor Therapy

PURPOSE

To iatients with neovascular age-related macular degenernvestigate the role of epiretinal membrane (ERM) on outcomes of anti-vascular endothelial growth factor therapy in pation (nAMD).

METHODS

This study is a retrospective observational case series and was conducted at the Gazi University School of Medicine, Ankara, Turkey. The reports of the patients with a diagnosis of new-onset nAMD, who were aged at least 50 years and treated with intravitreal anti-vascular endothelial growth factors (ranibizumab or bevacuzimab) between October 2010 and September 2013 in our retina clinic, were reviewed for the vitreomacular interface changes.

RESULTS

The study included 90 eyes of 90 patients with nAMD. The mean age of the patients was 70 ± 7.5 years, with 35 (38.9%) being male and 55 (61.1%) being female. According to the examinations with optical coherence tomography and B-mode ultrasonography, 43 patients had "concurrent" vitreomacular adhesion (30 focal, 13 broad; Group 1). Twenty-nine patients had complete posterior vitreous detachment (Group 2) and 18 patients (Group 3) had ERM. The number of injections was highest for the patients with ERM (Group 3), and this difference was statistically significant (P < 0.001). The mean interval between injections and the mean longest interval were shorter in Group 3 (P < 0.05).

CONCLUSION

The presence of ERM in association with nAMD seems to increase the number of anti-vascular endothelial growth factor injections and decrease the injection intervals for the treatment of nAMD. Although the anatomical and functional results are similar in eyes with or without ERM, the increased need for anti-vascular endothelial growth factors may mean that these membranes may decrease the penetration of the drugs through these membranes, which may act as a physical barrier. Additionally, increased inflammation in patients with ERM probably requires more frequent injections.

Gas-mediated vitreomacular adhesion release with intravitral ranibizumab injections for exudative age-related macular degeneration

PURPOSE

To evaluate the efficiency of gas-assisted vitreomacular adhesion (VMA) release combined with intravitreal ranibizumab injections for exudative age-related macular degeneration (AMD) patients.

MATERIALS AND METHODS

This prospective, interventional case series included a total of 23 eyes of 22 patients. The eyes were treated with intravitreal injection of 0.3 mL of perfluoropropane (C3F8) gas and concomitant intravitreal ranibizumab injection to stimulate VMA release. After three initial loading injections, additional intravitreal ranibizumab injections were performed pro re nata. Over a 12-month period, monthly examinations were performed for best-corrected visual acuity (BCVA, logMAR; logarithm of the minimum angle resolution), optical coherence tomography, and dilated fundus examinations.

RESULTS

After gas injection, 22 eyes (95.7 %) showed complete VMA release at 1 week. Complete VMA was achieved in all eyes at 2 months after VMA release, without serious ocular adverse events except one patient who developed a retinal tear. Mean BCVA was 0.61 ± 0.37 logMAR (20/81 Snellen equivalents) at baseline and 0.46 ± 0.30 logMAR (20/57 Snellen equivalents) at 12 months (P = 0.135). Mean central macular thickness was 357.9 ± 128.6 μm at baseline and 245.6 ± 60.0 μm at 12 months (P = 0.188). Mean numbers of intravitreal ranibizumab injections were 4.8 ± 2.4 times during 12 months (4 to 8 injections).

CONCLUSION

Gas-assisted VMA release can be used as an efficient alternative for exudative AMD patients with obvious VMA.

Pharmacologic Vitreolysis in Vascular Diseases of the Retina

Vascular diseases of the retina such as diabetic retinopathy and vascular occlusions account for a large proportion of visual morbidity and blindness worldwide. The role of vitreous in the pathogenesis of these conditions has been increasingly recognized. Despite advances in the surgical technique of pars plana vitrectomy, the use of intravitreal agents for the lysis of vitreous has received attention, guided largely by promising results from the trials involving patients with non-vascular retinal diseases such as vitreomacular traction. The purpose of this review is to provide a comprehensive summary of the present knowledge on pathophysiologic basis of pharmacologic vitreolysis and its efficacy in vascular diseases of the retina. A review of completed and ongoing clinical trials will be presented, along with insights into future directions of this therapy.

Effects of Vitreomacular Traction on Ranibizumab Treatment Response in Eyes with Neovascular Age-related Macular Degeneration

PURPOSE

To investigate the effects of vitreomacular traction (VMT) on ranibizumab treatment response for neovascular age-related macular degeneration (AMD).

METHODS

A retrospective review of 85 eyes of 85 patients newly diagnosed with neovascular AMD was conducted. Patients were eligible if they had received more than three consecutive monthly ranibizumab (0.50 mg) treatments and ophthalmic evaluations. Patients were classified into a VMT (+) group or VMT (-) group according to optical coherence tomography imaging. Best corrected visual acuity and central retinal thickness (CRT) measurements were obtained at three and six months after initial injection.

RESULTS

One month after the third injection, mean visual acuity (VA) increases of 6.36 and 9.87 letters were observed in the VMT (+) and VMT (-) groups, respectively. The corresponding mean CRT values decreased by 70.29 µm and 121.68 µm, respectively. A total 41 eyes were identified as eligible for a subsequent fourth injection; 71.1% of patients (27 eyes) in the VMT (+) group but only 29.8% of patients in the VMT (-) group needed a subsequent fourth injection. Follow-up was extended to six months for 42 of the 85 enrolled patients (49.4%). The trends in VA and optical coherence tomography were found to be maintained at six-month follow-up.

CONCLUSIONS

VA and CRT appeared to be more improved after ranibizumab treatment in the VMT (-) group compared to the VMT (+) group. VMT might antagonize the effect of ranibizumab treatment in a subpopulation of AMD patients.

Influence of the vitreomacular interface on the efficacy of intravitreal therapy for uveitis-associated cystoid macular oedema

PURPOSE

To evaluate the effect of the vitreomacular interface (VMI) on treatment efficacy of intravitreal therapy in uveitic cystoid macular oedema (CME).

METHODS

Retrospective analysis of CME resolution, CME recurrence rate and monthly course of central retinal thickness (CRT), retinal volume (RV) and best corrected visual acuity (BCVA) after intravitreal injection with respect to the VMI configuration on spectral-domain OCT using chi-squared test and repeated measures anova adjusted for confounding covariates epiretinal membrane, administered drug and subretinal fluid.

RESULTS

Fifty-nine eyes of 53 patients (mean age: 47.4 ± 16.9 years) were included. VMI status had no effect on complete CME resolution rate (p = 0.16, corrected p-value: 0.32), time until resolution (p = 0.09, corrected p-value: 0.27) or CME relapse rate (p = 0.29, corrected p-value: 0.29). Change over time did not differ among the VMI configuration groups for BVCA (p = 0.82) and RV (p = 0.18), but CRT decrease was greater and faster in the posterior vitreous detachment (PVD) group compared to the posterior vitreous attachment (PVA) and vitreous macular adhesion (VMA) groups (p = 0.04). Also, the percentage of patients experiencing a ≥ 20% CRT thickness decrease after intravitreal injection was greater in the PVD group (83%) compared to the VMA (64%) and the PVA (16%) group (p = 0.027), however, not after correction for multiple testing (corrected p-value: 0.11).

CONCLUSION

The VMI configuration seems to be a factor contributing to treatment efficacy in uveitic CME in terms of CRT decrease, although BCVA outcome did not differ according to VMI status.

Effects of Vitreomacular Adhesion on Age-Related Macular Degeneration

Herein, we review the association between vitreomacular adhesion (VMA) and neovascular age-related macular degeneration (AMD). Meta-analyses have shown that eyes with neovascular AMD are twice as likely to have VMA as normal eyes. VMA in neovascular AMD may induce inflammation, macular traction, decrease in oxygenation, sequestering of vascular endothelial growth factor (VEGF), and other cytokines or may directly stimulate VEGF production. VMA may also interfere with the treatment effects of anti-VEGF therapy, which is the standard treatment for neovascular AMD, and releasing VMA can improve the treatment response to anti-VEGF treatment in neovascular AMD. We also reviewed currently available methods of relieving VMA.

Idiopathic preretinal glia in aging and age-related macular degeneration

During analysis of glia in wholemount aged human retinas, frequent projections onto the vitreal surface of the inner limiting membrane (ILM) were noted. The present study characterized these preretinal glial structures. The amount of glial cells on the vitreal side of the ILM was compared between eyes with age-related macular degeneration (AMD) and age-matched control eyes. Retinal wholemounts were stained for markers of retinal astrocytes and activated Müller cells (glial fibrillary acidic protein, GFAP), Müller cells (vimentin, glutamine synthetase) and microglia/hyalocytes (IBA-1). Retinal vessels were labeled with UEA lectin. Images were collected using a Zeiss LSM 710 confocal microscope. Retinas were then cryopreserved. Laminin labeling of cryosections determined the location of glial structures in relation to the ILM. All retinas investigated herein had varied amounts of preretinal glia. These glial structures were classified into three groups based on size: sprouts, blooms, and membranes. The simplest of the glial structures observed were focal sprouts of singular GFAP-positive cells or processes on the vitreal surface of the ILM. The intermediate structures observed, glial blooms, were created by multiple cells/processes exiting from a single point and extending along the vitreoretinal surface. The most extensive structures, glial membranes, consisted of compact networks of cells and processes. Preretinal glia were observed in all areas of the retina but they were most prominent over large vessels. While all glial blooms and membranes contained vimentin and GFAP-positive cells, these proteins did not always co-localize. Many areas had no preretinal GFAP but had numerous vimentin only glial sprouts. In double labeled glial sprouts, vimentin staining extended beyond that of GFAP. Hyalocytes and microglia were detected along with glial sprouts, blooms, and membranes. They did not, however, concentrate in the retina below these structures. Cross sectional analysis identified small breaks in the ILM above large retinal vessels through which glial cells exited the retina. Preretinal glial structures of varied sizes are a common occurrence in aged retinas and, in most cases, are subclinical. While all retinal glia are found in blooms, vimentin labeling suggests that Müller cells form the leading edge. All retinas investigated from eyes with active choroidal neovascularization (CNV) had extensive glial membranes on the vitreal surface of the ILM. Although these structures may be benign, they may exert traction on the retina as they spread along the vitreoretinal interface. In cases with CNV, glial cells in the vitreous could bind intravitreally injected anti-vascular endothelial growth factor. These preretinal glial structures indicate the remodeling of both astrocytes and Müller cells in aged retinas, in particular those with advanced AMD.

Disappearance of soft drusen and subsequent development of choroidal neovascularization following macular hole surgery: a case report

BACKGROUND

Drusen are important risk factor for neovascular age-related macular degeneration (AMD) and have a dynamic nature as they can enlarge, newly form, or disappear over time. There have been few reports on drusen regression or choroidal neovascularization (CNV) development after macular hole surgery. We report, to our knowledge, the first case of both drusen regression and subsequent CNV development within 7 months of successful macular hole surgery.

CASE PRESENTATION

A 73-year-old woman presented with a stage 3 full-thickness macular hole and large, confluent soft macular drusen in the right eye and a neovascular age-related macular degeneration (AMD) in the fellow eye. Four months after the successful macular hole surgery, significant regression of drusen was seen, especially in the temporal area to the fovea. Three months later, the patient developed CNV and her best-corrected visual acuity decreased to 20/100, despite further regression of macular drusen.

CONCLUSIONS

Macular hole patients with macular soft drusen need to be carefully followed up after surgery for possible drusen regression and CNV development.

Influence of the Vitreomacular Interface on Treatment Outcomes in the Comparison of Age-Related Macular Degeneration Treatments Trials

OBJECTIVE

To assess the association of the vitreomacular interface with outcomes of eyes treated with anti-vascular endothelial growth factor drugs for neovascular age-related macular degeneration (AMD).

DESIGN

Prospective cohort study within a multicenter, randomized clinical trial.

PARTICIPANTS

Patients enrolled in the Comparison of AMD Treatments Trials (CATT).

METHODS

Treatment was assigned randomly as either ranibizumab or bevacizumab and as 3 different regimens for dosing over a 2-year period. Masked readers at a reading center assessed optical coherence tomography (OCT) scans at baseline and follow-up for vitreomacular traction (VMT) and vitreomacular adhesion (VMA), fluid, and central thickness. Visual acuity (VA) was measured by masked, certified examiners.

MAIN OUTCOME MEASURES

Anatomic features and VA at baseline and 1 and 2 years and number of treatments.

RESULTS

At baseline, 143 patient eyes (12.8%) had VMT or VMA. Compared with those with neither (n = 972), patients with VMT or VMA were younger (mean ± standard error, 75.5 ± 0.6 vs. 79.7 ± 0.24 years; P < 0.0001) and more likely to be male (52.4% vs. 36.2%; P = 0.0003), to be cigarette smokers (68.5% vs. 55.3%; P = 0.003), and to have subretinal fluid on OCT (86.7% vs. 81.0%; P = 0.047). Vitreomacular interface status was not associated with VA at baseline or follow-up. Among eyes treated as needed (n = 598) and followed up for 2 years (n = 516), the mean number of injections was 15.4 ± 0.9 for eyes having VMT at baseline or during follow-up (n = 60), 13.8 ± 0.7 for eyes with VMA at baseline or follow-up (n = 79), and 12.9 ± 0.4 (P = 0.02) for eyes without VMT or VMA (n = 377). In addition, the mean number of injections in eyes treated as needed increased from 13.0 ± 0.3 when VMT was not observed to 13.6 ± 1.3 when observed once and to 17 ± 1.2 when observed more than once during follow-up. At 2 years, geographic atrophy developed in a lower percentage of eyes with VMT or VMA at baseline (11.7%) than with neither condition (22.5%; P = 0.005).

CONCLUSIONS

In eyes in the CATT, VMT and VMA were infrequent. At baseline and follow-up, VMT or VMA were not associated with VA. Eyes with VMT or VMA treated as needed required on average 2 more injections over 2 years.

Preservation of the structure of enzymatically-degraded bovine vitreous using synthetic proteoglycan mimics

PURPOSE

Vitreous liquefaction and subsequent posterior vitreous detachment can lead to several sight-threatening diseases, including retinal detachment, macular hole and macular traction syndrome, nuclear cataracts, and possibly, open-angle glaucoma. In this study, we tested the ability of three novel synthetic chondroitin sulfate proteoglycan mimics to preserve the structure and physical properties of enzymatically-degraded bovine vitreous.

METHODS

Chondroitin sulfate proteoglycan mimics, designed to bind to type II collagen, hyaluronic acid, or both, were applied to trypsin- or collagenase-treated bovine vitreous in situ and in vitro. Rheology and liquefaction tests were performed to determine the physical properties of the vitreous, while Western blots were used to detect the presence and degradation of soluble collagen II (α1). Deep-etch electron microscopy (DEEM) identified the ultrastructure of mimic-treated and untreated enzyme-degraded bovine vitreous.

RESULTS

Proteoglycan mimics preserved the physical properties of trypsin-degraded bovine vitreous and protected against vitreous liquefaction. Although the collagen-binding mimic maintained the physical properties of collagenase-treated vitreous, liquefaction still occurred. Western blots indicated that the mimic provided only marginal protective ability against soluble collagen degradation. Deep-etch electron microscopy, however, showed increased density and isotropy of microstructural components in mimic-treated vitreous, supporting the initial result that vitreous structure was preserved.

CONCLUSIONS

Proteoglycan mimics preserved bovine vitreous physical properties after enzymatic degradation. These compounds may be useful in delaying or preventing the pathological effects of age-related, or enzymatically-induced, degradation of the vitreous body.

Effects of core vitrectomy in the treatment of age-related macular degeneration

PURPOSE

To investigate the clinical efficacy and safety of an additional core vitrectomy to the standard therapy in patients with exudative age-related macular degeneration (ARMD).

METHODS

In this prospective, controlled, single-centre study, 50 eyes of 50 patients (mean age: 74.1 ± 7.1; median 74 (69/78)) with ARMD were enrolled and randomized 1:1 to group 1 - core vitrectomy additional to three times injections of ranibizumab (3x Rbz) and Group 2 - 3x Rbz (control). 1 16 of 25 eyes in Group 1(64%) and 12 of 25 (48%) in Group 2 had a posterior vitreous detachment (PVD) prior to start of the study. Changes in best-corrected visual acuity (BCVA) using ETDRS charts, central macular thickness and macular volume (OCT) as well as the rate of reinjection with an OCT-based pro renata (PRN) protocol were monitored prospectively over 48 weeks. Forty-seven eyes completed follow-up at week 48.

RESULTS

In Group 1, 4 of 24 lost 1 line of BCVA (16.7%) and 3 of 24 lost 2 lines (12.5%), whereas 17 of 24 gained more than 1 line (70.8%) and improved in average by 9.8 letters. In Group 2, 3 of 23 remained stable and 20 of 23 gained more than or exactly 1 line (78.3%), resulting in 14.3 letters, with no loss of lines. Central macular thickness decreased by 85.58 μm (28.8%) in Group 1 and by 121.43 μm (32.68%) in Group 2 compared with baseline. In Group 1, four patients received three additional and two patients, two additional Rbz injections. In Group 2, three patients received three additional, three patients two and 12 patients one additional Rbz injections. This yielded in an average injection rate of 3.66 in Group 1 and 4.17 in Group 2 over 48 weeks. Posterior vitreous detachment (PVD) was identified in Group 1 in 16 of 24 (66.7%) and in Group 2 in 12 of 23 (52.2%) patients at baseline. At week 48, 6 of 8 (75%) of the patients in Group 1 with initial attached vitreous showed a vitreal detachment, whereas only 1 of 11 (9%) in Group 2 had a new occurred detachment of the vitreous. No systemic or ocular adverse events were noticed.

CONCLUSION

An initial core vitrectomy combined with a conventional ranibizumab injection regimen for exudative AMD patients was safe and lead to similar functional results with less intravitreal ranibizumab injections over 48 weeks.

Impact of vitreomacular adhesion on ranibizumab mono- and combination therapy for neovascular age-related macular degeneration

PURPOSE

To investigate the influence of vitreomacular adhesion on the efficacy of pro re nata (PRN) ranibizumab monotherapy and verteporfin photodynamic therapy (PDT) combination therapy for neovascular age-related macular degeneration.

DESIGN

Post hoc analysis of prospective randomized 12-month multicenter clinical trial data.

METHODS

PATIENT POPULATION

Total of 255 treatment-naïve patients with subfoveal choroidal neovascularization.

OBSERVATION PROCEDURE

Assessment of the vitreomacular interface on monthly optical coherence tomography with division of patients into the following categories according to continuous 1-year grading: posterior vitreous detachment (n=154), dynamic release of vitreomacular adhesion (n=32), stable vitreomacular adhesion (n=51).

MAIN OUTCOME MEASURES

Mean best-corrected visual acuity (BCVA) letter and central retinal thickness changes at month 12 in the vitreomacular interface groups.

RESULTS

Mean BCVA changes at month 12 were +3.5 (posterior vitreous detachment), +4.3 (release of vitreomacular adhesion), and +6.3 (vitreomacular adhesion) in patients receiving monotherapy (P=.767), and +0.1 (posterior vitreous detachment), +6.6 (release of vitreomacular adhesion), and +9.2 (vitreomacular adhesion) in patients receiving combination therapy (P=.009). Mean central retinal thickness changes were -113 μm (posterior vitreous detachment), -89 μm (release of vitreomacular adhesion), and -122 μm (vitreomacular adhesion) in monotherapy (P=.725) and -121 μm (posterior vitreous detachment), -113 μm (release of vitreomacular adhesion), and -113 μm (vitreomacular adhesion) in combination therapy (P=.924). Mean ranibizumab retreatments during 12 months were 4.9 (posterior vitreous detachment), 6.6 (release of vitreomacular adhesion), and 5.3 (vitreomacular adhesion) in monotherapy (P=.018) and 4.7 (posterior vitreous detachment), 5.2 (release of vitreomacular adhesion), and 5.8 (vitreomacular adhesion) in combination therapy (P=.942).

CONCLUSION

This study adds evidence that the vitreomacular interface status impacts functional outcomes and retreatment requirements. Patients with posterior vitreous detachment achieve acceptable results with fewer injections in PRN monotherapy, but lose potential vision gain with PDT. Patients with other vitreomacular interface configurations may potentially achieve optimized vision outcomes by combination of antiangiogenic treatment and vaso-occlusive PDT.

Profile of ocriplasmin and its potential in the treatment of vitreomacular adhesion

The recent approval by the US Food and Drug Administration of ocriplasmin for the treatment of symptomatic vitreomacular adhesion (VMA), often associated with vitreomacular traction (VMT) and macular hole (MH), has brought new attention to the field of pharmacologic vitreolysis. The need for an enzyme to split the vitreomacular interface, which is formed by a strong adhesive interaction between the posterior vitreous cortex and the internal limiting membrane, historically stems from pediatric eye surgery. This review summarizes the different anatomic classifications of posterior vitreous detachment or anomalous posterior vitreous detachment and puts these in the context of clinical pathologies commonly observed in clinical practice of the vitreoretinal specialist, such as MH, VMT, age-related macular degeneration, and diabetic macular edema. We revisit the outcome of the Phase II studies that indicated ocriplasmin was a safe and effective treatment for selected cases of symptomatic VMA and MH. Release of VMA at day 28 was achieved by 26.5% of patients in the ocriplasmin group versus 10.1% in the placebo group (P<0.001). Interestingly, for MHs, the numbers were more remarkable. Predictive factors for successful ocriplasmin treatment were identified for VMT (VMA diameter smaller than 1,500 μm) and MH (smaller than 250 μm). In comparison with the highly predictable outcome after vitrectomy, the general success rate of ocriplasmin not under clinical trial conditions has not fully met expectations and needs to be proven in real-world clinical settings. The ocriplasmin data will be compared in the future with observational data on spontaneous VMA release, will help retina specialists make more accurate predictions, and will improve outcome rates.

Ocriplasmin for symptomatic vitreomacular adhesion: an evidence-based review of its potential

Vitreomacular traction is a multicategory entity that may cause substantial visual loss due to the formation of a macular hole or traction-induced tissue distortion. The advent of optical coherent tomography (OCT) has demonstrated the anatomic features of persistent vitreomacular attachment (VMA) more definitively, including in many asymptomatic or minimally symptomatic patients. The indications for intervention are unclear, since it is not possible to predict which eyes might be likely to develop progressive visual loss. This has been especially important since for many years, the only treatment option involved surgical intervention (vitrectomy) to release the persistent VMA. Recently, a pharmacolytic agent, ocriplasmin, has become available after many years of development and investigation, and may offer a feasible alternative to surgery, or even a risk/benefit ratio sufficiently favorable to offer intervention at an earlier stage of VMA. Several studies, including a large, prospective clinical trial, have established the foundation of its rationale and efficacy, providing the basis of its approval. The role for ocriplasmin in clinical practice is in the process of being determined. This paper summarizes current knowledge and status of investigations regarding ocriplasmin-induced pharmacologic vitreolysis, and offers some evidence-based considerations for its use.

Retinal oxygen metabolism in exudative age-related macular degeneration

PURPOSE

To determine whether retinal vessel oxygen saturation in patients with exudative age-related macular degeneration (AMD) is different from that of a healthy population.

METHODS

Oxygen saturation was measured in retinal arterioles and venules in 46 eyes of 46 treatment-naïve exudative AMD patients and 120 eyes of 120 healthy controls. Simple and multiple linear regression analyses were used to compare the two study groups.

RESULTS

Oxygen saturation in retinal venules increases with age in patients with exudative AMD (0.45 ± 0.19% per year; p = 0.026), while it decreases with age in healthy individuals (-0.13 ± 0.03% per year; p = 0.0002). The slopes are statistically different (ANCOVA; p = 0.0003). The reverse is true for the arteriovenous difference in oxygen saturation, which decreases with age in AMD patients (-0.29 ± 0.16% per year; p = 0.065) and increases in healthy individuals (0.12 ± 0.03% per year; p < 0.0001). At age 80 years, AMD patients have 2.7 percentage points higher venous oxygen saturation than healthy persons and 4.2 percentage points less arteriovenous difference.

CONCLUSIONS

The data suggest that retinal oxygen metabolism may be altered in exudative AMD. The arteriovenous difference is smaller in exudative AMD than in a healthy cohort, consistent with reduced oxygen extraction by retinal vessels in AMD patients. Further studies are needed to fully understand the role of retinal oxygen metabolism in the pathophysiology of exudative AMD.

Clinical applications of optical coherence tomography in the posterior pole: the 2011 José Manuel Espino Lecture - Part I

Optical coherence tomography (OCT) is now a standard of care in ophthalmology and is considered essential for the diagnosis and monitoring of many retinal diseases. One of the major advances obtained with OCT was the understanding of the pathophysiology of macular holes. Non-full-thickness macular holes have been revisited because high-resolution OCT images can detect a lamellar macular defect that is not always visible clinically, and surgery has been advocated by some authors. OCT can be valuable in determining the need for and/or timing of surgical intervention on epiretinal membranes or vitreomacular traction syndrome. In addition, we can use this technology as a predictive factor in the prognosis and follow-up of the most common posterior pole pathologies.