EFFICACY AND SAFETY OF RANIBIZUMAB FOR THE TREATMENT OF CHOROIDAL NEOVASCULARIZATION DUE TO UNCOMMON CAUSE: Twelve-Month Results of the MINERVA Study

Inflammatory choroidal neovascularization: An evidence-based update

Inflammatory choroidal neovascularization (iCNV) significantly contributes to vision impairment and ranks as the third primary cause of CNV. Arising from both infectious and noninfectious uveitis, iCNV's pathogenesis involves Bruch membrane rupture, local inflammation, and choriocapillaris ischemia. The diagnosis of iCNV is challenging due to its symptomatic overlap with other uveitis-related conditions. We emphasize the importance of advanced multimodal imaging techniques, particularly optical coherence tomography (OCT) and OCT angiography (OCTA), for early detection and differentiation of iCNV from other types of CNV. Although anti-vascular endothelial growth factor agents have shown high efficacy in treatment, the integration of these treatments with anti-inflammatory therapies remains a critical area of active research. The diversity of uveitis presentations and the rarity of iCNV have resulted in a scarcity of randomized clinical trials, leading to reliance on fragmented data from case reports and series. We consolidate the most recent studies to provide a comprehensive, updated overview of the epidemiology, risk factors, pathogenesis, imaging techniques, and treatment modalities for iCNV, aiming to support clinical decision-making. The absence of standardized guidelines highlights the need for further research to establish best practices for managing iCNV effectively.

Therapeutic interventions for chronic central serous chorioretinopathy: a comprehensive assessment of systematic reviews

BACKGROUND

A variety of different treatments have been proposed to effectively treat chronic central serous chorioretinopathy but there remains uncertainty regarding the efficacy of a number of treatment options. We aim to evaluate the efficacy of several therapeutic options for chronic central serous chorioretinopathy including photodynamic therapy, conventional laser photocoagulation, subthreshold micropulse laser, selective retina therapy, vascular endothelial growth factor (VEGF) antagonists, and mineralocorticoid receptor antagonists.

METHODS

Pubmed, Embase, and Cochrane databases were searched for systematic reviews and meta-analyses evaluating treatment modalities for chronic central serous chorioretinopathy. Primary outcome measures included improvement in best corrected visual acuity (BCVA) and resolution of subretinal fluid (SRF). Conclusions regarding the efficacy of each modality were summarized and compared to findings of several key randomized controlled trials.

RESULTS

Ten systematic reviews and meta-analyses that incorporated 58 unique randomized controlled trials and observational studies were identified. Treatments that were shown to improve BCVA and promote SRF resolution included half-fluence and half-dose photodynamic therapy, conventional laser therapy, and subthreshold micropulse laser therapy. Evidence regarding selective retina therapy was limited and inconclusive. VEGF antagonists were not effective in the absence of choroidal neovascularization and mineralocorticoid receptor antagonists were not effective.

CONCLUSION

The most effective therapeutic option for chronic central serous chorioretinopathy is half-dose or half-fluence photodynamic therapy, however, conventional laser therapy is an acceptable alternative in cases when photodynamic therapy is unavailable and when fluid leakage sites are not subfoveal or juxtafoveal. Subthreshold micropulse laser is less effective but can be considered when other options are unavailable.

[Secondary choroidal neovascularization-Really so common?]

The occurrence of secondary choroidal neovascularization (CNV) is a complication in patients with chronic central serous chorioretinopathy. The diagnosis is made using multimodal imaging. The treatment usually includes intravitreal anti-vascular endothelial growth factor (VEGF) injections. A combination with photodynamic therapy can be useful; however, the response to anti-VEGF treatment is significantly reduced compared to other indications for CNV, so that an irreversible decrease of visual acuity often remains.

Multifocal Torpedo Maculopathy Complicated by Choroidal Neovascularization

Purpose: To present a pediatric patient with a unique configuration of torpedo maculopathy complicated by macular choroidal neovascularization (CNV). Methods: A single case was retrospectively reviewed. Results: An 8-year-old male child presented with decreased vision in the left eye and was found to have 2 distinct torpedo maculopathy lesions, 1 a smaller hypopigmented lesion in the temporal parafovea and the other a larger hyperpigmented comet-shaped lesion in the temporal periphery. Multimodal imaging showed active CNV. The patient received 2 intravitreal injections of ranibizumab with regression of CNV and recovery of visual acuity. Conclusions: CNV is a rare complication of torpedo maculopathy that can affect pediatric patients in the absence of choroidal excavation. The presence of a hyperpigmented peripheral lesion exhibiting symmetry across the horizontal raphe lends support to the hypothesis that an alteration in the development and migration of retinal pigment epithelium cells across the fetal bulge results in this disorder.

Choroidal Response to Intravitreal Bevacizumab Injections in Treatment-Naïve Macular Neovascularization Secondary to Chronic Central Serous Chorioretinopathy

BACKGROUND/OBJECTIVES

To evaluate the impact of intravitreal bevacizumab (IVB) therapy on anatomical and visual outcomes in patients with macular neovascularization (MNV) secondary to chronic central serous chorioretinopathy (cCSC).

METHODS

This retrospective observational study reviewed the medical records of treatment-naïve patients diagnosed with cCSC complicated by MNV and treated with IVB injections over a 5-year period. The presence of MNV was confirmed using optical coherence tomography angiography (OCTA). Best-corrected visual acuity (BCVA), subfoveal choroidal thickness (SFCT), and subretinal fluid (SRF) were recorded pre- and post-IVB treatment.

RESULTS

Twenty-two eyes of 22 patients (mean age, 68 ± 11 years) were included. After a mean follow-up of 21.0 ± 14.6 months, SRF significantly decreased from baseline (176.86 ± 115.62 µm) to the final follow-up (80.95 ± 87.32 µm, p = 0.003). A greater SRF reduction was associated with more injections (>7) (p = 0.047). However, no significant changes were observed in BCVA (p > 0.05) or SFCT (p > 0.05), irrespective of follow-up duration or injection frequency. Complete resolution of SRF was achieved in nine patients (40.9%), and a significantly greater reduction in SFCT was observed in complete responders compared to non-responders (p = 0.03).

CONCLUSIONS

IVB therapy significantly reduced SRF in cCSC patients with secondary MNV, though it did not lead to visual improvement or significant changes in SFCT. However, greater choroidal thinning in patients with complete fluid resorption may suggest distinct underlying mechanisms or alternative sources of subretinal fluid beyond the MNV itself.

Pseudoxanthoma elasticum - Genetics, pathophysiology, and clinical presentation

Pseudoxanthoma elasticum (PXE) is an autosomal-recessively inherited multisystem disease. Mutations in the ABCC6-gene are causative, coding for a transmembrane transporter mainly expressed in hepatocytes, which promotes the efflux of adenosine triphosphate (ATP). This results in low levels of plasma inorganic pyrophosphate (PPi), a critical anti-mineralization factor. The clinical phenotype of PXE is characterized by the effects of elastic fiber calcification in the skin, the cardiovascular system, and the eyes. In the eyes, calcification of Bruch's membrane results in clinically visible lesions, including peau d'orange, angioid streaks, and comet tail lesions. Frequently, patients must be treated for secondary macular neovascularization. No effective therapy is available for treating the cause of PXE, but several promising approaches are emerging. Finding appropriate outcome measures remains a significant challenge for clinical trials in this slowly progressive disease. This review article provides an in-depth summary of the current understanding of PXE and its multi-systemic manifestations. The article offers a detailed overview of the ocular manifestations, including their morphological and functional consequences, as well as potential complications. Lastly, previous and future clinical trials of causative treatments for PXE are discussed.

Anti-VEGF Treatment for Secondary Neovascularization in Pseudoxanthoma Elasticum - Age of Onset, Treatment Frequency, and Visual Outcome

PURPOSE

To assess the onset, treatment frequency, and visual outcome of anti-vascular endothelial growth factor (anti-VEGF) treatment due to secondary choroidal neovascularization (CNV) in patients with pseudoxanthoma elasticum (PXE).

DESIGN

Retrospective cohort study METHODS: One-hundred six eyes of 53 patients with PXE were analyzed. The assessment of CNV activity relied on hemorrhage visible on funduscopy and intra- / subretinal fluid on optical coherence tomography (OCT), individually defining a shortening or extension of treatment interval. Best-corrected visual acuity (BCVA) at baseline, age at anti-VEGF therapy initiation, and BCVA-drop events at exudation onset (worsening of BCVA of 2 or more lines) were documented. Further, we assessed the number of injections during the first year and the total number of injections, the time to treatment initiation of the fellow eye, and BCVA over time.

RESULTS

During a median observation period of 77 months (IQR 49; 126) patients received a median number of 28.0 anti-VEGF-injections (IQR 9.8; 43.5). Eight patients received no injection (median age at baseline 38.1 years), 11 patients underwent anti-VEGF treatment in one eye (median age 47.2 years) and 34 patients in both eyes (median age 51.8 years). The median age at the first anti-VEGF treatment was 52.80 years (IQR 47.2-57.6). Applying Cox regression models, the median "survival" time of fellow eye until treatment initiation was 16.8 months. In the group of bilateral treated patients, the median time difference was 9.6 months (IQR 2.1- 32.4, range 0-122) The median number of injections was 5.5 per eye in the first year of treatment (IQR 3-7) and was associated with the total number of injections in the observation period (2.33, CI 1.22-3.44, P < .001). A better BCVA at the last follow-up visit was associated with a better baseline BCVA (P < .001, R2 = 0.318) and with the absence of a BCVA drop at the onset of exudation (P = 0.035, R2 = 0.339).

CONCLUSIONS

The results of this study indicate that anti-VEGF treatment is required for most PXE patients at a relatively young age. Once treatment in one eye is initiated, the time to fellow eye treatment is relatively short. A BCVA drop before treatment initiation is a risk factor for worse visual outcomes, suggesting that treatment is prudent before exudation affects the central retina. Given the young age of onset and intensive treatment needs, patients with PXE might particularly benefit from longer-acting anti-VEGF therapeutics.

Macular neovascularization

Neovascularization of the macula, a common complication of many chorioretinal diseases such as neovascular age-related macular degeneration, polypoidal choroidal vasculopathy, and pathologic myopia, results from increased synthesis of vascular endothelial growth factor (VEGF) by the retinal pigment epithelium and/or Müller cells because of localized ischemia and inflammation. The Consensus on Neovascular AMD Nomenclature (CONAN) study group acknowledged that these vessels may originate from either the choriocapillaris or the retinal microvasculature, prompting them to propose the term 'macular neovascularization' (MNV) to include intraretinal, subretinal, and sub-pigment epithelial neovascularization localized to the macula. MNV frequently appears as a grey-green macular lesion with overlying intraretinal thickening and/or subretinal exudation, causing metamorphopsia, reduced central vision, relative central scotoma, decreased reading speed, and problems with color recognition. Multimodal imaging with optical coherence tomography (OCT), OCT angiography, dye-based angiographies, fundus autofluorescence, and multiwavelength photography help establish the diagnosis and aid in selecting an appropriate treatment. The standard of care for MNV is usually intravitreal anti-vascular endothelial growth factor injections, though thermal laser photocoagulation, verteporfin photodynamic therapy, and vitreoretinal surgery are occasionally used. We discuss the etiology and clinical features of MNV, the role of multimodal imaging in establishing the diagnosis, and the available therapeutic options.

Unilateral Vogt-Koyanagi-Harada Disease With Two Distinct Choroidal Neovascular Membranes: A Case Report

Vogt-Koyanagi-Harada (VKH) disease is a multisystem inflammatory disease that usually presents with bilateral panuveitis. Unilateral manifestations of VKH, albeit rare, have been described. Choroidal neovascularization may occur as a complication during the disease. Reactivation of uveitis may also occur during treatment. A patient with unilateral features of VKH disease presented with two distinct types of choroidal neovascular membranes and two episodes of reactivation of posterior uveitis. He underwent treatment with a combination of systemic steroids/immunosuppressive agents, intravitreal anti-vascular endothelial growth factor (anti-VEGF) agents, and dexamethasone implants with good clinical response.  Patients with VKH disease need to be diagnosed early, treated adequately with a combination of systemic and ocular medication, and followed up diligently for any complication that may arise, to optimize visual acuity.

Pachychoroid Spectrum Disease: Comparison of Patients with Central Serous Chorioretinopathy Complicated with Pachychoroid Neovasculopathy

PURPOSE

This study aimed to determine the incidence and visual outcomes of pachychoroid neovasculopathy (PNV) in patients initially diagnosed with central serous chorioretinopathy (CSC).

METHODS

In this study, 144 patients aged 20 to 55 years with treatment-naive chronic CSC, defined as the persistence of subretinal fluid (SRF) for ≥6 months, were retrospectively enrolled. Patients with PNV at the initial evaluation were categorized as group 1, whereas those who developed new-onset PNV during follow-up were categorized as group 2. Patients without PNV until the end of the follow-up were categorized as group 3.

RESULTS

Over a mean follow-up period of 49.9 ± 39.9 months, new-onset PNV was diagnosed in 11.8% of patients with CSC. The time taken to reach the initial resolution was longest in group 1 (group 1, 11.13 ± 10.70 months; group 2, 8.14 ± 7.90 months; group 3, 7.32 ± 9.55 months), although these differences were not statistically significant. The numbers of injections needed to achieve initial resolution were 3.76 ± 5.90, 1.64 ± 2.06, and 1.74 ± 4.33 in groups 1, 2, and 3, respectively, with no significant differences. SRF recurrence was recorded in seven patients (29.2%) in group 1, nine (64.3%) in group 2, and 28 (26.7%) in group 3. The recurrence rates were significantly higher in group 2 than those in group 1 or 3. At the end of the follow-up period, significant improvements in best-corrected visual acuity were achieved in groups 1 and 3, compared with baseline, but not in group 2.

CONCLUSIONS

Patients with chronic CSC with new-onset PNV exhibited higher SRF recurrence and worse visual outcomes compared to those with initial PNV or those with chronic CSC without PNV. Our study emphasizes the importance of routine screening for prompt diagnoses of new-onset PNV in individuals with chronic CSC.

Central serous chorioretinopathy: An evidence-based treatment guideline

Central serous chorioretinopathy (CSC) is a relatively common disease that causes vision loss due to macular subretinal fluid leakage and it is often associated with reduced vision-related quality of life. In CSC, the leakage of subretinal fluid through defects in the retinal pigment epithelial layer's outer blood-retina barrier appears to occur secondary to choroidal abnormalities and dysfunction. The treatment of CSC is currently the subject of controversy, although recent data obtained from several large randomized controlled trials provide a wealth of new information that can be used to establish a treatment algorithm. Here, we provide a comprehensive overview of our current understanding regarding the pathogenesis of CSC, current therapeutic strategies, and an evidence-based treatment guideline for CSC. In acute CSC, treatment can often be deferred for up to 3-4 months after diagnosis; however, early treatment with either half-dose or half-fluence photodynamic therapy (PDT) with the photosensitive dye verteporfin may be beneficial in selected cases. In chronic CSC, half-dose or half-fluence PDT, which targets the abnormal choroid, should be considered the preferred treatment. If PDT is unavailable, chronic CSC with focal, non-central leakage on angiography may be treated using conventional laser photocoagulation. CSC with concurrent macular neovascularization should be treated with half-dose/half-fluence PDT and/or intravitreal injections of an anti-vascular endothelial growth factor compound. Given the current shortage of verteporfin and the paucity of evidence supporting the efficacy of other treatment options, future studies-ideally, well-designed randomized controlled trials-are needed in order to evaluate new treatment options for CSC.

Efficacy of anti-VEGF intravitreal injection in traumatic submacular hemorrhage: a retrospective study

OBJECTIVE

In this study we investigated the efficacy of short-term intravitreal injections of anti-vascular endothelial growth factors (anti-VEGF) in treating traumatic submacular hemorrhage.

METHODS

A total of 115 patients were diagnosed with submacular hemorrhage between 2018 and 2022 at Shenzhen Eye Hospital. In a retrospective analysis, we examined 13 of these patients who presented with submacular hemorrhage and choroidal rupture due to ocular trauma. Eight patients were treated with intravitreal anti-VEGF injection and 5 with oral drugs. We systematically analyzed changes in their ocular conditions pre and post-treatment. The evaluations encompassed best-corrected visual acuity (BCVA), optical coherence tomography, fundus fluorescein angiography, and retinal imaging.

RESULTS

The 13 patients diagnosed with submacular hemorrhage comprised of 10 males and 3 female, with their age ranging between 27 and 64 years, with an average age of 38.1 years (standard deviation [SD]: 11.27). A statistically significant reduction in central foveal thickness (CFT) was observed following intravitreal injections of anti-VEGF drugs (P = 0.03). In control group, the CFT was reduced without statistical significance (P = 0.10). The BCVA of the patients in treatment group improved significantly from 1.15 (SD: 0.62. Range: 0.4-2) to 0.63 (SD: 0.59. Range: 0.1-1.6), indicating an average increase of 4.13 lines (SD: 3.36. Range: 0-9) as measured by the visual acuity test using an eye chart (P = 0.01). The difference between baseline visual acuity and final visual acuity was not statistically significant in control group (P = 0.51).

CONCLUSION

Short-term administration of anti-VEGF drugs exhibited significant efficacy in reducing submacular hemorrhage following ocular trauma and enhancing visual acuity.

Immunomodulatory Treatment Versus Systemic Steroids in Inflammatory Choroidal Neovascularization Secondary to Idiopathic Multifocal Choroiditis

PURPOSE

To evaluate the influence of immunomodulatory therapy (IMT) on visual and treatment outcomes of inflammatory choroidal neovascularization (iCNV) in patients affected by multifocal choroiditis (MFC), and to compare them to patients treated with steroids as needed.

DESIGN

Multicenter retrospective matched cohort study.

METHODS

Patients affected by MFC with iCNV were divided into a IMT group and a "steroids as needed" group and matched according to the time between diagnosis and beginning of systemic treatment. Visual acuity (VA), number of anti-vascular endothelial growth factor (VEGF) intravitreal injections, and number of iCNV reactivations during 2 years of follow-up after treatment initiation were compared between the 2 groups.

RESULTS

A total of 66 eyes of 58 patients were included, equally divided into the 2 groups. Patients in the IMT group had a lower relative risk (RR) of iCNV reactivation (0.64, P = .04) and of anti-VEGF intravitreal injection retreatment (0.59, P = .02). Relapses of MFC-related inflammation were independently associated with a higher RRs of iCNV reactivation (1.22, P = .003). Final VA was higher in the IMT compared to the steroids as needed group (mean [SD], 69.1 [15.1] vs 77.1 [8.9] letters, P = .01), and IMT was associated with greater VA gains over time (+2.5 letters per year, P = .04).

CONCLUSIONS

IMT was associated with better visual and treatment outcomes in MFC complicated by iCNV compared to steroids as needed. The better outcomes of the IMT group and the association between MFC-related inflammation and iCNV reactivations highlight the need for tighter control of inflammation to prevent iCNV relapses and visual loss.

The structure and function of the human choroid

In this manuscript, the structure of the human choroid is reviewed with emphasis of the macro- and microscopic anatomy including Bruch's membrane, choriocapillaris, Sattler's and Haller's layer, and the suprachoroid. We here discuss the development of the choroid, as well as the question of choroidal lymphatics, and further the neuronal control of this tissue, as well as the pathologic angiogenesis. Wherever possible, functional aspects of the various structures are included and reviewed.

Angioid Streaks Remain a Challenge in Diagnosis, Management, and Treatment

Aim: Angioid streaks (ASs) are a rare retinal condition and compromise visual acuity when complicated with choroidal neovascularization (CNV). They represent crack-like dehiscences at the level of the Bruch's membrane. This objective narrative review aims to provide an overview of pathophysiology, current treatment modalities, and future perspectives on this condition. Materials and Methods: A literature search was performed using "PubMed", "Web of Science", "Scopus", "ScienceDirect", "Google Scholar", "medRxiv", and "bioRxiv." Results: ASs may be idiopathic, but they are also associated with systemic conditions, such as pseudoxanthoma elasticum, hereditary hemoglobinopathies, or Paget's disease. Currently, the main treatment is the use of anti-vascular endothelial growth factors (anti-VEGF) to treat secondary CNV, which is the major complication observed in this condition. If CNV is detected and treated promptly, patients with ASs have a good chance of maintaining functional vision. Other treatment modalities have been tried but have shown limited benefit and, therefore, have not managed to be more widely accepted. Conclusion: In summary, although there is no definitive cure yet, the use of anti-VEGF treatment for secondary CNV has provided the opportunity to maintain functional vision in individuals with AS, provided that CNV is detected and treated early.

Punctate inner choroidopathy: A review of the current diagnostic and therapeutic approaches

Punctate inner choroidopathy (PIC) is an uncommon idiopathic inflammatory condition characterized by multifocal chorioretinopathy that primarily affects young adults, with a predilection for myopic females. Clinically, it manifests as small, yellowish-white lesions in the inner choroid and outer retina, often associated with inflammatory changes. Accurate diagnosis remains a challenge due to its resemblance to other posterior uveitic entities, necessitating an astute clinical eye and advanced imaging techniques for differentiation. Multimodal imaging plays a crucial role by offering valuable insights, as it enables the visualization of various abnormalities related to uveitis. The pathogenesis of PIC is still a subject of debate, with a complex interplay of genetic, immunological, and environmental factors proposed. Managing PIC presents multiple challenges for clinicians. Firstly, variable disease severity within and among patients requires diverse treatments, from observation to aggressive immunosuppression and/or anti-VEGF therapy. Secondly, treatment must distinguish between primary causes of vision loss. New or worsening PIC lesions suggest active inflammation, while new neovascular membranes may indicate secondary neovascular processes. Thirdly, deciding on maintenance therapy is complex, balancing PIC prognosis variability against immunosuppression risks. Some patients have long periods of inactivity and remission, while others face sudden, vision-threatening episodes during quiescent phases. Through a systematic review of the literature, this paper sheds light on the current understanding of PIC, its challenges, and the prospects for future research. By synthesizing existing knowledge, it aims to aid clinicians in accurate diagnosis and guide treatment decisions for improved visual outcomes in individuals affected by PIC.

Efficacy and safety of intravitreal injections of conbercept for the treatment of idiopathic choroidal neovascularization

BACKGROUND

To determine the efficacy and safety of intravitreally injected conbercept, a vascular endothelial growth factor receptor fusion protein, for the treatment of idiopathic choroidal neovascularization (ICNV).

METHODS

This retrospective study analyzed outcomes in 40 patients (40 eyes) with ICNV who received intravitreal injections of conbercept 0.5 mg (0.05 ml) and were followed up for at least 12 months. All patients underwent full ophthalmic examinations, including best-corrected vision acuity (BCVA), intraocular pressure (IOP), slit-lamp examination, color fundus photography, optical coherence tomography angiography, multifocal electroretinogram, and fundus fluorescence angiography, if necessary, at baseline and after 1, 3, 6, and 12 months. BCVA, macular central retinal thickness (CRT), IOP, CNV blood flow area, thickness of the CNV-pigment epithelial detachment complex, thickness of the retinal nerve fiber layer (RNFL), and the first positive peak (P1) amplitude density in ring 1 before and after treatment were compared.

RESULTS

Mean baseline BCVA (logMAR), CRT, CNV blood flow area, and CNV-pigment epithelial detachment complex thickness were significantly lower 1, 3, 6, and 12 months after than before conbercept treatment (P < 0.05 each). IOP and baseline RNFL thickness were unaffected by conbercept treatment. P1 amplitude density was significantly higher 1, 3, 6, and 12 months after than before conbercept treatment (P < 0.05 each). None of the 40 eyes showed obvious ocular adverse reactions, such as endophthalmitis, glaucoma, cataract progression, and retinal detachment, and none of the patients experienced systemic adverse events, such as cardiovascular and cerebrovascular accidents.

CONCLUSIONS

Intravitreal injection of conbercept is beneficial to eyes with ICNV, inducing the recovery of macular structure and function and improving BCVA, while not damaging the neuroretina. Intravitreal conbercept is safe and effective for the treatment of ICNV.

Macular neovascularization in inherited retinal diseases: A review

Inherited retinal diseases (IRDs) are the most common cause of blindness in working-age adults. Macular neovascularization (MNV) may be a presenting feature or occurs as a late-stage complication in several IRDs. We performed an extensive literature review on MNV associated with IRDs. MNV is a well-known complication of Sorsby fundus dystrophy and pseudoxanthoma elasticum. Those with late-onset Stargardt disease may masquerade as exudative age-related macular degeneration (AMD) when MNV is the presenting feature. Peripherinopathies may develop MNV that responds well to a short course of anti-vascular endothelial growth factor (anti-VEGF) therapy, while bestrophinopathies tend to develop MNV in the early stages of the disease without vision loss. Enhanced S-cone syndrome manifests type 3 MNV that typically regresses into a subfoveal fibrotic nodule. MNV is only a rare complication in choroideraemia and rod-cone dystrophies. Most IRD-related MNVs exhibit a favorable visual prognosis requiring less intensive regimens of anti-vascular endothelial growth factor therapy compared to age-related macular degeneration. We discuss the role of key imaging modalities in the diagnosis of MNV across a wide spectrum of IRDs and highlight the gaps in our knowledge with respect to the natural history and prognosis to pave the way for future directions of research.

[Long-term outcome of macular neovascularization secondary to choroidal osteoma with and without intravitreal anti-VEGF(vascular endothelial growth factor)- treatment]

BACKGROUND

Choroidal osteoma (CO) is a benign ossifying ocular tumor, which is unilateral in most cases. The CO may cause severe visual impairment, especially in the case of a secondary macular neovascularization (MNV).

OBJECTIVE

Based on a case series of patients with MNV secondary to CO, the variability of the clinical course with and without intravitreal anti-vascular endothelial growth factor (VEGF) treatment is presented.

METHODS

All patients diagnosed with secondary MNV due to CO between 2007 and 2023 were retrospectively assessed with respect to the clinical course.

RESULTS

In this study 7 eyes of 5 patients (4 women, 1 man) were diagnosed with secondary MNV due to CO. Intravitreal anti-VEGF treatment was carried out in 2 patients with unilateral MNV and 1 patient was treated in both eyes for bilateral MNV. In another case with bilateral MNV, only 1 eye was treated because of fibrosis in the other eye. A further case with unilateral CO and MNV scars at the initial diagnosis was left untreated. Overall, in 3 out of 5 eyes treated with intravitreal VEGF inhibition stabilization or improvement of visual acuity could be achieved.

CONCLUSION

In our case series intravitreal anti-VEGF treatment attained a functional stabilization or improvement in 3 out of 5 treated eyes. In one case of CO-associated MNV fibrosis rapidly developed without treatment. Therefore, the clarification for patients with CO about the lifelong risk for development of a secondary MNV is essential in individual cases for early treatment. As no standardized treatment scheme for intravitreal VEGF antibodies for CO-related MNV exists, the treatment is planned on an individual basis.

Intravitreal Brolucizumab for Pachychoroid Neovasculopathy Associated With Chronic Central Serous Chorioretinopathy

Purpose

To evaluate the anatomical and functional outcomes of intravitreal brolucizumab in eyes with chronic central serous chorioretinopathy complicated by pachychoroid neovasculopathy.

Methods

Retrospective analysis of 34 eyes treated with intravitreal brolucizumab. Twenty-five eyes (73.5%) had been treated with other anti-vascular endothelial growth factor agents before switching to brolucizumab, whereas nine eyes were naïve. Outcome measures included the change of central foveal thickness and subfoveal choroidal thickness, evaluation of sub/intraretinal fluid on optical coherence tomography, and change in best-corrected visual acuity.

Results

Before starting brolucizumab, 23 eyes showed subretinal fluid, 8 both subretinal and intraretinal fluid, and 3 intraretinal fluid only. At the last visit, 22 eyes (64.7%) showed complete reabsorption of both intraretinal and subretinal fluid, whereas subretinal fluid was still present in 8 eyes (23.5%), and both intraretinal and subretinal fluid in 4 eyes (11.8%). The mean number of brolucizumab injections required to achieve complete fluid reabsorption was 2.8 ± 1.8. central foveal thickness decreased from 317.8 ± 109.3 µm to 239.8 ± 74.8 µm (P = 0.0005) and subfoveal choroidal thickness decreased from 399.3 ± 86.2 µm to 355.5 ± 92.7 µm at the end of the follow-up period (P = 0.0008). The mean logarithm of the minimum angle of resolution best-corrected visual acuity improved from 0.4 ± 0.2 to 0.3 ± 0.2 at 1 month after the first injection and remained stable at the same values at the end of the follow-up period (P = 0.04).

Conclusions

Intravitreal brolucizumab is effective for the treatment of naïve and recalcitrant pachychoroid neovasculopathy.

Translational Relevance

Intravitreal brolucizumab may represent an option in patients with pachychoroid neovasculopathy complicating chronic central serous chorioretinopathy.

Randomized controlled trials in central serous chorioretinopathy: A review

Central serous chorioretinopathy (CSCR), a common chorioretinal disease, presents with a myriad of manifestations. Acute CSCR presents with localized neurosensory detachment whereas chronic CSCR may show widespread retinal pigment epithelium (RPE) changes, chronic shallow subretinal fluid, and choroidal neovascularization (CNV) suggestive of a variable natural history leading to suboptimal visual outcomes. Even though multiple treatment options including laser photocoagulation, photodynamic therapy, micropulse laser, anti-vascular endothelial growth factors, and systemic drugs (spironolactone, eplerenone, melatonin, mifepristone) are available, there is an absence of any standardized treatment protocol or gold standard treatment modality. Moreover, their performance compared to observation especially in acute CSCR is still debatable. Compared to other chorioretinal diseases such as age-related macular degeneration, diabetic retinopathy, diabetic macular oedema, and retinal vein occlusion, there is a relative dearth of randomized controlled trials in CSCR. Multiple inconsistencies including reliance on history of disease duration, variable inclusion criteria/disease descriptors/study endpoints, and availability of multiple treatment modalities lead to difficulties in designing RCTs. A consensus-based treatment protocol, therefore, is still elusive. We reviewed the literature and compiled the list of papers published to date, wherein we analyse and compare the inclusion criteria, imaging modalities, study endpoints, study duration, and study results. Correcting these discrepancies and deficiencies will help standardize future study designs, facilitating a next step toward a standardized treatment protocol.

Pushing Retinal Imaging Forward: Innovations and Their Clinical Meaning - The 2022 Ophthalmologica Lecture

Retinal imaging has greatly expanded our understanding of various pathological conditions. This article presents a summary of the key points covered during the 2022 Ophthalmologica Lecture held at the Euretina Congress in Hamburg. The first part of the article focuses on the use of optical coherence tomography angiography to examine and comprehend the choroid in age-related macular degeneration (AMD). Subsequently, we delve into the discussion of the "postreceptor neuronal loss" theory in AMD, which was studied using en face structural optical coherence tomography (OCT). Following that, we explore pertinent findings obtained through cross-sectional OCT in retinal and optic nerve diseases, such as AMD, diabetic macular edema, pathologic myopia, central serous chorioretinopathy, and Leber's hereditary optic neuropathy.

Comparing treatment outcomes in randomized controlled trials of central serous chorioretinopathy

PURPOSE

To perform a qualitative analysis of outcomes published from randomized controlled trials (RCTs) on central serous chorioretinopathy (CSCR) from 1979 to 2022.

DESIGN

Systematic review.

METHODS

All RCTs (including both therapeutic and non-therapeutic interventions) on CSCR available online till July 2022 were included after an electronic search in multiple databases such as PubMed, CENTRAL, MEDLINE, EMBASE, BIOSIS, Scopus, and Cochrane database. We analyzed and compared the inclusion criteria, imaging modalities, study endpoints, duration, and the results of the study.

RESULTS

The literature search yielded 498 potential publications. After excluding duplicate studies and studies that met clear exclusion criteria, 64 were screened for further evaluation, of which 7 were removed due to a lack of necessary inclusion criteria. A total of 57 eligible studies are described in this review.

CONCLUSION

This review provides a comparative overview of key outcomes reported between RCTs investigating CSCR. We describe the current landscape of treatment modalities for CSCR and note the discrepancies between results in these published studies. Challenges arise when attempting to compare similar study designs without comparable outcome measures (i.e., clinical vs. structural) which may limit the overall evidence presented. To mitigate this issue, we present the collected data from each study in tables detailing the measures that are and are not assessed in each publication.

Inner retinal degeneration associated with optic nerve head drusen in pseudoxanthoma elasticum

BACKGROUND/AIMS

To determine the association of age, presence of optic nerve head drusen (ONHD) and number of previous intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections with inner retinal layer thicknesses in patients with pseudoxanthoma elasticum (PXE).

METHODS

In this retrospective case-control study, longitudinal spectral-domain optical coherence tomography imaging data from patients with PXE were compared with controls. A custom deep-learning-based segmentation algorithm was trained and validated to quantify the retinal nerve fibre layer (RNFL) and ganglion cell layer (GCL). The association of age, number of anti-VEGF injections and ONHD with the RNFL and GCL thickness in the outer ETDRS subfields as dependent variables was investigated using mixed model regression.

RESULTS

Fourty-eight eyes of 30 patients with PXE were compared with 100 healthy eyes. The mean age was 52.5±12.9 years (range 21.3-68.2) for patients and 54.2±18.7 years (range 18.0-84.5) for controls. In patients, ONHD were visible in 15 eyes from 13 patients and 31 eyes had received anti-VEGF injections. In the multivariable analysis, age (-0.10 µm/year, p<0.001), the diagnosis of PXE (-2.03 µm, p=0.005) and an interaction term between age and the presence of ONHD (-0.20 µm/year, p=0.001) were significantly associated with the GCL thickness. Including the number of intravitreal injections did not improve the model fit. The RNFL thickness was not significantly associated with any of these parameters.

CONCLUSIONS

This study demonstrates a significant association of ageing and ONHD with GCL thinning in patients with PXE, but not with the number of anti-VEGF injections. Given the severity of inner retinal degeneration in PXE, a clinical trial investigating neuroprotective therapy warrants consideration.

Diagnostic and Management Strategies of Bietti Crystalline Dystrophy: Current Perspectives

Bietti crystalline dystrophy (BCD) is a rare, genetically determined chorioretinal dystrophy presenting with intraretinal crystalline deposits and varying degrees of progressive chorioretinal atrophy commencing at the posterior pole. In some cases, there can be concomitant corneal crystals noted first in the superior or inferior limbus. CYP4V2 gene, a member of the cytochrome P450 family is responsible for the disease and more than 100 mutations have been defined thus far. However, a genotype-phenotype correlation has not been established yet. Visual impairment commonly occurs between the second and third decades of life. By the fifth or sixth decade of life, vision loss can become so severe that the patient may potentially become legally blind. Multitudes of multimodal imaging modalities can be utilized to demonstrate the clinical features, course, and complications of the disease. This present review aims to reiterate the clinical features of BCD, update the clinical perspectives with the help of multimodal imaging techniques, and overview its genetic background with future therapeutic approaches.

Efficacy and safety of Aflibercept for the treatment of inflammatory choroidal neovascularization: The ALINEA study

PURPOSE

To evaluate mean change in best-corrected visual acuity (BCVA) at 52 weeks in patients with inflammatory choroidal neovascularization (CNV) treated with aflibercept.

METHODS

We conducted a prospective non-comparative open-label trial. Following one mandatory intravitreal injection of aflibercept, patients were treated under a pro re nata (PRN) dosing regimen with monthly visits.

RESULTS

A total of 19 patients were included, but one presented exclusion criteria; 16 patients were followed for the whole 52-week study, and data for the primary endpoint analysis were available for 14. At baseline, mean BCVA and mean central retinal thickness (CRT) were 64.53 (±19.64) letters and 351.79 (±97.77) μm, respectively. At 52 weeks, the mean change in BCVA was +9.50 (±12.90) letters [95%CI = +2.05-+16.95]. One patient had lost more than 15-letters at 24 weeks, and another one at 52 weeks. CRT change was -62.77 (±100.73) μm at 24 weeks and -66.53 (±97.47) μm at 52 weeks. There was a mean number of 3.56 (±3.29) intravitreal injections at 52 weeks (min = 1; max = 12). No serious ocular adverse events related to the treatment were reported.

CONCLUSIONS

Our study shows that aflibercept is clinically effective, both anatomically and functionally in the treatment of inflammatory CNV. Following the first injection, the PRN strategy appears sufficient for treating most choroidal neovessels.

A customized regimen of intravitreal aflibercept for the treatment of choroidal neovascularization secondary to different chorioretinal diseases

BACKGROUND

To assess the response of CNV secondary to chorioretinal diseases to IVA and to explore the adequate dosing regimen and the long-term results.

METHODS

A retrospective study including patients with treatment-naïve active CNV secondary to chorioretinal diseases. All patients received an initial IVA injection followed by a PRN regimen. The main outcome measures were improvement of BCVA, improvement of anatomical morphology and vascularity of the CNV on SS-OCT, and SS-OCTA, respectively, and ocular or systemic complications attributed to IVA.

RESULTS

The study included 17 eyes of 15 patients. Nine patients (60%) were females. The median age was 20 years. The main primary chorioretinal disease was vitelliform macular dystrophy (29%). The mean baseline BCVA was 0.16. The mean follow-up period was 15 months. Final BCVA improved by a mean of 6 lines. The CNV regressed or became inactive in all eyes. The median number of IVA injections was 2. There were no ocular or systemic complications attributed to IVA.

CONCLUSION

The customized IVA regimen is effective in inducing long-term regression of secondary CNV and in improving BCVA. Multimodal imaging is fundamental in establishing the diagnosis of CNV, and in monitoring its response to IVA.

Intravitreal Injection Planning during COVID-19 Pandemic: A Retrospective Study of Two Tertiary University Centers in Italy

The COVID-19 pandemic has hampered the optimum management of retinal diseases. This study examined the impact of the pandemic on the intravitreal-injection practice in two academic centers in Italy along with the related medico-legal implications. A retrospective analysis of electronic medical records from 16 March 2020 to 14 March 2021 at the ophthalmological departments of University of Cagliari (SGD) and University Magna Græcia of Catanzaro (UMG) was conducted. The data collected between 16 March 2020 and 14 June 2020 (lockdown), 15 June 2020 and 13 September 2020 (unlock), and 14 September 2020 and 14 March 2021 (second wave) were compared with those of the same period of the previous year. Weekly data on the administered drug and the number and type of treated disease were collected and analyzed. During the lockdown, a drop of 59% at SGD (p < 0.00001) and 77% at UMG (p < 0.00001) in intravitreal injections was found. In the first year of the pandemic, the reduction in injections was approximately of 27% (p < 0.0008) and 38% (p < 0.0001) at SGD and UMG, respectively. The COVID-19-related containment measures and the health resources redistribution have led to a delay in the treatment of chronic diseases of the retina, prioritizing the undeferrable ones. The lack of management guidelines has conceived relevant ethical and medico-legal issues that need to be considered in future measures planning.

Central serous chorioretinopathy: A review

Central serous chorioretinopathy (CSC) is the fourth most common non-surgical retinopathy associated with fluid leakage. The pathogenesis is not yet completely understood, but changes in the choroid, sclera and RPE have been described associated with venous congestion of choroidal outflow. CSC can be categorised into acute, chronic, and recurrent subtypes with recent classifications of simple and complex based on the area of RPE change seen on fundus autofluorescence. A multimodal imaging approach is helpful in the diagnosis and management of CSC and secondary complications such as type 1 neovascularisation. Although spontaneous resolution with relatively good visual outcomes is common, treatment should be considered in patients with persistent or recurrent SRF. Treatment options include laser, systemic medications, intravitreal therapy, and surgery. Of these, argon laser for focal extramacular fluid leaks and photodynamic therapy of leakage identified by indocyanine-green angiography currently have the greatest supportive evidence.

[Choroidal neovascularization in central serous chorioretinopathy]

The literature review discusses the features of the pathogenesis, differential diagnosis and antiangiogenic therapy of choroidal neovascularization (CNV) associated with central serous chorioretinopathy (CSC), with particular attention given to the choice of antiangiogenic drug and therapy regimen to achieve optimal anatomical and functional outcomes in patients with CSC complicated by CNV.

Individual vs. combined imaging modalities for diagnosing neovascular central serous chorioretinopathy

PURPOSE

To assess the diagnostic accuracy of individual and combined imaging modalities compared with multimodal imaging for the detection of choroidal neovascularization (CNV) in central serous chorioretinopathy (CSC).

METHODS

We analyzed patients with CSC with and without CNV who had indocyanine green angiography (ICGA), structural optical coherence tomography (OCT), and OCT angiography (OCTA) obtained on the same day. The presence of CNV was determined using multimodal imaging by a senior retina specialist (i.e., diagnostic reference). Individual and combined (i.e., ICGA + structural OCT) imaging modalities were then graded by two expert readers for the presence of CNV. Sensitivity, specificity, positive (PPV), and negative (NPV) predictive values were computed for individual and combined imaging modalities relative to the diagnostic reference.

RESULTS

CNV was detected in 17 eyes in 17 out of 33 CSC patients according to the reference standard. Using ICGA, the identification of CNV had a sensitivity of 66.7%, specificity of 66.7%, PPV of 70.6%, and NPV of 62.5%. Structural OCT had the following diagnostic accuracy values: 83.3% of sensitivity, 53.3% of specificity, 68.1% of PPV, and 72.7% of NPV. Using OCTA, CNV was graded to be present with a sensitivity of 77.8%, specificity of 86.7%, PPV of 87.5%, and NPV of 76.5%. The combination of ICGA and structural OCT granted the identification of CNV with a sensitivity of 83.3%, specificity of 86.7%, PPV of 88.2%, and NPV of 81.3%.

CONCLUSIONS

OCTA has an elevated diagnostic accuracy in identifying CSC-associated CNV, though a combination of ICGA and structural OCT has a comparable diagnostic efficiency.

Type one macular neovascularization in central serous chorioretinopathy: Short-term response to anti-vascular endothelial growth factor therapy

PURPOSE

The aim of this study was to assess the short-term effect of anti-vascular endothelial growth factor (VEGF) treatment on type 1 macular neovascularization (MNV) secondary to central serous chorioretinopathy (CSCR) and to identify potential predictive factors for treatment response using multimodal imaging.

METHODS

Retrospective, multicentre study in CSCR patients with MNV detected by OCT-angiography and treated with anti-VEGF injections. Clinical and multimodal imaging data before and after anti-VEGF injections was reviewed. Univariate and multivariate linear regression analyses were performed to evaluate associations between the change in central macular thickness (CMT) after anti-VEGF therapy and other factors.

RESULTS

Forty patients were included. One month after receiving a mean number of 2.7 anti-VEGF intravitreal injections, visual acuity increased significantly from 0.46 ± 0.3 logMAR at baseline to 0.38 ± 0.4 logMAR (p = 0.04). The CMT and foveal serous retinal detachment (SRD) decreased significantly from 330 ± 81.9 µm at baseline to 261.7 ± 63.1 µm after treatment (p < 0.001) and from 145.1 ± 98.8 µm at baseline to 52.6 ± 71.3 µm (p < 0.001), respectively. Subretinal fluid and/or intraretinal fluid were still present in 18 eyes (45%) one month after treatment. In the multivariate analysis, a higher SRD height was associated with a greater CMT change (p = 0.002) and a lower CMT change with the presence of subretinal hyperreflective material (SHRM) (p = 0.04).

CONCLUSION

Fluid resorption was incomplete in about half of the patients with MNV secondary to CSCR after anti-VEGF injections. Shallower SRD or the presence of SHRM were predictors of poor response to anti-VEGF.

Long-Term Effect of Anti-Vascular Endothelial Growth Factor (Anti-VEGF) Injections in Choroidal Neovascularization Secondary to Angioid Streaks

Purpose

This study aimed to evaluate the long-term effectiveness of intravitreal anti-vascular endothelial growth factor (VEGF) injections in the treatment of choroidal neovascularization (CNV) associated with angioid streaks.

Methods

Multicenter retrospective cohort study, including eyes with CNV secondary to angioid streaks treated with anti-VEGF injections, were performed. Best-corrected visual acuity (BCVA) in ETDRS letters; qualitative and quantitative (foveal thickness) OCT parameters; anti-VEGF type; and number of injections were collected at baseline and at 3, 6, 12, 24, 36, 48, 60, and 72 months.

Results

Thirty-nine eyes from 29 patients, 17 (58.6%) females, were included. The mean follow-up time was 69.4 ± 34.5 months. BCVA was 59.3 ± 23.3 letters at baseline and 63.7 ± 21.9 letters at 48 months. At 3 months, BCVA improved 6.9 ± 11.7 letters (P=0.003). Then, BCVA remained stable. The mean foveal thickness decreased from 343.3 ± 120.2 μm at baseline to 268.3 ± 65.4 at 48 months (P=0.021). The mean number of injections was 4.6 ± 2.1 at 12 months, decreasing to 1.7 ± 2.4 injections between 36 and 48 months (P=0.093).

Conclusion

This real-world study suggests that the functional and morphologic response to anti-VEGF therapy for CNV related to angioid streaks is generally satisfactory and maintained in the long term.

Long term results of three anti-vascular endothelial growth factor agents in pachychoroid neovasculopathy

PURPOSE

To assess morphological changes and visual results in eyes with pachychoroid neovasculopathy (PNV) that underwent different intravitreal anti-vascular endothelial growth factor (VEGF) agents.

MATERIALS AND METHODS

This is a retrospective, observational, comparative study included 76 PNV eyes in 76 patients that were allocated to 3 groups according to monotherapy injection procedure, as follows: the intravitreal bevacizumab (IVB) group, intravitreal ranibizumab (IVR) group, and intravitreal aflibercept (IVA) group. Central macular thickness (CMT), best-corrected visual acuity (BCVA), and subfoveal choroidal thickness (SFCT) were measured at baseline, after treatment 1^st month, 3^rd month, 6^th month, and 12^th month, and at the final post-treatment examination.

RESULTS

Mean age of the patients was 57.31 ± 5.91 years (range: 34-67 years). Mean duration of follow-up was 31.50 ± 12.91 months (range: 13-60 months). The IVB group included 30 eyes, the IVR group included 22 eyes, and the IVA group included 24 eyes. There weren't any significant differences in BCVA changes between the groups at any post-baseline measurement time point. Although CMT did not change significantly in the IVB group from baseline to final follow-up visit (baseline: 376.33 ± 86.31µm; final visit: 340.80 ± 122.70 µm) (p = 0.172), CMT did change significantly in the IVA group (baseline: 383.41 ± 131.83 µm; final visit: 297.33 ± 103.81 µm) (p = 0.029) and IVR group (baseline: 379.18 ± 97.93 µm; final visit: 335.72 ± 111.45 µm) (p = 0.041). SFCT decreased significantly in the IVR and IVA groups (p = 0.015 and p < 0.001, respectively). The mean number of injections was 12.06 ± 4.72 (range: 6-20) in the IVB group, 11.81 ± 3.31(range: 7-17) in the IVR group, and 7.16 ± 3.15 (range: 4-13) in the IVA group (p = 0.004).

CONCLUSION

All 3 anti-VEGFs were effective in terms of visual results in patients with PNV. Patients treated with IVA required fewer injections than those treated with IVB or IVR. Furthermore, IVR and IVA treatment significantly decreased SFCT, whereas IVB did not.

The identification of activity of choroidal neovascularization complicating angioid streaks

OBJECTIVES

To inspect the inter-reader agreement of different diagnostic modalities in identifying choroidal neovascularization (CNV) activity secondary to angioid streaks (AS) and to analyze the prevalence of subretinal hyper-reflective material (SHRM) in active CNV.

METHODS

Retrospective study of patients with AS with active CNV; optical coherence tomography (OCT), OCT angiography (OCTA), fundus fluorescein angiography (FFA), and indocyanine green angiography (ICGA) from each patient were collected. Agreement between two readers using different diagnostic modalities is presented as free-marginal kappa (k) and 95% confidence interval (CI).

RESULTS

This study included 19 eyes of 12 patients with active CNV (5 naive and 14 previously treated). Agreement among readers on CNV activity was excellent for OCT (k =0.88; 95% CI 0.71-1.00), good for FFA (k = 0.70; 95% CI 0.46-0.94) and ICGA (k = 0.58; 95% CI 0.31-0.84), and poor using OCTA (k = 0.39; 95% CI 0.11-0.68). SHRM was the most common OCT finding associated with active CNV (100%); fuzzy borders were present in 53% of SHRM cases at baseline.

CONCLUSIONS

Identification of CNV activity in AS is challenging; OCT was the best modality to inspect active CNV. The identification of SHRM contributed to recognizing active CNV. Further studies are needed to assess the role of SHRM in anticipating prognosis and guiding treatment of CNV secondary to AS.

Comparative Efficacy and Safety of Advanced Intravitreal Therapeutic Agents for Noninfectious Uveitis: A Systematic Review and Network Meta-Analysis

Background: To compare the efficacy and safety of advanced intravitreal therapeutic regimens, including a dexamethasone implant at 350 and 700 μg; a fluocinolone acetonide (FA) implant, 0.2 µg/day, 0.59 and 2.1 mg; intravitreal bevacizumab, 1.25 mg; intravitreal ranibizumab, 0.5 mg; intravitreal triamcinolone acetonide (IVTA), 2 and 4 mg; and standard of care (SOC, systemic therapy) for noninfectious uveitis.

Methods: We searched the Cochrane Library database, EMBASE, Medline, clinicaltrials.gov until April 2021 with 13 RCTs (1806 participants) identified and conducted a pairwise and Bayesian network meta-analysis with random effects.

Results: No specific regimen showed a statistically significant advantage or disadvantage to another treatment regimen with regard to efficacy. However, the FA implant, 0.59 mg was associated with a higher risk of cataract (RR 4.41, 95% CI 1.51–13.13) and raise in intraocular pressure (IOP) (RR 2.53 95% CI 1.14–6.25) compared with SOC at 24 months. IVTA, 4 mg at 6 months was associated with lower risk of IOP rising compared with FA implant, 0.2 µg/day at 36 months (RR 3.43 95% CI 1.12–11.35).

Conclusion: No intravitreal therapeutic regimens showed a significant advantage or disadvantage with regard to efficacy. However, SOC was associated with lower risk of side effects compared with FA implants. IVTA, 4 mg, might be the best choice with lowest risk of IOP rising.

Systematic Review Registration:clinicaltrials.gov, identifier CRD42020172953

Review for Diagnostics of the Year: Inflammatory Choroidal Neovascularization – Imaging Update

Inflammatory choroidal neovascularization (iCNV) is a rare complication of uveitis but is a major cause of vision compromise in affected patients. Fluorescein angiography (FA) has been the gold standard for diagnosis. However, it is an invasive modality and when used alone, it might be difficult to distinguish iCNV from inflammatory lesions. Optical coherence tomography (OCT) is a noninvasive and rapid imaging modality that can provide additional features to diagnose iCNV. OCT angiography (OCTA) uses intrinsic motion contrast to visualize flow and is useful to distinguish iCNV from inflammatory lesions. However, its role in evaluating iCNV activity and treatment response is still unclear and more studies are required to reach consensus. In conclusion, the use of data from multimodal imaging is necessary to identify and promptly treat iCNV, thus preserving patient vision.

Vascular endothelial growth factor-A level in human breast milk after intravitreal injection of ranibizumab: a case report

Background

Ranibizumab is one of intravitreal anti-vascular endothelial growth factor agents. It is applied in the treatments of choroidal neovascularization, age-related macular degeneration, diabetic macular edema, and macular edema secondary to retinal vein occlusion. Preliminary evidence suggests that intravitreal ranibizumab may enter the plasma and human breast milk in very low-level concentration. As a precaution, breastfeeding is not recommended during the treatment of intravitreal injection of ranibizumab. There are limited data regarding the change of anti-vascular endothelial growth factor concentration in human breast milk after intravitreal injection of ranibizumab, especially in the first 24 h after injection. The purpose of this report is to analyse the concentration change of vascular endothelial growth factor-A in human breast milk with time, in the short term after intravitreal injection of ranibizumab.

Case presentation

In June 2018, a 30-year-old patient breastfeeding a six-month-old baby was diagnosed with choroidal neovascularization of left eye in Eye Hospital of Wenzhou Medical University. She received four administrations of 0.5 mg intravitreal injection of ranibizumab of the left eye, and breast milk was collected just before the injection, and 1–3, 6, 12, 24, 48, and 72 h after intravitreal injection, and assessed for vascular endothelial growth factor-A concentration. The change in vascular endothelial growth factor-A concentration in human breast milk showed the same trend after each injection, decreasing significantly within 6–12 h (about 20–30% lower), and increasing to pre-injection level by 24 h after injection.

Conclusions

The concentration of vascular endothelial growth factor-A in human breast milk of a mother who continues lactating dropped initially and rose to pre-injection level about 24 h after intravitreal injection of ranibizumab. The data may offer more information to evaluate the impact of anti-vascular endothelial growth factor agent intravitreal injection of lactating mothers and their breastfed infants.

Predictors of anti-VEGF efficacy in chronic central serous chorioretinopathy based on intraocular cytokine levels and pigment epithelium detachment subtypes

PURPOSE

The aim of this study was to compare intraocular cytokines among different types of pigment epithelial detachments (PEDs) in patients with chronic central serous chorioretinopathy (CSC) and to investigate the association of cytokine levels and PED types with response to anti-vascular endothelial growth factor (VEGF) therapy.

METHODS

We included 88 patients with chronic CSC and 30 controls. The anti-VEGF agent conbercept was given intravitreally to chronic CSC patients. Cytokines VEGF, interleukin-6 (IL-6), IL-8, IL-10, interferon-inducible protein-10 and monocyte chemoattractant protein-1 in aqueous humour were measured. Treatment efficacy, cytokine levels, changes in best-corrected visual acuity (BCVA) and optical coherence tomography parameters were assessed at baseline and 1 month after treatment.

RESULTS

Patients were divided into three groups: flat irregular PED (FIPED) with choroidal neovascularization (CNV), FIPED without CNV and focal PED. Vascular endothelial growth factor (VEGF) was the only cytokine significantly higher in chronic CSC FIPED patients. There were no significant differences in VEGF between FIPED patients with or without CNV (p = 0.234). At 1 month after conbercept injection, treatment effective rates in FIPED patients with or without CNV were significantly higher than in patients with focal PED (p < 0.05). Best-corrected visual acuity (BCVA) was improved in both FIPED groups (p < 0.05), but not in the focal PED group (p = 0.180). All three groups had significant decreases in central macular thickness (p < 0.05), and PED heights in FIPED patients were reduced (p < 0.05).

CONCLUSIONS

Patients with FIPED in chronic CSC had elevated intraocular VEGF levels and responded favourably to conbercept. Anti-VEGF treatment may be an option for FIPED CSC patients with or without secondary CNV.

EFFICACY AND SAFETY OF AFLIBERCEPT FOR THE TREATMENT OF IDIOPATHIC CHOROIDAL NEOVASCULARIZATION IN YOUNG PATIENTS: The INTUITION Study

PURPOSE

To evaluate the mean change in visual acuity at 52 weeks in patients with idiopathic choroidal neovascularization treated with aflibercept.

METHODS

We conducted a prospective noncomparative open-label Phase-II trial. The dosage regimen evaluated in this study was structured into two periods: (1) from inclusion to 20 weeks: a treat-and-extend period composed of three mandatory intravitreal injections, and complementary intravitreal injections performed if needed; (2) from 21 weeks to 52 weeks: a pro re nata period composed of intravitreal injections performed only if needed.

RESULTS

A total of 19 patients were included, and 16 completed the 52-week study. At baseline, the mean best corrected visual acuity was 66.56 (±20.72) letters (≈20/50 Snellen equivalent), and the mean central retinal thickness was 376.74 µm (±93.77). At 52 weeks, the mean change in the best-corrected visual acuity was +19.50 (±19.36) letters [95% confidence interval = +9.18 to +29.82]. None of the patients included lost ≥15 letters at 24 weeks or 52 weeks. The mean change in central retinal thickness was -96.78 µm (±104.29) at 24 weeks and -86.22 µm (±112.27) at 52 weeks. The mean number of intravitreal injections was 5.4 (±3.0) at 52-weeks. No ocular serious adverse events related to the treatment were reported.

CONCLUSION

The present analysis shows clinically significant functional and anatomical treatment effect of aflibercept in case of idiopathic choroidal neovascularization. The treat-and-extend regimen proposed after the first injection seems adequate to treat most neovessels.

INTRAVITREAL RANIBIZUMAB IN PREGNANT PATIENT WITH MYOPIC CHOROIDAL NEOVASCULAR MEMBRANE. A CASE REPORT

AIM

To present the case of a patient with myopic choroidal neovascular membrane (mCNV) in the 3rd trimester of pregnancy, who was treated with intravitreal ranibizumab.

CASE REPORT

The 34-year-old patient was referred to the Department of Ophthalmology of the University Hospital Kralovske Vinohrady in January 2020 for mCNV on her right eye (RE). The patient was in the 34th week of pregnancy. Initial best corrected visual acuity (BCVA) was 68 ETDRS letters. Spherical equivalent of the RE was -11.5 dioptres, axial length of the RE was 27.7 mm. Pigmented CNV with small haemorrhage was present on the retina of the RE. Optical coherence tomography (OCT) of the RE showed a hyperreflective mass above the retinal pigment epithelium, central retinal thickness (CRT) was 310 µm. OCT angiography confirmed the presence of a classic CNV in the macula of the RE. Two weeks later, the hyperreflective lesion and oedema in the macula of the RE increased, the CRT was 329 µm, BCVA remained stable. After discussion with the patient and the treating gynaecologist, intravitreal ranibizumab was administered in the RE in the 36th week of pregnancy. On check-up 3 weeks later, we observed the decrease of macular oedema to 276 µm and the improvement of BCVA to 78 ETDRS letters. The patient delivered a healthy baby girl in the 39th week of pregnancy via caesarean section, postnatal adaptation of the newborn was normal. During further visits, the BCVA improved to 83 ETDRS letters and the macular oedema disappeared completely. 8 months after the first ranibizumab injection, the CNV reactivated, BCVA decreased to 72 ETDRS letters, oedema was present in the macula and the CRT was 309 µm. Another ranibizumab was administered into the RE. The patient then discovered that she was pregnant; according to calculations, she was in the 3rd week of pregnancy at the time of the second ranibizumab injection. After the second injection, BCVA improved to 79 ETDRS letters, macular oedema on the OCT disappeared and CRT decreased to 264 µm. The pregnancy was terminated per patients request.

CONCLUSION

Intravitreal administration of ranibizumab in the 3rd trimester of pregnancy led to the improvement of BCVA and decrease of macular oedema in the patient with mCNV. The injection had no adverse effect on the pregnancy or the postnatal adaptation of the newborn. However, it is always necessary to consider the risk/benefit ratio when administering intravitreal antiVEGF drugs in pregnant patients. Thorough discussion with the patient is necessary.

Optical Coherence Tomography Angiography Compared with Multimodal Imaging for Diagnosing Neovascular Central Serous Chorioretinopathy

PURPOSE

To assess the diagnostic accuracy of optical coherence tomography angiography (OCTA) compared with multimodal imaging for choroidal neovascularization (CNV) in central serous chorioretinopathy (CSC) eyes and to determine the features that predicted CNV.

DESIGN

Prospective cross-sectional study.

METHODS

Consecutive CSC patients were recruited from retina clinic. The reference standard for CNV was determined by interpretation of multimodal imaging with OCTA, structural OCT line scan, fluorescein angiography (FA), indocyanine green angiography (ICGA), ultra-widefield fundus photography and fundus autofluorescence (FAF). Two independent masked graders examined OCTA without FA and ICGA to diagnose CNV. Univariate and multivariate analyses were performed to evaluate factors associated with CNV.

RESULTS

CNV was detected in 69 eyes in 64 out of 277 CSC patients according to reference standard. The two masked graders who examined OCTA had sensitivity of 81.2% (95% Confidence Interval [CI], 71.9%-90.4%) and 78.3% (95% CI, 68.5%-88.0%), specificity of 97.3% (95% CI, 95.9%-98.8%) and 96.2% (95% CI, 94.5%-98.0%), positive predictive values of 82.4% (95% CI, 73.3%-91.4%) and 76.1% (95% CI, 66.1%-86.0%), and negative predictive values of 97.1% (95% CI, 95.6%-98.7%) and 96.7% (95% CI, 95.0%-98.3%). Their mean area under the receiver operating characteristic curve (AUC) was 0.88 with good agreement (Kappa coefficient 0.80 [95% CI, 0.72-0.89]). Flat irregular pigment epithelial detachment on structural OCT, neovascular network on OCTA and ill-defined late leakage on FA significantly correlated with CNV in CSC from multiple regression (P < 0.001, P < 0.001 and P = 0.005, respectively).

CONCLUSIONS

There is discordance between OCTA and multimodal imaging in diagnosing CNV in CSC. This study demonstrated the caveats in OCTA interpretation, such as small extrafoveal lesions and retinal pigment epithelial alterations. Comprehensive interpretation of OCTA with dye angiography and structural OCT is recommended.

Pachychoroid disease spectrum: review article

PURPOSE

The aim of this article is to do a comprehensive literature review about the current understandings of the pachychoroid disease spectrum, describing its multimodal imaging analysis, pathophysiology, differential diagnosis, and current types of management.

METHODS

This comprehensive literature review was performed based on a search on the PubMed database, of relevant pachychoroid published papers according to our current knowledge.

DISCUSSION

The pachychoroid disease spectrum, according to some authors, includes the following: pachychoroid pigment epitheliopathy (PPE), central serous chorioretinopathy (CSC), pachychoroid neovasculopathy (PNV), polypoidal choroidal vasculopathy (PCV)/aneurysmal type 1 neovascularization (AT1), and more recently focal choroidal excavation (FCE) and peripapillary pachychoroid syndrome (PPS). Each one of these entities will be described and discussed in this article.

CONCLUSION

Significant advances in multimodal imaging have enabled a better understanding of the typical choroidal changes in pachychoroid disease spectrum. The clinical knowledge and managing options about this disease significantly increased in the last years. However, it is still unclear why some eyes with typical pachychoroid disease phenotype show no evidence of RPE damage and subretinal fluid (uncomplicated pachychoroid) while others present progressive tissue damage, neovascularization, and atrophy.

Central Serous Chorioretinopathy - an Overview

Central serous chorioretinopathy (CSCR) is characterised by retinal serous detachment usually localised in the macular region. CSCR predominantly affects men between 30 and 50 years of age. Traditional classification differentiates between acute (duration shorter than 4 to 6 months) and chronic disease (duration longer than 4 to 6 months). The pathogenesis is multifactorial and current thinking assumes the presence of localised choroidal hyperpermeability with subsequent secondary changes in the retinal pigment epithelium (RPE). The symptoms of acute CSCR include central blurred vision, often with deterioration in visual acuity. Optical coherence tomography (OCT) reveals subretinal fluid (SRF) and/or single retinal pigment epithelial detachments. Fluorescein angiography (FA) usually shows a leaking point with absent or only minor RPE changes in the acute phase and indocyanine green angiography (ICG) highlights circumscribed areas of thickened and hyperpermeable choroid. Acute cases may show spontaneous resolution of SRF, but may also recur and/or become chronic. After the initial diagnosis, spontaneous remission is seen in about 70 to 80% of cases, with a recurrence rate of about 50%. Due to the favourable spontaneous course, it is recommended to wait for 4 to 6 months after the first symptoms manifest. Steroid therapy is considered as a major risk factor. Chronic cases are characterised by slow deterioration in visual acuity with reduced contrast and colour perception. There are extensive RPE changes, with secondary degenerative changes of the photoreceptors. The disease can by complicated by choroidal neovascularisation (CNV), especially in elderly patients. The literature lists a number of treatments: The leakage point (visible in the FA) can be treated by focal laser therapy, either micropulse laser or, if sufficiently distant from the fovea, by argon laser coagulation. Randomised trials in chronic CSCR demonstrated good outcomes with photodynamic therapy. With observation periods ranging from 3 to 6 months, several case series reports found improvement after systemic administration of mineralocorticoid receptor antagonists, carbonic anhydrase inhibitors or non-steroidal anti-inflammatory drugs. In the presence of secondary CNV, anti-VEGF treatment should be initiated. It is unclear whether the combination with PDT might be useful.

[Choroidal neovascularization due to a punctate inner choroidopathy visualized by optical coherence tomography angiography]

Punctate inner choroidopathy (PIC) is often accompanied by the development of choroidal neovascularization (CNV). The identification of a fresh CNV in the context of PIC is often difficult. We present the case of a 30-year-old female patient with typical morphological features of PIC. A CNV could not be detected with certainty by optical coherence tomography (OCT) or by fluorescein angiography (FAG); however, OCT angiography (OCT-A) revealed a circumscribed CNV. The case suggests that there are a high number of undiagnosed, subclinical secondary CNVs not requiring treatment in PIC patients.