ASSESSMENT OF HYPERREFLECTIVE FOCI AFTER BEVACIZUMAB OR DEXAMETHASONE TREATMENT ACCORDING TO DURATION OF MACULAR EDEMA IN PATIENTS WITH BRANCH RETINAL VEIN OCCLUSION

Integrated Assessment of OCT, Multimodal Imaging, and Cytokine Markers for Predicting Treatment Responses in Retinal Vein Occlusion Associated Macular Edema: A Comparative Review of Anti-VEGF and Steroid Therapies

Retinal vein occlusion (RVO) is a significant cause of vision loss, characterized by the occlusion of retinal veins, leading to conditions such as central retinal vein occlusion (CRVO) and branch retinal vein occlusion (BRVO). Macular edema (ME), a prevalent consequence of RVO, is the primary cause of vision impairment in affected patients. Anti-VEGF agents have become the standard treatment, showing efficacy in improving visual acuity (VA) and reducing ME. However, a subset of patients exhibit a suboptimal response to anti-VEGF therapy, necessitating alternative treatments. Corticosteroids, which address inflammatory pathways implicated in ME, have shown promise, particularly in cases resistant to anti-VEGF. This review aims to identify biomarkers that predict treatment response to corticosteroids in RVO-associated ME, utilizing multimodal imaging and cytokine assessments. Baseline imaging, including SD-OCT and OCT-A, is essential for evaluating biomarkers like hyperreflective foci (HRF), serous retinal detachment (SRF), and central retinal thickness (CRT). Elevated cytokine levels, such as IL-6 and MCP-1, correlate with ME severity and poor anti-VEGF response. Early identification of these biomarkers can guide timely transitions to corticosteroid therapy, potentially enhancing treatment outcomes. The practical conclusion of this review is that integrating biomarker assessment into clinical practice enables personalized treatment decisions, allowing for earlier and more effective management of RVO-associated ME by transitioning patients to corticosteroid therapy when anti-VEGF agents are insufficient. Advanced diagnostics and machine learning may further refine personalized treatment strategies, improving the management of RVO-associated ME.

Comparison of changes in number of hyperreflective dots after intravitreal ranibizumab or dexamethasone implant in patients with branch retinal vein occlusion

PURPOSE

To compare the effect of intravitreal ranibizumab (IVR) or intravitreal dexamethasone implants (IVD) on the regression of hyperreflective dots (HRDs) in patients with branch retinal vein occlusion (BRVO).

MATERIALS AND METHODS

Thirty-seven eyes with cystoid macular edema who received IVR or IVD and followed up for at least 12 months were included in this study. The patients were divided into three Groups according to intravitreal treatments. Group 1 consisted of 12 eyes who received only IVD, Group 2 consisted of 10 eyes who received only IVR, and Group 3 consisted of 15 eyes who received both IVD and IVR. The number of HRDs and best-corrected visual acuity (BCVA) were compared between the Groups through the follow-up time.

RESULTS

The mean number of HRDs in inner and outer retinal layers was significantly decreased in Group 1 and Group 3 (For Group 1; P < 0.001, P = 0.001, for Group 3; P < 0.001, P < 0.001). At the 1st year, the number of HRDs in inner and outer retinal layers was significantly lower in Group 1 and Group 3 than Group 2 (All P < 0.05). The BCVA was higher in Group 3 than Group 2 at 1st year (P = 0.048).

CONCLUSION

The HRDs should be considered inflammatory markers in the follow-up of CME in BRVO.

Exploration on OCT biomarker candidate related to macular edema caused by diabetic retinopathy and retinal vein occlusion in SD-OCT images

To improve the understanding of potential pathological mechanisms of macular edema (ME), we try to discover biomarker candidates related to ME caused by diabetic retinopathy (DR) and retinal vein occlusion (RVO) in spectral-domain optical coherence tomography images by means of deep learning (DL). 32 eyes of 26 subjects with non-proliferative DR (NPDR), 77 eyes of 61 subjects with proliferative DR (PDR), 120 eyes of 116 subjects with branch RVO (BRVO), and 17 eyes of 15 subjects with central RVO (CRVO) were collected. A DL model was implemented to guide biomarker candidate discovery. The disorganization of the retinal outer layers (DROL), i.e., the gray value of the retinal tissues between the external limiting membrane (ELM) and retinal pigment epithelium (RPE), the disrupted and obscured rate of the ELM, ellipsoid zone (EZ), and RPE, was measured. In addition, the occurrence, number, volume, and projected area of hyperreflective foci (HRF) were recorded. ELM, EZ, and RPE are more likely to be obscured in RVO group and HRFs are observed more frequently in DR group (all P ≤ 0.001). In conclusion, the features of DROL and HRF can be possible biomarkers related to ME caused by DR and RVO in OCT modality.

Aflibercept 5+PRN with retinal laser photocoagulation is more effective than retinal laser photocoagulation alone and aflibercept 3+PRN with retinal laser photocoagulation in patients with high-risk proliferative diabetic retinopathy and diabetic macular edema: a 12-month clinical trial

Objective

This study aimed to investigate and compare the efficacy and safety of retinal laser photocoagulation (PRP) alone, PRP with aflibercept 3+PRN, and PRP with aflibercept 5+PRN in patients with both high-risk proliferative diabetic retinopathy (PDR) and diabetic macular edema (DME).

Methods

Overall, 170 patients with high-risk PDR and DME (170 eyes from 170 patients) who visited our ophthalmology clinic from December 2018 to December 2020 were divided into the PRP (n=58), aflibercept 5+PRN with PRP (n=53), and aflibercept 3+PRN with PRP (n= 59) groups. General information, such as age, sex, and eye category, was obtained. Moreover, best-corrected visual acuity (BCVA), baseline central macular foveal thickness (CFT), microaneurysm (MA), area of neovascularization (NV), area of hard exudate (HE), and cytokine levels in atrial fluid before and after treatment, were assessed. The χ2 test was used for comparison between groups for statistical data. Analysis of variance was used for the statistical description of measurement data, independent samples were analyzed using Student's t-test, and Student-Newman-Keuls test was used for group comparisons. Differences were considered statistically significant at P < 0.05.

Results

After treatment, no significant improvement in the BCVA (logMAR) of patients in the PRP group was observed. The BCVA (log MAR) decreased from 0.72 ± 0.17 and 0.74 ± 0.17 to 0.50 ± 0.13 and 0.53 ± 0.17 in PRP with aflibercept 5+PRN and PRP with aflibercept 3+PRN groups, respectively, with a statistically significant difference compared to those in the PRP group (P<0.05 in all cases). However, no statistically significant difference was observed between the combined treatment groups (P>0.05). The CFT in the PRP-only group decreased slightly from 361.80 ± 36.70 μm to 353.86 ± 40.88 μm, with no statistically significant difference (P>0.05), whereas the CFT in the aflibercept 5+PRN with PRP and aflibercept 3+PRN with PRP groups decreased from 356.57 ± 37.57 μm and 358.17 ± 44.66 μm to 284.87 ± 31.52 μm and 303.19 ± 37.00 μm, respectively, with statistically significant differences before and after treatment (P<0.05 for both groups). Statistically significant differences were observed in CFT between the three groups after treatment (P<0.05 in all cases). The number of MA (pcs) in the PRP, aflibercept 5+PRN with PRP, and aflibercept 3+PRN with PRP groups decreased from 118.34 ± 27.96, 118.60 ± 33.34, and 116.59 ± 28.95 to 92.95 ± 29.04, 44.60 ± 20.73, and 54.26 ± 25.43, respectively. The two-way comparison of the three groups revealed statistically significant differences in MA (P<0.05 in all cases). In the three groups, NV decreased from 1.00 ± 0.21 mm², 1.01 ± 0.18 mm², and 0.98 ± 0.20 mm² before treatment to 0.49 ± 0.17 mm², 0.31 ± 0.16 mm², and 0.38 ± 0.14 mm², respectively, with statistically significant differences (P<0.05 in all cases). After 12 months of treatment, 13, 18, and 18 patients had reduced HE area in the PRP-only, aflibercept 5+PRN with PRP, and aflibercept 3+PRN with PRP groups, respectively, with statistically significant differences (P<0.05 in all cases). After 12 months of treatment, vascular endothelial growth factor, monocyte chemoattractant protein-1, and glial fibrilliary acidic protein levels (pg/mL) in the aqueous humor decreased in both combined treatment groups compared with that at baseline, with statistically significant differences; however, no significant difference was observed between the two combined treatment groups (P>0.05).

Conclusion

Aflibercept 5+PRN combined with PRP was safe and effective in treating patients with high-risk PDR and DME, and was more effective than PRP-only and aflibercept 3+PRN with PRP in improving CFT and MA.

Comparison of quantification of intraretinal hard exudates between optical coherence tomography en face image versus fundus photography

PURPOSE

To compare the quantification of intraretinal hard exudate (HE) using en face optical coherence tomography (OCT) and fundus photography.

METHODS

Consecutive en face images and corresponding fundus photographs from 13 eyes of 10 patients with macular edema associated with diabetic retinopathy or Coats' disease were analyzed using the machine-learning-based image analysis tool, "ilastik."

RESULTS

The overall measured HE area was greater with en face images than with fundus photos (en face: 0.49 ± 0.35 mm2 vs. fundus photo: 0.34 ± 0.34 mm2, P < 0.001). However, there was an excellent correlation between the two measurements (intraclass correlation coefficient [ICC] = 0.844). There was a negative correlation between HE area and central macular thickness (CMT) (r = -0.292, P = 0.001). However, HE area showed a positive correlation with CMT in the previous several months, especially in eyes treated with anti-vascular endothelial growth factor (VEGF) therapy (CMT 3 months before: r = 0.349, P = 0.001; CMT 4 months before: r = 0.287, P = 0.012).

CONCLUSION

Intraretinal HE can be reliably quantified from either en face OCT images or fundus photography with the aid of an interactive machine learning-based image analysis tool. HE area changes lagged several months behind CMT changes, especially in eyes treated with anti-VEGF injections.

Retinal Macrophage-Like Cells as a Biomarker of Inflammation in Retinal Vein Occlusions

Aim: To study the macrophage-like cells (MLC) of the inner retinal surface in eyes with retinal vein occlusions (RVO) and the association of MLC with clinical characteristics of RVO. Methods: In this retrospective cross-sectional study, the medical records and multimodal imaging data of treatment-naïve patients with unilateral RVO and no abnormalities of vitreoretinal interface electronic were reviewed and analyzed. To visualize MLC, structural projections of optical coherence tomography (OCT) angiography scans within a slab between two inner limiting membrane segmentation lines (with 0 and −9 µm offset) were evaluated. The density of MLC was calculated and compared between affected and fellow eyes of each patient with regards to OCT and clinical characteristics of RVO. Results: Thirty-six eyes (twenty-eight branch RVO and eight central RVO) of 36 patients (21 males and 15 females, mean age 48.9 ± 9.8 years) were included. The density of MLC in affected eye was statistically significantly higher than that of the fellow eye, 8.5 ± 5.5 and 4.0 ± 3.6 cells/mm2, respectively (p < 0.001). The MLC density in the affected eye had a statistically significantly correlation with that of the fellow eye (r = 0.76, p = 0.0001), but with none of the OCT and clinical characteristics of the affected eye apart from the presence of subfoveal fluid. Eyes with subfoveal fluid had a statistically significantly higher mean number of MLC than that of eyes without subfoveal fluid, 12.6 ± 6.3 and 6.9 ± 4.0 cells/mm2, respectively (p = 0.009). Conclusion: The number of MLC on the inner retinal surface increases in RVO eyes which may reflect the activation of inflammatory pathways.

Characterization of Macrophage-Like Cells in Retinal Vein Occlusion Using En Face Optical Coherence Tomography

Purpose

To investigate the clinical features of a macrophage-like cell (MLC) obtained by en face optical coherence tomography (OCT) in retinal vein occlusion (RVO).

Methods

The study involved 36 patients with treatment-naïve unilateral acute RVO, including 21 branch RVO (BRVO) and 15 central RVO. Vessel density and macular thickness were quantified using OCT angiography. A 3-μm en face OCT slab on the inner limiting membrane in the optic nerve head (ONH) region or macular region was used to visualize the MLCs. The MLCs were binarized and quantified using a semiautomated method. The unaffected fellow eyes served as the control group.

Results

The morphology of MLCs appeared larger and plumper in RVO eyes. The mean MLC density in the ONH and macular regions was 2.46 times and 2.86 times higher than their fellow eyes, respectively (p < 0.001). The macular MLC density of the occlusive region was significantly lower than that of the unaffected region in BRVO (p = 0.01). The ONH and macular MLC densities in the non-perfused region were significantly lower than those in the perfused region in all RVO eyes (p < 0.001). The ONH MLC density in RVO eyes was negatively correlated with radial peripapillary capillary vessel density (r = -0.413, p = 0.012). Both ONH and macular MLC densities were positively correlated with macular thickness (r = 0.505, p = 0.002; r = 0.385, p = 0.02, respectively).

Conclusion

The increased density and changes of morphology characterized by OCT may indicate generalized activation and aggregation of MLCs in RVO. More MLCs are recruited in the perfused region rather than the non-perfused region. RVO eyes with a higher density of MLCs tend to suffer from the thicker macula.

Predictors of Dexamethasone Response of Residual Edema by Branch Retinal Vein Occlusion after Bevacizumab Injection

Purpose: To predict the response to intravitreal dexamethasone (IVD) implant injection in cases where macular edema (ME) caused by branch retinal vein occlusion persists despite intravitreal bevacizumab injection.Methods: Three consecutive (monthly) bevacizumab injections were given to treat ME caused by branched retinal vein occlusion (BRVO) 63 eyes that received additional dexamethasone or bevacizumab injection 1 month later to treat residual ME were retrospectively studied. Each injection group was divided into two subgroups according to ME disappearance status by 6 months after diagnosis. Initial central retinal thickness (CRT), subfoveal choroidal thickness (SFCT), and hyperreflective focus status were compared among the subgroups, as were the changes in these values.Results: At the decision point, the dexamethasone good response subgroups exhibited thicker CRTs and smaller CRT changes than the dexamethasone partial response subgroups (all p < 0.05). The good dexamethasone response subgroup showed smaller SFCT changes, a thicker CRT, and smaller CRT changes than the bevacizumab good response subgroup (all p < 0.05) at the decision point. The cutoff values of the Youden index were 409 μm for the CRT and 62.5 μm for the CRT change (p = 0.002 and p = 0.011, respectively).Conclusions: If ME persists after three bevacizumab injections, IVD more effectively reduces edema if the CRT is thick or if the CRT change is small.

RADIATION MACULOPATHY IS ANTICIPATED BY OCT HYPERREFLECTIVE RETINAL FOCI: A Large, Prospective, Confirmation Study

PURPOSE

To investigate, by means of spectral domain optical coherence tomography, retinal reflectivity changes as an early biomarker anticipating radiation-induced macular edema (ME) in patients treated by iodine-125 (I-125) brachytherapy.

METHODS

Thirty patients planned for I-125 brachytherapy because of uveal melanoma were prospectively included and followed every 4 months for five years. Reflectivity alterations, namely hyperreflective retinal foci, were characterized and counted by two independent masked examiners by means of spectral domain optical coherence tomography imaging. Hyperreflective retinal foci were defined as discrete intraretinal reflectivity changes ≤30 µm, with reflectivity similar to nerve fiber layer and without back shadowing.

RESULTS

Macular edema occurred in 17 patients (24.2 ±15.1 months) (group 1) after irradiation. Thirteen patients showed no signs of ME at the 5-year follow-up (group 2). The number of hyperreflective retinal foci was statistically higher in sequential visits until the evidence of ME in group 1 vs group 2 (P < 0.0001). In group 1, hyperreflective retinal foci at the follow-up before the evidence of ME were significantly related to the OCT central subfield thickness at ME appearance (P = 0.0002, r2=0.6129). The intergrader agreement was almost perfect (intraclass correlation coefficient = 0.80).

CONCLUSION

Hyperreflective retinal foci may be considered as an early in vivo imaging biomarker of retinal inflammatory response to ocular irradiation, anticipating the development of radiation maculopathy.

Changes of Optical Coherence Tomography Biomarkers in Macular Edema Secondary to Retinal Vein Occlusion After Anti-VEGF and Anti-Inflammatory Therapies

Purpose

Patients and Methods

Results

Conclusion

Aggravation of retinal hard exudates after intravitreal anti-vascular endothelial growth factor therapy for cystoid macular edema and the risk factors: a retrospective study

Background/aims

To evaluate retinal hard exudates (HEs) progression in patients with cystoid macular edema (CME) secondary to diabetic retinopathy (DR) or branch retinal vascular occlusion (BRVO) after intravitreal injections of ranibizumab (IVR) treatment and identify the risk factors for the deterioration of HEs.

Methods

This retrospective study enrolled 288 eyes with center-involving CME secondary to DR or BRVO from 288 patients (one eye per patient). All patients were treated with three loading doses of ranibizumab intravitreally at a monthly interval. The morphologic features of HEs were observed, and the HEs areas were quantified using a semi-automatic method at baseline, 1 month after the first dose of IVR and 1 month after the third dose of IVR therapy. HEs progression was defined as having a > =2-grade increase in the HEs severity scale. The best-corrected vision acuity (BCVA) and alterations in HEs areas were compared between DR and BRVO groups. And logistic regression analyses were used to identify the risk factors for HEs exacerbation.

Results

Morphological changes of retinal HEs occurred in all eyes after IVR therapy, although HEs area was not significantly changed in some eyes. DR group has a higher percentage of eyes with progressed HEs area than the BRVO groups (34.9% vs. 21.8%, P = 0.019) 1 month after the first dose of IVR. Both DR and BRVO groups had a decreased percentage of enlarged HEs 1 month after the third injection, but the DR group is still higher than the BRVO group (17.1% vs. 8.4%, P = 0.027). At baseline, there was no correlation between VA and HEs areas. After the first and third doses of IVR, there still was no consistent correlation between HEs severity and change in VA over time. Furthermore, CME with subretinal fluid (SRF) is associated with a higher risk of HEs progression (P = 0.001). Long CME duration and high serum low-density lipoprotein cholesterol (LDL-C) level were identified as risk factors for HEs progression following IVR treatment in both univariable and multivariable regression analyses (Odds ratio (OR) = 1.88, P = 0.012 and OR = 1.14, P = 0.021, respectively).

Conclusions

Alterations in the area of retinal HEs are widely observed after IVR treatment for CME. The eyes with CME secondary to DR have a higher percentage of progressed HEs than the BRVO eyes. DME with SRF, extended duration of CME, and high LDL-C level are potential risk factors of deteriorated HEs after IVR treatment.

Significance of Hyperreflective Foci as an Optical Coherence Tomography Biomarker in Retinal Diseases: Characterization and Clinical Implications

Hyperreflective foci (HRF) is a term coined to depict hyperreflective dots or roundish lesions within retinal layers visualized through optical coherence tomography (OCT). Histopathological correlates of HRF are not univocal, spacing from migrating retinal pigment epithelium cells, lipid-laden macrophages, microglial cells, and extravasated proteinaceous or lipid material. Despite this, HRF can be considered OCT biomarkers for disease progression, treatment response, and prognosis in several retinal diseases, including diabetic macular edema, age-related macular degeneration (AMD), retinal vascular occlusions, and inherited retinal dystrophies. The structural features and topographic location of HRF guide the interpretation of their significance in different pathological conditions. The presence of HRF less than 30 μm with reflectivity comparable to the retinal nerve fiber layer in the absence of posterior shadowing in diabetic macular edema indicates an inflammatory phenotype with a better response to steroidal treatment. In AMD, HRF overlying drusen are associated with the development of macular neovascularization, while parafoveal drusen and HRF predispose to macular atrophy. Thus, HRF can be considered a key biomarker in several common retinal diseases. Their recognition and critical interpretation via multimodal imaging are vital to support clinical strategies and management.