Biomarkers and predictors for functional and anatomic outcomes for small gauge pars plana vitrectomy and peeling of the internal limiting membrane in naïve diabetic macular edema: The VITAL Study

Vitrectomy as an Adjunct to Treat-and-Extend Anti-VEGF Injections for Diabetic Macular Edema: The Vitrectomy in Diabetic Macular Oedema (VIDEO) Randomized Clinical Trial

Importance

There are reported benefits from vitrectomy for diabetic macular edema (DME); however, data precede anti-vascular endothelial growth therapy (VEGF) therapy, supporting a need to assess the current role of vitrectomy.

Objective

To determine rates of recruitment and efficacy outcomes of vitrectomy plus internal limiting membrane (ILM) peeling adjunctive to treat-and-extend (T&E) anti-VEGF injections for diabetic macular edema (DME).

Design, Setting, and Participants

This was a single-masked, multicenter randomized clinical trial at 21 sites in the United Kingdom from June 2018 to January 2021, evaluating single eyes of treatment-naive patients with symptomatic vision loss from DME for less than 1 year. Inclusion criteria were best-corrected visual acuity (BCVA) Early Treatment Diabetic Retinopathy Study letter score greater than 35 (approximate Snellen equivalent, 20/200 or better) and central subfield thickness (CST) greater than 350 μm after 3 monthly intravitreal injections of ranibizumab or aflibercept. Data analysis was performed in July 2023.

Interventions

Patients were randomized 1:1 into vitrectomy plus standard care or standard care alone and further stratified into groups with vs without vitreomacular interface abnormality. Both groups received a T&E anti-VEGF injection regimen with aflibercept, 2 mg, or ranibizumab, 0.5 mg. The vitrectomy group additionally underwent pars plana vitrectomy with epiretinal membrane or ILM peel within 1 month of randomization.

Main Outcomes and Measures

Rate of recruitment and distance BCVA. Secondary outcome measures were CST, change in BCVA and CST, number of injections, rate of completed follow-up, and withdrawal rate.

Results

Over 32 months, 47 of a planned 100 patients were enrolled; 42 (89%; mean [SD] age, 63 [11] years; 26 [62%] male) completed 12-month follow-up visits. Baseline characteristics appeared comparable between the control (n = 23; mean [SD] age, 66 [10] years) and vitrectomy (n = 24; mean [SD] age, 62 [12] years) groups. No difference in 12-month BCVA was noted between groups, with a 12-month median (IQR) BCVA letter score of 73 (65-77) letters (Snellen equivalent, 20/40) in the control group vs 77 (67-81) letters (Snellen equivalent, 20/32) in the vitrectomy group (difference, 4 letters; 95% CI, -8 to 2; P = .24). There was no difference in BCVA change from baseline (median [IQR], -1 [-3 to 2] letters for the control group vs -2 [-8 to 2] letters for the vitrectomy group; difference, 1 letter; 95% CI, -5 to 7; P = .85). No difference was found in CST changes (median [IQR], -94 [-122 to 9] μm for the control group vs -32 [-48 to 25] μm for the vitrectomy group; difference, 62 μm; 95% CI, -110 to 11; P = .11).

Conclusions and Relevance

Enrollment goals could not be attained. However, with 47 participants, evidence did not support a clinical benefit of vitrectomy plus ILM peeling as an adjunct to a T&E regimen of anti-VEGF therapy for DME.

Trial Registration

isrctn.org Identifier: ISRCTN59902040.

Selective ILM Staining and Safety of Two Vital Dyes During a Human-Like Pars Plana Vitrectomy Ex Vivo in Porcine Eyes

PURPOSE

An ideal dye for intraocular use should effectively stain the target tissue while being easy to apply and remove. Additionally, it should not have any adverse effects resulting from prolonged contact with the retinal tissue. Recently, concerns have been raised about the safety of some vital dyes during surgical procedures as they may cross the internal limiting membrane and deposit on the retina. In this study, we aimed to investigate whether commercially available vital dyes, VIEW-ILM® and TWIN® (AL.CHI.MI.A. S.r.l., Ponte San Nicolò, Padova, Italy), have the potential to cross the internal limiting membrane during vitreoretinal surgery and deposit on the retina. Furthermore, we evaluated their safety in vitro and in vivo.

METHODS

A human-like pars plana vitrectomy was performed on porcine eyes ex vivo, with VIEW-ILM® or TWIN® used to stain the internal limiting membrane either with or without subsequent internal limiting membrane peeling. The two dyes were then extracted from retinal punches with or without internal limiting membrane, and quantified using high performance liquid chromatography. Safety was evaluated through in vitro cytotoxicity tests and in vivo skin sensitization and irritation tests according to ISO standards.

RESULTS

High performance liquid chromatography analyses demonstrated that VIEW-ILM® and TWIN® effectively stained the internal limiting membrane without crossing the membrane. No residual dyes were found in the retinal layers after internal limiting membrane removal. Furthermore, both in vitro and in vivo safety tests confirmed the absence of cytotoxicity, skin sensitization, and irritation.

CONCLUSION

The results of this study support the safety and efficacy of VIEW-ILM® and TWIN® for internal limiting membrane staining. The experimental protocol described in this study could be utilized to gain a comprehensive understanding of the characteristics of vital dyes.

Effectiveness of intravitreal ranibizumab for diabetic macular edema in vitrectomized versus non-vitrectomized eyes: a Meta-analysis

AIM

To evaluate the effectiveness and safety of intravitreal ranibizumab (IVR) for diabetic macular edema (DME) in vitrectomized versus non-vitrectomized eyes.

METHODS

The PubMed, EMBASE, Web of Science, Cochrane, EBSCO were comprehensively searched for studies comparing vitrectomized and non-vitrectomized eyes with DME. Clinical outcomes of best-corrected visual acuity (BCVA), central macular thickness (CMT), the mean number of intravitreal injection and adverse events were extracted and analyzed.

RESULTS

Six studies involving 641 eyes were included. Final visual gain significantly improved and CMT significantly reduced in vitrectomized eyes at 6mo and 12mo visits (P<0.05). Although the mean reduction in CMT among non-vitrectomized eyes was significantly greater than in vitrectomized eyes at the 6mo [mean difference (MD)=53.57, 95% confidence interval (CI): 28.03 to 78.72, P<0.0001] and 12mo (MD=49.65, 95%CI: 19.58 to 79.72, P=0.01), no significant difference was detected in improvement in BCVA at either 6mo (MD=0.05, 95%CI: -0.02 to 0.13, P=0.14) or 12mo (MD=0.03, 95%CI: -0.04 to 0.09, P=0.43). Injection number of ranibizumab in non-vitrectomized eyes was significantly less than that in vitrectomized eyes during 6-month period (MD=0.60, 95%CI: 0.16 to 1.04, P=0.008), while there was no statistically significant difference between the two groups during 12mo of follow-up.

CONCLUSION

Evidence from current study suggests that IVR was useful for both vitrectomized group and non-vitrectomized group with DME. Although less reduction in macular thickness is found in vitrectomized group, visual improvement between two groups is similar.

Influence of prior treatment protocol on intravitreal dexamethasone implant behavior in patients with diabetic macular edema in real-world practice

BACKGROUND AND OBJECTIVE

Intravitreal dexamethasone implant (DEXI) has been placed as an effective option to treat diabetic macular edema (DME). However, there is no consensus on the best time to introduce it. We conducted a study to evaluate anatomical and functional behavior after the first DEXI according to previous treatment.

RESEARCH DESIGN AND METHODS

This retrospective, real-world study between 2013 and 2020 investigated changes in best-corrected visual acuity (BCVA) and central macular thickness (CMT at months 2 and 6 after the first DEXI in DME. Patients were divided into naive, early switch (≤3 anti-VEGF injections), or late switch (>3 anti-VEGF injections) groups.

RESULTS

Among 112 consecutive eyes, mean BCVA and CMT improved significantly in all groups at month 2, with no difference between them. However, this improvement was not maintained at 6 months. The Naíve group presented better BCVA all over the study period. The previously treated groups, which started with worse initial visual acuity, showed more visual gain without reaching the BCVA of the naive group. CMT performance was similar between groups.

CONCLUSIONS

There was similar anatomical and functional behavior in all groups. Poorer visual acuity at baseline was associated with worse functional outcome despite good anatomic response.

Accuracy of biomicroscopy, ultrasonography and spectral-domain OCT in detection of complete posterior vitreous detachment

BACKGROUND

To evaluate the accuracy of preoperative biomicroscopy (BM), ultrasonography (US), and spectral domain optical coherence tomography (SD-OCT) to determine complete posterior vitreous detachment (PVD) confirmed by intraoperative findings of triamcinolone acetonide-assisted pars plana vitrectomy (PPV).

METHODS

This prospective study included all consecutive patients admitted for surgical treatment of the epiretinal membrane (ERM) and macular hole (MH). The presence of complete PVD was determined one day before PPV using BM, US, SD-OCT. The preoperative findings were compared to the PVD status determined during PPV.

RESULTS

A total of 123 eyes from 123 patients were included in the study. Indications for PPV included ERM in 57 (46.3%), full thickness macular hole in 57 (46.3%) and lamellar macular hole in 9 (7.3%) patients. Complete PVD during PPV was observed in 18 (31.6%; 95%CI:18.7-49.9) patients with ERM and 13 (19.7%; 95%CI:10.4-33.7) patients with MH. The sensitivity of preoperative BM, US, SD-OCT was 48.4% (95%CI:30.2-66.9), 61.3% (95%CI:42.2-78.2) and 54.8% (95%CI:36.0-72.7) respectively. The specificity of preoperative BM, US, SD-OCT was 81.5% (95%CI:72.1-88.9), 90.2% (95%CI:82.2-95.4) and 85.9% (95%CI:77.0-92.3) respectively. With a prevalence of 25.2% of PVD in our sample the positive predictive value of preoperative BM, US, SD-OCT was 46.9% (95%CI:29.1-65.3), 67.9% (95%CI:47.6-84.1) and 56.7% (95%CI:37.4-74.5) respectively.

CONCLUSION

Preoperative BM, US, and SD-OCT showed relatively low sensitivity but also good specificity in assessing complete PVD. A combination of all three diagnostic methods can provide a good assessment of the vitreoretinal interface state.

Microinvasive pars plana vitrectomy combined with internal limiting membrane peeling versus anti-VEGF intravitreal injection for treatment-naïve diabetic macular edema (VVV-DME study): study protocol for a randomized controlled trial

BACKGROUND

Diabetic macular edema (DME) is the main cause of vision loss in diabetic patients. Currently, anti-vascular endothelial growth factor (VEGF) intravitreal injection stands as the first-line therapy for DME. However, some patients exhibit insufficient response to anti-VEGF agents and often require multiple injections, imposing psychological and economic burdens. While microinvasive pars plana vitrectomy (PPV) has been shown to be safe and effective in treating refractory DME, scant research has explored its application to treatment-naïve DME. The purpose of this study is to determine whether early PPV combined with internal limiting membrane (ILM) peeling can lessen the therapeutic burden of DME patients, prevent vision loss, and maintain long-term stabilization of diabetic retinopathy.

METHODS

This is a single-center, prospective, parallel-group, non-inferiority randomized controlled trial involving 102 DME participants. Participants will be randomly assigned to either the study group (PPV combined with ILM peeling) or the control group (conbercept intravitreal injection (IVC)) at a 1:1 ratio, with a scheduled follow-up at 12 months post-operation. Comparative analysis of results between the two groups will be conducted at months 1, 3, 6, and 12 after the intervention. The primary outcomes involve evaluating the changes in central subfield thickness (CST) and best corrected visual acuity (BCVA). The secondary outcomes include assessment of optical coherence tomography (OCT) and OCT angiography (OCTA) biomarkers, re-treatment and adverse events rates, diabetic retinopathy (DR) development, cost-effectiveness analysis, and vision-related quality of life (VRQL).

DISCUSSION

Some patients do not respond well to anti-VEGF drugs and repeated intravitreal injections increase the treatment burden for patients. The VVV study aims to explore whether PPV combined with ILM peeling could become an initial treatment option for treatment-naïve DME patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05728476. Registered on 15 February 2023.

In Vivo Electroporation Improves Retinal Delivery of Intravitreally Injected Exosomes

Purpose: Mesenchymal stem cell (MSC)-derived exosomes are promising therapeutic agents and natural nanoscale delivery platforms for treating degenerative retinal diseases. This study investigated the effect of electroporation on the retinal delivery of intravitreally administered MSC-derived exosomes in a murine model. Methods: Exosomes isolated from adipose tissue-derived MSCs were stained with ExoGlow exosome-specific dye and administered to the right eyes of 40 Sprague-Dawley rats. Electroporation was performed in 20 rats immediately after intravitreal injection (electroporation group); 5 square pulses of 40 V/cm for 50 ms each with 950-ms intervals were administered. The remaining 20 rats were assigned to the no-electroporation group. The eyeballs were harvested 24 h later for evaluation. The total number of fluorescent particles per hyperfield was counted from the retinal flat mounts to quantify the retinal delivery of exosomes. Tissue damage after electroporation was evaluated using retinal histological sections and a terminal deoxynucleotidyl transferase-mediated deoxyuridine nick end labeling (TUNEL) assay. Results: A significantly higher number of fluorescent particles per hyperfield were observed in the retinal flat mounts of the electroporation group compared with that in the no-electroporation group (599.0 ± 307.5 vs. 376.9 ± 175.4; P = 0.013). Retinal histological sections and TUNEL assays showed no signs of tissue damage after electroporation. Conclusions: In vivo electroporation can improve the retinal delivery of intravitreally injected exosomes.

Role of Vitrectomy in Nontractional Refractory Diabetic Macular Edema

Background: Currently, the gold standard of diabetic macular edema (DME) treatment is anti-vascular endothelial growth factor (VEGF) injections, although a percentage of patients do not respond optimally. Vitrectomy with or without internal limiting membrane (ILM) peeling is a well-established treatment for DME cases with a tractional component while its role for nontractional cases is unclear.The aim of this study is to evaluate the role of vitrectomy with or without ILM peeling in nontractional refractory DME.Methods: We performed a retrospective review of twenty-eight eyes with nontractional refractory DME treated with vitrectomy at San Giuseppe Hospital, Milan, between 2016 and 2018. All surgeries were performed by a single experienced vitreoretinal surgeon. In 43.4% of cases, the ILM was peeled. Best corrected visual acuity and optical coherence tomography (OCT) scans were assessed preoperatively and at 6, 12, and 24 months post-vitrectomy. Results: The mean central macular thickness improved from 413.1 ± 84.4 to 291.3 ± 57.6 μm at two years (p < 0.0001). The mean logarithm of the minimum angle of resolution logMAR best-corrected visual acuity (BCVA) improved after two years, from 0.6 ± 0.2 to 0.2 ± 0.1 (p < 0.0001). We found no difference between ILM peeling vs. no ILM peeling group in terms of anatomical (p = 0.8) and visual outcome (p = 0.3). Eyes with DME and subfoveal serous retinal detachment (SRD) at baseline had better visual outcomes at the final visit (p = 0.001). Conclusions:We demonstrated anatomical and visual improvement of patients who underwent vitrectomy for nontractional refractory DME with and without ILM peeling. Improvement was greater in patients presenting subretinal fluid preoperatively.

Intralenticular Ozurdex injection in an eye with thicker lens and the therapeutic effect maintained for 15 months

Introduction

To report a case of accidental intralenticular Ozurdex injection in an eye with thicker lens. During the follow-up period of 15 months, the therapeutic effect of intralenticular Ozurdex was maintained.

Case description

Ozurdex was accidently injected into the lens of an eye with uveitis, and the lens thickness was measured to be 5.70 mm. The uveitis was under good control, and no significant development of cataract was observed until 7 months after the intralenticular Ozurdex injection. Then due to the outbreak of COVID-19, follow-up was suspended. Fifteen months after the injection, the patient returned to the doctor. At this time, significant cataract development was observed, whereas uveitis was still under good control. Accordingly, cataract surgery and Ozurdex extraction were performed. Two months after surgery, a mild recurrence of uveitis occurred.

Conclusions

A thicker lens might be an important risk factor for accidental intralenticular Ozurdex injections. However, after intralenticular Ozurdex injection, the development of cataract was slow, and Ozurdex could still have a therapeutic effect on uveitis in this case. Thus, immediate surgery might be unnecessary for certain accidental intralenticular Ozurdex injection cases, and a follow-up strategy could be chosen to maintain the effect of Ozurdex.

Changes in the Hyperreflective Bands of Outer Retinal Layers after Idiopathic Epiretinal Membrane Surgical Removal

Purpose: The purpose of this study was to describe the relationship between the outer retinal hyperreflective bands and visual acuity recovery after idiopathic epiretinal macular membrane (ERM) surgical removal.Methods: A prospective longitudinal non-comparative study was conducted that included a total of 68 patients with idiopathic ERM, who underwent consecutive 23 G pars plana vitrectomy (PPV) at San Juan University Hospital (Alicante, Spain) from January 2019 to January 2021. All patients underwent a complete preoperative standard ophthalmic examination, including measurement of best corrected visual acuity (BCVA) and spectral-domain optical coherence tomography (SD-OCT) examination. This protocol was repeated at 1 and 3 months after surgery.Results: Mean preoperative decimal BCVA was 0.30 ± 0.13 and disruption of the first, second, third and fourth outer retinal hyperreflective bands was observed by SD-OCT in 9 (27.9%), 27 (39.7%), 33 (48.5%) and 17 patients (25%), respectively. BCVA improved after ERM peeling at 1 and 3 months in all patients, regardless of the presence of disruption in any hyperreflective band. Significantly larger improvement of BCVA was found at 3 months after surgery in patients not showing disruption of hyperreflective bands 1 and 4 (p = 0.048 and 0.001, respectively).Conclusions: The integrity of the outer retinal hyperreflective bands by SD-OCT in patients with idiopathic ERM is a valuable tool to determine the visual prognosis of the surgical treatment of this condition. A successful recovery of hyperreflective bands 1 and 4 with ERM surgery may be a potential biomarker of the visual improvement achieved due to their important anatomical relation with cone photoreceptors at the foveal level.

Metformin therapy as a strategy to compensate anti-VEGF resistance in patients with diabetic macular edema

Diabetic macular edema (DME) is the complication of diabetic retinopathy, the leading cause of vision loss among diabetic patients. Metformin is the main antidiabetic treatment. It is preferable for its great anti-angiogenic and anti-inflammatory effects. Anti-vascular endothelial growth factor (VEGF) therapy is the preferable treatment for DME despite its lack of convincing results in some patients. To assess whether the combination of metformin and anti-VEGF drugs may decrease the risk of anti-VEGF resistance among DME patients. We included DME patients with a central retinal thickness (CRT) ≥ 250 μm who consecutively underwent at least 3 anti-VEGF therapies from January 1, 2020, to December 30, 2021. Anti-VEGF resistance was defined as persistent macular edema with decreased CRT ≤ 25% after 3 anti-VEGF injections. 109 patients were considered for this research, of whom 65 (59.6%) were resistant to anti-VEGF therapy. The mean CRT of the non-metformin group decreased from 344.88 ± 129.48 to 318.29 ± 123.23 (20.85%) and from 415.64 ± 144.26 to 277.11 ± 99.25 (31.51%) (P = .031) in the metformin group. Moreover, the metformin group had fewer resistant patients than the non-metformin, 24 (45.3%) versus 41 (73.2%). Furthermore, a considerable gain in visual acuity was observed in both groups, with a BCVA gain of 40.41% in the metformin group and 39.9% in the non-metformin group. Metformin may be combined with an anti-VEGF drug to minimize the risk of anti-VEGF resistance among DME patients. Moreover, it can serve to design effective therapeutic deliveries.

Association of Paracentral Acute Middle Maculopathy with Visual Prognosis in Retinal Artery Occlusion: A Retrospective Cohort Study

Background

The association between paracentral acute middle maculopathy (PAMM) and visual acuity in patients with retinal artery occlusion (RAO) is unknown. This study explored the clinical features and prognostic factors for visual acuity of RAO accompanied by PAMM.

Methods

This retrospective study included patients with RAO who underwent FFA and OCT examinations at Shenzhen Eye Hospital from July 2015 to June 2019. The changes in vision and macular structure were observed.

Results

Eighty-eight patients were included. There were 58 patients (65.9%) with central RAO (CRAO) and 30 (34.1%) with branch RAO (BRAO). Fifty-two eyes were diagnosed with PAMM, of which 33 eyes (63.5%) were from CRAO patients and 19 (36.5%) were from BRAO patients. At diagnosis, the PAMM group had significantly better logMAR BCVA values than the no-PAMM group (median (IQR), 1.35 (0.725–2) vs. 2.15 (1.47–2.3), P=0.002). In addition, the PAMM group had significantly better logMAR BCVA values during follow-up than the no-PAMM group (median (IQR), 1 (0.05–2) vs. 2 (1.15–2.3), P=0.001). After adjustment for age, gender, CRAO/BRAO, comorbidities, and symptom duration, PAMM was associated with good visual acuity improvement (RR = 3.29, 95% CI: 1.29–8.37, P=0.013).

Conclusion

PAMM was associated with good visual acuity improvement during follow-up in patients with RAO.

Prognostic Factors for Visual Outcomes in Closed Idiopathic Macular Holes after Vitrectomy: Outcomes at 4 Years in a Monocentric Study

Purpose

To identify predictive factors of visual outcomes in the eyes after successful macular hole (MH) surgery.

Methods

It is a retrospective monocentric study of the eyes that underwent successful vitrectomy for full-thickness MH in an academic, tertiary care center (CHU de Québec–Université Laval, Québec, Canada) between 2014 and 2018. We included a single eye per patient and excluded the eyes with ocular comorbidities. Clinical and anatomical features of patients were collected, including demographics, MH duration, baseline MH size, baseline visual acuity (VA), and final VA. Multiple logistic regressions were performed to determine predictive factors of VA ≥70 ETDRS letters (Snellen equivalent: 20/40) and VA gain ≥15 ETDRS letters at final follow-up. Areas under the receiver operating characteristic curve (AUC) were used to determine the performance of each model and identify the Youden index maximizing performance at a given threshold.

Results

A total of 460 eyes were included in this study; 274/460 eyes (60%) achieved final VA ≥70 ETDRS letters and 304/460 eyes (66%) had a VA gain ≥15 ETDRS letters at 24 months follow-up. Multiple logistic regression analyses showed that the main predictive factors for final VA ≥70 ETDRS letters (model AUC = 0.716) were baseline VA (OR = 1.064; p < 0.001), MH duration (OR = 0.950; p=0.005), and age (OR = 0.954; p=0.004). Predictors of VA gain ≥15 ETDRS letters at final follow-up (model AUC = 0.615) were baseline VA (OR = 0.878; p < 0.001), MH duration (OR = 0.940; p < 0.001), and MH size (OR = 0.998; p=0.036). Thresholds for the final VA ≥70 ETDRS letters model and the VA gain ≥15 ETDRS letters model were VA ≥55.5 ETDRS letters (Snellen equivalent: 6/30) and MH size of 237 μm, respectively.

Conclusion

The eyes with shorter MH duration, smaller MH size, and higher preoperative VA achieved better visual outcomes after successful MH surgery.

Initial observation or treatment for diabetic macular oedema with good visual acuity: two-year outcomes comparison in routine clinical practice: data from the Fight Retinal Blindness! Registry

Purpose

To compare visual acuity (VA) change at 24 months in eyes with clinically significant DME (CSDME) and good VA initially treated versus initially observed in routine clinical practice.

Methods

Retrospective analysis of treatment‐naïve eyes with CSDME and good VA (baseline VA ≥ 79 letters), with at least 24 months of follow‐up and initially managed with treatment (intravitreal treatment and/or macular laser) or observation with possible treatment after 4 months that were tracked in a prospectively designed observational registry.

Results

We identified 150 eligible eyes (98 initially observed, 52 initially treated) of 130 patients. The proportion of eyes with at least a 5‐letter VA loss at 24 months was not significantly different between the groups: 65% with initial observation and 42% with initial treatment (p = 0.39). However, initially observed eyes were more likely to have a 10‐letter VA loss at 24 months (OR = 4.6, p = 0.022). Most of eyes in the initial observation group received at least one treatment (an intravitreal injection in 66% and macular laser in 20%) during the 24‐month period.

Conclusions

The risk of 5 letters loss was similar between both management groups. However, initially observed eyes were more at risk of developing moderate visual loss and more than 80% of them required treatment over 24 months.

Proteome changes associated with the VEGFR pathway and immune system in diabetic macular edema patients at different diabetic retinopathy stages

PURPOSE

Diabetic macular edema (DME) is a major cause of vision loss in all stages of diabetic retinopathy (DR). However, there is limited recognition of aqueous humor (AH) proteome profiles of DME patients at different DR stages. In this study, we aimed to investigate the AH proteome changes between DME patients at the nonproliferative diabetic retinopathy (NPDR) stage and those at the proliferative diabetic retinopathy (PDR) stage.

METHODS

A label-free data-independent acquisition based liquid chromatography tandem mass spectrometry (LC-MS/MS) analysis was performed to profile the abundances of AH proteins in 73 eyes from DME patients at different DR stages. Enzyme-linked immunosorbent assay (ELISA) was used to confirm the proteomics results with AH samples from non-diabetic patients and DME patients at the NPDR or PDR stage.

RESULTS

LC-MS/MS results showed significantly changed expression of 308 proteins between DME patients in the NPDR and PDR groups. Compared to the NPDR group, the proteins relatively up-regulated in the PDR group are involved in the immune system and/or negative regulation of the cell cycle, while proteins relatively down-regulated in the PDR group are associated with the vascular endothelial growth factor receptor (VEGFR) pathway and/or metabolism. ELISA results further verified the proteomic result of down-regulated expression of the immune-associated protein cystatin C (CST3) in the PDR group compared to that in the NPDR and non-diabetic groups.

CONCLUSIONS

In this study, we reported for the first time the decreased abundances of AH proteins associated with the VEGFR pathway and both down- and up-regulated expression of AH proteins associated with the immune system in the PDR group compared to that in the NPDR group. Furthermore, we found negative correlations of immune-associated protein, CST3 concentration in AH with DR severity and central retinal thickness, suggesting CST3 as a promising target independent of the VEGFR pathway in DME-involved DR treatment.

Intraprocedural OCT monitoring of the immediate treatment response during indocyanine green angiography-guided laser therapy of teleangiectatic capillaries in diabetic macular edema

In this retrospective study the morphological response of teleangiectatic capillaries (TCs) to focal laser treatment and the functional and morphological outcome after Indocyanine green angiography (ICGA)-guided laser therapy was evaluated. TCs in eyes with diabetic macular edema (DME) were treated with laser therapy. The immediate and subsequent reaction of the TCs lumina to direct photocoagulation was monitored with customized OCT single scans. Additionally, patients were treated with intravitreal anti-VEGF as needed. 12 eyes of 9 patients with treatment naive (6 eyes) and pretreated (6 eyes) DME were followed-up for a mean of 24 months (± 8.1SD). Best-corrected visual acuity improved from 0.25 logMar (± 0.2SD) to 0.12 (± 0.10SD; p = 0.06) at each patient’s last visit. During laser treatment a darkening of the TCs lumina was achieved in 91.3% of lesions. All these lesions fully resolved, whereas TCs, which showed no darkening of their lumen in OCT persisted and required re-treatment with laser. Additional anti-VEGF injections were indicated in only one eye (8.3%). The darkening of the TCs lumina visible in OCT might provide an image-biomarker that indicates successful coagulation of aneurysmatic lesions. Consequently, a significant functional and morphological improvement with need for anti-VEGF treatment in only one eye, was achieved.

Information concerning the registration of the trial: date of registration: 11th of december, 2019. Trial registration number: 107/2019.

The association between different hypoglycemic regimens and postoperative diabetic macular edema after vitrectomy in the Japanese patients with proliferative diabetic retinopathy

PURPOSE

To study the association between different hypoglycemic regimens and postoperative diabetic macular edema (DME).

METHODS

A secondary analysis based on a retrospective cohort study.

RESULTS

In this secondary analysis, 124 eyes from patients with proliferative diabetic retinopathy (PDR) who underwent pars plana vitrectomy (PPV) between January 2008 and September 2012 were included. We found that compared with oral hypoglycemic medication, oral hypoglycemic medication plus insulin treatment revealed an insignificant relationship with postoperative DME (odds ratio [OR]=0.8, 95% confidence interval [CI]: 0.12-5.21, P=0.8167), only insulin treatment revealed a significant association with postoperative DME (OR=0.10, 95% CI: 0.01-0.84, P=0.0337) after adjusted age, sex. After adjusted age, sex, diabetes mellitus (DM) duration, glycosylated hemoglobin (HbA1c), the results did not have obvious changes (OR=0.61, 95% CI: 0.09-4.26, P=0.6187; OR=0.07, 95% CI: 0.01-0.65, P=0.0197). Furthermore, after adjusted age, sex, DM duration, HbA1c, hypertension, intraoperative retinal photocoagulation, vitreous hemorrhage, macular detachment, fibrovascular membrane, intraocular lens implantation and microincision vitrectomy surgery, the results were consistent (OR=0.66, 95% CI: 0.05-9.49, P=0.7621; OR=0.06, 95% CI: 0.00-0.81, P=0.0342). The same trend was observed in these adjusted models as well (p for trend was 0.0254, 0.0141, and 0.0311, respectively).

CONCLUSION

In conclusion, our results of the secondary analysis should be interpreted as a significant association between insulin treatment and reduced risks of postoperative DME in Japanese PDR patients with PPV surgery, compared with oral medications. Well glycemic control with longstanding insulin therapy may be beneficial to reduce the risks of postoperative DME in PDR patients. Our investigation calls for large-scale and long-term prospective clinical studies for a full evaluation of the exact role of insulin in the progression of postoperative DME.

Feasibility of Therapeutic Ultrasound Application in Topical Scleral Delivery of Avastin

Purpose

Macromolecules have been shown to be effective in vision-saving treatments for various ocular diseases, such as age-related macular degeneration and diabetic retinopathy. The current delivery of macromolecules requires frequent intraocular injections and carries a risk of serious adverse effects.

Methods

We tested the application of therapeutic ultrasound as a minimally invasive approach for the delivery of Avastin into the diseased regions of the eye. Avastin (bevacizumab) is an anti-vascular endothelial growth factor (VEGF) antibody with a molecular weight of 149 kDa. We tested the effectiveness and safety of Avastin delivery through rabbit sclera in vitro using a standard diffusion cell model. Ultrasound at frequencies of 400 kHz or 3 MHz with an intensity of 1 W/cm2 was applied for the first 5 minutes of 1-hour drug exposure. Sham treatments mimicked the ultrasound treatments, but ultrasound was not turned on. Absorbance measurements of the receiver compartment solution were performed at 280 nm using a spectrophotometer.

Results

Absorbance measurements indicated no statistical difference between the sham (n = 13) and 400 kHz ultrasound group (n = 15) in the delivery of Avastin through the sclera. However, the absorbance values were statistically different (P < 0.01) between the 3 MHz ultrasound group (0.004, n = 8) and the matched sham group (0.002, n = 7). There was 2.3 times increase in drug delivery in the 3 MHz ultrasound when compared to the corresponding sham group. Histological studies indicated no significant damage in the ultrasound-treated sclera due to ultrasound application.

Conclusions

Our preliminary results provided support that therapeutic ultrasound may be effective in the delivery of Avastin through the sclera.

Translational Relevance

Our study offers clinical potential for a minimally invasive retinopathy treatment.

Vitrectomized versus non-vitrectomized eyes in diabetic macular edema response to ranibizumab-retinal layers thickness as prognostic biomarkers

To evaluate the role of the vitreous in the management of diabetic macular edema with ranibizumab intravitreal injections in a pro re nata regimen. Prospective study of 50 consecutive eyes with diabetic macular edema treated with ranibizumab and 12 months of follow-up. Primary endpoint: to assess differences between non-vitrectomized and vitrectomized eyes in the number injections needed to control the edema. Secondary endpoints: comparison of groups regarding best corrected visual acuity, central foveal thickness and thickness of seven retinal layers. 46 eyes from 38 patients, 10 vitrectomized and 36 non-vitrectomized, completed the follow-up. At month 12, the two groups achieved an equivalent anatomical outcome and needed a similar number of ranibizumab intravitreal injections. In vitrectomized eyes final visual acuity was worse when baseline retinal nerve fiber layers in the central foveal subfield were thicker, showing a strong correlation (r = − 0.942, p < 0.001). A similar, albeit moderate correlation was observed in non-vitrectomized eyes (r = − 0.504, p = 0.002). A decrease of retinal nerve fiber layers inner ring thickness was correlated with a better final visual acuity only in vitrectomized eyes (r = 0.734, p = 0.016). The effect of diabetic macular edema seems to be worse in vitrectomized eyes, with a thinner inner retina reservoir.

Clinicaltrials.govNCT04387604.

Vitrectomy for diabetic macular edema and the relevance of external limiting membrane

PURPOSE

To evaluate the relevance of external limiting membrane (ELM) on the visual and morphological results in eyes with diabetic macular edema (DME) that underwent pars plana vitrectomy (PPV) with epiretinal membrane (ERM) and internal limiting membrane (ILM) peeling.

METHODS

Medical records of patients with DME who underwent PPV at our unit between January 2017 and December 2019 were reviewed. We assessed preoperative and postoperative best-corrected visual acuity (BCVA), central macular thickness (CMT) using spectral domain OCT (optical coherence tomography). Exclusion criteria were previous PPV; incomplete data; concomitant diseases including retinal vein occlusion, age-related macular degeneration, uveitis; and a follow-up of less than 12 months. The surgeries were performed using 23- or 27-gauge vitrectomy. The ELM was graded depending on its configuration (grade 0 = intact, grade 1 to 3: disruption of varying extent).

RESULTS

Ninety-nine eyes were enrolled. The postoperative follow up averaged 23.7 months. The preoperative and final BCVA averaged 0.71 ± 0.28 and 0.52 ± 0.3 logMAR, respectively (p = 0.002). The CMT averaged 515.2 ± 209.1 μm preoperatively and 327 ± 66.1 μm postoperatively (p = 0.001). Eyes with intact ELM (n = 8) had a significantly better BCVA compared to those with ELM disruption (0.28 ± 0.14 vs. 0.7 ± 0.25 logMAR, p = 0.01). The final CMT was similar among the groups (intact ELM: 317 ± 54.6 μm; ELM disruption: 334 ± 75.2, p = 0.31).

CONCLUSIONS

PPV with ERM and ILM peeling is an effective treatment of DME. Eyes with intact ELM preoperatively had a significantly better final visual outcome. To maximize the benefit for patients with DME we recommend early PPV as long as ELM is intact.

Treatment outcomes of optic disc pit maculopathy over two decades

Aim

To study the long-term outcomes of optic disc pit maculopathy.

Methods

Electronic medical records of 154 patients with optic disc pit were reviewed and 50 patients with optic disc pit maculopathy who met the study criteria were included in the study. Demographic profile of patients, along with clinical characteristics, optical coherence tomography (OCT) features and change in best-corrected visual acuity (BCVA) was recorded. Patients were treated either by observation, barrage laser alone or pars plana vitrectomy (PPV) with optional additional surgical procedures. The primary outcome measures were the change in BCVA and resolution of fluid on OCT.

Results

The mean age of patients was 29.96 years (3-62 years) with a follow-up of 27.16 months. The mean baseline BCVA in observation, laser and vitrectomy group was log MAR 0.94, 0.76 and 0.87 and final BCVA was log MAR 0.9, 0.67 and 0.46, respectively. There was a statistically significant improvement in the final BCVA and reduction in subretinal fluid with resolution of the schisis cavity in vitrectomy group than in other groups. On regression analysis significant association was found between final BCVA with baseline BCVA (R ² = 0.815, p = 0.002), use of C3 F8 endotempanode (p = 0.004) ILM peeling (p = 0.012) and use of triamcinolone (TA; p = 0.003). No significant association was found with juxtapapillary endolaser (p = 0.062).

Conclusions

In patients with disc pit maculopathy, PPV lead to better functional and anatomical outcomes as compared to laser or observation alone. Use of surgical adjuvants like ILM peeling, TA and C3F8 tamponade improved the outcomes, unlike juxtapapillary endolaser treatment.

Effect of Dexamethasone Implant on Subfoveal Choroidal Thickness in Early Period in Vitrectomized Eyes with Diabetic Macular Edema

Aim

To investigate the change in subfoveal choroidal thickness (SFCT) in vitrectomized eyes with intravitreal dexamethasone (IVD) implant injection for the treatment of diabetic macular edema (DME).

Method

In this prospective and controlled study, the vitrectomized eyes of diabetic patients were included. The study group (Group 1) was formed by diabetic vitrectomized eyes with DME. The control group (Group 2) was formed by diabetic vitrectomized eyes without DME. Only one intravitreal IVD implant was injected into the eyes in Group 1. In the first, second, and fourth months, choroidal layers were measured by optical coherence tomography and complete ophthalmologic examinations were performed for all cases.

Results

Ninety-six eyes of 96 cases were included in the study. There were 48 eyes of 48 different patients in each group. After IVD injection, statistically significant improvement was observed in the best corrected visual acuity in Group 1. The mean SFCT in eyes with DME was statistically significantly thinner (p < 0.01) and thinness became more pronounced during the four-month follow-up period after IVD implant injection (p < 0.01).

Conclusion

In the presence of DME in vitrectomized eyes, the thinness of the SFCT may become evident after dexamethasone implant injection.

Quantification of Fluid Resolution and Visual Acuity Gain in Patients With Diabetic Macular Edema Using Deep Learning: A Post Hoc Analysis of a Randomized Clinical Trial

Importance

Large amounts of optical coherence tomographic (OCT) data of diabetic macular edema (DME) are acquired, but many morphologic features have yet to be identified and quantified.

Objective

To examine the volumetric change of intraretinal fluid (IRF) and subretinal fluid (SRF) in DME during anti-vascular endothelial growth factor treatment using deep learning algorithms.

Design, Setting, and Participants

This post hoc analysis of a randomized clinical trial, the Diabetic Retinopathy Clinical Research Network (protocol T), assessed 6945 spectral-domain OCT volume scans of 570 eyes from 570 study participants with DME. The original trial was performed from August 21, 2012, to October 18, 2018. This analysis was performed from December 7, 2017, to January 15, 2020.

Interventions

Participants were treated according to a predefined, standardized protocol with aflibercept, ranibizumab, or bevacizumab with or without deferred laser.

Main Outcomes and Measures

The association of treatment with IRF and SRF volumes and best-corrected visual acuity (BCVA) during 12 months using deep learning algorithms.

Results

Among the 570 study participants (302 [53%] male; 369 [65%] white; mean [SD] age, 43.4 [12.6] years), the mean fluid volumes in the central 3 mm were 448.6 nL (95% CI, 412.3-485.0 nL) of IRF and 36.9 nL (95% CI, 27.0-46.7 nL) of SRF at baseline and 161.2 nL (95% CI, 135.1-187.4 nL) of IRF and 4.4 nL (95% CI, 1.7-7.1 nL) of SRF at 12 months. The presence of SRF at baseline was associated with a worse baseline BCVA Early Treatment Diabetic Retinopathy Study (ETDRS) score of 63.2 (95% CI, 60.2-66.1) (approximate Snellen equivalent of 20/63 [95% CI, 20/50-20/63]) in eyes with SRF vs 66.9 (95% CI, 65.7-68.1) (approximate Snellen equivalent, 20/50 [95% CI, 20/40-20/50]) without SRF (P < .001) and a greater gain in ETDRS score (0.5; 95% CI, 0.3-0.8) every 4 weeks during follow-up in eyes with SRF at baseline vs 0.4 (95% CI, 0.3-0.5) in eyes without SRF at baseline (P = .02) when adjusted for baseline BCVA. Aflibercept was associated with greater reduction of IRF volume compared with bevacizumab after the first injection (difference, 79.8 nL; 95% CI, 5.3-162.5 nL; P < .001) and every 4 weeks thereafter (difference, 10.4 nL; 95% CI, 0.7-20.0 nL; P = .004). Ranibizumab was associated with a greater reduction of IRF after the first injection compared with bevacizumab (difference, 75.2 nL; 95% CI, 1.4-154.7 nL; P < .001).

Conclusions and Relevance

Automated segmentation of fluid in DME revealed that the presence of SRF was associated with lower baseline BCVA but with good response to anti-vascular endothelial growth factor therapy. These automated spectral-domain OCT analyses may be used clinically to assess anatomical change during therapy.

Trial Registration

ClinicalTrials.gov Identifier: NCT01627249.

Evaluation of Macular Changes in the Long Term after Pars Plana Vitrectomy with Internal Limiting Membrane Peeling for Diabetic Macular Edema

AIM

To evaluate long-term macular changes following pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling for diabetic macular edema (DME).

METHODS

Forty eligible eyes of 37 patients were included in this retrospective study. Best corrected visual acuity (BCVA), central macular thickness (CMT), and 5-mm macular volume (5-MV) were examined preoperatively, postoperatively after 1, 2, 3, 6, 12, and 24 months, and at a final visit. Response to surgical treatment was considered as recurrence, reincrease, or recovery of DME based on macular changes.

RESULTS

Mean follow-up time was 51.1 ± 19.0 months after surgery. Recurrence (n = 5) and reincrease (n = 17) of DME was observed in 22 eyes (55%) and additional treatments were applied. Recovery of DME was observed in 18 eyes (45%). Preoperative and final-visit mean BCVA (logMAR) was 1.08 ± 0.37 and 0.93 ± 0.45, respectively (p = 0.02). Preoperative and final-visit mean CMT was 514.74 ± 155.65 and 281.87 ± 112.58 µm, respectively (p < 0.001). The 5-MV significantly decreased following surgery (from 8.18 ± 1.57 to 6.52 ± 1.39 mm3; p < 0.001). DME was present in 12 eyes (30%) at the final visit.

CONCLUSION

Although PPV with ILM peeling had efficacy in DME management, this effect tended to decrease over time, such that a considerable number of patients required additional treatment.

Dril Influences Short-term Visual Outcome after Intravitreal Corticosteroid Injection for Refractory Diabetic Macular Edema

Purpose: Intravitreal injections (IVI) of anti-vascular endothelial growth factor (anti-VEGF) are considered the gold standard for diabetic macular edema (DME). Despite adequate anti-VEGF treatments, many patients present persistent DME. The aim of this study is to identify systemic, ocular and anatomical characteristics influencing functional and anatomical outcomes in refractory DME patients treated with IVI of corticosteroid.Materials and Methods: Retrospective multicenter hospital-based cohort study including type 2 diabetic adult patients with refractory DME that switched from intravitreal anti-VEGF to intravitreal corticosteroid between January 2017 and September 2018. Sociodemographic, clinical data, DME and treatment characteristics were collected at baseline (visit before switch), as well as spectral domain OCT features.Results: A total of 101 eyes were included. The median number of anti-VEGF injections before switch was 5.0 (min-max: 4.0-9.0) and the median anti-VEGF treatment duration before switch was 33.2 (min-max: 19.5-50.3) months. More than half of the patients (56; 54.9%) were diagnosed with diffuse DME. At baseline, 80 (88%) patients had cystoid DME, 55 (62.5%) patients had disorganization of retinal inner layers (DRIL) and 16 (17.6%) had subretinal fluid. Dexamethasone was the corticosteroid more commonly used (71.4%), followed by triamcinolone (24.4%) and fluocinolone (4.2%). Regarding best corrected visual acuity (BCVA), post-switch results showed no statistically significant improvement at three-month follow-up (p = .048/0.096), but the mean central macular thickness (CMT) decreased significantly from 486.3 (SD = 159) µm to 369.3 (SD = 129) µm at three-month follow-up (p < .001). DRIL was the tomographic characteristic able to influence significantly both CMT and BCVA final results (p = .02 and 0.012, respectively).Conclusions: Subfoveal DRIL on structural OCT was the DME factor influencing significantly clinical and imaging outcomes in refractory DME patients treated with intravitreal corticosteroid. Portuguese care trend towards DME shows preference for the use of dexamethasone implant after therapeutic failure with ranibizumab or bevacizumab injection.

Three-year outcomes of vitrectomy combined with intraoperative dexamethasone implantation for non-tractional refractory diabetic macular edema

This retrospective, consecutive interventional study investigated the long-term clinical outcomes of combined vitrectomy with intraoperative dexamethasone implants for non-tractional refractory diabetic macular edema (DME). The study included 43 eyes from 39 participants with DME that had continued for more than 6 months despite repeated non-surgical treatment. Postoperative changes in best-corrected visual acuity (BCVA) and central macular thickness (CMT) were evaluated over 3 years. A Kaplan-Meier curve was obtained for any additional non-surgical treatment, and the average number of non-surgical treatments required for DME before and after surgery was compared. Other postsurgical complications were also investigated. The logMAR BCVA improved from 0.526 ± 0.417 (20/67) preoperatively to 0.294 ± 0.374 (20/39) 3 years postoperatively (p < 0.001, generalized estimating equation). The CMT improved from 478 ± 122 μm preoperatively to 314 ± 90 μm 3 years postoperatively (p < 0.001, generalized estimating equation). Additional non-surgical treatment was not required for 29 (67%) eyes. The average number of annual non-surgical treatments decreased from 5.04 times preoperatively to 0.34 times postoperatively. Seventeen (40%) eyes developed temporary ocular hypertension after surgery, which normalized after antihypertensive eye drop instillation. In conclusion, vitrectomy combined with intraoperative dexamethasone implantation provides satisfactory long-term clinical outcomes for non-tractional refractory DME while reducing the number of intraocular injections for DME.

Behavior of SD-OCT Detectable Hyperreflective Foci in Diabetic Macular Edema Patients after Therapy with Anti-VEGF Agents and Dexamethasone Implants

PURPOSE

Diabetic macular edema (DME) is the most common cause of blindness in the working-age population. Spectral-domain optical coherence tomography (SD-OCT) allows detection and monitoring of the edema and a detailed analysis of the retinal structure. Hyperreflective foci (HF) are small, circumscribed lesions on OCT, and their origin is yet to be determined. Our study was aimed to shed light on HF pathophysiology, by analyzing their number and location in DME patients at baseline and after therapy.

METHODS

A prospective, observational study on 59 eyes of 51 DME patients who were treated with antivascular endothelial growth factor (VEGF) therapy (VEGF group, n = 40 eyes) or dexamethasone implant (DEX group, n = 19). HF and hard exudates (HE) were discriminated by their appearance on fundus photographs and their size on OCT. Quantity and location of HF and HE were analyzed at baseline and after therapy.

RESULTS

DME decreased in 75% of patients in the VEGF (455.5 μm vs. 380.8 μm, p = 0.02) and in 95% of patients in the DEX group (471.6 μm vs. 381.9 μm, p = 0.007). The number of foci decreased in 62.5% of patients after anti-VEGF (130.6 vs. 111.1, p = 0.07) and in 68% of patients after dexamethasone injection ((123.4 vs. 94.9, p = 0.02) 5.1). A subgroup of 15% of eyes, all treated with anti-VEGF, showed accumulation of larger HF in outer retinal layers to visible HE during DME resolution, whereas smaller HF, found in all retinal layers, remained unchanged. There was a trend towards a dynamic shift of the foci from inner to outer retinal layers.

CONCLUSION

The dynamic rearrangement of the small HF and their slightly greater reduction after anti-inflammatory therapy suggest inflammatory cells as their origin, whereas larger HF in the outer retinal layers correspond to microexudates. Furthermore, we found a more favourable outcome in patients with HF after treatment with dexamethasone implants compared to anti-VEGF agents.

Comparisons of One to Three Monthly Injections of Aflibercept for Diabetic Macular Edema by Practical Protocol

The purpose of this study was to compare the efficacies of one initial intravitreal injection of aflibercept followed by a pro re nata (PRN; 1+PRN) regimen to those of three consecutive monthly injections followed by the PRN (3+PRN) regimen for diabetic macular edema (DME) with practical protocols. The medical records of 95 eyes of 71 cases that were diagnosed with DME and had received intravitreal aflibercept (IVA) injections were reviewed. Fifty-seven eyes had received IVA with the 1+PRN regimen, and 38 eyes had received IVA with the 3+PRN regimen. The best-corrected visual acuity (BCVA) and the central macular thickness (CMT) were measured at the baseline and at 1, 3, 6, and 12 months after the IVA. The mean number of injections of the 1+PRN group was 2.9 ± 1.7, which was significantly fewer than that of the 3+PRN group at 4.6 ± 1.4 (P < 0.001). The change of the mean BCVA before and after the IVA at 12 months of the 3+PRN group was -0.14 ± 0.17 logMAR units which was significantly better than that of the 1+PRN group of -0.045 ± 0.25 logMAR units (P = 0.02). The change of the CMT before and after the IVA at 6 months of the 3+PRN group was -141.3 ± 152.4 μm which was significantly more than that of the 1+PRN group at -86.1 ± 117.8 μm (P = 0.013). Although the mean number of injections was more than that in the 1+PRN regimen, the 3+PRN regimen had better visual outcomes at 12 months. In a practical protocol, we recommend the 3+PRN regimen for patients with DME (IRB#3541).

The Jidong Eye Cohort Study: objectives, design, and baseline characteristics

Background

To describe the objective, design and baseline characteristics of the Jidong Eye Cohort Study (JECS), a community-based cohort in China based on etiology, imaging and biomarkers. The JECS will clarify the pathogenesis of visual impairment and status of ocular indicators in the occurrence and progression of cardio-cerebrovascular and neurological diseases.

Methods

Between August 2019 and January 2020, the JECS recruited consecutive participants aged 18 years and older from the Jidong communities in China. The demographic and clinical characteristics were collected by trained site personnel via face-to-face interviews. The relevant biological samples were also collected. The participants underwent comprehensive ophthalmic examination, such as retinal photography and optical coherence tomography (OCT) angiography. The following outcomes were measured annually: ocular vascular abnormality, optic nerve degeneration, cardiovascular diseases (CVD) and neurological diseases. The study will be performed until 2024.

Results

Among 3377 participants, the average age was 45.0 ± 12.5 years and 1809 (53.6%) were women. Hypertension occurred in 825 individuals (25.0%), diabetes in 258 (7.7%), hyperglycemia in 474 (14.2%), and a CVD history in 100 (3.0%). The mean best-corrected visual acuity was 0.1 logMAR in the recruited subjects. The average OCT signal index was 8.2 ± 1.2. Additionally, the mean vessel densities for the entire measured area were 46.4% and 50.8% for the superficial and deep vascular complex, respectively. Mean area and perimeter of foveal avascular zone was 0.3 mm² and 2.3 mm.

Conclusions

The JECS is a large community-based prospective cohort in North China. Rich data collected from this study will provide the opportunity to identify risk factors, imaging, and biomarkers of visual impairment (either ocular vascular anomalies or optic nerve degeneration) and to evaluate their associations with CVD and neurological diseases.

Interdigitation and Ellipsoid Zones Disruption Correlate with Visual Outcomes among Treatment-Naive Patients with Diabetic Macular Edema

INTRODUCTION

We have recently shown that defects in interdigitation and ellipsoid zones (IZ and EZ) can predict response to anti-VEGF therapy in a small group of treatment-naive diabetic macular edema (DME) patients. The aim of the current study is to further evaluate this association in a larger study group of patients over a longer follow-up time.

METHODS

Thirty eyes of 30 treatment-naive DME patients were analyzed in this retrospective study. The integrity of foveal IZ and EZ was evaluated using optical coherence tomography at the diagnosis of DME and following anti-VEGF injections. The defect size was correlated with best-corrected visual acuity (BCVA) and central macular thickness (CMT).

RESULTS

The mean patients' age at baseline was 63.0 ± 10.0 years. Patients underwent 3.9 ± 2.9 anti-VEGF injections for a mean of 9.1 ± 4.8 months. Following treatment, the mean Snellen visual acuity (VA) improved from 20/52 to 20/44 (p = 0.05), CMT decreased from 432.5 ± 141.4 μm to 375.2 ± 121.4 µm (p = 0.05) and IZ/EZ defect size decreased from 259.83 ± 375.94 µm to 65.34 ± 143.97 µm (p = 0.001). In patients with no IZ/EZ defects at baseline, the mean Snellen VA was better when compared to those with IZ/EZ defects (20/36 vs. 20/70, p = 0.031). The number of eyes with IZ/EZ defects decreased from 17 (57%) at baseline to 6 (20%) at end of follow-up (p < 0.01). BCVA gain correlated with IZ/EZ defect size reduction (r = 0.41, p = 0.02) but not with improvement in CMT (r = 0.28, p = 0.121).

CONCLUSIONS

IZ/EZ defect size correlated not only with baseline BCVA but also predicted the change in BCVA after anti-VEGF treatment. Possible future automatic measurement of IZ/EZ defect size might prove helpful for the evaluation of treatment response.

Vitrectomy with internal limiting membrane peeling versus nonsurgical treatment for diabetic macular edema with massive hard exudates

Purpose

To compare the anatomical and functional outcomes of severe diabetic macular edema (DME) with massive hard exudates managed by pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling or nonsurgical treatment.

Methods

We retrospectively reviewed 40 eyes with DME and massive hard exudates treated with either PPV with ILM peeling (vitrectomy group, 21 eyes) or nonsurgical treatment with anti-vascular endothelium growth factor (VEGF) and/or steroids (nonsurgical group, 19 eyes). Changes in best-corrected visual acuity (BCVA) and central retinal thickness (CRT) and resolution of macular hard exudates were compared between the two groups.

Results

After treatment, CRT decreased steadily in the vitrectomy group but fluctuated in the nonsurgical group. Compared with eyes in the nonsurgical group, eyes in the vitrectomy group had better visual improvement (P < 0.05 at 6 and 12 months and the final visit) and greater decrease in CRT (P < 0.05 at 3 and 6 months and the final visit) after adjustment for baseline BCVA. Hard exudates resolved more rapidly in the vitrectomy group than in the nonsurgical group, with 94.1% versus 47.4% eyes showing significant absorption after 6 months of the treatment (P = 0.003). In the vitrectomy group, 62% eyes did not require any further injections for treating DME after the operation.

Conclusions

PPV with ILM peeling resulted in rapid resolution of hard exudates with significant anatomical and functional improvement in DME with massive hard exudates.

Ranibizumab Pretreatment in Vitrectomy with Internal Limiting Membrane Peeling on Diabetic Macular Edema in Severe Proliferative Diabetic Retinopathy

AIM

To evaluate the efficacy of intravitreal ranibizumab (IVR) pretreatment for pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling in severe proliferative diabetic retinopathy (PDR) combined with macular edema (ME).

METHODS

Sixty-three patients with ME and PDR were divided into IVR and control groups. Three days before PPV stripping, ranibizumab was injected into the patients in the IVR group. The patients were followed for 6 months. The best-corrected visual acuity (BCVA), visual acuity improvement, centre macular thickness (CMT), and intraoperative and postoperative complications were compared between the two groups.

RESULTS

The BCVA of the IVR group was significantly improved at 1, 3 and 6 months compared with the preoperative BCVA (P < 0.01). The BCVA of the control group was significantly improved at 3 and 6 months compared with the preoperative BCVA (P < 0.01), but was not significantly improved at 1 month. At 1 and 3 months, the BCVA of the IVR group was significantly better than that of the control group after surgery, with no difference between the two groups at 6 months. The CMT of the IVR group was thinner than that of the control group at 1 and 3 months (P < 0.01), with no significant difference at 6 months after surgery. The surgical time, the risk of intraoperative bleeding, the incidence of iatrogenic retinal breaks, the frequency of endodiathermy and the rate of silicone oil tamponade were significantly different between the two groups (all P < 0.05). There was no significant difference between the two groups in terms of postoperative complications.

CONCLUSIONS

Ranibizumab pretreatment may improve the outcome of PPV with ILM peeling for severe PDR with ME by decreasing ME and intraoperative complications.

Revisiting pars plana vitrectomy in the primary treatment of diabetic macular edema in the era of pharmacological treatment

Diabetic macular edema (DME) is the most common cause of moderate visual loss in diabetic patients. The current treatment of choice for center-involved DME is anti-vascular endothelial growth factor (VEGF) treatment. Most patients that undergo pharmacological inhibition with anti-VEGF agents need multiple monitoring visits that include optical coherence tomography imaging and multiple injections. Despite this intensive treatment, up to 60% of eyes will have persistent DME after six consecutive monthly injections of an anti-VEGF. Its sustainability over the long term has been questioned. Pars plana vitrectomy (PPV) by increasing the vitreous cavity oxygenation, relieving vitreomacular traction, and removing cytokines from the vitreous cavity may cause long-term resolution of DME without the aforementioned concerns in selected cases. Eyes with vitreomacular traction clearly benefit from PPV as the primary treatment. The role of PPV for eyes with DME without tractional elements is less clear and needs to be explored further.

Characteristics of diabetic macular edema patients with serous retinal detachment

To determine characteristics of diabetic macular edema patients with serous retinal detachment (SRD).We classified naïve diabetic macular edema (DME) patients with or without SRD, and compared their baseline characteristics; intravitreal bevacizumab (IVB) responsiveness; aqueous concentrations of IL (interleukin)-1β, -2, -8, -10, -17, placental growth factor (PlGF), and vascular endothelial growth factor (VEGF). In addition, factors associated with the existence of SRD were identified.Of the 64 DME patients, 14 had SRD. The average levels of aqueous VEGF and PlGF were significantly higher in the SRD group than in the control group (P = .022 and P = .041, respectively). The best-corrected visual acuity (BCVA) and central subfield thickness (CST) did not differ significantly between the 2 groups at baseline or after 3 consecutive monthly IVBs. In multivariate logistic regression analysis, the level of aqueous VEGF was the only factor associated with the existence of SRD (odds ratio: 1.03; P = .038).Rather than aqueous inflammatory cytokines, levels of aqueous VEGFs were associated with the occurrence of SRD in DME patients. In terms of prognosis, the existence of SRD was not related with BCVA or CST changes.

Surgical Therapy for Macular Edema: What We Have Learned through the Decades

Macular edema is a leading cause of functional visual loss in retinal vascular or ocular inflammatory diseases. Because persistent macular edema can lead to irreversible retinal damage, multi-approached treatment should be considered to achieve complete resolution of macular edema. With an enhanced understanding of its pathophysiology, numerous therapeutic options have been developed for the management of macular edema over the decades. Although medical therapies account for the mainstay of treatment, surgical approaches with vitrectomy can play an important role in the management of macular edema, depending on its mechanism of fluid accumulation. The index review focuses on the efficacy of surgical therapy for macular edema secondary to various ocular diseases including diabetic retinopathy, uveitis, and retinal vein occlusion, and consequently provides the evidences that may expand the knowledge and support the employment of surgical options.

Surgical Innovations in the Treatment of Diabetic Macular Edema and Diabetic Retinopathy

PURPOSE OF REVIEW

Diabetic macular edema (DME) and complications of proliferative diabetic retinopathy (PDR) are the primary causes of vision loss in patients with diabetic retinopathy. As the incidence of diabetes increases worldwide, new, cost-effective treatments for DME and PDR will become paramount. Currently, anti-vascular endothelial growth factor (anti-VEGF) medications are considered first-line treatment. However, multiple visits for injections and the economic and time burden they entail make this treatment modality less than ideal. Early vitrectomy as well as depot delivery systems for medications could potentially reduce the treatment burden of patients with diabetes, prevent visual loss, and provide long-term stabilization of retinopathy in patients with diabetes. Newer port delivery systems for anti-VEGF medications could one day make this treatment modality better suited for patients across the globe.

RECENT FINDINGS

Real-world data shows poor compliance with treatment among patients with diabetes. Recent publications show catastrophic results when anti-VEGF treatments are stopped abruptly. The port delivery system for ranibizumab shows maintenance of adequate anti-VEGF levels in the vitreous cavity for many months. Early vitrectomy can provide cost-effective long-term stabilization in eyes with diabetic retinopathy. Microincisional vitrectomy as a treatment for DME and PDR remains controversial and larger trials are needed to definitively prove its superiority over other modalities; however, small-scale data point towards its usefulness in specific populations. Newer port delivery systems of anti-VEGF show promise in decreasing the number of office visits in patients with diabetic retinopathy.

Outer retinal hyperreflective deposits (ORYD): a new OCT feature in naïve diabetic macular oedema after PPV with ILM peeling

AIMS

We aimed to investigate a novel optical coherence tomography (OCT) finding of outer retinal hyperreflective deposits (ORYDs) in patients with naïve diabetic macular oedema (DMO) seen after small gauge pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling. Furthermore, we evaluated the predictive value of ORYD for visual outcome over 24 months follow-up.

METHODS

Retrospective cohort study including 111 eyes from 111 patients with naïve DMO treated by PPV and ILM peeling with a follow-up of 24 months. OCT scans were analysed for the presence of ORYD 1 week and 1, 6, 12, 18 and 24 months after surgery. Change in baseline best-corrected visual acuity (BCVA) and central subfoveal thickness (CST) after surgery were measured over the follow-up period. Presence of ORYD was correlated with baseline characteristics and BCVA after 24 months.

RESULTS

Hundred and eleven eyes from 111 patients were included (mean age 67.5±14.8 years). ORYD was identified in the outer plexiform layer as hyperreflective deposits in 92 patients (82.8%) 7 days after surgery but it was not present before surgery. There was a significant reduction in the presence of ORYD. After 24 months ORYD disappeared in all cases (p<0.001).

CONCLUSIONS

We describe a novel OCT feature of ORYD present in the early postoperative phase in the majority of patients after PPV with ILM peeling for naïve DMO, disappearing over the postoperative course. These deposits might be a result of sudden desinflammation and could shed new light on the process of DMO resolution after operative intervention.

Vitrectomy for Diabetic Macular Edema: Optical Coherence Tomography Criteria and Pathology of the Vitreomacular Interface

PURPOSE

To correlate spectral-domain optical coherence tomography (SDOCT) criteria and clinical data with pathology of the vitreomacular interface (VMI) in eyes with diabetic macular edema (DME).

DESIGN

Retrospective cross-sectional study and laboratory investigation.

METHODS

We included specimens of 27 eyes of 26 patients with center-involved DME that underwent vitrectomy with peeling of the internal limiting membrane (ILM). Selection of specimens was consecutive and in retrospect using our register of the Vitreoretinal Pathology Unit. Clinical data and SDOCT examinations were correlated to immunocytochemistry and transmission electron microscopy. Classification of DME comprised sponge-like diffuse retinal thickening, cystoid macular edema, and serous retinal detachment. VMI was evaluated for presence of epiretinal membrane (ERM) and thickened vitreous cortex (tVC).

RESULTS

ERMs and tVC were found in all DME types. Diffuse DME showed tVC more often than cystoid DME. Hyalocytes, contractile myofibroblasts, glial cells, matrix metalloproteinases-2 and -9, and collagen type I, II, and III were positive tested irrespective of DME type. There were no significant cell fragments at the retinal side of the ILM. Visual acuity improved in the majority of cases and macular thickness decreased significantly during mean follow-up of 17 ± 10 months.

CONCLUSIONS

All eyes presented pathologic VMI changes irrespective of the OCT classification of DME type or presence of ERM. Composition of fibrocellular membranes at the VMI indicated remodeling of vitreous cortex and transdifferentiation of hyalocytes into myofibroblasts. Our findings might argue for an early surgical intervention in eyes with DME irrespective of the presence of traction formation imaged by SDOCT.