Enhanced durability and evolution of retreatment criteria of intravitreal antivascular endothelial growth factor agents for diabetic macular edema

PURPOSE OF REVIEW

The increasing prevalence of diabetic macular edema (DME) necessitates an updated review of treatment modalities. While the shift from laser to anti-vascular endothelial growth factor (anti-VEGF) therapy has transformed patient outcomes, benefits of these agents are not fully realized in real-world implementation relative to the setting of controlled clinical trials. This review outlines the evolution of intravitreal anti-VEGF treatment extension protocols for DME that reflect efforts to address treatment adherence challenges while optimizing visual outcomes.

RECENT FINDINGS

Recent studies highlight the efficacy of extended-interval dosing with anti-VEGF agents in managing DME. Trials such as RISE/RIDE, VISTA/VIVID, and LUCIDATE have established the foundation of these regimens by demonstrating sustained visual gains with continuous treatment. However, newer trials including PROTOCOL T, KESTREL/KITE, YOSEMITE/RHINE, and PHOTON have furthered this concept, revealing that less frequent dosing of various anti-VEGF agents can maintain similar visual acuity and anatomical outcomes to traditional monthly injections.

SUMMARY

The reviewed findings suggest a paradigm shift in DME treatment toward less frequent anti-VEGF injections. This has significant implications for clinical practice, potentially leading to greater adherence to treatment regimens and sustained visual function in patients, while minimizing treatment burden and healthcare costs. Further investigation into the long-term effects of extended dosing intervals is required.

Gene therapy for neovascular age-related macular degeneration by subretinal delivery of RGX-314: a phase 1/2a dose-escalation study

BACKGROUND

Frequent anti-vascular endothelial growth factor A (VEGF-A) injections reduce the risk of rapid and severe vision loss in patients with neovascular age-related macular degeneration (nAMD); however, due to undertreatment, many patients lose vision over time. New treatments that provide sustained suppression of VEGF-A are needed. RGX-314 (currently known as ABBV-RGX-314) is an adeno-associated virus serotype 8 vector that expresses an anti-VEGF-A antigen-binding fragment, which provides potential for continuous VEGF-A suppression after a single subretinal injection. We report results on the safety and efficacy of subretinal injection of RGX-314 in patients with nAMD.

METHODS

For this open-label, multiple-cohort, multicentre, phase 1/2a, dose-escalation study conducted at eight sites in the USA, we enrolled participants with nAMD aged 50-89 years who had previously been treated with anti-VEGF injections into five cohorts (with five different doses of RGX-314). To be eligible, participants had to have macular neovascularisation secondary to nAMD with subretinal or intraretinal fluid in the centre subfield, be pseudophakic (after cataract removal), and have a best-corrected visual acuity (BCVA) in the study eye between 20/63 and 20/400 for the first participant in each cohort and between 20/40 and 20/400 for others. Subretinal injection of RGX-314 was done without a pre-bleb by a wet-laboratory-trained vitreoretinal surgeon. Cohort 1 received 3 × 109 genome copies per eye, cohort 2 received 1 × 1010, and cohort 3 received 6 × 1010. Two additional dose cohorts (cohort 4: 1·6 × 1011; cohort 5: 2·5 × 1011) were added. Participants were seen 1 day and 1 week after administration of RGX-314, and then monthly for 2 years (up to week 106). The primary outcome was safety of RGX-314 delivered by subretinal injection up to week 26. This analysis includes all 42 patients enrolled in the study. This study is registered with ClinicalTrials.gov, NCT03066258.

FINDINGS

Between May 12, 2017, and May 21, 2019, we screened 110 patients for eligibility and enrolled 68. 42 participants demonstrated the required anatomic response to intravitreal ranibizumab and then received a single RGX-314 injection (dose range 3 × 109 to 2·5 × 1011 genome copies per eye) and were followed up for 2 years. There were 20 serious adverse events in 13 participants, of which one was possibly related to RGX-314: pigmentary changes in the macula with severe vision reduction 12 months after injection of RGX-314 at a dose of 2·5 × 1011 genome copies per eye. Asymptomatic pigmentary changes were seen in the inferior retinal periphery several months after subretinal injection of RGX-314 most commonly at doses of 6 × 1010 genome copies per eye or higher. There were no clinically determined immune responses or inflammation beyond that expected following routine vitrectomy. Doses of 6 × 1010 genome copies or higher resulted in sustained concentrations of RGX-314 protein in aqueous humour and stable or improved BCVA and central retinal thickness with few or no supplemental anti-VEGF-A injections in most participants.

INTERPRETATION

Subretinal delivery of RGX-314 was generally well tolerated with no clinically recognised immune responses. RGX-314 gene therapy provides a novel approach for sustained VEGF-A suppression in patients with nAMD that has potential to control exudation, maintain vision, and reduce treatment burden after a single administration. Results from this study informed the pivotal programme to evaluate RGX-314 in patients with nAMD.

FUNDING

RegenxBio.

Clinical Outcomes of Faricimab in Patients with Previously Treated Neovascular Age-Related Macular Degeneration

PURPOSE

To assess the anatomic and functional outcomes in eyes with neovascular age-related macular degeneration (nAMD) previously treated with anti-VEGF therapy in response to intravitreal faricimab.

DESIGN

Retrospective, interventional, consecutive case series.

SUBJECTS

Patients with previously treated nAMD who received ≥ 4 consecutive injections of faricimab were included. The study period was from March through November 2022.

METHODS

Clinical and imaging data were extracted from the electronic medical record. Central foveal thickness (CFT), maximum fibrovascular pigment epithelial detachment (fvPED) height, and Snellen visual acuity (VA) were obtained. Generalized estimating equations were used to analyze the change in CFT, maximum fvPED height, and logarithm of the minimum angle of resolution VA.

MAIN OUTCOME MEASURES

Change in CFT, maximum fvPED height, and Snellen VA before faricimab and after ≥ 4 faricimab intravitreal injections.

RESULTS

During the study period, 218 eyes of 191 patients met inclusion criteria. Mean age was 79.9 (range, 70.6-89.2) years. The mean number of intravitreal anti-VEGF injections received before faricimab was 34.2 (range, 6.4-62). The following results were found after ≥ 4 faricimab injections. Mean logarithm of the minimum angle of resolution VA before switching to faricimab was 0.58 (Snellen VA ∼20/76; range, 20/22-20/264) and was 0.55 (Snellen VA ∼20/71; range, 20/21-20/235; P = 0.20) after switching. Mean maximum fvPED height was 195.0 (range, 50.2-339.8) μm before switching to faricimab and improved to 165.0 (range, 33.6-296.4; P < 0.001) μm after switching. Mean CFT was 354.8 (range, 184.7-524.9) μm before switching to faricimab and improved to 306.6 (range, 144.4-468.8; P < 0.001) after switching. The proportion of eyes with intraretinal fluid was 36.7% (80/218 eyes) before switching, and decreased to 24.8% (54/218 eyes, P < 0.001) after switching. The proportion of eyes with subretinal fluid was 53.2% (116/218 eyes) before switching and decreased to 26.6% (58/218 eyes, P < 0.001) after switching.

CONCLUSIONS

Intravitreal faricimab may improve anatomic outcomes in patients with previously treated nAMD, while maintaining VA in the short-term.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Artificial Intelligence, Digital Imaging, and Robotics Technologies for Surgical Vitreoretinal Diseases

OBJECTIVE

To review recent technological advancement in imaging, surgical visualization, robotics technology, and the use of artificial intelligence in surgical vitreoretinal (VR) diseases.

BACKGROUND

Technological advancements in imaging enhance both preoperative and intraoperative management of surgical VR diseases. Widefield imaging in fundal photography and OCT can improve assessment of peripheral retinal disorders such as retinal detachments, degeneration, and tumors. OCT angiography provides a rapid and noninvasive imaging of the retinal and choroidal vasculature. Surgical visualization has also improved with intraoperative OCT providing a detailed real-time assessment of retinal layers to guide surgical decisions. Heads-up display and head-mounted display utilize 3-dimensional technology to provide surgeons with enhanced visual guidance and improved ergonomics during surgery. Intraocular robotics technology allows for greater surgical precision and is shown to be useful in retinal vein cannulation and subretinal drug delivery. In addition, deep learning techniques leverage on diverse data including widefield retinal photography and OCT for better predictive accuracy in classification, segmentation, and prognostication of many surgical VR diseases.

CONCLUSION

This review article summarized the latest updates in these areas and highlights the importance of continuous innovation and improvement in technology within the field. These advancements have the potential to reshape management of surgical VR diseases in the very near future and to ultimately improve patient care.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

OCT-Based Description of Spontaneous Reattachment of Macula-Off Tractional Retinal Detachment With Significant Vision Improvement

Purpose: To describe the clinical course and optical coherence tomography (OCT) features of patients with spontaneous reattachment of macula-off tractional retinal detachments (TRDs). Methods: Findings on clinical examination and OCT were evaluated. Results: Four eyes of 4 patients with a history of macula-off TRD secondary to diabetic retinopathy (n = 3) or sickle cell retinopathy (n = 1) were included. OCT confirmed spontaneous resolution of the macular RD without complete posterior vitreous separation in all eyes. The median (interquartile range [IQR]) time from TRD diagnosis to OCT-confirmed foveal reattachment was 6 months (10.25; range, 1-12 months). The median logMAR visual acuity (VA) at the time of macula-off TRD was 0.544 (IQR, 0.452; Snellen 20/70), which improved to 0.350 (IQR, 0.156; Snellen 20/45), with reattachment characterized by OCT (P = .068). Conclusions: Nonsurgical spontaneous retinal reattachment and significant VA improvement can occur in eyes with a TRD, albeit rarely. In these cases, no OCT evidence of posterior vitreous separation was found, suggesting that some relaxation of the contractile fibrovascular membranes occurred.

Outcomes of Intentionally Suspending Treatment in Eyes With Advanced Neovascular Age-Related Macular Degeneration

PURPOSE

To determine the outcomes of intentionally suspending anti-vascular endothelial growth factor (anti-VEGF) injections in eyes with advanced neovascular age-related macular degeneration (nAMD).

DESIGN

Retrospective cohort study.

METHODS

The study sample comprised 93 patients with nAMD and best available Snellen visual acuity (VA) ≤20/400 in which anti-VEGF treatment was suspended by the treating physician. VA and optical coherence tomography (OCT) characteristics were evaluated to determine visual and anatomical outcomes up to 24 months after treatment suspension.

RESULTS

A total of 93 eyes from 93 patients who had received a mean of 16 anti-VEGF injections over a mean of 962 (SD 562) days were included. Comparing the treatment suspension visit to 24 months later, no significant change in mean central foveal thickness (163 [SD 118, range 19-704] μm vs 164 [SD 217, range 19-1468], P = .97), greatest lesion diameter (2547 [SD 1294, range 134-5707] μm vs 2442 [SD 1158, range 421-5305] μm, P = .43), greatest lesion thickness (194 [SD 136, range 0-618] μm vs 205 [SD 131, range 0-573] μm, P = .40), or VA (1.87 [SD 0.37], 20/1482, vs 1.94 [SD 0.28], 20/1741, P = .16) was found. In total, 7 eyes (7.5%) restarted treatment following a mean of 977 (SD 450) days after treatment suspension.

CONCLUSIONS

Suspension of anti-VEGF injections in eyes with advanced nAMD and VA ≤20/400 may be reasonable in cases where the treating physician deems additional treatment is unlikely to provide benefit. Although the visual and anatomical findings remained stable after treatment suspension in most, a small number restarted anti-VEGF therapy, suggesting that eyes should still be monitored for disease progression.

Durable vision improvement after a single intravitreal treatment with antisense oligonucleotide in CEP290-LCA: Replication in two eyes

Purpose

An intravitreally injected antisense oligonucleotide, sepofarsen, was designed to modulate splicing within retinas of patients with severe vision loss due to deep intronic c.2991 + 1655A > G variant in the CEP290 gene. A previous report showed vision improvements following a single injection in one eye with unexpected durability lasting at least 15 months. The current study evaluated durability of efficacy beyond 15 months in the previously treated left eye. In addition, peak efficacy and durability were evaluated in the treatment-naive right eye, and re-injection of the left eye 4 years after the first injection.

Observations

Visual function was evaluated with best corrected standard and low-luminance visual acuities, microperimetry, dark-adapted chromatic perimetry, and full-field sensitivity testing. Retinal structure was evaluated with OCT imaging. At the fovea, all visual function measures and IS/OS intensity of the OCT showed transient improvements peaking at 3-6 months, remaining better than baseline at ∼2 years, and returning to baseline by 3-4 years after each single injection.

Conclusions and Importance

These results suggest that sepofarsen reinjection intervals may need to be longer than 2 years.

Incidence and Risk Factors for Retinal Detachment and Retinal Tear after Cataract Surgery: IRIS® Registry (Intelligent Research in Sight) Analysis

Objective

To report the incidence of and evaluate demographic, ocular comorbidities, and intraoperative factors for rhegmatogenous retinal detachment (RRD) and retinal tear (RT) after cataract surgery in the American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight).

Design

Retrospective cohort study.

Participants

Patients aged ≥ 40 years who underwent cataract surgery between 2014 and 2017.

Methods

Multivariable logistic regression was used to evaluate demographic, comorbidity, and intraoperative factors associated with RRD and RT after cataract surgery.

Main Outcome Measures

Incidence and risk factors for RRD or RT within 1 year of cataract surgery.

Results

Of the 3 177 195 eyes of 1 983 712 patients included, 6690 (0.21%) developed RRD and 5489 (0.17%) developed RT without RRD within 1 year after cataract surgery. Multivariable logistic regression odds ratios (ORs) showed increased risk of RRD and RT, respectively, among men (OR 3.15; 95% confidence interval [CI], 2.99-3.32; P < 0.001 and 1.79; 95% CI, 1.70-1.89; P < 0.001), and younger ages compared with patients aged > 70, peaking at age 40 to 50 for RRD (8.61; 95% CI, 7.74-9.58; P < 0.001) and age 50 to 60 for RT (2.74; 95% CI, 2.52-2.98; P < 0.001). Increased odds of RRD were observed for procedure eyes with lattice degeneration (LD) (10.53; 95% CI, 9.82-11.28; P < 0.001), hypermature cataract (1.61; 95% CI, 1.06-2.45; P = 0.03), complex cataract surgery (1.52; 95% CI, 1.4-1.66; P < 0.001), posterior vitreous detachment (PVD) (1.24; 95% CI, 1.15-1.34; P < 0.001), and high myopia (1.2; 95% CI, 1.14-1.27; P < 0.001). Lattice degeneration conferred the highest odds of RT (43.86; 95% CI, 41.39-46.49; P < 0.001).

Conclusion

In the IRIS Registry, RRD occurs in approximately 1 in 500 cataract surgeries in patients aged > 40 years within 1 year of surgery. The presence of LD conferred the highest odds for RRD and RT after surgery. Additional risk factors for RRD included male gender, younger age, hypermature cataract, PVD, and high myopia. These data may be useful during the informed consent process for cataract surgery and help identify patients at a higher risk of retinal complications.

Financial Disclosures

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Progression of Geographic Atrophy: Retrospective Analysis of Patients from the IRIS® Registry (Intelligent Research in Sight)

Purpose

To evaluate disease progression and associated vision changes in patients with geographic atrophy (GA) secondary to age-related macular degeneration (AMD) in 1 eye and GA or neovascular AMD (nAMD) in the fellow eye using a large dataset from routine clinical practice.

Design

Retrospective analysis of clinical data over 24 months.

Subjects

A total of 256 635 patients with GA from the American Academy of Ophthalmology (Academy) IRIS® Registry (Intelligent Research in Sight) Registry (January 2016 to December 2017).

Methods

Patients with ≥ 24 months of follow-up were grouped by fellow-eye status: Cohort 1, GA:GA; Cohort 2, GA:nAMD, each with (subfoveal) and without subfoveal (nonsubfoveal) involvement. Eyes with history of retinal disease other than AMD were excluded. Sensitivity analysis included patients who were managed by retina specialists and had a record of imaging within 30 days of diagnosis.

Main Outcome Measures

Change in visual acuity (VA), occurrence of new-onset nAMD, and GA progression from nonsubfoveal to subfoveal.

Results

In total, 69 441 patients were included: 44 120 (64%) GA:GA and 25 321 (36%) GA:nAMD. Otherwise eligible patients (57 788) were excluded due to follow-up < 24 months. In both GA:GA and GA:nAMD cohorts, nonsubfoveal study eyes had better mean (standard deviation) VA at index (67 [19.3] and 66 [20.3] letters) than subfoveal eyes (59 [23.9] and 47 [26.9] letters), and 24-month mean VA changes were similar for nonsubfoveal (-7.6 and -6.2) and subfoveal (-7.9 and -6.5) subgroups. Progression to subfoveal GA occurred in 16.7% of nonsubfoveal study eyes in the GA:GA cohort and 12.5% in the GA:nAMD cohort. More new-onset study-eye nAMD was observed in the GA:nAMD (21.6%) versus GA:GA (8.2%) cohorts. Sensitivity analysis supported the robustness of the observations in the study.

Conclusions

This retrospective analysis describes the natural progression of GA lesions and the decline in VA associated with the disease.

Financial Disclosures

Proprietary or commercial disclosure may be found after the references.

Primary Retinal Detachment Repair in Eyes Deemed High Risk for Proliferative Vitreoretinopathy: Surgical Outcomes in 389 Eyes

PURPOSE

To evaluate surgical outcomes in eyes with primary rhegmatogenous retinal detachment (RRD) deemed at high risk for postoperative proliferative vitreoretinopathy (PVR).

DESIGN

Retrospective, consecutive case cohort study.

PARTICIPANTS

Eyes undergoing primary RRD repair with pars plana vitrectomy (PPV) or combined PPV with scleral buckling (PPV/SB) between January 1, 2016, and December 30, 2017, at Wills Eye Hospital.

METHODS

Eyes were defined as "high risk" if ≥ 1 of the following risk factors for PVR was present on preoperative examination: preoperative PVR grade A or B, vitreous hemorrhage, RRD involving ≥ 50% of retinal area, presence of ≥ 3 retinal breaks, history of prior cryotherapy, presence of choroidal detachment, or duration of RRD > 2 weeks. Surgical failure was defined as an additional intervention required for the retinal reattachment.

MAIN OUTCOMES MEASURES

Single surgery attachment success (SSAS) rate 3 months after first surgical intervention for primary RRD.

RESULTS

Of 2053 reviewed charts, a total of 389 eyes (18.9%) met the definition of high risk and were included in the analysis. Mean patient age was 63.5 years. PPV/SB was performed in 125 (32.1%) eyes and PPV alone in 264 (67.9%) eyes. SSAS rate of the overall cohort was 71.5% at 3 months. SSAS rate was significantly higher in eyes treated with PPV/SB compared with PPV (80.8% vs. 67%, respectively, P = 0.006). On multivariate analysis, use of PPV/SB was the only feature associated with SSAS (odds ratio, 2.04; 95% confidence interval, 1.12-3.69, P = 0.019).

CONCLUSION

In eyes with primary RRD and risk factors for PVR, overall SSAS was 71.5% after primary repair. In this cohort, use of PPV/SB was associated with a significantly higher SSAS compared with PPV alone.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

VITRECTOMY FOR VITREOUS HEMORRHAGE ASSOCIATED WITH RETINAL VEIN OCCLUSION: Visual Outcomes, Prognostic Factors, and Sequelae

PURPOSE

To report the outcomes of pars plana vitrectomy for vitreous hemorrhage (VH) associated with retinal vein occlusion and to identify prognostic indicators.

METHODS

Interventional, retrospective consecutive case series between 2015 and 2021.

RESULTS

The study included 138 eyes of 138 patients (64 female and 74 male); 81 patients had branch retinal vein occlusion and 57 had central retinal vein occlusion. The mean age was 69.8 years. The mean duration between the diagnosis of VH and surgery was 79.6 ± 115.3 (range, 1-572) days. The mean follow-up was 27.2 months. The logarithm of the minimum angle of resolution visual acuity significantly improved from 1.95 ± 0.72 (Snellen equivalent, 20/1782) to 0.99 ± 0.87 (20/195) at 6 months and to 1.06 ± 0.96 (20/230) at the final visit (both P < 0.001). The visual acuity at 6 months improved by three or more lines in 103 eyes (75%). Postoperative complications during follow-up included recurrent VH in 16 eyes (12%) (of which 8 eyes underwent reoperations), rhegmatogenous retinal detachment in six eyes (4%), and new neovascular glaucoma in three eyes (2%). Worse final visual acuity was significantly associated with older age ( P = 0.007), concurrent neovascular glaucoma ( P < 0.001), central retinal vein occlusion ( P < 0.001), worse preoperative visual acuity ( P < 0.001), postoperative new neovascular glaucoma ( P = 0.021), and postoperative retinal detachment ( P < 0.001). The duration of VH was not associated with visual outcomes ( P = 0.684). Preoperative antivascular endothelial growth factor injections and tamponade did not prevent postoperative recurrent VH.

CONCLUSION

Pars plana vitrectomy is effective for VH associated with retinal vein occlusion, regardless of the duration of hemorrhage. However, pre-existing risk factors and postoperative sequelae may limit visual recovery.

Neurotrophic keratopathy following rhegmatogenous retinal detachment surgery

PURPOSE

To describe clinical characteristics and visual outcomes of eyes developing neurotrophic keratopathy (NK) following rhegmatogenous retinal detachment (RRD) repair.

METHODS

All eyes with NK at Wills Eye Hospital following RRD repair from June 1, 2011, to December 1, 2020 were included. Patients with prior ocular procedures (other than cataract surgery), herpetic keratitis, and diabetes mellitus were excluded.

RESULTS

During the study period, 241 patients were diagnosed with NK, and 8179 eyes underwent RRD surgery, giving a 9-year prevalence rate of 0.1% (95% CI, 0.1%-0.2%). Mean age was 53.4 ± 16.6 years during RRD repair and 56.5 ± 13.4 years during NK diagnosis. Mean time to NK diagnosis was 3.0 ± 5.6 years (range, 6 days to 18.8 years). Mean visual acuity before NK was 1.10 ± 0.56 logMAR (20/252 Snellen), and it was 1.01 ± 0.62 logMAR (20/205 Snellen) at final visit (p = 0.75). Six eyes (54.5%) developed NK <1 year following RRD surgery. Mean final visual acuity was 1.01 ± 0.53 logMAR (20/205 Snellen) in this group versus 1.01 ± 0.78 logMAR (20/205 Snellen) in the delayed NK group (p = 1.00).

CONCLUSIONS

NK may present acutely or up to several years following surgery, with severity of corneal defects ranging from stage 1 to stage 3 NK. Surgeons should be mindful of the potential for this rare complication following RRD repair and consider close corneal monitoring.

Endophthalmitis following cataract surgery: visual outcomes, microbial spectrum and complications

PURPOSE OF REVIEW

The aim of this study was to update visual outcomes, microbial spectrum and complications in eyes with endophthalmitis following cataract surgery.

RECENT FINDINGS

A single-institution, retrospective review of eyes treated for endophthalmitis following cataract surgery between 2 January 2014 and 10 January 2017. This study included 112 cases of endophthalmitis following cataract surgery, 58 of which were culture-positive (51.8%). The most isolated organisms were coagulase-negative Staphylococci (56.9%). Oral flora were present in 17.2% of cases. At 6 months, 71.7% of patients achieved visual acuity of at least 20/200 and 51.7% achieved at least 20/40 or better. Visual acuity was better in culture-negative vs. culture-positive cases (∼20/290 vs. ∼20/80, P   =  0.03), and in nonoral flora-associated vs. oral flora-associated culture-positive cases (∼CF vs. ∼20/150, P   <  0.01).

SUMMARY

Following postcataract surgery endophthalmitis, approximately 70% of eyes achieved vision of 20/200 or better and half achieved vision of 20/40 or better 6 months after treatment. Poor visual outcomes were seen in eyes with positive bacterial cultures and with oral flora.

Recent advances in the management of proliferative diabetic retinopathy

PURPOSE OF REVIEW

The prevalence of diabetic retinopathy continues to rise. This review highlights advances in imaging, medical, and surgical management of proliferative diabetic retinopathy (PDR) in recent years.

RECENT FINDINGS

Ultra-widefield fluorescein angiography has been shown to better characterize which patients have predominantly peripheral lesions and who may advance to more advanced forms of diabetic retinopathy. This was well demonstrated in DRCR Retina Network's Protocol AA. Protocol S demonstrated that antivascular endothelial growth factor (VEGF) treatment alone can be useful in the management of select PDR patients - particularly those without high-risk features. However, a growing body of literature highlights how lapse in care is a significant concern in PDR patients, and tailoring one's approach to treatment based on patient needs is recommended. In patients with high-risk features or where there is concern for lost-to-follow-up, incorporation of panretinal photocoagulation in the treatment paradigm is recommended. Protocol AB highlighted how patients with more advanced disease may benefit from earlier surgical intervention for earlier visual recovery but that continued anti-VEGF treatment may result in similar visual outcomes over a longer period. Finally, earlier surgical intervention for PDR without vitreous hemorrhage (VH) or retinal detachment is being considered a potential option to minimize treatment burden.

SUMMARY

Recent advances in imaging, as well as medical and surgical treatment options for PDR, have provided a deeper understanding of PDR management, which can be optimized for the individual patient.

Patient Accessibility to Eye Care in the United States

PURPOSE

The United States (US) federal government uses health provider shortage areas (HPSAs) to define patient accessibility to primary care physicians. It is unclear whether HPSAs can be applied to eye care providers (ECPs). Our study determined the applicability of federal HPSA designations to ECP availability in the US.

DESIGN

Cross-sectional study.

PARTICIPANTS

US general population and ophthalmologists/optometrists in the Medicare database.

METHODS

The primary care HPSA score, visual impairment prevalence, and ECP location were determined for each census tract or county using data from the US Department of Health and Human Services, the Centers for Disease Control and Prevention, and Centers for Medicare and Medicaid Services.

MAIN OUTCOME MEASURES

Association of HPSA with vision loss and ECP density was examined. The 2-step floating catchment area approach was used to newly define eye care shortage areas (patient accessibility score [PAS], higher being worse accessibility) for every county in the US, by weighting the 2-step FCA scores by prevalence of vision loss and ECP density. Multivariable logistic regression was used to identify sociodemographic variables associated with areas of ECP shortage.

RESULTS

Among 72 735 census tracts included, statistically significant but weak correlations of HPSA score with visual impairment (VI) (r = 0.38; P < 0.0001) and ECP density per county population (r = -0.18; P < 0.0001) were found. Only 54.0% of census tracts with < 25th percentile ECP density per county were HPSAs (P < 0.0001). Of census tracts > than 75th percentile for VI only 58.0% were HPSAs (P < 0.0001). Multivariable regression found a higher odds of ECP PAS ≥ 75th percentile (worse accessibility) in rural counties (adjusted odds ratio [aOR], 2.47; 95% confidence interval [CI], 1.93-3.67; P < 0.001) and counties with a greater prevalence of residents with less than a high school education (aOR, 1.21; 95% CI, 1.19-1.25; P < 0.001), residents ≥ 65 years of age (aOR, 1.10; 95% CI, 1.07-1.13; P < 0.001), and uninsured residents (aOR, 1.04; 95% CI, 1.01-1.06; P < 0.001). Counties with a greater proportion of men (aOR, 0.93; 95% CI, 0.89-0.967; P < 0.001) or White residents (aOR, 0.99; 95% CI, 0.98-0.99) had a lower odds of ECP PAS ≥ 75th percentile.

CONCLUSIONS

Current HPSAs only weakly correlate with ECP supply. We propose a new approach to identify counties with high need but limited access to eye care.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Factors Associated with Fluctuations in Central Subfield Thickness in Patients with Diabetic Macular Edema Using Diabetic Retinopathy Clinical Research Protocols T and V

PURPOSE

To identify baseline ocular and systemic factors associated with central subfield thickness (CST) fluctuations in patients with diabetic macular edema (DME) using data from Diabetic Retinopathy Clinical Research Protocols T and V.

DESIGN

Post hoc analysis of clinical trial databases.

SUBJECTS

Patients in Protocols T and V.

METHODS

The standard deviation (SD) of all recorded CSTs for each patient during each Protocol's study period was calculated. The CST SD (corresponding to CST fluctuations) for each patient was analyzed against baseline ocular and systemic factors using linear regression analyses. Each Protocol was analyzed separately.

MAIN OUTCOME MEASURES

Factors associated with CST fluctuations.

RESULTS

A total of 1197 eyes of 1197 subjects were included. In Protocol T (559 eyes, mean CST SD was 56.4 ± 35.1 microns), using multivariate linear regression analysis, baseline urine albumin/creatine ratio (for every 1000 mg/g, CST point estimate 3.50, 95% confidence interval [CI] 0.58 to 6.43, P = 0.0190), and baseline CST (for every 10 microns, 0.87, 95% CI 0.58 to 1.16, P < 0.0001) were positively associated with CST fluctuations. Baseline visual acuity (for every 10 ETDRS letters, -9.52, 95% CI -11.89 to -7.15, P < 0.0001) was negatively associated with CST fluctuations. In Protocol V (638 eyes, mean CST SD 36.6 ± 28.4 microns), gender (female, 2.18, 95% CI 0.30 to 4.06, P = 0.0227), baseline CST (for every 10 microns, 2.51, 95% CI 2.21 to 2.82, P < 0.0001), systolic blood pressure (for every 1 mm of mercury, 0.11, 95% CI 0.01 to 0.21, P = 0.0261), and observation with deferred anti-VEGF injections (5.04, 95% CI 2.51 to 7.58, P < 0.0001) were positively associated with CST fluctuations. Type 2 diabetes (-7.37, 95% CI -13.64 to -1.11, P = 0.0209) and prompt anti-VEGF injections (-6.51, 95% CI -9.07 to -3.96, P < 0.0001) were negatively associated with CST fluctuations.

CONCLUSIONS

Worse visual acuity at baseline, baseline renal disease, hypertension, female gender, type 1 diabetes, and delayed anti-VEGF treatment may be associated with increased CST fluctuations in patients with DME. Addressing these parameters may limit CST fluctuations and help identify patients requiring more frequent monitoring or treatment.

Evaluating the Effect of Hypoglycemic Agents on Diabetic Retinopathy Progression

BACKGROUND AND OBJECTIVE

Newer hypoglycemics such as dipeptidyl peptidase 4 (DPP-4) inhibitors, sodium-glucose cotransporter-2 (SGLT-2) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists have been increasingly used in diabetes. This study aimed to assess the relationship between usage of these hypoglycemic agents and effect on diabetic retinopathy (DR).

MATERIALS AND METHODS

Using the Vestrum Health Retina Database, patients with DR with 1 year follow-up after use of a hypoglycemic agent were included and stratified by agent, including no pharmacotherapy.

RESULTS

Of 60,649 eyes, in 1 year after hypoglycemic agent usage, progression rates from severe nonproliferative diabetic retinopathy (NPDR) to proliferative diabetic retinopathy (PDR) were the following: DPP-4 (17%), SGLT-2 (12%), GLP-1 (21%), metformin (18%), and none (20%). Progression rates from moderate NPDR to severe NPDR or PDR were the following: DPP-4 (11%), SGLT-2 (10%), GLP-1 (11%), metformin (10%), none (13%). Progression rates from mild NPDR to moderate/severe NPDR or PDR were the following: DPP-4 (6%), SGLT-2 (9%), GLP-1 (9%), metformin (7%), and none (10%).

CONCLUSIONS

Within a large real-world database, patients prescribed GLP-1 agonists were found to have DR progression rates comparable to those of patients receiving no hypoglycemic agents. [Ophthalmic Surg Lasers Imaging Retina 2023; 54(3):158-165.].

Trends in Utilization of Vitreoretinal Services Following the Initial Phase of the 2020 COVID-19 Pandemic

BACKGROUND

To identify vitreoretinal practice patterns in the months following the initial 2020 national shutdown due to the COVID-19 pandemic in the United States (US).

STUDY DESIGN

Retrospective analysis of vitreoretinal practice patterns from multiple retinal centers across the US from January 1, 2018 to December 31, 2020.

RESULTS

The lowest utilization of retina care occurred during the week of March 23, 2020, after which utilization returned to pre-pandemic levels by July 2020. Patients with retinal detachments (RDs) presented with worse visual acuity during March, April, and May 2020 compared to the same time periods of 2018 and 2019 (P values < 0.05). However, only comparing eyes that presented in March 2018 to March 2020, was the year 1 vision significantly worse (P = 0.008).

CONCLUSION

The COVID-19 pandemic significantly impacted vitreoretinal care. The vision of patients with RDs may not have been affected by the delayed presentation. [Ophthalmic Surg Lasers Imaging Retina 2023;54:15-23.].

Intravitreal Nesvacumab (Anti-Angiopoietin-2) Plus Aflibercept in Neovascular AMD: Phase 2 ONYX Randomized Trial

Purpose:

To compare intravitreal nesvacumab (anti-angiopoietin-2) + aflibercept vs intravitreal aflibercept injection (IAI) in neovascular age-related macular degeneration (nAMD).

Methods:

Eyes were randomized (1:2:3) to nesvacumab 3 mg + aflibercept 2 mg (LD combo), nesvacumab 6 mg + aflibercept 2 mg (HD combo), or IAI 2 mg at baseline, week 4, and week 8. The LD combo was continued every 8 weeks (q8w). At week 12, the HD combo was re-randomized to q8w or every 12 weeks (q12w) and IAI was re-randomized to q8w, q12w, or HD combo q8w through week 32.

Results:

The study comprised 365 eyes. At week 12, the mean best-corrected visual acuity (BCVA) gains from baseline were similar in the LD combo group, HD combo group, and IAI group (5.2 letters, 5.6 letters, and 5.4 letters, respectively); the mean central subfield thickness (CST) reductions were similar (182.2 µm, 200.0 µm, and 178.6 µm, respectively). The mean changes in BCVA and CST through week 36 were similar across groups. At week 12, complete retinal fluid resolution was observed in 49.1% (LD combo), 50.8% (HD combo), and 43.6% (IAI) of eyes; the proportions with a CST of 300 μm or less were similar across groups. Numerical trends at week 32 toward complete retinal fluid resolution with combination treatment were not maintained at week 36. Serious ocular adverse events were infrequent and comparable across groups.

Conclusions:

In nAMD, nesvacumab + aflibercept showed no additional BCVA or CST benefit over IAI monotherapy.

REFRACTIVE ERROR CHANGE DURING TREATMENT OF DIABETIC MACULAR EDEMA: A Post Hoc Analysis of the Diabetic Retinopathy Clinical Research Protocol T Trial

PURPOSE

To evaluate the impact of anti-vascular endothelial growth factor therapy on the refractive error in eyes with diabetic macular edema.

METHODS

Post hoc analysis of Diabetic Retinopathy Clinical Research protocol T. Spherical equivalent (SE) was calculated for study and fellow eyes at baseline, 1-year, and 2-year visits. The SE change of the eyes with edema was compared with those with resolved edema. The correlation between refractive error changes and central subfield thickness was evaluated.

RESULTS

Among 543 study eyes, SE changed from -0.17 (2.04) D at baseline visit to -0.16 (2.14) D at 2 years giving a hyperopic shift of 0.04 (0.82) D (P = 0.022). Among fellow eyes, mean (SD) SE changed from -0.19 (2.1) D at baseline to -0.11 (2.1) D at 2 years, giving a hyperopic shift of 0.12 (0.84) D (P = 0.001). No significant difference in SE shift was found between eyes with and without edema at 2 years in phakic (0.12D and 0.08 D, P = 0.87) and pseudophakic eyes (-0.24D and -0.08D, P = 0.30). The SE shift was not correlated with central subfield thickness change at the end of the second year (r = 0.02, P = 0.62).

CONCLUSION

Diabetic macular edema patients have minimal changes in refractive error. The correction of refractive error may be considered during treatment, regardless of the presence of edema.

Night vision restored in days after decades of congenital blindness

Signaling of vision to the brain starts with the retinal phototransduction cascade which converts visible light from the environment into chemical changes. Vision impairment results when mutations inactivate proteins of the phototransduction cascade. A severe monogenically inherited blindness, Leber congenital amaurosis (LCA), is caused by mutations in the GUCY2D gene, leading to a molecular defect in the production of cyclic GMP, the second messenger of phototransduction. We studied two patients with GUCY2D-LCA who were undergoing gene augmentation therapy. Both patients had large deficits in rod photoreceptor-based night vision before intervention. Within days of therapy, rod vision in both patients changed dramatically; improvements in visual function and functional vision in these hyper-responding patients reached more than 3 log10 units (1000-fold), nearing healthy rod vision. Quick activation of the complex molecular pathways from retinal photoreceptor to visual cortex and behavior is thus possible in patients even after being disabled and dormant for decades.

Utility of Removal of Vitreous Cortex Remnants during Vitrectomy for Primary Rhegmatogenous Retinal Detachment Repair

PURPOSE

To investigate the prevalence of vitreous cortex remnants (VCR) in primary rhegmatogenous retinal detachment (RRD) and the utility of VCR removal using diamond-dusted membrane scrapers (DDMS) during pars plana vitrectomy (PPV).

METHODS

One hundred and eighty-seven eyes (187 consecutive patients) were retrospectively studied. We evaluated the prevalence of VCR on the retinal surface extending from the macula to outside the vascular arcade in eyes that underwent PPV for primary RRD by a single surgeon between July 2014 and February 2021. The VCR outside the vascular arcade was completely removed using a DDMS. Preoperative factors and surgical outcomes were compared between eyes with VCR removed intraoperatively to those without VCR.

RESULTS

VCR was present and removed (group A) in 86 (46%) eyes and absent (group B) in 101 (54%) eyes. Patients with VCR were significantly older than those without (P = 0.006). The preoperative BCVA (logMAR) tended to be worse in group A (1.23 ± 0.92 [Snellen equivalent, 20/340]) than in group B (1.03 ± 0.89 [20/214]), however, the difference was not statistically significant (P = 0.095). There were no between-group differences in postoperative BCVA (group A; 0.44 ± 0.54 [20/55]; group B; 0.42 ± 0.50 [20/53]; P = 0.38). Single surgery anatomic success (group A; 90%, group B; 91%, P = 0.573) and the incidence of postoperative PVR (group A; 9%, group B; 6%, P = 0.554) were comparable between the groups.

CONCLUSIONS

Nearly half of the patients had VCR, which was more likely to occur in older patients. VCR removal resulted in favorable functional and anatomic outcomes similar to those in eyes without any VCR in patients with RRD.

Pilocarpine 1.25% and the changing landscape of presbyopia treatment

PURPOSE OF REVIEW

Despite affecting approximately 1.8 billion individuals worldwide, until recently, a pharmacologic treatment for presbyopia was not available. This special commentary reviews the treatment of presbyopia with a focus on the recently approved medication Vuity (pilocarpine 1.25%, Allergan, an AbbVie Company).

RECENT FINDINGS

Vuity is a re-engineered formulation of pilocarpine 1.25% specifically designed for the treatment of presbyopia. Recently published results from the GEMINI 1 Phase 3 clinical trial reported improvement in distance corrected near vision without significant compromise in distance vision. No unexpected safety findings were reported with mild headache being the most common adverse event. Notably, there were no reported cases of retinal detachment or angle closure during the 30-day phase 3 clinical trials.

SUMMARY

Vuity is the first treatment designed and FDA approved to treat the growing presbyopia market. Phase 3 clinical trials demonstrated its ability to improve near vision without significant compromise in distance vision. We recognize this paradigm shift in the treatment of presbyopia and anxiously await additional treatment options for this ubiquitous condition.

Restoration of Cone Sensitivity to Individuals with Congenital Photoreceptor Blindness within the Phase 1/2 Sepofarsen Trial

Purpose

To understand consequences of reconstituting cone photoreceptor function in congenital binocular blindness resulting from mutations in the centrosomal protein 290 (CEP290) gene.

Design

Phase 1b/2 open-label, multicenter, multiple-dose, dose-escalation trial.

Participants

A homogeneous subgroup of 5 participants with light perception (LP) vision at the time of enrollment (age range, 15–41 years) selected for detailed analyses. Medical histories of 4 participants were consistent with congenital binocular blindness, whereas 1 participant showed evidence of spatial vision in early life that was later lost.

Intervention

Participants received a single intravitreal injection of sepofarsen (160 or 320 μg) into the study eye.

Main Outcome Measures

Full-field stimulus testing (FST), visual acuity (VA), and transient pupillary light reflex (TPLR) were measured at baseline and for 3 months after the injection.

Results

All 5 participants with LP vision demonstrated severely abnormal FST and TPLR findings. At baseline, FST threshold estimates were 0.81 and 1.0 log cd/m² for control and study eyes, respectively. At 3 months, study eyes showed a large mean improvement of –1.75 log versus baseline (P < 0.001), whereas untreated control eyes were comparable with baseline. Blue minus red FST values were not different than 0 (P = 0.59), compatible with cone mediation of remnant vision. At baseline, TPLR response amplitude and latency estimates were 0.39 mm and 0.72 seconds, respectively, for control eyes, and 0.28 mm and 0.78 seconds, respectively, for study eyes. At 3 months, study eyes showed a mean improvement of 0.44 mm in amplitude and a mean acceleration of 0.29 seconds in latency versus baseline (P < 0.001), whereas control eyes showed no significant change versus baseline. Specialized tests performed in 1 participant confirmed and extended the standardized results from all 5 participants.

Conclusions

By subjective and objective evidence, intravitreal sepofarsen provides improvement of light sensitivity for individuals with LP vision. However, translation of increased light sensitivity to improved spatial vision may occur preferentially in those with a history of visual experience during early neurodevelopment. Interventions for congenital lack of spatial vision in CEP290-associated Leber congenital amaurosis may lead to better results if performed before visual cortex maturity.

Intravitreal antisense oligonucleotide sepofarsen in Leber congenital amaurosis type 10: a phase 1b/2 trial

CEP290-associated Leber congenital amaurosis type 10 (LCA10) is a retinal disease resulting in childhood blindness. Sepofarsen is an RNA antisense oligonucleotide targeting the c.2991+1655A>G variant in the CEP290 gene to treat LCA10. In this open-label, phase 1b/2 ( NCT03140969 ), 12-month, multicenter, multiple-dose, dose-escalation trial, six adult patients and five pediatric patients received ≤4 doses of intravitreal sepofarsen into the worse-seeing eye. The primary objective was to evaluate sepofarsen safety and tolerability via the frequency and severity of ocular adverse events (AEs); secondary objectives were to evaluate pharmacokinetics and efficacy via changes in functional outcomes. Six patients received sepofarsen 160 µg/80 µg, and five patients received sepofarsen 320 µg/160 µg. Ten of 11 (90.9%) patients developed ocular AEs in the treated eye (5/6 with 160 µg/80 µg; 5/5 with 320 µg/160 µg) versus one of 11 (9.1%) in the untreated eye; most were mild in severity and dose dependent. Eight patients developed cataracts, of which six (75.0%) were categorized as serious (2/3 with 160 µg/80 µg; 4/5 with 320 µg/160 µg), as lens replacement was required. As the 160-µg/80-µg group showed a better benefit-risk profile, higher doses were discontinued or not initiated. Statistically significant improvements in visual acuity and retinal sensitivity were reported (post hoc analysis). The manageable safety profile and improvements reported in this trial support the continuation of sepofarsen development.

Stellate nonhereditary idiopathic foveomacular retinoschisis and an approach to the differential diagnosis of macular star

PURPOSE OF REVIEW

This review aims to introduce stellate nonhereditary idiopathic foveomacular retinoschisis (SNIFR) and its differential diagnosis. We summarize findings from case reports and series published in the last few years on the clinical and imaging findings in SNIFR.

RECENT FINDINGS

SNIFR presents as either a unilateral or bilateral macular star on fundus examination without clinical or imaging evidence of exudation or frank vitreomacular traction. optical coherence tomography (OCT) imaging shows schisis cavities in the Henle fibre and outer plexiform layers that correspond to the stellate en face findings. Visual acuity is usually minimally affected, and the presence of significant vision loss should prompt high clinical suspicion for alternate diagnoses.

SUMMARY

SNIFR is a recently characterized clinical entity that serves as an important addition to the differential diagnosis of a macular star. It is a diagnosis of exclusion and should be distinguished from other causes of macular star such as neuroretinitis, vitreomacular traction, ocular manifestations of malignant hypertension, congenital juvenile X-linked macular schisis, myopic maculopathy, optic pit maculopathy, nicotinic acid maculopathy or taxane maculopathy among others.

Indications for surgical management of retained lens fragments

PURPOSE OF REVIEW

Retained lens fragments are a relatively rare occurrence after cataract surgery. While no definite guidelines for the surgical management or timing of surgery of this complication exist, surgery is indicated for patients with large lens fragments, persistent inflammation, secondary glaucoma, corneal edema, retinal tears or detachments, and associated endophthalmitis. The aim of this review is to summarize the current surgical management of retained lens material.

RECENT FINDINGS

The Intelligent Research in Sight registry database of 2.26 million patients who underwent cataract surgery in the US indicated that 0.18% (1 in 563) had secondary removal of retained lens fragments in the anterior chamber in the operating room within 1 year of the original cataract surgery. The risk of returning to the operating room for retained lens material removal was greater among men, smokers, patients with Medicaid or military insurance, and those who had complex cataract surgery. Medical management with topical corticosteroids or observation may be considered for small lens fragments, but surgical removal remains the mainstay of the treatment for large lens fragments.

SUMMARY

Retained lens fragments following cataract surgery may result in various vision-threatening complications. Understanding the risk factors, diagnosis, and surgical management of retained lens fragments are critical to preserving good visual outcomes. Vitrectomy is effective in patients with posterior nuclear fragments, retinal detachment, endophthalmitis, or uncontrolled glaucoma not responding to medical management. The best timing for surgery for retained lens fragments should be further investigated in a prospective study.

Recent advances in diagnosis and management of sympathetic ophthalmia

PURPOSE OF REVIEW

Sympathetic ophthalmia is a bilateral granulomatous uveitis that occurs following unilateral trauma or surgery and is sight-threatening in the contralateral eye. Despite significant potential morbidity, disease remains poorly understood. Variable presentations and clinical courses, as well as a lack of definitive diagnostic laboratory tests can complicate the diagnosis and result in delayed treatment, which can beget permanent vision loss. This review focuses on recent advances in areas of pathophysiology, classification, diagnosis and treatment.

RECENT FINDINGS

Sympathetic ophthalmia is thought to involve a cell-mediated immune response to retinal and uveal antigens exposed through trauma or surgery. Multiple mechanisms have been implicated, including activation of the interleukin-23/IL-17 pathway. Ongoing emphasis is placed on early disease recognition and prompt treatment with multimodal imaging. Multiple authors advocate for the routine use of optical coherence tomography (OCT) for screening and disease monitoring. Systemic steroids and steroids sparing-immunosuppressive agents remain the mainstay of treatment.

SUMMARY

Understanding pathophysiology may provide useful targets for drug development, as well as allow for identification of patients at risk. OCT is a useful tool in early diagnosis and management of sympathetic ophthalmia, as OCT changes may precede clinical symptoms and signs, allowing for early disease detection and better visual outcomes.

Systemic considerations with pigmented fundus lesions and retinal pigment epithelium hamartomas in Turcot syndrome

PURPOSE OF REVIEW

To illustrate retinal pigment epithelium hamartomas (RPEHs) in a patient with known Turcot syndrome and to demonstrate the significance of these lesions in other colonic polyposis syndromes.

RECENT FINDINGS

The presence of multiple, bilateral RPEHs is a specific marker for familial adenomatous polyposis (FAP). Recent studies have noted RPEHs in associated syndromes including Gardner and Turcot syndromes. Herein, we illustrate an 18-year-old male patient with known brain medulloblastoma who was documented 7 years later to have asymptomatic RPEHs in both eyes, demonstrating hypo-autofluorescence.

SUMMARY

This patient with previous medulloblastoma and known Turcot syndrome was later found to have typical RPEHs, a feature that is important in family screening. Confirmation of RPEHs related to Turcot syndrome was made, and genetic evaluation confirmed germline mutation in the adenomatous polyposis coli (APC) gene. Observation was advised. Due to the fairly rapid progression to colorectal cancer if untreated, ophthalmologists should be aware that RPEHs can be the first extracolonic manifestation of FAP, Gardner syndrome, and Turcot syndrome.

Pars Plana Vitrectomy for Idiopathic Epiretinal Membrane: Optical Coherence Tomography Biomarkers of Visual Outcomes in 322 Eyes

OBJECTIVE

To investigate optical coherence tomography (OCT)-based biomarkers of visual acuity (VA) in eyes with idiopathic epiretinal membranes (ERM) undergoing surgical intervention.

PURPOSE

To assess surgical outcomes of pars plana vitrectomy (PPV) and membrane peel (MP) surgery in eyes with idiopathic ERM and identify potential imaging-based biomarkers of vision outcomes.

METHODS

Retrospective, consecutive case series of eyes with idiopathic ERM that underwent PPV and MP surgery between 1/1/2017 and 1/1/2019. A previously described ERM grading scale was utilized for OCT analysis. The primary outcome was VA at post-operative month 6 and final follow-up. A secondary outcome was the association of OCT structural features, including ectopic inner foveal layers (EIFL), inner microcystoid changes, and ellipsoid zone (EZ) disruption, with VA outcomes.

RESULTS

A total of 322 eyes with idiopathic ERM were included. Mean (± SD) follow-up was 506.6 ± 324.6 days after MP surgery. VA improved from logMAR 0.49 ± 0.27 (Snellen 20/61) pre-MP to 0.41 ± 0.30 (Snellen 20/51, p< 0.001) at 6 months after MP and 0.31 ± 0.29 (Snellen 20/41, p<0.001) at final follow-up. A total of 21 (6.5%) eyes were graded as Stage 1, 38 (11.8%) as Stage 2, 188 (58.4%) as Stage 3, and 75 (23.3%) as Stage 4, with higher ERM stages associated with worse pre-MP VA (p<0.001). Presence of inner microcystoid changes was associated with worse pre-MP VA (p=0.04). Stage 4 ERM characteristics (p=0.03), presence of EZ disruption (p=0.01) at month 3, and presence of inner microcystoid changes at month 3 (p=0.02) were associated with worse VA at 6 months. Presence of EIFL was not associated with 6 month or final VA on multivariate analysis. When analyzed within defined age groups, patients older than 80 years old had worse final VA (p=0.02) and were more likely to have inner microcystoid changes on OCT (p=0.01).

CONCLUSIONS

VA improvement was noted after surgery in eyes with idiopathic ERM across all stages. Pre-operative stage 4 characteristics were associated with worse VA at 6 months. Post-operative inner microcystoid changes and EZ disruption at month 3 were additional OCT biomarkers associated with worse 6 month and final VA outcomes.

Barriers to Follow-Up Retinal Care During the COVID-19 Pandemic: A Survey Study

BACKGROUND AND OBJECTIVE

To characterize patient-identified barriers to care in those non-compliant with retina appointments during the coronavirus disease 2019 (COVID-19) pandemic.

PATIENTS AND METHODS

Inclusion criteria included non-compliant patients from March 1, 2020 to May 1, 2020. Ultimately, 1,345 patients were invited to complete a 14-question survey. A retrospective chart review correlated clinical and demographic information. Univariate logistic regression, independent-samples t-test, and Pearson correlation coefficient identified differences among subgroups.

RESULTS

Of the 1,345 patients, 181 (13.5%) completed the survey. The most significant barriers to care included fear of COVID (76/181; 42.0%), wait times (21/181; 11.6%), and costs (11/181; 6.1%). Patients who got their COVID information from the Centers for Disease Control and Prevention (7.8 ± 2.4) and televised news (8.0 ± 2.0) had higher levels of fear. Finally, patients with diabetic retinopathy and higher Charlson Comorbidity Index scores had greater concerns of COVID (P = .034 and P = .047, respectively).

CONCLUSION

This survey study suggests fear of COVID-19 is a prominent new barrier to retinal care. Identifying those at risk for loss to follow-up can guide practices as the pandemic continues. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:526-533.].

Geographic Access Disparities of Clinical Trials in Neovascular Age-Related Macular Degeneration in the United States

To identify geographic and socioeconomic variables predictive of residential proximity to neovascular age-related macular degeneration (nAMD) clinical trial locations.

DESIGN

Retrospective, cross-sectional study.

METHODS

Census tract-level data from public datasets and trial-level data from ClinicalTrials.gov were analyzed. We calculated the driving distance (>60 miles) and time (>60 minutes) from the population-weighted US census tract centroid to the nearest clinical trial site.

RESULTS

We identified 42 trials studying nAMD across 829 unique clinical trial sites in the United States. In a multivariable model, driving distance >60 miles had a significant association with rural location (adjusted odds ratio [aOR] 5.54; 95% confidence interval [CI] 3.86-7.96, P < .0001) and with Midwest (aOR 2.30; 95% CI 1.21-4.38, P = .01) and South (aOR 2.43; 95% CI 1.21-4.91, P = .01) as compared to the Northeast region, and with some college or an associate's degree, as compared to a bachelor's degree (aOR 1.02; 95% CI 1.01-1.04, P = .0007, and aOR 1.05; 95% CI 1.00-1.10, P = .04, respectively). Lower odds of traveling >60 miles to the nearest nAMD trial site were associated with census tracts with a higher percentage of blacks (aOR 0.98; 95% CI 0.97-0.99, P < .0001), Hispanics (aOR 0.97; 95% CI 0.95-0.99, P = .002), and Asians (aOR 0.90; 95% CI 0.88-0.93, P < .0001), as compared to whites, and with a lower percentage of the population <200% of the federal poverty level. Similar predictors were found in time traveled >60 minutes.

CONCLUSIONS

There are geographic access disparities of clinical trial sites for nAMD in the United States.

Comparative Incidence of Postoperative Hemorrhage in Vitreoretinal Surgery in Patients on Anti-Coagulants

BACKGROUND AND OBJECTIVE

Data regarding hemorrhagic complications of direct oral anticoagulants (DOACs) and vitreoretinal surgery are limited.

PATIENTS AND METHODS

Multicenter analysis of longitudinal, aggregated electronic health records of patients undergoing pars plana vitrectomy (PPV) with no prior history of ocular hemorrhage. Retrospective analysis of patients undergoing PPV between January 1, 2013, and December 31, 2019. The main outcomes were development of postoperative hemorrhagic complications within 1 month following vitreoretinal surgery.

RESULTS

A total of 58,131 eyes underwent PPV, with 2,956 (5.1%) on anticoagulant medication prior to surgery. Eight hundred twenty-eight eyes (1.4%) developed a postoperative hemorrhage. Of eyes with anticoagulation use, 50 of 2,956 (1.29%) developed a hemorrhage, whereas 778 of 55,175 (1.41%) of the eyes with no prior anticoagulation use developed a postoperative hemorrhage (P = .2107).

CONCLUSION

Use of DOACs prior to vitreoretinal surgery does not appear to be associated with increased rates of postoperative intraocular hemorrhage. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:374-379.].

Outcomes of eyes with retinal vein occlusion that are lost to follow-up after antivascular endothelial growth factor therapy

BACKGROUND/AIMS

To evaluate the outcomes of eyes with macular oedema due to retinal vein occlusion (RVO) that are lost to follow-up (LTFU) after antivascular endothelial growth factor (VEGF) injections.

METHOD

A retrospective, single-centre, consecutive case series of RVO patients receiving injections who were LTFU >6 months was conducted. Data were collected from the visit before LTFU; return visit; 3 months, 6 months and 12 months after return; and the final visit.

RESULTS

Ninety eyes of 83 patients were included. Fifty (55.5%) eyes had branch RVO and 40 (44.5%) had central RVO. Mean LTFU duration was 277.8 days with additional mean follow-up for 748.1 days after return. Mean logarithm of the minimum angle of resolution visual acuity (VA) (Snellen) at the visit before LTFU was 0.72 (20/105) which worsened on return [1.04 (20/219), p<0.001) and remained worse at all timepoints after return: 0.92 (20/166) at 3 months (p<0.001), 0.97 (20/187) at 6 months (p<0.001), 0.94 (20/174) at 12 months (p<0.001) and 1.01 (20/205) at final visit (p<0.001). Mean central foveal thickness (CFT) increased from 252 µm at the visit before LTFU to 396 µm at the return visit (p<0.001). No difference in CFT was noted by 3 months (258 µm, p=0.71), 6 months (241 µm, p=0.54) or 12 months after return (250 µm, p=0.95). CFT was thinner at the final visit (215 µm, p=0.018).

CONCLUSION

RVO patients receiving anti-VEGF injections who were LTFU experienced a decline in VA that did not return to the levels seen before LTFU despite improvement in CFT after restarting therapy, underscoring the importance of ongoing treatment.

Safety and improved efficacy signals following gene therapy in childhood blindness caused by GUCY2D mutations

A first-in-human clinical trial of gene therapy in Leber congenital amaurosis due to mutations in the GUCY2D gene is underway, and early results are summarized. A recombinant adeno-associated virus serotype 5 (rAAV5) vector carrying the human GUCY2D gene was delivered by subretinal injection to one eye in three adult patients with severe visual loss, nystagmus, but preserved retinal structure. Safety and efficacy parameters were monitored for 9 months post-operatively. No systemic toxicity was detected; there were no serious adverse events, and ocular adverse events resolved. P1 and P2 showed statistically significant rod photoreceptor vision improvement by full-field stimulus testing in the treated eye. P1 also showed improvement in pupillary responses. Visual acuity remained stable from baseline in P1 and P2. P3, however, showed a gain of 0.3 logMAR in the treated eye, indicating greater cone-photoreceptor function. The results show safety and both rod- and cone-mediated efficacy of this therapy.

Durable vision improvement after a single treatment with antisense oligonucleotide sepofarsen: a case report

Leber congenital amaurosis due to CEP290 ciliopathy is being explored by treatment with the antisense oligonucleotide (AON) sepofarsen. One patient who was part of a larger cohort (ClinicalTrials.gov NCT03140969 ) was studied for 15 months after a single intravitreal sepofarsen injection. Concordant measures of visual function and retinal structure reached a substantial efficacy peak near 3 months after injection. At 15 months, there was sustained efficacy, even though there was evidence of reduction from peak response. Efficacy kinetics can be explained by the balance of AON-driven new CEP290 protein synthesis and a slow natural rate of CEP290 protein degradation in human foveal cone photoreceptors.

Sociodemographic Factors Influencing Rhegmatogenous Retinal Detachment Presentation and Outcome

PURPOSE

The impact of sociodemographic factors on the presentation and outcomes of rhegmatogenous retinal detachment (RRD) in the United States has not been described. We analyzed the impact of these factors on the presenting fovea-on or off status of RRD, single operation anatomic success (SOAS) of repair, and postoperative visual acuity (VA).

DESIGN

Retrospective, single-center, cohort study.

PARTICIPANTS

Participants included 4061 patients from Wills Eye Hospital/Mid Atlantic Retina from February 2015 to February 2020.

METHODS

Sociodemographic factors including age, gender, race, and regional mean household income (MHI) as determined by ZIP code were recorded. The VA at baseline and 12 months post-RRD repair was recorded. Multiple regression analysis was used to evaluate the relationship between sociodemographic factors to fovea-on or off presentation of RRD, SOAS, and 12-month VA.

MAIN OUTCOME MEASURES

Foveal attachment at presentation of RRD, SOAS, and 12-month VA.

RESULTS

Older age (odds ratio [OR], 1.34 per decade, 95% confidence interval [CI], 1.27-1.41, P < 0.001), male gender (OR, 1.27, 95% CI, 1.11-1.45, P < 0.001), non-White race (OR, 2.41, 95% CI, 1.92-3.03, P < 0.001), and lower MHI (OR, 0.94 per $10 000, 95% CI, 0.91-0.98, P = 0.005) were independent risk factors for fovea-off presentation of RD. The need for reoperation to repair RRD within 90 days was independently associated with fovea-off presentation (OR, 1.47, 95% CI, 1.24-1.74, P < 0.001) and non-White race (OR, 1.72, 95% CI, 1.27-2.39, P < 0.001). Finally, 12-month postoperative VA was worse in patients who were fovea-off (P < 0.001), older (P = 0.041), male (P = 0.038), and non-White (P = 0.007) but was not related to MHI (P = 0.24).

CONCLUSIONS

These findings reveal associations between the sociodemographic factors and the presentation and outcomes of RRD. Physicians should be aware that socioeconomic disparities can negatively impact the prognosis of patients with RRD. Further study confirming these findings and efforts to mitigate their effects are warranted and will be of interest to the greater ophthalmology community.

Real-World Performance of a Self-Operated Home Monitoring System for Early Detection of Neovascular Age-Related Macular Degeneration

The real-world performance of a home telemonitoring strategy (ForeseeHome AMD Monitoring System^®, Notal Vision, Inc.,Manassas VA, USA) was evaluated and compared to the device arm of the AREDS2-HOME study among patients with intermediate AMD (iAMD) who converted to neovascular AMD (nAMD). All patients with confirmed conversion to nAMD who used the home monitoring system from 10/2009 through 9/2018 were identified by Notal Vision Diagnostic Clinic’s medical records. Selected outcome variables were evaluated, including visual acuity (VA) at baseline and at conversion, and change in visual acuity (VA) from baseline to time of conversion. In total, 8991 patients performed 3,200,999 tests at a frequency of 5.6 ± 3.2 times/week. The 306 eyes that converted from iAMD to nAMD over the study period (a 2.7% annual rate) were included in the analyses. There was a median (interquartile range) change of −3.0 (0.0–(−10.0)) letters among converted eyes, 81% [95% confidence interval (72–88%)] maintained a VA ≥ 20/40 at the time of conversion, while 69% of the conversion detections were triggered by system alerts. The real-world performance of an at-home testing strategy was similar to that reported for the device arm of the AREDS2-HOME study. The home telemonitoring system can markedly increase early detection of conversion to nAMD.

TOPICAL DORZOLAMIDE-TIMOLOL WITH INTRAVITREOUS ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR FOR RETINAL VEIN OCCLUSION: A PILOT STUDY

PURPOSE

To evaluate topical dorzolamide hydrochloride-timolol maleate as an adjunct therapy to intravitreous anti-vascular endothelial growth factor injections in eyes with retinal vein occlusion resistant to treatment.

METHODS

Retinal vein occlusion patients with a history of persistent macular edema, despite fixed-interval intravitreous anti-vascular endothelial growth factor injections, were enrolled between April 4, 2016, and June 4, 2017. On enrollment, patients were instructed to administer one drop of topical dorzolamide-timolol twice daily for the duration of the study. They were maintained on the same anti-vascular endothelial growth factor drug and same interval between injections as preenrollment for the subsequent two visits. Primary outcome measures were change in central foveal thickness, central subfield thickness, and thickest macular cut at the final study visit.

RESULTS

Eight patients (8 eyes) were eligible for enrollment and completed the study. There was a significant decrease in central foveal thickness (P = 0.02), central subfield thickness (P = 0.03), and thickest macular cut (P = 0.01) between the enrollment visit and the final visit. There was a decrease in mean (±SD) logarithm of the minimal angle of resolution from 0.52 (±0.35) (20/66, Snellen equivalent) at the enrollment visit to 0.41 (±0.35) (20/51, Snellen equivalent) at the final visit (P = 0.08).

CONCLUSION

Topical dorzolamide-timolol may have a beneficial anatomical and functional effect in eyes with macular edema secondary to retinal vein occlusion resistant to treatment.

Characterizing Progression to Neovascular AMD in Fellow Eyes of Patients Treated With Intravitreal Anti-VEGF Injections

BACKGROUND AND OBJECTIVE

The purpose of this study was to assess the real-world incidence of conversion to bilateral neovascular age-related macular degeneration (nAMD) following treatment initiation of nAMD in the initial eye.

PATIENTS AND METHODS

This was a retrospective cohort of electronic health records from retinal centers across the United States (Vestrum Database) of all patients with unilateral nAMD treated with anti-vascular endothelial growth factor therapy.

RESULTS

A total of 22,553 patients with unilateral nAMD were included. Fellow eyes of 8,522 patients (38%) converted to nAMD. Among these, 2,639 (12%), 2,030 (9%), and 1,802 (8%) patients converted in Years 1, 2, and 3, respectively, after diagnosis in the first eye. Fellow eyes had better vision at conversion and 1 year following conversion.

CONCLUSIONS

The fellow eye should be monitored at regular intervals to detect signs of neovascularization. Fellow eyes presented with significantly better vision at diagnosis than the initial eye and maintained better visual acuity with less injections. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:123-128.].

The Impact of Physician Face Mask Use on Endophthalmitis After Intravitreal Anti-Vascular Endothelial Growth Factor Injections

PURPOSE

To evaluate the effect of physician face mask use on rates and outcomes of postinjection endophthalmitis.

DESIGN

Retrospective, comparative cohort study.

METHODS

Setting: Single-center. StudyPopulation: Eyes receiving intravitreal anti-vascular endothelial growth factor injections from July 1, 2013, to September 1, 2019.

INTERVENTION

Cases were divided into "Face Mask" group if face masks were worn by the physician during intravitreal injections or "No Talking" group if no face mask was worn but a no-talking policy was observed during intravitreal injections. MainOutcomeMeasures: Rate of endophthalmitis, visual acuity, and microbial spectrum.

RESULTS

Of 483,622 intravitreal injections administered, 168 out of 453,460 (0.0371%) cases of endophthalmitis occurred in the No Talking group, and 9 out of 30,162 (0.0298%) cases occurred in the Face Mask group (odds ratio, 0.81; 95% confidence interval, 0.41-1.57; P = .527). Sixteen cases of oral flora-associated endophthalmitis were found in the No Talking group (1 in 28,341 injections), compared to none in the Face Mask group (P = .302). Mean logMAR visual acuity at presentation in cases that developed culture-positive endophthalmitis was significantly worse in the No Talking group compared to the Face Mask group (17.1 lines lost from baseline acuity vs 13.4 lines lost; P = .031), though no difference was observed at 6 months after treatment (P = .479).

CONCLUSION

Physician face mask use did not influence the risk of postinjection endophthalmitis compared to a no-talking policy. However, no cases of oral flora-associated endophthalmitis occurred in the Face Mask group. Future studies are warranted to assess the role of face mask use to reduce endophthalmitis risk, particularly attributable to oral flora.

Endophthalmitis following Intravitreal Anti-Vascular Endothelial Growth Factor Therapy: Changes in Incidence and Outcomes over a 9-Year Period

Aims: To evaluate whether the incidence, microbial spectrum, and visual outcomes of endophthalmitis following intravitreal injections have changed over time.Methods: Retrospective cohort study of endophthalmitis in eyes receiving intravitreal injection of anti-vascular endothelial growth factor between 2009-2012 and 2016-2017 at a single, large retina practice.Results: A total of 283,315 injections resulted in 96 suspected infectious endophthalmitis cases. Comparing 2009-2012 and 2016-2017, the rate of suspected endophthalmitis changed from 1 in 2,663 injections to 1 in 3,195 injections (p = .37). Visual outcomes 6 months after endophthalmitis were significantly better during the latter period (p = .04), with an average loss of 6.3 lines of VA in 2009-2012 compared to a loss of 3.6 lines in 2016-2017. In multivariate analysis, a "no-talking" policy during injections resulted in a trend towards a decrease in endophthalmitis incidence (p = .08). Cessation of post-injection topical antibiotic use did not independently decrease endophthalmitis incidence (p = .24) when the effect of a "no-talking" policy was taken into account. A lower rate of endophthalmitis was seen after prefilled vs. conventionally prepared ranibizumab syringe use for injection (0.014% vs. 0.035%, respectively), though this difference did not meet statistical significance (p = .16).Conclusion: The incidence of endophthalmitis after intravitreal injection decreased and visual outcomes improved between the periods of 2009-2012 and 2016-2017. A "no-talking" policy during injections was associated with a trend toward a decrease in endophthalmitis rate.

Effect of Adjuvant Topical Dorzolamide-Timolol vs Placebo in Neovascular Age-Related Macular Degeneration: A Randomized Clinical Trial

Importance

Some eyes with neovascular age-related macular degeneration (AMD) have persistent exudation despite frequent intravitreal anti-vascular endothelial growth factor (VEGF) injections. Adjuvant therapies that further reduce edema may improve vision outcomes.

Objective

To compare the short-term effect of topical dorzolamide-timolol vs placebo in eyes with neovascular AMD that have persistent exudation following intravitreal anti-VEGF injections.

Design, Setting, and Participants

Randomized placebo-controlled clinical trial with enrollment from March 1, 2017, through October 30, 2018. Multicenter trial at 4 clinical sites in the United States. Sixty-three patients with neovascular AMD who had persistent exudation despite intravitreal anti-VEGF injections at 4-week, 5-week, or 6-week intervals.

Interventions

Patients were randomized to use dorzolamide-timolol or artificial tears for the study duration. They continued to receive the same anti-VEGF drug at the same interval as the 2 visits before enrollment for 3 additional study visits.

Main Outcomes and Measures

The primary outcome measure was change in mean central subfield thickness on optical coherence tomography from baseline to visit 3 (approximately 3 months). Secondary measures included change in mean maximum subretinal fluid height, mean maximum pigment epithelial detachment height, and mean visual acuity (VA).

Results

This trial included 52 patients. All 27 patients (100%) assigned to dorzolamide-timolol and 23 of 25 (92%) assigned to placebo were analyzed for the primary outcome. Mean (SD) age was 78.4 (7) years, and 34 of 50 patients (68%) were women. Mean (SD) injections were 20.5 (14) (range, 4-58) before enrollment. Mean (SD) baseline logMAR VA was 0.361 (0.26) (approximate Snellen equivalent, 20/50). Comparing the dorzolamide-timolol with placebo group from baseline to visit 3, mean (SD) change in central subfield thickness (primary outcome) was -36.6 (54) μm vs 1.7 (52.3) μm (difference, 30.8; 95% CI, 0.3-61.3; P = .04); secondary outcomes: maximum PED height was -39.1 (65) μm vs 1.1 (16) μm (difference, 39.6; 95% CI, 9.6-69.6; P = .01) and change in VA from baseline to visit 3 was -2.3 (5) vs 0.3 (1) letters (difference, 2.6 letters; 95% CI, -1.9 to 7.1 letters; P = .78).

Conclusions and Relevance

These findings suggest use of dorzolamide-timolol in patients with neovascular AMD with persistent exudation resulted in anatomic but not visual acuity improvements compared with placebo at approximately 3 months. Additional clinical trials with longer follow-up and larger sample sizes presumably would be needed to determine the role, if any, of dorzolamide-timolol in neovascular AMD.

Trial Registration

ClinicalTrials.gov Identifier: NCT03034772.

Creating an Ocular Biofactory: Surgical Approaches in Gene Therapy for Acquired Retinal Diseases

ABSTRACT

Gene therapy offers the potential to treat inherited retinal disorders and deliver sustained therapy for acquired retinal diseases. In the latter case, host cells can be harnessed to produce non-native proteins that have beneficial properties, such as antivascular endothelial growth factor activity, transforming the eye into an ocular "biofactory." Several gene therapy programs have entered clinical testing for delivery to the vitreous, subretinal, and suprachoroidal space. Improved viral vectors and refined surgical techniques are critical to successful delivery of therapeutic products to the target tissue. In this review, we discuss the development of gene therapy products aimed at acquired retinal diseases and the surgical techniques utilized to achieve targeted delivery.

Clinical Outcomes of Eyes With Diabetic Macular Edema Switched From Aflibercept to Ranibizumab Therapy

BACKGROUND AND OBJECTIVE

In 2018, cases of inflammation were reported after intravitreal aflibercept (IVA), which resulted in switches to intravitreal ranibizumab (IVR). The authors' purpose was to evaluate outcomes after switching from IVA to IVR in diabetic macular edema (DME).

PATIENTS AND METHODS

Retrospective cohort study. Eyes switched from IVA to IVR for treating DME were included. Data were gathered from three visits before to three visits post-switch. Outcome measures included central subfoveal thickness (CFT) and Snellen visual acuity (VA).

RESULTS

There was a statistically significant increase in CFT at the first visit (325 μm ± 234 μm; P = .006) compared to the switch visit, but no difference later visits (268 μm ± 103 μm; P = .32; 284 μm ± 118 μm; P = .11; n = 54). There was no statistically significant change in mean logarithm of the minimum angle of resolution VA between the switch and later visits (0.43 ± 0.38, P = .95; 0.38 ± 0.30, P = .12; 0.41 ± 0.37, P = .69).

CONCLUSIONS

The authors observed transient worsening of macular edema in eyes treated for DME when switched from aflibercept to ranibizumab. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:691-697.].