Interpretable detection of epiretinal membrane from optical coherence tomography with deep neural networks

This study aimed to automatically detect epiretinal membranes (ERM) in various OCT-scans of the central and paracentral macula region and classify them by size using deep-neural-networks (DNNs). To this end, 11,061 OCT-images were included and graded according to the presence of an ERM and its size (small 100-1000 µm, large > 1000 µm). The data set was divided into training, validation and test sets (75%, 10%, 15% of the data, respectively). An ensemble of DNNs was trained and saliency maps were generated using Guided-Backprob. OCT-scans were also transformed into a one-dimensional-value using t-SNE analysis. The DNNs' receiver-operating-characteristics on the test set showed a high performance for no-ERM, small-ERM and large-ERM cases (AUC: 0.99, 0.92, 0.99, respectively; 3-way accuracy: 89%), with small-ERMs being the most difficult ones to detect. t-SNE analysis sorted cases by size and, in particular, revealed increased classification uncertainty at the transitions between groups. Saliency maps reliably highlighted ERM, regardless of the presence of other OCT features (i.e. retinal-thickening, intraretinal pseudo-cysts, epiretinal-proliferation) and entities such as ERM-retinoschisis, macular-pseudohole and lamellar-macular-hole. This study showed therefore that DNNs can reliably detect and grade ERMs according to their size not only in the fovea but also in the paracentral region. This is also achieved in cases of hard-to-detect, small-ERMs. In addition, the generated saliency maps can be used to highlight small-ERMs that might otherwise be missed. The proposed model could be used for screening-programs or decision-support-systems in the future.

The time course of spontaneous closure of idiopathic full-thickness macular holes

PURPOSE

Spontaneous closure of idiopathic full-thickness macular holes (iFTMH) has been reported regularly. However, little is known about its probability and timeline.

METHODS

In this retrospective study all consecutive patients who presented between August 2008 and August 2019 were screened for the presence of a macular hole and only iFTMHs were included. The primary outcome measure was the spontaneous closure of the iFTMH.

RESULTS

Of 1256 eyes with macular holes, 338 fulfilled the inclusion criteria. Spontaneous closure of the iFTMH was detected in 31 eyes (9.2%) with a median time of 44 days after diagnosis. Eyes exhibiting spontaneous closure demonstrated a higher baseline best-corrected visual-acuity (BCVA) and smaller iFTMH diameter (p < 0.0001 and p < 0.0001, respectively). The mean BCVA improved from 0.4 logMAR (SD ± 0.21) to 0.29 logMAR (SD ± 0.20) after spontaneous closure (p = 0.031). The iFTMH diameter was positively correlated with the time to spontaneous closure (Pearson-r = 0.37, p = 0.0377). Spontaneously closed iFTMHs reopened in 16% (n = 5) of cases, with a median of 136 days after closure. A logistic regression model showed the hole diameter was associated with spontaneous closure (odds-Ratio 0.97, 95%CI [0.96, 0.98]). The Kaplan-Meier-Curve revealed that approximately 25% of small-iFTMH (n = 124) and 55% of iFTMH with a diameter < 150µm (n = 48) closed spontaneously within two months.

CONCLUSION

The established gold-standard for the treatment of iFTMHs is macular surgery. However, the potential for spontaneous closure of small iFTMHs must be acknowledged. Therefore, if surgical treatment is delayed in individual cases, close observation is recommended.

Fall-related ocular trauma in patients over 90 years in tertiary ophthalmic center in Germany: 90-TOSG Report 1

PURPOSE

To investigate the clinical characteristics of fall-related ocular trauma in patients over 90 years of age.

METHODS

Retrospective, medical record reviews. Patients over the age of 90 years treated in a tertiary center with fall-related ocular trauma were included in the study.

RESULTS

Fifty consecutive patients (fifty eyes) were analyzed. The mean age was 93.6 ± 1.8 years and 41 patients (82%) were female. The most common site of the injuries was orbital fracture (18 patients, 36%), accompanied with open globe rupture (OGR) in three patients, and globe contusion in two patients. Seventeen patients (34%) presented with OGR. Ocular trauma score in those patients was category 1 in 10 patients (58.8%) and category 2 in the others. Conjunctival hemorrhage and/or periocular contusion was seen in 14 patients (28%) and globe contusion in six patients (12%). At the presentation, the mean best corrected visual acuity (BCVA) was 2.82 ± 0.24 logMAR in patients with OGR and 1.98 ± 0.81 logMAR in six patients with globe contusion. Three of the patients with OGR had a final vision of 20/200 or better whereas the remaining patients had hand movements or less. The most common risk factors were female gender (82%) and use of antihypertensive drugs (46%).

CONCLUSION

Patients with OGR had a poor visual outcome despite the early treatment. It is important to raise public awareness about of the poor prognosis of ocular injuries due to falls in the elderly population in order to establish preventive measures.

Clinical characteristics of patients with epiretinal membrane-Foveoschisis

PURPOSE

The purpose of this study is to investigate the clinical and morphological characteristics of epiretinal membrane (ERM)-Foveoschisis.

METHODS

Medical charts of 2088 patients diagnosed with idiopathic ERM were screened and eyes with ERM-Foveoschisis were included. All eyes underwent a complete ophthalmological examination including spectral domain optical coherence tomography (SD-OCT). OCT features and best corrected visual acuity (BCVA) were analysed. ERM-Foveoschisis was defined as open, closed, elevated or flat based on the OCT features. Ellipsoidal zone (EZ) abnormality, intraretinal cystoid spaces, central foveal thickness (CFT), posterior vitreous detachment (PVD) and lens status were assessed.

RESULTS

One hundred-sixty-six patients (175 eyes) (72% female, mean age 70.46 years) were included. Incidence of ERM-Foveoschisis was 6.7%. Open type was seen in 86.8% and had a significantly better mean BCVA than closed type (p = 0.01). No statistically significant difference of mean BCVA was noted between the elevated and flat types. Mean BCVA was significantly lower in eyes with EZ abnormality (p = 0.03) and eyes with intraretinal cystoid spaces (p = 0.02). Patients with 'closed' ERM-Foveoschisis showed a significant higher median CFT than 'open' ERM-Foveoschisis (respectively, 364 µm and 176 µm, p < 0.001). A total of 81.9% eyes had PVD.

CONCLUSION

We differentiated four morphological types of ERM-Foveoschisis based on the OCT examination. Closed ERM-Foveoschisis presented with a higher CFT and lower BCVA than the open type. ERM-Foveoschisis with cystoid intraretinal spaces presented with a lower BCVA. The impact of the morphological types of the ERM-Foveoschisis on the clinical course and for therapy decision requires further long-term studies.

Natural Course of Optic Disc Pit Maculopathy: An Optical Coherence Tomography Study

PURPOSE

The aim of this study was to analyze the impact of OCT characteristics on the natural course of optic disc pit maculopathy (ODP-M).

METHODS

This was a single-center, retrospective, observational case series. Patients with ODP-M were included in the study. Baseline demographic characteristics, central macular thickness (CMT), IPP, subretinal fluid (SRF), subretinal precipitations, outer retinal fluid (ORF), and outer retinal layer hole were evaluated. The changes in the OCT characteristics were analyzed with respect to the best-corrected visual acuity (BCVA) from baseline to the last visit.

RESULTS

Twenty-two eyes of 22 patients were evaluated with a mean follow-up time of 37.6 (median 22) months. The mean BCVA was 0.31 logMAR at baseline and 0.28 logMAR at the final visit (p = 0.521). Baseline BCVA was significantly related to CMT (β coefficient 0.001, p = 0.002). Mean BCVA increased in 7 patients (group 1), remained stable in nine (group 2), and decreased (group 3) in 6 patients. No significant difference was found between the groups regarding the baseline BCVA, CMT, and extent of retinal fluid. In patients with subretinal deposits, BCVA remained stable in 3 patients and worsened in one. ORF was recorded in all patients. In patients with SRF, the mean change of BCVA during follow-up differed significantly, depending on the presence (0.07 logMAR) or absence (-0.125 logMAR) of SRF (p = 0.019).

CONCLUSION

Among the OCT characteristics, SRF was a negative prognostic factor in ODP-M. Most ODP-M patients showed improved or stable vision over 3 years of follow-up. Therefore, observation may be considered in patients with reasonable vision and without SRF even when they present with remarkable OCT findings.

Impact of OCT scan-patterns in identifying morphological features of lamellar macular holes and macular pseudoholes

AIM: To evaluate the impact of the optical coherence tomography (OCT) scan patterns on the detection of the features associated with lamellar macular hole (LMH) and macular pseudohole (MPH). METHODS: This is a retrospective analysis of 100 consecutive eyes with LMH (n=41) and MPH (n=59) having at least three of the following OCT features, which include mandatory criteria for the diagnosis of LMH and MPH: Epiretinal membrane, epiretinal proliferation, verticalization, intraretinal cystoid spaces, foveoschisis, irregular foveal contour, foveal cavity with undermined edges, and ellipsoid line disruption. Primary outcome measurement was the detection frequency of the features in three different OCT scan patterns: 1) volume scan; 2) six radial scans (R6); and 3) vertical and horizontal radial scans (R2). RESULTS: Of the total eight features, the maximal detection frequency was found as 4.45±1.45, 4.35±1.47, and 3.70±1.59, by the volume, R6 and R2, respectively. R2 was inferior to the other patterns in detection of the total features (P<0.001), whereas R6 and volume patterns were found comparable (P=0.312). CONCLUSION: The physician should be aware that the selection of the OCT-scan pattern may influence the detection of mandatory morphological criteria for the diagnosis of LMH and MPH.

Posterior Uveal Effusion after Cataract Surgery

We report a case of posterior uveal effusion (UE) with a long-term follow-up that has occurred following cataract surgery. A 64-year-old woman presented with diminished vision of the right eye (RE) 3 weeks after an uneventful phacoemulsification and intraocular lens implantation. Complete ophthalmic examination including fluorescein angiography (FA), indocyanine green angiography (ICGA), echography and optical coherence tomography (OCT) were performed. Best corrected visual acuity (BCVA) of the RE was 20/50. Anterior segment and intraocular pressure were unremarkable. OCT revealed prominent folds of the choroid and retina, subretinal fluid and darkening of the choroid with reduced visibility of the choroidal vessels and the scleral border. The left eye (LE) was unremarkable. BCVA of the LE was: 20/20. After topical anti-inflammatory and systemic corticosteroid therapy for 5 months, no morphological change of the macula was seen. The patient was observed without any treatment. Forty-three months after the cataract surgery and 38 months after cessation of the corticosteroid therapy, OCT revealed a normal macular morphology and the BCVA improved to 20/25. Even though rare, UE at the posterior pole may occur after modern cataract surgery. OCT examination is a reliable tool in monitoring the macular morphology. Since morphological and functional improvement can be seen in long-term, observation may be considered for some cases of posterior UE with resistance to the therapy.

Identification of Postoperative Foveal Displacement after Macular Surgery for Idiopathic Epiretinal Membrane

Introduction: To analyze foveal displacement after macular surgery for idiopathic epiretinal membrane (iERM). Methods: Twenty-eight patients who underwent macular surgery for symptomatic iERM in one eye by one physician were included in this retrospective study. Spectral domain optical coherence tomography (SD-OCT) volume scans were acquired with a Spectralis OCT device (Heidelberg Spectralis). Using the follow-up view mode, the displacement of the fovea was classified and measured according to its postoperative location in the horizontal and/or vertical plane. Results: One day after surgery, 86% of eyes (24/28) showed foveal displacement. Vertical displacement occurred in a superior direction in 50% eyes, and in an inferior direction in 36% of the eyes. The postoperative mean foveal displacement on the vertical plane was 99 ± 82 μm (range, 0-300). Horizontal displacement occurred in a nasal direction in 21%, and temporally in 21%. The postoperative mean foveal displacement on the horizontal plane was 35 ± 45 μm (range, 0-123). One year after the macular surgery 69% of the eyes showed still a foveal dislocation. Discussion: Most of the eyes with iERM showed a foveal dislocation after the macular surgery. Our findings emphasize the necessity to carefully study of the OCT images in such eyes after the surgery as the manually determined postoperative foveal position may be in a different vertical or horizontal plane than the machine-generated pre- and postoperative overlay for the foveal position. Our findings may thus be helpful for surgeons to avoid misinterpretation when evaluating OCT images pre- and postoperatively.

Rebound Phenomenon after Intravitreal Injection of Triamcinolone Acetonide for Macular Edema

INTRODUCTION

The aim of this article was to report on a rebound phenomenon after intravitreal triamcinolone acetonide (IVTA) injection for macular edema secondary to diabetic retinopathy (DR) and central or branch retinal vein occlusion (CRVO/BRVO).

METHODS

The data were analyzed retrospectively. Complete ophthalmic examinations, including spectral domain optical coherence tomography, were performed before and 2 months after IVTA injection. The incidence of a rebound phenomenon was defined as an increase in central retinal thickness of >10% from baseline at 2 months after IVTA injection.

RESULTS

This retrospective study included 211 consecutive patients (268 eyes). One hundred ninety (71.2%), 39 (14.6%), and 39 (14.6%) eyes had macular edema (ME) due to DR, CRVO, and BRVO. In total, 9.7% of the eyes showed a rebound phenomenon (DR: 9.5%, CRVO: 5.2%, BRVO: 15.4%). The mean number of prior injections of vascular endothelial growth factor inhibitor or corticosteroid agent was statistically significantly higher in the rebound group (6.8 vs. 5.3) than in the nonrebound group (p = 0.01).

CONCLUSION

Our study shows that 9.7% of the eyes with ME secondary to DR and RVO developed a rebound phenomenon following IVTA injection, limiting its therapeutic effect. We found an increased number of prior intravitreal pharmacotherapy to be a risk factor for a rebound phenomenon.

[Acute loss of visual acuity after pregnancy]

A 28-year-old female patient presented with acute loss of visual acuity after pre-eclampsia. Funduscopy revealed minor alterations of the posterior pole of the macula. Optical coherence tomography displayed a bilateral neurosensory detachment. Fluorescence angiography showed filling defects of the choroid in both eyes. These findings were in line with choroidal ischemia following a hypertensive episode. The symptoms disappeared completely after 3 months without additional treatment. To clarify ambiguous pathologies the ophthalmologist should always initiate a comprehensive evaluation in internal medicine to find the right diagnosis and treatment.

Photodynamic therapy with double duration for circumscribed choroidal haemangioma: functional and anatomical results based on initial parameters

IMPORTANCE

Pre-treatment symptoms longer than 12 months and foveal cystoid changes are indicators for poor anatomical and functional outcome after photodynamic therapy (PDT).

BACKGROUND

To evaluate the prognostic factors on the effectiveness of PDT with double duration for treatment of exudative circumscribed choroidal haemangioma.

DESIGN

Retrospective study.

PARTICIPANTS

Twenty-seven patients with symptomatic exudative circumscribed choroidal haemangioma treated with PDT.

METHODS

Clinical charts of patients with exudative circumscribed choroidal haemangioma treated with PDT were analysed with regard to visual acuity, duration of symptoms, subfoveal fluid, foveal cystoid changes and foveal thickness in optical coherence tomography.

MAIN OUTCOME MEASURES

Change of best-corrected visual acuity, sub- and intrafoveal fluid and foveal thickness measured with optical coherence tomography from baseline to last follow-up.

RESULTS

Mean visual acuity improved by 0.05 from 0.42 logMAR (standard deviation [SD] 0.34) to 0.37 logMAR (SD 0.47). In 70% of the patients, PDT stopped exudation and revealed a dry fovea. The recurrence or persistence of sub- or intrafoveal fluid was significantly associated with pre-therapeutic symptoms existing for more than 12 months (P = 0.046). Mean foveal thickness in optical coherence tomography decreased from 324 μm (SD 223 μm) to 209 μm (SD 109 μm).

CONCLUSIONS AND RELEVANCE

PDT proved to be a safe and effective treatment procedure for exudative circumscribed choroidal haemangioma in our series, with few side effects. We observed a more successful treatment with regard to anatomical and functional results in cases with pre-existing symptoms less than 12 months and in cases without pre-therapeutic foveal cystoid changes.

Submacular predominantly hemorrhagic choroidal neovascularization: resolution of bleedings under anti-VEGF therapy

Purpose

To report the visual and morphological outcomes following intravitreal bevacizumab in neovascular age-related macular degeneration (nAMD) with submacular, predominantly hemorrhagic, lesions.

Methods

Retrospective study of patients with a follow-up after 1 year. All eyes with submacular hemorrhages larger than 50% of the total lesion size and received only anti-VEGF (vascular endothelial growth factor) monotherapy (intravitreous administration of 1.25 mg bevacizumab, PRN). The primary endpoint was the change in hemorrhage size and time to resolution, in association with the mean best-corrected visual acuity (BCVA). The eyes were grouped based on the size of the hemorrhage: group A (≥1 to <4 disc area [DA]), group B (≥4 to <9 DA), and group C (≥9 DA).

Results

Forty-six consecutive eyes were included. The mean area of the hemorrhage was 6 DA at baseline. Eyes with smaller bleeding (group A) had better chances of stabilized or improved vision. Complete resolution of the hemorrhage was seen in 96% of the eyes within 1 year. The mean BCVA increased from 0.81 logarithm of the minimum angle of resolution (logMAR) (95% confidence interval [CI]: 0.70–0.92) (Snellen 20/125) at baseline to 0.75 logMAR (95% CI: 0.62–0.88) (20/125) after 1 year (P=0.11). BCVA improved (one or more ETDRS [Early Treatment of Diabetic Retinopathy Study] lines) in 57% of the eyes (13/23) in group A; 53% (8/15) in group B; and 38% (3/8) in group C.

Conclusion

Many of the eyes with hemorrhagic lesions showed stabilization or improvement of the mean BCVA after treatment within 1 year. Anti-VEGF treatment can be considered as a useful treatment option in eyes with hemorrhages secondary to nAMD.

Environmental and genetic risk factors for retinal angiomatous proliferation

PURPOSE

To identify genetic and environmental risk factors in patients with retinal angiomatous proliferation (RAP), a clinical subtype of age-related macular degeneration (AMD).

METHODS

In this case-control study, 108 AMD cases with RAP, 258 AMD patients with choroidal neovascularization (CNV) without RAP and 443 healthy controls were evaluated. Single nucleotide polymorphisms in age-related maculopathy susceptibility 2 (ARMS2) and complement factor H (CFH) and various environmental risk factors were analysed. Statistical analysis was performed by univariate and multivariate regression analysis.

RESULTS

High age, female sex and genetic variants in CFH and ARMS2 were identified as risk factors for developing any CNV. In RAP patients, arterial hypertension was also identified as a risk factor (OR 2.39; p = 0.0005). Compared with the 'non-RAP' CNV group, the association with high age (OR 1.05; p = 0.008) and arterial hypertension (OR 1.82; p = 0.02) was significantly higher in RAP patients, while the association with CFH risk alleles (homozygous OR 0.40; p = 0.003) was significantly lower, which was confirmed in a multivariate analysis (OR 0.41; p = 0.03 for the heterozygous risk allele and OR 0.38; p = 0.03 for the homozygous risk allele).

CONCLUSION

The association with the CFH Y402 risk allele was less pronounced in RAP patients than in 'non-RAP' CNV patients, while the association with high age and arterial hypertension appeared to be stronger. These findings stress the importance of detailed phenotyping in AMD to identify homogeneous AMD subtypes and their different risk factors and disease mechanisms.

Grid laser photocoagulation for macular oedema due to branch retinal vein occlusion in the age of bevacizumab? Results of a prospective study with crossover design

BACKGROUND AND AIM

To investigate the long term effectiveness of grid laser photocoagulation (GLP) versus intravitreal bevacizumab (BEV) in macular oedema (MO) secondary to branch retinal vein occlusion (BRVO), and to evaluate the treatment courses after treatments were switched.

METHODS

In this prospective interventional consecutive case series, previously untreated eyes with perfused MO were enclosed over a period of 16 months for BEV and for 29 months for GLP. The follow-up period was 1 year. Patients with persistent MO after 12 months of BEV were offered GLP and vice versa, and were followed-up for another 12 months.

RESULTS

Both BEV (23 eyes) and GLP (21 eyes) caused a significant (p<0.05) reduction in central retinal thickness (CRT) at 12 months although this was delayed with GLP. However, BEV revealed a significantly better best corrected visual acuity (BCVA) compared with GLP (0.2 vs 0.5 logMAR; p<0.04). Switching therapy for non-responders revealed a reduced CRT at another 12 months, although this was not significant.

CONCLUSIONS

Functionally and anatomically, BEV appears to be more effective than GLP for the therapy of MO due to BRVO. BCVA is significantly better after 1 year and the anatomical response of the MO is faster. Furthermore, non-responders with persistent MO despite BEV or GLP treatment might benefit from switching therapy.

Treatment of age-related macular degeneration: focus on ranibizumab

Ranibizumab, a humanized antigen-binding fragment (Fab) that binds all isoforms of VEGF-A, significantly slows down loss of vision and causes significant visual improvement in many patients with choroidal neovascularization (CNV) due to exudative age-related macular degeneration (AMD). These benefits of intravitreal ranibizumab apply to all angiographic subtypes of neovascular AMD and across all lesion sizes when the drug is injected at monthly intervals as shown in two pivotal phase III trials (ANCHOR and MARINA). The results from the PrONTO study suggest that less frequent treatment with ranibizumab through a variable dosing regimen dependent on optical coherence tomography (OCT) findings is a treatment option that results in comparably favorable visual outcomes. Currently, it is unclear whether combination therapy of ranibizumab with photodynamic therapy (PDT) provides any significant advantage over ranibizumab monotherapy (FOCUS trial); however, the combination of PDT and ranibizumab may decrease the need for frequent retreatment. This question will be addressed in the SUMMIT trial. Therapy with ranibizumab is generally very well tolerated with a low rate of seriously adverse ocular events or systemic side-effects. The advent of vascular endothelial growth factor (VEGF) inhibitors has revolutionized the therapy of neovascular AMD. Ranibizumab at the moment appears to be the most effective approved treatment for neovascular AMD.

[Diabetic maculopathy. Diagnosis and treatment]

Due to demographic change the incidence of diabetic retinopathy has risen in spite of new facilities and prevention campaigns and is still one of the leading causes of blindness in Germany. The combination of focal/grid laser photocoagulation and an intravitreal anti-VEGF (vascular endothelial growth factor) regimen is the first line approach for clinically significant macular edema with foveal involvement and is evidence-based. Vitreomacular interface abnormalities can be effectively treated by modern vitreomacular surgery. Unfortunately, no proven treatment modality can be provided for ischemic maculopathy. The management of systemic risks factors, such as hyperglycemia and arterial hypertension, remains a task of great importance despite all modifications and increase of knowledge during recent years. Innovative developments in the field of intravitreal pharmacotherapy have opened up new vistas. There are good prospects that modern ophthalmology will not be limited to preserving visual function but to allow improvements and consequently enhance health-related quality of life for diabetic patients.

Macular pigment and fixation after macular translocation surgery

BACKGROUND

After full macular translocation (MT) surgery with 360 degrees retinotomy, the fovea is rarely identifiable. Our aim was to verify the position of the fovea, to determine how patients fixate after MT and to examine distribution and optical density of macular pigment (MP).

METHODS

9 patients after MT were investigated. The Utrecht Macular Pigment Reflectometer was used to quantify the MP optical density. A scanning laser ophthalmoscope (SLO) was used to identify the fovea as the centre of MP distribution and determine the retinal locus of fixation.

RESULTS

In all patients, the fovea was identified as the centre of MP distribution. The retinal areas used for fixation were displayed by SLO fixation analysis. Comparing their spatial relationship with the fovea, five patients fixated centrally and four eccentrically up to 7.5 degrees . In those patients, microperimetry showed that the atrophy caused by choroidal neovascularisation (CNV) extraction prevented central fixation.

CONCLUSION

The combination of MP distribution and fixation analysis allows fixation behaviour to be quantified, even if the fovea morphologically cannot be localised. Our results suggest that the scotoma caused by spreading chorioretinal atrophy is the main cause for reduced visual acuity after MT, and so the MT rotation angle is crucially important.

[Neovascular age-related macular degeneration in Germany. Encroachment on the quality of life and the financial implications]

BACKGROUND

Approximately 35,000 cases of neovascular age-related macular degeneration (AMD) occur annually in Germany. The neovascular form of AMD (NV-AMD) is responsible for severe vision loss associated with the disease in 90% of the cases. This study was conducted to assess the humanistic and economic burden of NV-AMD in the German population.

METHODS

A cross-sectional, observational study of subject self-reported functional health, well-being, and disease burden among elderly subjects with (n=83) and without (n=93) NV-AMD in Germany was conducted. Patients participated in telephone surveys involving the National Eye Institute Visual Function Questionnaire (NEI-VFQ-25), the EuroQol (EQ-5D), the Hospital Anxiety and Depression Scale (HADS), and also reported history of falls, fractures, and healthcare resource utilization. Furthermore, the healthcare utilization and unit costs for the NV-AMD patients were calculated.

RESULTS

The mean age of NV-AMD patients was 77.2 years and 64% were female. NV-AMD patients reported significantly worse vision-related function and overall well-being than controls (adjusted mean scores: NEI-VFQ-25 overall scale: 51.3 vs 96.3; p<0.0001) and significantly more depression symptoms than controls (HADS depression: 6.2 vs. 2.7; p<0.0001). NV-AMD patients also reported that the need for assistance with daily activities was more than 10 times greater compared to controls (26.5% vs. 2.2%; p<0.0001) and the prevalence of falls was 3 times that of the control group (13.3% vs 4.3%; p=0.031). Annual NV-AMD costs per patient were <euro> 9871, 6 times that of elderly patients without NV-AMD (<euro> 1559). Of the NV-AMD costs one-half were direct non-medical-related costs (assistance of ADL or social benefit) and one-third were direct medical costs.

CONCLUSIONS

NV-AMD is associated with decreased functional abilities and quality of life, which result in an increase in healthcare resource utilization. Consequently, costs were higher for NV-AMD patients compared to controls. These findings emphasize the need for new NV-AMD treatments that will prevent vision loss and progression to blindness, and lessen the ensuing economic burden. Sponsored by Pfizer Inc. New York, US.

Full macular translocation (FMT) versus photodynamic therapy (PDT) with verteporfin in the treatment of neovascular age-related macular degeneration: 2-year results of a prospective, controlled, randomised pilot trial (FMT-PDT)

BACKGROUND

To report the outcome of best-corrected visual acuity (BCVA), near visual acuity (NVA), contrast sensitivity (CS) and vision-related quality of life (VRQOL) in patients 2 years after undergoing photodynamic therapy (PDT) or full macular translocation (FMT) for the treatment of neovascular age-related macular degeneration (AMD).

METHODS

Fifty patients with predominantly classic subfoveal choroidal neovascularisation (CNV) secondary to AMD were randomized to PDT or FMT. BCVA was determined according a standardized protocol with ETDRS charts. NVA were calculated after testing with SNAB (Swiss National Association of and for the Blind) visual acuity cards. CS was measured with Pelli-Robson charts. The 39-item National Eye Institute Visual Function Questionnaire (NEI-VFQ-25 plus supplement) was performed. Primary end points were the changes of BCVA, NVA, CS and VRQOL at 24-month examination.

RESULTS

A stabilisation of BCVA (+0.3 letters) was found in the FMT group, whereas a decrease of more than 12 letters (-12.6 letters) was found in the PDT group (p = 0.052). Mean NVA improved by 7.0 letters in the FMT group and was superior to the PDT group (-9.6 letters, p = 0.036), while mean CS showed a time-dependent decrease in both treatment groups (FMT: -3.3 letters, PDT: -3.8 letters, p = 0.726). Considering the results of the VRQOL scores, the improvement of the subscales scores for general vision (p = 0.015), mental health (p = 0.028) and near activity (p = 0.020) were significantly higher in the FMT group.

CONCLUSIONS

FMT can stabilise BCVA and improve NVA over a period of 2 years in patients with subfoveal classic CNV secondary to neovascular AMD, whereas a decrease of BCVA and NVA was found in the PDT group. CS did not differ between FMT and PDT. A significant increase of VRQOL scores was only found in the FMT group and not in the PDT group. FMT seems to be a therapeutic approach that can increase visual function resulting in an improvement of patient's VRQOL, but exhibits a higher number of severe complications compared to PDT.

[Macular translocation - a therapeutic approach for neovascular macular degeneration in the era of anti-VEGF therapy?]

Since anti-VEGF treatment has been proven to achieve a significant improvement of visual acuity in a cohort of patients with neovascular age-related macular degeneration (AMD), macular surgery and particularly the macular translocation with 360 degrees retinotomy (FMT: full macular translocation) have lost their former popularity. However, the approach of macular surgery still remains a promising therapy in selected cases. A prospective randomised study, comparing FMT and photodynamic therapy in subfoveal classic choroidal neovascularisation (CNV), recently showed the superiority of FMT in terms of visual gain. In spite of the postoperative complications and the disturbed binocular vision, the reading acuity and the life quality of many patients improved. Therefore, it is justified to discuss the chances and advantages of the FMT at least in selected cases. After all, case selection was an important determinant also in the phase III studies of ranibizumab; many patients seen during the routine consulting hours were excluded as a consequence of the study criteria. Most of them were suspected to achieve a less favourable outcome of the anti-VEGF regimen. Thus, patients who did not meet the inclusion criteria of recent studies or showed no response to the anti-VEGF therapy, as well as patients with extensive submacular bleeding or ruptures of the pigment epithelium can also be considered as candidates of FMT. Generally, in the presence of highly effective anti-VEGF drugs, FMT can be discussed for second-line treatment, if the fellow eye has poor function and no additional risk factors of the affected eye are known (e. g., hyperopia, large lesion size, etc). Detailed information relating to the potential adverse events have to be mentioned. Although the indication is restricted, surgeons should have the continuing ability to perform the challenging surgical procedure.

[Asteroid hyalosis within an epiretinal membrane]

CASE REPORT

In May 2007 an 80-year-old man with a known proliferative diabetic retinopathy presented in our outpatient department with a decrease in visual acuity of his right eye. There was a thick asteroid hyalosis preventing fundus examination. Sonographically, there were vitreoretinal tractions requiring a vitrectomy. During surgery an epipapillary membrane was removed.

RESULTS

Microscopically round amorphous bodies were conspicuous which were slightly basophilic in the H&E stain. The amorphous bodies were strongly positive in the periodic acid-Schiff staining. They were embedded in a fibrovascular stroma and partly surrounded by inflammatory cells with numerous giant cells of foreign body reaction.

CONCLUSION

Asteroid hyalosis is a common degenerative disorder in the vitreous body. The aetiology and the pathogenesis of the asteroid bodies are not yet fully understood. An association of asteroid hyalosis with systemic diseases like diabetes mellitus, arterial hypertension, hyperlidpidaemia and atherosclerotic vasculopathy is postulated. Normally, therapy for an asymptomatic asteroid hyalosis is not necessary. The tractive proliferative diabetic retinopathy in our patient did require surgery. The incorporation of hyaloid bodies into an epiretinal membrane with the induction of a foreign body reaction is unusual.

One-year results after intravitreal bevacizumab therapy for macular edema secondary to branch retinal vein occlusion

BACKGROUND

To investigate the long-term effectiveness of intravitreal bevacizumab treatment in eyes with perfused macular edema due to branch retinal vein occlusion (BRVO).

METHODS

In this prospective interventional case series, 23 consecutive, previously untreated eyes with perfused macular edema were treated with intravitreal bevacizumab (1.25 mg) injections and followed for 1 year. The main outcome measures were visual acuity (VA) and central retinal thickness (CRT). In addition, VA data were adapted to the non-logarithmic VA charts used in the previously published grid laser photocoagulation BRVO Study.

RESULTS

The median VA gained 3.0 lines from baseline at 48 weeks. This was accompanied by a significant decrease of 39% of the median CRT. The mean number of re-injections was 1.6 during the first 6 months of follow-up and only 0.8 during the subsequent 6 months. In 65% of the cases, adapted VA data showed a gain of 1 or more lines and no eye lost more than 1 line.

CONCLUSIONS

Repetitive intravitreal bevacizumab injections result in a significant long-term improvement of VA and CRT. The number of re-injections necessary to maintain this effect declined over time. However, the treatment seems to be only slightly better than grid laser photocoagulation.

Can the risk of retinal pigment epithelium tears after bevacizumab treatment be predicted? An optical coherence tomography study

BACKGROUND

Retinal pigment epithelium (RPE) tears after bevacizumab treatment for neovascular age-related macular degeneration accompanied by a pigment epithelial detachment (PED) might be caused by stretching forces on the already weakened RPE. The purpose of this study was to evaluate whether simple measurements of optical coherence tomography (OCT) can predict the individual risk of an RPE tear in preoperative candidates.

METHODS

A retrospective chart review study of 393 consecutive patients with neovascular age-related macular degeneration evaluated OCT images (Stratus-OCT Zeiss, Jena, Germany). The height of the PED, the central retinal thickness, and the maximum retinal thickness were determined by two independent observers and retrospectively analysed.

RESULTS

Fifteen patients with an RPE tear had a significant higher PED than the remaining study population. In contrast, no correlation was seen with the central retinal thickness. In a linear regression model, the probability of an RPE tear exponentially increased in dependence of the extent of PED.

CONCLUSION

The risk of an RPE tear can be estimated by simple measurement of the height of the PED on OCT.

Full macular translocation versus photodynamic therapy with verteporfin in the treatment of neovascular age-related macular degeneration: 1-year results of a prospective, controlled, randomised pilot trial (FMT-PDT)

BACKGROUND

The purpose of this study was to compare full macular translocation (FMT) with photodynamic therapy (PDT) in the treatment of neovascular age-related macular degeneration (AMD).

METHODS

In a prospective, randomised, non-masked, mono-center, pilot-trial, 50 eyes of 50 patients were assigned to either FMT or PDT. Baseline and control examinations in 3-monthly intervals over a 12-month period included standardized protocol refraction, visual acuity testing and fluorescein angiography. Primary outcome measurements were made to establish the change in distant visual acuity from the baseline to the 12-month examination. The statistical analyses were carried out on the intent-to-treat principle.

RESULTS

The improvement of one or more ETDRS lines was 56% (14/25) of the eyes in the FMT and 16% (4/25) of the eyes in the PDT arm (P = 0.007). Twenty eyes (80%) in the FMT and 16 eyes (64%) in the PDT group had less than three ETDRS lines of vision loss (P = 0.35). Retinal detachment (six eyes) and diplopia (five patients) were recorded in the FMT group. None of the eyes treated in the FMT group had phtysis.

CONCLUSION

This pilot study showed that no statistically significant difference existed between the FMT and PDT in terms of the vision loss of less than three ETDRS lines in eyes with neovascular AMD. The chance of vision improvement was significantly higher for the patients in the FMT group. However, in the era of promising therapy with anti-vascular endothelial growth factor for neovascular AMD, FMT should not be offered as a standard primary procedure for neovascular AMD.

Reading performance with low-vision aids and vision-related quality of life after macular translocation surgery in patients with age-related macular degeneration

PURPOSE

The aim of the present study was to evaluate the power of magnification required, reading performance with low-vision aids and vision-related quality of life with reference to reading ability and ability to carry out day-to-day activities in patients after macular translocation.

METHODS

This study included 15 patients who had undergone macular translocation with 360-degree peripheral retinectomy. The mean length of follow-up was 19.2 +/- 10.8 months (median 11 months). At the final examination, the impact of visual impairment on reading ability and quality of life was assessed according to a modified 9-item questionnaire in conjunction with a comprehensive clinical examination, which included assessment of best corrected visual acuity (BCVA), the magnification power required for reading, use of low-vision aids and reading speed. Patients rated the extent to which low vision restricted their ability to read and participate in other activities that affect quality of life. Responses were scored on a scale of 1.0 (optimum self-evaluation) to 5.0 (very poor).

RESULTS

In the operated eye, overall mean postoperative BCVA (distance) was not significantly better than mean preoperative BCVA (0.11 +/- 0.06 and 0.15 +/- 0.08, respectively; p = 0.53). However, 53% of patients reported a subjective increase in visual function after treatment. At the final visit, the mean magnification required was x 7.7 +/- 6.7. A total of 60% of patients needed optical magnifiers for reading and in 40% of patients closed-circuit TV systems were necessary. All patients were able to read newspaper print using adapted low-vision aids at a mean reading speed of 71 +/- 40 words per minute. Mean self-reported scores were 3.2 +/- 1.1 for reading, 2.5 +/- 0.7 for day-to-day activities and 2.7 +/- 3.0 for outdoor walking and using steps or stairs. Patients' levels of dependency were significantly correlated with scores for reading (p = 0.01), day-to-day activities (p < 0.001) and outdoor walking and using steps (p = 0.001).

CONCLUSIONS

The evaluation of self-reported visual function and vision-related quality of life in patients after macular translocation is necessary to obtain detailed information on treatment effects. Our results indicated improvement in patients' subjective evaluations of visual function, without significant improvement in visual acuity. The postoperative clinical benefits of treatment coincide with subjective benefits in terms of reading ability, quality of life and patient satisfaction. Our study confirms the importance and efficiency of visual rehabilitation with aids for low vision after surgery.

Primary silicone oil tamponade in the management of severe intraocular foreign body injuries: an 8-year follow-up

PURPOSE

To evaluate the long-term outcome of pars plana vitrectomy and primary silicone oil tamponade in patients with severe intraocular foreign body (IOFB) injuries and high risk of proliferative vitreoretinopathy (PVR).

METHODS

This retrospective consecutive study included 23 patients with severe IOFB injuries who had extensive lacerations including sclera, choroid, and retina, and were complicated by predictive factors for elevated proliferative activity and an unfavorable outcome. All patients underwent pars plana vitrectomy, removal of the IOFB, and primary silicone oil tamponade and were followed up for a mean 8.9 years. Main functional outcome was assessed as final best-corrected visual acuity. Anatomic success was defined as permanent retinal attachment.

RESULTS

PVR occurred in 70% of all eyes and required 16 revisions. Silicone oil was removed in 78% of the eyes after a mean tamponade duration of 9.1 months. Complete retinal attachment was achieved in 83% of the eyes. Three eyes developed a persisting hypotony that was stabilized under permanent silicone oil. Functional stabilization was observed in the third year resulting in a final visual acuity of 20/630. Useful vision of better than 20/400 could be preserved in 55% of the patients. Only one eye underwent a late enucleation after 6.8 years.

CONCLUSIONS

Primary silicone oil stabilizes the retina during the critical period of active PVR and may limit the visual loss in selected high-risk eyes in the long term.

Full macular translocation following photodynamic therapy in neovascular age-related macular degeneration

PURPOSE

To report the long-term functional and anatomical outcome of full macular translocation (FMT) in eyes with neovascular age-related macular degeneration (AMD) following photodynamic therapy (PDT).

METHODS

Twelve eyes of 12 consecutive patients with neovascular AMD who were PDT-nonresponders and underwent FMT were analysed. Best-corrected visual acuity (BCVA) measurement, fundus photography, and fluorescein angiography at baseline and at follow-up examinations in 3 months intervals were performed. Primary end point was change of BCVA from baseline to last visit.

RESULTS

Totally 12 eyes of 12 patients were analysed. Mean time interval between the last PDT and FMT was 3.7 months (range 1-10 months). Mean follow-up after FMT was 25.6 months. BCVA ranged at baseline from 20/1000 to 20/80 (mean 20/230). At the last visit, mean BCVA was by 20/185. BCVA improved in 50% (6/12) of eyes by more than 1 line. Twenty five per cent (3/12) of eyes had final BCVA within +/-1 line from baseline. In 25% (3/12) of eyes the BCVA decreased by more than 1 line. One eye had recurrent CNV. In four eyes a cystoid macular oedema developed. No retinal detachment or disturbing diplopia was noted.

CONCLUSIONS

In the present study, FMT in PDT-nonresponders stabilised or improved visual acuity in the majority of the eyes in a mean follow-up period of nearly 2 years. FMT can be considered as a therapeutical option in eyes who are nonresponders to the PDT in neovascular AMD.

The retinal tolerance to bevacizumab in co-application with a recombinant tissue plasminogen activator

AIM

To investigate the retinal toxicity of bevacizumab in co-application with a commercially available recombinant tissue plasminogen activator (rt-PA), and to facilitate a new therapeutic concept in the treatment of massive subretinal haemorrhage caused by neovascular age-related macular degeneration (AMD).

METHODS

Isolated bovine retinas were perfused with an oxygen-preincubated nutrient solution. The electroretinogram (ERG) was recorded as a transretinal potential using Ag/AgCl electrodes. Bevacizumab (0.25 mg/ml) and rt-PA (20 microg/ml) were added to the nutrient solution for 45 min. Thereafter, the retina was reperfused for 60 min with normal nutrient solution. Similarly, the effects of rt-PA (20 microg/ml, 60 microg/ml and 200 mug/ml) on the a- and b-wave amplitudes were investigated. The percentages of a- and b-wave reduction during application and at washout were calculated.

RESULTS

During application of bevacizumab (0.25 mg/ml) in co-application with 20 microg/ml (rt-PA), the ERG amplitudes remained stable. The concentrations of rt-PA alone (20 microg/ml and 60 microg/ml) did not induce significant reduction of the b-wave amplitude. In addition, 20 microg/ml rt-PA did not alter the a-wave amplitude. However, 60 microg/ml rt-PA caused a slight but significant reduction of the a-wave amplitude. A full recovery was detected for both concentrations during the washout. At the highest tested concentration of 200 microg/ml rt-PA, a significant reduction of the a- and b-wave amplitudes was provoked during the exposure. The reduction of ERG amplitudes remained irreversible during the washout.

CONCLUSION

The present study suggests that a subretinal injection of 20 microg/ml rt-PA in co-application with bevacizumab (0.25 mg/ml) for the treatment of massive subretinal haemorrhage seems possible. This is a safety study. Therefore, we did not test the clinical effectiveness of this combined treatment.

Quality of life in a prospective, randomised pilot-trial of photodynamic therapy versus full macular translocation in treatment of neovascular age-related macular degeneration--a report of 1 year results

PURPOSE

To assess visual function and its effects on vision-targeted, health-related quality of life (QOL) of patients with neovascular age-related macular degeneration (AMD) treated with photodynamic therapy (PDT) or full macular translocation (FMT).

METHODS

Fifty patients with predominantly classic subfoveal choroidal neovascularisation (CNV) secondary to AMD were randomised to PDT or FMT. To test the vision-targeted QOL, the 39-item National Eye Institute Visual Function Questionnaire (NEI-VFQ-25 plus supplement) was administered prior to and 1 year after therapy. The change of vision-related QOL at 1 year in comparison to baseline was defined as primary end point.

RESULTS

The vision-related subscales showed a stabilisation or even higher mean scores at 1 year in both treatment groups. A significant improvement in the quality of the subject's vision-related subscales was only observed after FMT correlating with a more frequent increase in visual acuity. Comparing the results of the QOL scores after 1 year, the improvement of the subscale scores general vision (p = 0.03), mental health (p = 0.02) and dependency (p = 0.03) were significantly higher in the FMT arm.

CONCLUSIONS

FMT and PDT can achieve a stabilisation in vision-related QOL, in which FMT was superior to the PDT after 1 year. The discrepancy between the amount of patients with an increased visual acuity after FMT and a moderate improvement in QOL might be caused by the onset of complications related to this surgical procedure. Besides visual acuity, the impact of therapy-related complications has to be taken into consideration when evaluating new therapeutic concepts in exudative AMD.

Surgical treatment of peripapillary choroidal neovascularisation

OBJECTIVE

To report the functional and morphological outcome of surgical treatment of peripapillary choroidal neovascularisation due to age-related macular degeneration.

METHODS

Consecutive interventional case series of eight patients with extensive peripapillary choroidal neovascularisation and accompanying haemorrhage who underwent subretinal surgery including extraction of the neovascular complex. Ophthalmic examination, including visual acuity testing, colour photography and fluorescein angiography, was performed at baseline and at 3, 6, 9 and 12 months, and then yearly.

RESULTS

Mean follow-up was 26 months (12-60 months). Preoperative best corrected visual acuity (BCVA) ranged from logMAR (logarithm of minimum angle of acuity) 1.0 (20/200) to logMAR 0.0 (20/20), with a mean of logMAR 0.5 (20/63). Mean postoperative BCVA was logMAR 0.3 (20/40). BCVA improved in six patients, was stable in one patient and deteriorated in one patient. Two years after surgery, one patient developed recurrence of the CNV that was removed surgically. One patient showed retinal detachment 5 years after subretinal surgery.

CONCLUSIONS

In this small case series of PPCNV, functional improvement was achieved after surgery in the majority of patients. Surgical extraction of the CNV represents an alternative treatment option in eyes with vision-threatening extensive PPCNV. Randomised controlled studies seem to be justified to evaluate further the beneficial effect and long-term functional outcome of this therapy approach.

Horseshoe-like macular tear following recurrent branch retinal vein occlusion

BACKGROUND

A macular hole can develop as a late complication secondary to a branch retinal vein occlusion (BRVO). We report about an atypical horseshoe-like tear occurring in the fovea after recurrent BRVO.

METHODS

An interventional case report.

RESULTS

In 1997, a 53-year-old man was seen with an occlusion of macular part of inferior temporal vein of the retina on the left eye. After experiencing several recurrent BRVO in this eye, 6 years later he presented with a horseshoe-like tear in the fovea. Visual acuity was 20/200. The patient underwent standard three-port vitrectomy and installation of C3F8 16%. Intraoperatively, massive traction of the vitreous was detected on the edges of the tear. Six months after the operation, the tear remained attached. The visual acuity was 20/200.

CONCLUSIONS

The uniqueness of the presented case is the occurrence of a macular tear following recurrent BRVO, its horseshoe-like shape and foveal location. To the best of our knowledge, this is the first report on a horseshoe-like tear seen in the fovea secondary to BRVO. We assume that chronic macular edema and retinal ischemia following BRVO were additional factors beside the vitreous traction, contributing to the formation of the macular tear. Anatomical closure of the tear and stabilisation of visual acuity can be achieved by vitreoretinal surgery.

Intravitreal bevacizumab (Avastin) for occult choroidal neovascularization in age-related macular degeneration

BACKGROUND

The purpose of the study is to report data on short-term safety of intravitreal bevacizumab treatment and its effect on visual function, central retinal thickness, and angiographical changes of occult choroidal neovascularization due to age-related macular degeneration.

METHODS

A consecutive interventional case series of 30 patients with active subfoveal occult choroidal neovascularization secondary to age-related macular degeneration was followed after one intravitreal injection of 1.25 mg bevacizumab at baseline and subsequent injections following standardized criteria. At baseline and follow-up visits patients had visual acuity assessment, intraocular pressure measurement, fluorescein angiography, and optical coherence tomography imaging.

RESULTS

No serious ocular or systemic adverse events were identified. A significant increase of intraocular pressure or signs of retinal toxicity or endophthalmitis were not detected in any patient. Optical coherence tomography revealed significant decrease (p < 0.001) in central retinal thickness after 1 week, 4 weeks, and 12 weeks, respectively. Fluorescein leakage decreased within 1 week and improvement was maintained at week 12 in the majority of patients. Visual acuity improved or remained stable in 29 of 30 patients; improvement of 3 or more lines was seen in 14 of 30 patients; one patients showed improvement of 6 lines. No patient had severe vision loss of 6 lines or more; moderate vision loss of 3 lines was seen in one patient. Re-injections of bevacizumab according to standard criteria were performed one to two times during the follow-up period of 12 weeks with a re-injection interval of 4 to 18 weeks (median 8 weeks).

CONCLUSIONS

Short-term results suggest that intravitreal injection of bevacizumab is well tolerated and for the majority of patients with occult choroidal neovascularization in AMD results in improvement of visual acuity, decrease in central retina thickness, and reduction of angiographic leakage of the lesion. Bevacizumab as intravitreal treatment may provide a novel therapeutic option for selected patients with exudative AMD. Randomized prospective multicenter trials seem justified to further evaluate long term effects and impact of intravitreal bevacizumab on different subtypes of AMD compared to established therapies.

A case of cutaneous melanoma metastatic to the vitreous cavity: possible pathomechanism and review of the literature

BACKGROUND

Isolated vitreous metastases are extremely rare and the pathogenesis of metastasis is still unclear. Here we present the detailed description of the disease progression in a 68-year-old patient with vitreous seeding of a metastatic cutaneous melanoma beginning at a very early stage.

METHODS

Interventional case report and review of the literature.

RESULTS

The initial retrohyaloidal metastatic lesion was identified adjacent to a small epiretinal hemorrhage. As the disease progressed golden brown spherules appeared in the posterior vitreous emanating from the area of the lesion. Further progression led to a dense metastatic infiltration of the entire vitreous cavity and a decline of the visual acuity to 20/1200. Diagnostic and therapeutic pars plana vitrectomy was performed to confirm the diagnosis and preserve the eye and useful vision.

CONCLUSIONS

For the first time the formation of vitreous metastases derived from cutaneous melanoma was carefully studied beginning at a very early stage. This made it possible to analyze the rare mechanism of vitreous metastasis, which has not been conclusively known till now. The features of metastatic cutaneous melanoma to the vitreous are discussed in context of a review of the literature that resulted from the study of 17 patients with 22 affected eyes.