Baseline characteristics of eyes with early residual fluid post loading phase of aflibercept therapy in neovascular AMD: PRECISE study report 3

PURPOSE

To compare the baseline characteristics in patients with and without early residual fluid (ERF) after aflibercept loading phase (LP) in patients with treatment naïve neovascular age related macular degeneration (nAMD).

METHODS

Patients with nAMD initiated on LP of three intravitreal aflibercept doses were recruited from December 2019 to August 2021. Baseline demographic and OCT features associated with any ERF were analysed using Generalised Estimating Equations to account for inter-eye correlation. Receiver operating characteristic (ROC) curve was performed for selection of CST threshold.

RESULTS

Of 2128 patients enrolled, 1999 eyes of 1862 patients with complete data were included. After LP, ERF was present in 1000 (50.0%), eSRF in 746(37.3%) and eIRF in 428 (21.4%) eyes. In multivariable analysis of baseline features, eyes with increased central subfield thickness (CST) (OR 1.31 per 100 microns increase [95% CI 1.22 to 1.41]; P < 0.001), eyes with IRF and SRF at baseline (1.62 [95% CI 1.17 to 2.22]; P = 0.003), and those with SRF only (OR 2.26 [95% CI 1.59 to 3.20]; P < 0.001) relative to IRF only were determinants of ERF. CST ≥ 418 microns had 57% sensitivity and 58% specificity to distinguish ERF from no ERF at visit 4.

CONCLUSION

On average, 50% of eyes have ERF after aflibercept LP. Clinically relevant baseline determinants of ERF include CST ≥ 418 µ and presence of only SRF. These eyes may require further monthly treatment before extending treatment intervals.

Transcriptomic insights into multiple system atrophy from a PLP-α-synuclein transgenic mouse model

Multiple system atrophy (MSA) is a rare, neurodegenerative disorder with rapid motor and non-motor symptom progression. MSA is characterized by protein aggregations of α-synuclein found in the cytoplasm of oligodendrocytes. Despite this pathological hallmark, there is still little known about the cause of this disease, resulting in poor treatment options and quality of life post-diagnosis. In this study, we investigated differentially expressed genes (DEGs) via RNA-sequencing of brain samples from a validated PLP-α-synuclein transgenic mouse model, identifying a total of 40 DEGs in the PLP group compared to wild-type (WT), with top detected genes being Gm15446, Mcm6, Aldh7a1 and Gm3435. We observed a significant enrichment of immune pathways and endothelial cell genes among the upregulated genes, whereas downregulated genes were significantly enriched for oligodendrocyte and neuronal genes. We then calculated possible overlap of these DEGs with previously profiled human MSA RNA, resulting in the identification of significant downregulation of the Tsr2 gene. Identifying key gene expression profiles specific to MSA patients is crucial to further understanding the cause, and possible prevention, of this rapidly progressive neurodegenerative disorder.

Exploring Patient Demographics and Presence of Retinal Vascular Disease in Paracentral Acute Middle Maculopathy

PURPOSE

To investigate the sociodemographic profile, the association with retinal vascular diseases (RVD) and systemic comorbidities, and visual outcomes of patients with paracentral acute middle maculopathy (PAMM) in a large, ethnically diverse single-center cohort.

DESIGN

Retrospective cohort study.

METHODS

Electronic health record query for all patients presenting with PAMM at Moorfields Eye Hospital, London, was completed. Detailed demographic, clinical, and systemic information were collected and analyzed.

RESULTS

A total of 78 eyes of 78 patients with confirmed PAMM were included in the study. Forty patients (51.3%) presented with no RVD, 20 patients (25.6%) with retinal vein occlusion (RVO), 16 patients (20.5%) with retinal artery occlusion (RAO), and 2 patients (2.6%) with concomitant RAO and RVO. Patients with PAMM+RAO were older than those with RVO (P = .02) and more likely to have a history of major adverse cardiovascular events (MACE) (P = .01), with a significantly worse presenting best corrected visual acuity (BCVA) (20/50) compared to patients with RVO (P = .02) and no RVD (P < .001). Individuals with isolated PAMM had a significantly higher prevalence of previous MACE (P = .04) and sickle cell disease (SCD) (P = .04) compared to those with RVO. At the last follow-up, 64 patients (85.3%) had a good BCVA (>20/32).

CONCLUSIONS

The significant association of PAMM with RVD supports the hypothesis of an ischemic etiology. Individuals with isolated PAMM had a higher prevalence of MACE and SCD. Thus, it is important to prompt immediate referral for a comprehensive systemic evaluation. Across the whole cohort, PAMM was associated with good BCVA improvement during follow-up, indicating a good visual prognosis.

Efficacy and Safety outcomes of a novel model to assess new medical retina referrals in a high-volume medical retina virtual clinic

BACKGROUND

Ophthalmology outpatient attendances have significantly increased recently with rising pressure from backlogs arising from the pandemic. Medical retina digital surveillance clinics for stable follow-up appointments are well established. We present a model for assessing new referrals and evaluating clinical outcomes and long-term sustainability in a complex high-volume medical retina service.

METHODS

Suitable routine new patient referrals were identified from electronic referrals and referred to this new pathway. Structured history, visual acuities, and intraocular pressures were recorded, and widefield colour fundus and optical coherence tomography imaging were performed at a imaging hub for asynchronous consultant-led review.

RESULTS

1458 patients were invited to attend over four months, with a 13.2% did-not-attend (DNA) rate. Common diagnoses included stable diabetic retinopathy (19.9%), early age-related macular degeneration (6.7%), central serous retinopathy (8.8%), and retinal vein occlusion (6.3%). 7 patients (0.05%) required urgent same-day review. 61 (5.0%) required urgent face-to-face (F2F) assessment within two weeks. A total of 727 (59.0%) were either discharged or remained in the virtual pathway following their first visit.

CONCLUSION

This study encourages the use of a digital model that efficiently assesses suitable newly referred medical retina patients in both complex and local eye unit settings. This decreased the need for F2F clinics and resources. Further patient satisfaction surveys for digital services are currently being evaluated to guide long-term sustainability of this model.

Eyes and the heart: what a clinician should know

The eye is prone to various forms of afflictions, either as a manifestation of primary ocular disease or part of systemic disease, including the cardiovascular system. A thorough cardiovascular examination should include a brief ocular assessment. Hypertension and diabetes, for example, would present with retinopathy and dyslipidaemia would present with corneal arcus. Multisystem autoimmune diseases, such as Graves' disease, rheumatoid arthritis and sarcoidosis, would present with proptosis, episcleritis and scleritis, respectively. Myasthenia gravis, while primarily a neuromuscular disease, presents with fatigable ptosis and is associated with Takotsubo cardiomyopathy and giant cell myocarditis. Connective tissue diseases such as Marfan syndrome, which commonly presents with aortic root dilatation, would be associated with ectopia lentis and myopia. Wilson's disease, which is associated with arrhythmias and cardiomyopathies, would present usually with the characteristic Kayser-Fleischer rings. Rarer diseases, such as Fabry disease, would be accompanied by ocular signs such as cornea verticillata and such cardiac manifestations include cardiac hypertrophy as well as arrhythmias. This review examines the interplay between the eye and the cardiovascular system and emphasises the use of conventional and emerging tools to improve diagnosis, management and prognostication of patients.

Indications for replantation and factors that predict success

Since the advent of replantation techniques, there has been uneven progress in terms of success-even considering whether success is defined as continued perfusion of the digit or long term functional outcomes. Early enthusiasm and success have not been maintained despite increasing familiarity with microsurgical techniques and greater understanding of how to optimize outcomes for the individual components of replantation such as tendon repair, nerve repair, and osteosynthesis. Practitioners participating in the care of patients undergoing replantation should be familiar with the history and current understanding of both the indications and contraindications for the procedure, post-operative rehabilitation, and factors contributing to functional outcomes. A review of the literature from the first publications on the topic demonstrates evolution in practice and understanding of which patients should be indicated for replantation. Indications can be considered in three broad categories: injury factors, patient factors, and care context factors. These factors intersect with one another and can inform the surgeon pre-operatively regarding the most likely outcome for a given patient. This insight is critical to discuss pre-operatively with the patient in order to make a shared decision about how to manage their injury.

Outcomes of anti-VEGF treatment for macular edema secondary to central retinal vein occlusion in patients with poor baseline visual acuity

OBJECTIVE

To report the visual outcomes of intravitreal anti-vascular endothelial growth factor (anti-VEGF) treatment for macular edema secondary to central retinal vein occlusion (CRVO) in patients with baseline visual acuity of ≤23 ETDRS letters vision.

DESIGN

Retrospective observational cohort study.

METHODS

This is a single-institution study. A total of 173 eyes from 173 patients who had completed 3 consecutive monthly anti-VEGF injections for macular edema secondary CRVO and best-corrected visual acuity (BCVA) ≤23 ETDRS letters were included. The main outcome measures were visual acuity at month 3 and month 12.

RESULTS

At month 3, BCVA increased to 34.1 ETDRS letters (95% CI, 30.7-37.5), with a gain of 25.0 letters (95% CI, 22.0-28.5; p < 0.001). The mean central subfield thickness decreased by 519 μm (95% CI, 475.5-567.0; p < 0.001). Most patients (67.6%) gained >15 ETDRS letters. A total of 160 patients were followed up for 12 months, and the mean BCVA was 31.2 ETDRS letters (95% CI, 27.5-34.9) at the end of this period. A third of eyes that did not respond (<5-letter gain) after a single injection experienced a 15-letter or more improvement after 3 consecutive injections.

CONCLUSIONS

Anti-VEGF treatment in eyes with CRVO and poor baseline visual acuity results in significant visual improvement, and moderate improvement is still noted despite a poor response after a single injection.

Shoulder Surgery Google Search Trends during the COVID-19 Pandemic

The Coronavirus disease 2019 (COVID-19) pandemic has strained many healthcare systems. Google Trends is a tool that provides information on online interest in selected keywords and topics over time. The purpose of this study is to describe the effect of the COVID-19 pandemic on online interest in elective shoulder pathology. Online search pattern data were obtained via Google Trends from November 2019 to November 2020 using the search terms 'orthopedic surgery' and 'shoulder pathology' search terms. Relative search volume index (SVI) graphs were generated from this data and the 7-day average of new COVID-19 cases in the United States. Orthopaedic surgery and shoulder pathology search trends decreased during March 2020 with a sudden rise in the 7-day average of new COVID-19 cases. After March 2020, orthopaedic surgery and shoulder pathology search terms approached pre-COVID-19 pandemic values despite continued increases in the 7-day average of new COVID-19 cases. (Journal of Surgical Orthopaedic Advances 32(1):014-016, 2023).

Visual Outcomes Associated With Patterns of Macular Edema Resolution in Central Retinal Vein Occlusion Treated With Anti-Vascular Endothelial Growth Factor Therapy: A Post Hoc Analysis of the Lucentis, Eylea, Avastin in Vein Occlusion (LEAVO) Trial

IMPORTANCE

It is unclear how visual outcomes vary between patterns of macular edema (ME) resolution in eyes with central retinal vein occlusion (CRVO).

OBJECTIVE

To assess best-corrected visual acuity (BCVA) outcomes at 100 weeks based on macular fluid resolution patterns by 52 and 100 weeks among patients receiving anti-vascular endothelial growth factor therapy for CRVO-related ME.

DESIGN, SETTING, AND PARTICIPANTS

Post hoc analysis of the prospective, 3-arm, double-masked, randomized noninferiority trial Lucentis, Eylea, Avastin in Vein Occlusion (LEAVO), which evaluated intravitreal aflibercept (2.0 mg/0.05 mL), bevacizumab (1.25-mg/0.05 mL), or ranibizumab (0.5 mg/0.05 mL) over 100 weeks in adult patients (18 years and older) with CRVO-related ME with BCVA Early Treatment Diabetic Retinopathy Study (ETDRS) letter score of 19 to 78 in the study eye (approximate Snellen equivalent, 20/400 to 20/32, respectively) from December 2014 to December 2016 at 44 UK National Health Service ophthalmology departments. A total of 140 of 154 eyes were randomized to aflibercept, 144 of 154 randomized to bevacizumab, and 141 of 155 randomized to ranibizumab. Data were analyzed from January 2019 to March 2019.

EXPOSURES

Persistent ME included eyes with central subfield thickness (CST) 320 μm or greater, and persistently dry macula (no ME) included eyes with CST less than 320 μm at 52 and 100 weeks. Recurrent ME included eyes that did not meet the criteria for persistently dry or wet. If CST was missing, the closest intervening visit was carried forward.

MAIN OUTCOMES AND MEASURES

Adjusted mean BCVA at 100 weeks.

RESULTS

The mean (SD) age of the 425 included participants was 69.2 (12.7) years, and 243 participants (57.2%) were men. A total of 425 eyes from 425 participants were included. By 100 weeks, 117 eyes (28.5%) were persistently dry, 44 (10.7%) were persistently wet (with ME), and 250 (60.8%) had recurrent ME. Persistent ME at 100 weeks was associated with worse VA compared with dry macula (adjusted difference, -10.98 ETDRS letters; 95% CI, -16.19 to -5.76; P < .001) and recurrent ME (adjusted difference, -5.39 letters; 95% CI, -10.15 to -0.64; P = .03). By 52 weeks, individuals with persistent ME also had poorer 100-week BCVA compared with individuals with dry macula (adjusted difference, -7.39; 95% CI, -11.72 to -3.05; P < .001) and recurrent ME (adjusted difference, -3.92; 95% CI, -8.05 to 0.20; P = .06). By 100 weeks, more eyes treated with bevacizumab had persistently wet macula than those treated with aflibercept (26 of 140 [18.6%] vs 7 of 134 [5.2%]; difference, 13.3%; 95% CI, 5.9 to 20.8; P < .001) or ranibizumab (11 of 137 [8%]; difference, 10.5%; 95% CI, 2.7 to 18.4; P = .01).

CONCLUSIONS AND RELEVANCE

These findings suggest that attempts should be made to maintain persistently fluid-free macula for optimal visual acuity outcomes.

Phenotyping of retinal neovascularization in ischemic retinal vein occlusion using wide field OCT angiography

BACKGROUND/OBJECTIVES

Abnormal retinal neovascularization caused by ischemic retinal vein occlusion (RVO) is a frequent cause of visually significant vitreous hemorrhage. The early detection of new vessels may be challenging and often requires the use of invasive tests such as fundus fluorescein angiography (FA). We demonstrate the use of wide-field optical coherence tomography angiography (WF-OCTA) in the detection and characterization of neovascularization secondary to ischemic RVO.

SUBJECTS/METHODS

We conducted a retrospective observational case series of patients diagnosed with ischemic RVO between August 2018 and March 2019, who underwent WF-SS-OCTA imaging (PLEX Elite 9000, Carl Zeiss Meditec). We performed real-life montage imaging, covering the involved area and compared the findings of WF-SS-OCTA to standard clinical examination and when available, ultrawide-field fluorescein angiography (UWF-FA, Optos 200TX).

RESULTS

In the included 39 eyes with ischemic RVO, neovascularization elsewhere (NVE) was encountered in 16 of 39 eyes (41%) on WF-OCTA and were characterized as sea-fan type vessels and nodular type vessels, based on their appearance and localization. NVE was identified in 4/39 eyes on standard clinical examination, equating to a detection rate of 10.3%. All were of a sea-fan morphology. In one case, NVE found on WF-OCTA was not observed on UWF-FA, which was a nodular type. Neovascularization of the disc (NVD) was detected in one eye.

CONCLUSIONS

WF-OCTA may become a useful noninvasive tool in the detection of neovascularization in patients with ischemic RVO. Furthermore, the characterization of different morphologies of neovascularization detected by WF-OCTA could be of clinical relevance.

Validation and Clinical Applicability of Whole-Volume Automated Segmentation of Optical Coherence Tomography in Retinal Disease Using Deep Learning

Question

Is deep learning–based segmentation of macular disease in optical coherence tomography (OCT) suitable for clinical use?

Findings

In this diagnostic study of OCT data from 173 patients with age-related macular degeneration or diabetic macular edema, model segmentations qualitatively ranked better or comparable for clinical applicability to 1 or more expert grader segmentations in 127 scans (73%) by a panel of 3 retinal specialists. Scans with high quantitative accuracy scores were not reliably associated with higher rankings.

Meaning

These findings suggest that qualitative evaluation adds to quantitative approaches when assessing clinical applicability of segmentation tools and clinician satisfaction in practice.

Importance

Quantitative volumetric measures of retinal disease in optical coherence tomography (OCT) scans are infeasible to perform owing to the time required for manual grading. Expert-level deep learning systems for automatic OCT segmentation have recently been developed. However, the potential clinical applicability of these systems is largely unknown.

Objective

To evaluate a deep learning model for whole-volume segmentation of 4 clinically important pathological features and assess clinical applicability.

Design, Setting, Participants

This diagnostic study used OCT data from 173 patients with a total of 15 558 B-scans, treated at Moorfields Eye Hospital. The data set included 2 common OCT devices and 2 macular conditions: wet age-related macular degeneration (107 scans) and diabetic macular edema (66 scans), covering the full range of severity, and from 3 points during treatment. Two expert graders performed pixel-level segmentations of intraretinal fluid, subretinal fluid, subretinal hyperreflective material, and pigment epithelial detachment, including all B-scans in each OCT volume, taking as long as 50 hours per scan. Quantitative evaluation of whole-volume model segmentations was performed. Qualitative evaluation of clinical applicability by 3 retinal experts was also conducted. Data were collected from June 1, 2012, to January 31, 2017, for set 1 and from January 1 to December 31, 2017, for set 2; graded between November 2018 and January 2020; and analyzed from February 2020 to November 2020.

Main Outcomes and Measures

Rating and stack ranking for clinical applicability by retinal specialists, model-grader agreement for voxelwise segmentations, and total volume evaluated using Dice similarity coefficients, Bland-Altman plots, and intraclass correlation coefficients.

Results

Among the 173 patients included in the analysis (92 [53%] women), qualitative assessment found that automated whole-volume segmentation ranked better than or comparable to at least 1 expert grader in 127 scans (73%; 95% CI, 66%-79%). A neutral or positive rating was given to 135 model segmentations (78%; 95% CI, 71%-84%) and 309 expert gradings (2 per scan) (89%; 95% CI, 86%-92%). The model was rated neutrally or positively in 86% to 92% of diabetic macular edema scans and 53% to 87% of age-related macular degeneration scans. Intraclass correlations ranged from 0.33 (95% CI, 0.08-0.96) to 0.96 (95% CI, 0.90-0.99). Dice similarity coefficients ranged from 0.43 (95% CI, 0.29-0.66) to 0.78 (95% CI, 0.57-0.85).

Conclusions and Relevance

This deep learning–based segmentation tool provided clinically useful measures of retinal disease that would otherwise be infeasible to obtain. Qualitative evaluation was additionally important to reveal clinical applicability for both care management and research.

Topographical Response of Retinal Neovascularization to Aflibercept or Panretinal Photocoagulation in Proliferative Diabetic Retinopathy: Post Hoc Analysis of the CLARITY Randomized Clinical Trial

Question

What is the topographic distribution of retinal neovascularization in patients with proliferative diabetic retinopathy, and is there an association between response to treatment and the retinal location of the neovascularization?

Findings

In this post hoc unmasked analysis of the Clinical Efficacy and Mechanistic Evaluation of Aflibercept for Proliferative Diabetic Retinopathy (CLARITY) randomized clinical trial, treatment-naive retinal neovascularization elsewhere (NVE) had a predilection for the nasal quadrant. By 52 weeks, the aflibercept group was more likely to have regression of NVE; neither treatment was likely to be associated with complete regression of disc neovascularization (NVD).

Meaning

This study further elaborates on the outcomes of the CLARITY trial in that, anatomically, despite the superior outcomes among patients within NVE who received aflibercept, regression was seen more in NVE than in NVD.

Importance

Eyes with proliferative diabetic retinopathy have a variable response to treatment with panretinal photocoagulation (PRP) or anti–vascular endothelial growth factor agents. The location of neovascularization (NV) is associated with outcomes (eg, patients with disc NV [NVD] have poorer visual prognosis than those with NV elsewhere [NVE]).

Objective

To investigate the distribution of NV in patients with proliferative diabetic retinopathy and the topographical response of NV to treatment with aflibercept or PRP.

Design, Setting, and Participants

This post hoc analysis of the phase 2b randomized clinical single-masked multicenter noninferiority Clinical Efficacy and Mechanistic Evaluation of Aflibercept for Proliferative Diabetic Retinopathy (CLARITY) trial was conducted from November 1, 2019, to September 1, 2020, among 120 treatment-naive patients with proliferative diabetic retinopathy to evaluate the topography of NVD and NVE in 4 quadrants of the retina on color fundus photography at baseline and at 12 and 52 weeks after treatment.

Exposures

In the CLARITY trial, patients were randomized to receive intravitreal aflibercept (2 mg/0.05 mL at baseline, 4 weeks, and 8 weeks, and as needed from 12 weeks onward) or PRP (completed in initial fractionated sessions and then on an as-needed basis when reviewed every 8 weeks).

Main Outcomes and Measures

Main outcomes were per-retinal quadrant frequencies of NV at baseline and frequencies of patterns of regression, recurrence, and new occurrence at 12-week and 52-week unmasked follow-up.

Results

The study included 120 treatment-naive patients (75 men; mean [SD] age, 54.8 [14.6] years) with proliferative diabetic retinopathy (there was a 1:1 ratio of eyes to patients). At baseline, NVD with or without NVE was observed in 42 eyes (35.0%), and NVE only was found in 78 eyes (65.0%); NVE had a predilection for the nasal quadrant (64 [53.3%]). Rates of regression with treatment were higher among eyes with NVE (89 of 102 [87.3%]) compared with eyes with NVD (23 of 43 [53.5%]) by 52 weeks, with NVD being more resistant to either treatment with higher rates of persistence than NVE (20 of 39 [51.3%] vs 29 of 100 [29.0%]). Considering NVE, the regression rate in the temporal quadrant was lowest (32 of 42 [76.2%]). Eyes treated with aflibercept showed higher rates of regression of NVE compared with those treated with PRP (50 of 52 [96.2%] vs 39 of 50 [78.0%]; difference, 18.2% [95% CI, 5.5%-30.8%]; P = .01), but no difference was found for NVD (11 of 17 [64.7%] vs 12 of 26 [46.2%]; difference, 18.6% [95% CI, −11.2% to 48.3%]; P = .23).

Conclusions and Relevance

This post hoc analysis found that NVD is less frequent but is associated with more resistance to currently available treatments than NVE. Aflibercept was superior to PRP for treating NVE, but neither treatment was particularly effective against NVD by 52 weeks. Future treatments are needed to better target NVD, which has poorer visual prognosis.

Trial Registration

isrctn.org Identifier: ISRCTN32207582

Outcomes following implementation of a high-volume medical retina virtual clinic utilising a diagnostic hub during COVID-19

BACKGROUND

To describe the clinical outcomes following implementation of a high-volume medical retina virtual clinic utilising a diagnostic hub.

METHODS

Retrospective consecutive case-series of all patients attending the medical retina virtual clinics at Moorfields Eye Hospital (City Road) for 6 weeks from September 21, 2020.

RESULTS

In 6 weeks, 1006 patients attended the medical retina virtual clinics, which included an appointment in the diagnostic hub followed by an assessment asynchronously the following working day. The vast majority of patients were follow-up attendances (969, 96.3%) with much fewer new patient attendances (37, 3.7%). The most common diagnoses made overall were diabetic retinopathy (457, 45.4%), age-related macular degeneration (208, 20.7%) and retinal vein occlusion (80, 8.0%). The majority of patient (643, 63.9%) outcomes were follow-up in the medical retina virtual clinics including 313 (31.1%) with OCT-only pathway and 330 (32.8%) with OCT and widefield fundus imaging. Routine follow-up requested after virtual assessment included 320 (31.8%) with a 3-4 month review and 267 (26.5%) with a 6 months assessment. Only 62 patients (6.2%) were asked to return for face-to-face assessment within 2 weeks.

CONCLUSIONS

We describe a new high-volume medical retina virtual clinic utilising a diagnostic hub in which more than 1000 patients were seen and assessed asynchronously. Most patients were assessed as suitable for routine follow-up in this virtual pathway and only a small proportion required urgent reviews (within 2 weeks). In the COVID-19 era, this form of high-volume virtual clinic has the potential to review patients efficiently and safely.

Widefield imaging with Clarus fundus camera vs slit lamp fundus examination in assessing patients referred from the National Health Service diabetic retinopathy screening programme

OBJECTIVES

To compare diabetic retinopathy (DR) grading and management plan between virtual review using widefield Clarus imaging and macular optical coherence tomography (OCT) versus slit lamp clinical examination and macular OCT.

METHOD

New referrals over 3 months from the National Diabetic Eye Screening programme (DESP) were screened. Patients who had both Clarus widefield imaging and macular OCT were included. All patients underwent slit lamp examination in clinic. Data obtained from electronic patient records included referral reason, DR grading and management plan. Two graders retrospectively reviewed imaging and formulated a management plan blinded to results from patients' clinic visit. Results from virtual examination were compared with those from slit lamp examination.

RESULTS

One-hundred and two eyes of 51 patients were assessed. 11 fundus photos from 7 patients and 15 fundus photos from 10 patients were deemed inadequate by grader G1 and G2, respectively. Eighteen (35%) patients and 11 (22%) patients from virtual assessment by G1 and G2, respectively were found to need a face a face appointment to aid diagnosis. Compared to slit lamp examination, 15% and 7.5% of patients from G1 and G2's virtual assessment respectively had different proposed management plan. Agreement of DR grading between both virtual graders and slit lamp examination was fair (Kappa's coefficient = 0.56). One case of slit lamp noted retinal neovascularization, which was graded as background retinopathy by DESP was also graded as such on virtual assessment.

CONCLUSION

Widefield Clarus and OCT imaging allowed two-thirds of DESP referrals to be safely managed virtually.

Long-term follow-up of a case of posterior microphthalmos (PRSS56) with hyperautofluorescent retinal pigment epithelial deposits

PURPOSE

To report a case of posterior microphthalomos (PM) related to PRSS56 gene mutation with long term follow up with multimodal imaging findings.

METHODS

Single retrospective case report.

RESULTS

A 43-year old male patient presented in 2009 with bilateral reduced vision. Clinical examination and multimodal imaging showed features consistent with posterior microphthalmos with prominent bilateral horizontal papillomacular retinal folds. Posterior pole hyperautofluorescent RPE deposits were present. Gradual worsening of visual acuity and rod and cone photoreceptor function more so on the left was demonstrated during the 8 years of follow up.

CONCLUSION

Hyperautofluorescent RPE deposits may occur in patients with posterior microphthalmos and such patient's may experience only gradual disease progression over long term follow up.

Deep Learning-Based Segmentation and Quantification of Retinal Capillary Non-Perfusion on Ultra-Wide-Field Retinal Fluorescein Angiography

Reliable outcome measures are required for clinical trials investigating novel agents for preventing progression of capillary non-perfusion (CNP) in retinal vascular diseases. Currently, accurate quantification of topographical distribution of CNP on ultrawide field fluorescein angiography (UWF-FA) by retinal experts is subjective and lack standardisation. A U-net style network was trained to extract a dense segmentation of CNP from a newly created dataset of 75 UWF-FA images. A subset of 20 images was also segmented by a second expert grader for inter-grader reliability evaluation. Further, a circular grid centred on the FAZ was used to provide standardised CNP distribution analysis. The model for dense segmentation was five-fold cross-validated achieving area under the receiving operating characteristic of 0.82 (0.03) and area under precision-recall curve 0.73 (0.05). Inter-grader assessment on the 20 image subset achieves: precision 59.34 (10.92), recall 76.99 (12.5), and dice similarity coefficient (DSC) 65.51 (4.91), and the centred operating point of the automated model reached: precision 64.41 (13.66), recall 70.02 (16.2), and DSC 66.09 (13.32). Agreement of CNP grid assessment reached: Kappa 0.55 (0.03), perfused intraclass correlation (ICC) 0.89 (0.77, 0.93), non-perfused ICC 0.86 (0.73, 0.92), inter-grader agreement of CNP grid assessment values are Kappa 0.43 (0.03), perfused ICC 0.70 (0.48, 0.83), non-perfused ICC 0.71 (0.48, 0.83). Automated dense segmentation of CNP in UWF-FA images achieves performance levels comparable to inter-grader agreement values. A grid placed on the deep learning-based automatic segmentation of CNP generates a reliable and quantifiable method of measurement of CNP, to overcome the subjectivity of human graders.

Widefield optical coherence tomography angiography for early detection and objective evaluation of proliferative diabetic retinopathy

PURPOSE

To evaluate the utility of widefield optical coherence tomography angiography (WF-OCTA) compared with clinical examination in grading diabetic retinopathy in patients diagnosed clinically with proliferative diabetic retinopathy (PDR) or severe non-proliferative diabetic retinopathy (NPDR).

DESIGN

This retrospective observational case series included patients diagnosed clinically with PDR or severe NPDR. Patients underwent standard clinical examination and WF-OCTA imaging (PLEX Elite 9000, Carl Zeiss Meditec AG) using 12×12 montage scans between August 2018 and January 2019. Two trained graders identified neovascularisation at the disc (NVD) and neovascularisation elsewhere (NVE) on WF-OCTA which were compared with the clinical examination, and to ultra-widefield fluorescein angiography (UWFA) when available.

RESULTS

Seventy-nine eyes of 46 patients were evaluated. Of those, 57 eyes were diagnosed clinically with PDR, and 22 with severe NPDR. NVD was detected on OCTA-B scan as preretinal hyperreflective material (PRHM) in 39 eyes (100%) with evident flow signals in 79.5% compared with 51.3% detected clinically. We further classified NVD on OCTA into four subtypes and found that subtypes 1 and 2 could not be seen on clinical examination alone. WF-OCTA detected NVE in 81% of the cases compared with 55.7% detected clinically. Using WF-OCTA resulted in a higher percentage of PDR grading (88.6%) than on clinical examination (72.2%). When available, UWFA confirmed the WF-OCTA diagnosis in the majority of cases.

CONCLUSION

This study demonstrates that WF-OCTA has a higher detection rate of PDR than clinical examination. This suggests that this modality could be used non-invasively for the purpose of early detection and characterisation of neovascularisation.

Retinal Nonperfusion Characteristics on Ultra-Widefield Angiography in Eyes With Severe Nonproliferative Diabetic Retinopathy and Proliferative Diabetic Retinopathy

Importance

Threshold of retinal nonperfusion for the development of proliferative diabetic retinopathy (PDR) is unclear.

Objectives

To identify a threshold of retinal nonperfusion for the presence of retinal neovascularization and the distribution and area of retinal nonperfusion in eyes with severe nonproliferative diabetic retinopathy (NPDR), PDR, neovascularization of the optic disc (NVD), and retinal neovascularization elsewhere (NVE).

Design, Setting, and Participants

This cross-sectional image analysis study was performed between September 24, 2018, and October 24, 2018, at a multicenter national study in the United Kingdom. Baseline images were obtained from 2 completed randomized clinical trials (Ranibizumab for Diabetic Macular Edema Panretinal Photocoagulation [RDP] study and Clinical Efficacy of Intravitreal Aflibercept vs Panretinal Photocoagulation for Best Corrected Visual Acuity in Patients With Proliferative Diabetic Retinopathy at 52 Weeks [CLARITY] study). The RDP study recruited eyes with severe NPDR between April 1, 2014, and December 31, 2015, and the CLARITY study recruited eyes with PDR between August 22, 2014, and November 20, 2015. Ultra-widefield angiography images of eyes with no prior panretinal photocoagulation treatment were included.

Main Outcomes and Measures

The total area of retinal nonperfusion, the area of posterior pole retinal nonperfusion, and the area of peripheral retinal nonperfusion were measured.

Results

A total of 92 patients (92 eyes) were included in the study: 59 in the PDR group (mean [SD] age, 42 [15] years; 20 female [33.9%]) and 33 in the NPDR group (mean [SD] age, 63 [10] years; 3 female [9.1%]). Forty eyes had NVE and 19 had NVD with or without NVE. We identified a retinal nonperfusion threshold of 118.3 disc areas (DA) with a specificity of 84.9% (95% CI, 68.1% to 94.9%) for PDR. The median area of retinal nonperfusion was 67.8 DA (95% CI, 44.2 to 107.3 DA) in the NPDR eyes and 147.9 DA (95% CI, 127.4 to 173.5 DA) for eyes with proliferative changes, with a difference of 69.0 DA (95% CI, 42.2 to 97.7 DA; P < .001). No difference was found in the median area of posterior nonperfusion between NPDR and PDR, with a difference of 0 DA (95% CI, -6.7 to 5.2 DA; P = .56). As for peripheral nonperfusion, NPDR eyes measured 64.1 DA and PDR eyes measured 130.6 DA, with a difference of 70.8 DA (95% CI, 48.4 to 94.9 DA; P < .001). Eyes with NVD had the largest total area of retinal nonperfusion, with a difference of 65.1 DA (95% CI, 28.6 to 95.8 DA; P < .001) compared with eyes with only NVE.

Conclusions and Relevance

These findings suggest eyes with at least 107.3 DA of nonperfusion are at risk of proliferative disease, and eyes with NVD have the largest area of retinal nonperfusion.

Ten-year outcomes of antivascular endothelial growth factor therapy in neovascular age-related macular degeneration

Purpose

Single center, noninterventional cohort study to assess 10-year visual and anatomical outcomes following initiation of treatment with antivascular endothelial growth factor (anti-VEGF) agents in neovascular age-related macular degeneration (AMD) patients. Neovascular AMD patients initiated on intravitreal anti-VEGF injections in 2008–2009 and continued to be followed up for at least 10 years were included in this study.

Methods

The Moorfields OpenEyes database was searched for all patients who were initiated on anti-VEGF therapy for neovascular AMD in 2008–2009 and the visual acuity (VA) in Early Diabetic Retinopathy Study (ETDRS) letters and injection records were analyzed for those who have had at least 10-year follow-up. The spectral-domain optical coherence tomography (SD-OCT) scans, color fundus photos, and fundus fluorescein angiography (FA) were graded by two retinal physicians. The outcomes were also compared between those with good and poor VA outcomes based on pre-defined criteria. The primary end point was change in VA at 10 years; secondary outcomes included percentage with VA of 20/40 or better, 20/70 or better, VA gains and losses, anatomic outcomes and number of injections.

Results

After a mean of 10.04 years after initiation of anti-VEGF therapy, the mean decline in VA from baseline was −2.1 ETDRS letters (SD 19.9, p = 0.65). One hundred eyes (67.1%) achieved a VA threshold of 20/70 or better, 33.5% achieved a VA of 20/40 or better, and 76.5% eyes maintained VA defined as a loss of less than 15 letters. Fourteen percent of study eyes had VA of 20/200 or worse and 23.5% declined by 15 letters or more. 87.5% of eyes were switched from ranibizumab to aflibercept during the course of 10 years and the eyes received a mean of 52.2 (SD 18.1) injections over 10 years. From this cohort, 87 (58.3%) eyes are having on-going treatment. On OCT, 34.9% had persistent fluid at the last visit, 6.7% patients showed new onset atrophy compared to baseline, and 43.7% had increased area of macular atrophy. The mean area of atrophy at the final visit was 4.15 mm². Comparison between the good and worse visual outcome groups showed lower baseline VA, fovea-involving atrophy and final area of atrophy had a statistically significant negative effect on the final visual outcome (p < 0.05).

Conclusions

Regular monitoring and anti-VEGF treatment over 10 years reduce the risk of visual loss of 15 letters or more in patients with neovascular AMD. The most common cause of substantial visual decline was macular atrophy.

The Relationship Between Retinal Vessel Oxygenation and Spatial Distribution of Retinal Nonperfusion in Retinal Vascular Diseases

Purpose

We study the relationship between retinal vessel oxygenation and the spatial distribution of retinal nonperfusion using ultrawide field angiography in eyes with retinal vascular diseases.

Methods

This prospective single center study recruited 57 eligible eyes from 44 patients with retinal vascular diseases. Retinal oximetry measurements were obtained using the Oxymap T1 device to determine the arteriovenous (AV) difference. Retinal nonperfusion was measured from ultrawide field angiography images taken with the Optos 200TX system and superimposing the images with the concentric rings template to determine the area and distribution of retinal nonperfusion.

Results

Seven (12.3%) eyes had a diagnosis of a branch or hemiretinal vein occlusion, 24 (42.1%) with central retinal vein occlusion and 26 (45.6%) with diabetic retinopathy (11 [19.3%] nonproliferative and 15 [26.3%] proliferative diabetic retinopathy). The correlation between the total area of retinal nonperfusion with the AV difference controlling for age was not statistically significant (R = -0.103, P = 0.449). However, when analyzing the correlation of AV difference with the area of retinal nonperfusion in the posterior pole controlling for age and peripheral nonperfusion, this was significant (R = -0.295, P = 0.029). This was not significant for the area of retinal nonperfusion in the periphery while controlling for posterior pole nonperfusion and age (R = 0.124, P = 0.368).

Conclusions

Retinal nonperfusion has a negative correlation with AV difference measured on retinal oximetry. This correlation is significant in the posterior pole, but not in the peripheral retina.

Mechanistic Evaluation of Panretinal Photocoagulation Versus Aflibercept in Proliferative Diabetic Retinopathy: CLARITY Substudy

Purpose

The purpose of this study was to study the effects of panretinal photocoagulation (PRP) and intravitreal aflibercept on retinal vessel oxygen saturations, area of retinal nonperfusion, and area of neovascularization in proliferative diabetic retinopathy.

Methods

This is a prospective randomized single center study. Forty patients with proliferative diabetic retinopathy were randomized to PRP or intravitreal aflibercept treatment for 52 weeks. Retinal oximetry and ultra-widefield angiography were performed at baseline and week 52. Ultra-widefield color fundus imaging was performed at baseline, week 12, and week 52. The outcomes were retinal arterio-venous oximetry differences (AVD), area of retinal nonperfusion, and area of neovascularization in disc areas (DA).

Results

The AVD in the PRP group increased from 36.7% at baseline to 39.7%, whereas it decreased from 33.4% to 32.5% in the aflibercept group. The difference in AVD between groups at week 52 was 4.0% (95% confidence interval, -0.08, 8.8; P = 0.10). The baseline mean area of retinal nonperfusion of 125.1 DA and 131.2 DA in the PRP and aflibercept groups increased to 156.1 DA and 158.4 DA, respectively, at week 52 (P = 0.46). The median baseline area of neovascularization decreased from 0.98 DA to 0.68 DA in the PRP group and from 0.70 DA to 0 DA in the aflibercept group at week 12 (P = 0.019). At week 52, this measured 0.24 DA in the PRP group and 0 DA in the aflibercept group (P = 0.45).

Conclusions

Intravitreal aflibercept achieved an earlier and complete regression of neovascularization in proliferative diabetic retinopathy compared with PRP. There were no significant differences in global change in intravascular oxygen saturation or areas of retinal nonperfusion between the two groups by 52 weeks.

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

BACKGROUND

Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world.

METHODS

This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231.

FINDINGS

Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p<0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05-2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p<0·001).

INTERPRETATION

Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication.

FUNDING

DFID-MRC-Wellcome Trust Joint Global Health Trial Development Grant, National Institute of Health Research Global Health Research Unit Grant.

Retinal Nonperfusion in the Posterior Pole Is Associated With Increased Risk of Neovascularization in Central Retinal Vein Occlusion

PURPOSE

To review the definition of ischaemic central retinal vein occlusion (CRVO) and stratify the risk of neovascular complication based on wider areas of visible retinal non-perfusion.

DESIGN

Retrospective consecutive case series and image analysis study.

METHODS

Setting: Moorfields Eye Hospital, London, United Kingdom.

STUDY POPULATION

Forty-two consecutive treatment-naïve eyes with CRVO imaged with ultra-widefield angiography with a minimum of 12 months follow-up.

OBSERVATION PROCEDURE

The spatial location and total area of retinal nonperfusion (measured in disc areas, DA) were determined using the validated concentric rings method. The area was corrected for projection distortion. The images were graded by 2 retinal physicians and average measurements used.

MAIN OUTCOME MEASURES

Development of neovascular complications.

RESULTS

The percentage of eyes developing new vessels increased from none in eyes with less than 10 DA of nonperfusion in total to 14.3% in eyes with 10-30 DA, 20.0% for 30-75 DA, and 80% risk with 75-150 DA of nonperfusion. From 13 (31.0%) eyes with a perfused posterior pole (an area encompassing a 5 disc diameter radius centered at the fovea) and more than 10 DA of nonperfusion isolated in the periphery (beyond the posterior pole), only 1 (7.7%) eye developed new vessels, odds ratio (OR) 0.12 [95% confidence interval (CI): 0.01, 1.03]. Comparatively, for 13 (31.0%) eyes with more than 10 DA of nonperfusion in the posterior pole, 11 (84.6%) developed new vessels, OR 74.25 [95% CI: 9.26, 595.30], P < .001.

CONCLUSION

With ultra-widefield angiography, we have ascertained that posterior pole nonperfusion of more than 10 DA remains the key risk factor for new vessel development compared to areas of nonperfusion confined to the periphery.

Self-reported knee pain and disability among healthy individuals: reference data and factors associated with the Knee injury and Osteoarthritis Outcome Score (KOOS) and KOOS-Child

OBJECTIVE

To develop normative reference data for the Knee injury and Osteoarthritis Outcome Score (KOOS) and KOOS-Child, as well as investigate socio-demographic, psychological and physical factors associated with knee pain and disability among healthy adults.

METHOD

The KOOS or KOOS-Child (each containing five subscales) was administered to participants aged 8-101 years within the 1000 Norms Project, an observational study of 1000 self-reported healthy individuals. Self-efficacy, physical activity, body mass index (BMI), lower limb alignment, knee frontal plane projection angle (FPPA), knee range of motion (ROM), knee and hip strength, six-minute walk, 30-second chair stand and timed up and down stairs tests were collected. KOOS data were dichotomised using established cut-off scores and logistic regression analyses were conducted for each subscale.

RESULTS

Socio-demographic characteristics were similar to the Australian population. Normative reference data were generated for children (8-17 years) and adults (18-101 years). Female adults were up to twice as likely to report knee pain, symptoms and sport/recreation (Sport/Rec) limitations compared to males (P < .05). Older age, lower self-efficacy, greater BMI, varus lower limb alignment, lower knee flexion ROM and lower hip external rotation (ER) strength were independently associated with knee pain and disability among adults.

CONCLUSIONS

Age- and gender-stratified reference data for the KOOS and KOOS-Child have been developed to guide interpretation of results in practice and research for individuals with knee disorders. Psychological and physical factors are linked with self-reported knee pain/disability among adults, and longitudinal studies to investigate causation are required.

Quantifying Retinal Area in Ultra-Widefield Imaging Using a 3-Dimensional Printed Eye Model

PURPOSE

To study the effects of different axial lengths on ultra-widefield imaging to determine the presence of distortion in images despite software correction and calculate an enlargement factor based on angular location.

DESIGN

Experimental image analysis study.

STUDY OBJECTS

Three 3-dimensional printed model eyes simulating eyes with axial lengths of 22, 24, and 26 mm. Each model has a grid of rings 9° apart centered at the posterior pole.

METHODS

Single-center study performed at the National Institute for Health Research Moorfields Biomedical Research Centre (London, UK). Each model was imaged using Optos 200TX (Optos, Dunfermline, UK). Two images for each model eye that were corrected using V2 Vantage Pro software (Optos) were used for analysis and the average values obtained. Each image inter-ring area was measured using ImageJ to obtain a measured image area in pixel and square millimeters. This was compared with the true calculated object inter-ring area and an enlargement factor was determined.

MAIN OUTCOME MEASURES

Measured image inter-ring area in pixels and square millimeters. True calculated object inter-ring area in square millimeters.

RESULTS

The enlargement factor of the rings gradually increases toward the periphery with factors of 1.4 at 45° and 1.9 at the equator. The axial lengths did not affect the enlargement factor of the rings imaged in 3 different model eyes (P = 0.9512). The anterior equator exhibits a significant distortion despite the software correction.

CONCLUSION

The enlargement factor depends on angular location and not axial length. The enlargement factors can be used in clinical practice to more accurately measure area in ultra-widefield imaging.

Influence of baseline diabetic retinopathy status on initial anatomical response of intravitreal ranibizumab therapy for diabetic macular oedema

PurposeIntraocular vascular endothelial growth factor (VEGF) levels increases with the severity of diabetic retinopathy. Response of diabetic macular oedema (DMO) to ranibizumab is driven by VEGF suppression. We hypothesised that the initial reduction of central macular thickness by ranibizumab should be maximum in severe diabetic retinopathy until the levels of VEGF decreases to the levels observed in eyes with mild retinopathy.MethodsConsecutive patients with centre-involving DMO (central subfield thickness (CSFT)>300 μm) who had three consecutive monthly ranibizumab injections followed by as needed therapy were included. Retinopathy status was graded as mild non-proliferative diabetic retinopathy (NPDR) (G1), moderate to severe NPDR with no prior panretinal photocoagulation (G2), and treated PDR (G3).ResultsTwo hundred and thirty-nine eyes from 204 patients with a mean age of 64.9 years were included. The distribution was 31.4 G1, 32.2 G2, and 36.4% G3. Mean baseline CSFT for all eyes was 458.5±110.8 μm. Baseline CSFT for G1, G2, and G3, respectively, were 437.6±90.9, 472.3±109.8, and 464.7±124.9 μm (P=0.2155). Mean change in CSFT after three consecutive injections was 128.5±116.6 μm. The mean changes were 95.8±101.4 μm for G1, 137.2±112.9 μm for G2, and 148.9±126.9 μm for G3. The changes in CSFT between groups adjusted for baseline CSFT were statistically significant (P=0.0473). At 6 and 12 months after a mean of 4.5 and 7.7 injections, the changes between groups were no longer significant, P=0.4783 and P=0.8271, respectively.ConclusionsThe initial anatomical response of DMO with intravitreal ranibizumab injections was maximum in eyes with treated PDR, suggesting that the higher the VEGF levels, the better the response with ranibizumab.

Differences in mortality characteristics in neonates with Down's syndrome

OBJECTIVE

Neonates with Down's syndrome (nDS) may have multiple medical issues that place them at increased risk for mortality during the newborn period. Goal of this study was to determine if there are differences in baseline characteristics, medical complications or procedures performed during hospitalization between nDS who survived versus those who died during initial hospitalization.

STUDY DESIGN

Data from 2000 to 2014 were reviewed using the Pediatric Health Information Systems (PHIS) database on all DS patients admitted to the hospital <30 days postnatal life. Baseline demographics, medical complications, procedures performed and mortality were recorded. Patients were divided into nDS patients who were discharged alive (nDS-a) versus nDS patients who died (nDS-d). Multivariate logistic analysis with odds ratios was performed to determine significant predictors of death. A P<0.05 was considered significant.

RESULTS

A total of 5737 nDS were evaluated. Overall mortality was 7.5% (431/5737). nDS-d were more likely than nDS-a to have a lower birth weight (1.0 (0.9 to 1.0)), presence of a diaphragmatic hernia (6.9 (1.9 to 25.1), or a cardiac diagnosis of a pulmonary venous abnormality (6.8 (1.9 to 24.4)), Ebstein's anomaly (3.2 (1.2 to 8.5)) or left-sided obstructive lesion (2.0 (1.3 to 3.0). nDS-d were more likely to develop hydrops (5.7 (3.5 to 9.5)) and necrotizing enterocolitis (1.7 (1.2 to 2.6)). In addition, nDS-d had significantly higher odds of requiring mechanical ventilation (20.7 (9.9 to 43.1)) or extracorporeal membrane oxygenation (8.7 (4.7 to 16.1)).

CONCLUSIONS

A number of characteristics, specifically certain cardiac diagnosis, place nDS at increased risk for mortality. Furthermore, development of specific medical complications or need for particular procedures increases the odds for mortality in nDS. Caregivers should be cognizant that they are taking care of a high-risk population nDS with an increased risk for mortality if these variables are present.

Oral Mineralocorticoid-Receptor Antagonists: Real-Life Experience in Clinical Subtypes of Nonresolving Central Serous Chorioretinopathy With Chronic Epitheliopathy

PURPOSE

To evaluate the efficacy and safety of oral mineralocorticoid-receptor antagonist (MRa) therapy in three clinical presentations of nonresolving central serous chorioretinopathy (CSCR) with chronic epitheliopathy.

METHODS

Retrospective case series of consecutive patients with nonresolving CSCR treated with oral eplerenone or spironolactone. Treatment criteria were: persistent CSCR with subretinal fluid (SRF) lasting longer than 4 months; recurrent CSCR with SRF lasting longer than 2 months; persistent CSCR (SRF ≥ 4 months) with fundus autofluorescence gravitational tracks. Outcomes at 1, 3, and 6 months were: foveal SRF height, central macular thickness (CMT), subfoveal choroidal thickness (SFCT), best-corrected visual acuity (BCVA), and occurrence of side effects.

RESULTS

Among 54 eyes from 42 patients (mean age: 53 years), mean foveal SRF, CMT, and SFCT decreased significantly at 1, 3, and 6 months after treatment initiation. Mean BCVA improved significantly at 6 months. In the subgroup analysis, mean foveal SRF, CMT, and SFCT decreased significantly at 3 and 6 months in the persistent and recurrent groups. In persistent cases with tracks, a significant diminution of mean CMT and SFCT was achieved at 6 months. Treatment-related side effects were observed in 6 patients, prompting treatment discontinuation in one case.

CONCLUSION

Response to treatment was observed in the three subgroups. In persistent CSCR with tracks the response was delayed compared with persistent and recurrent cases, suggesting that longer treatment durations would be beneficial in patients with gravitational tracks of RPE alteration.

TRANSLATIONAL RELEVANCE

The clinical response to oral MRa is consistent with the involvement of the mineralocorticoid pathway in CSCR pathogenesis.

Diagnostic accuracy of disorganization of the retinal inner layers in detecting macular capillary non-perfusion in diabetic retinopathy

BACKGROUND

Disorganization of the retinal inner layers (DRIL) on optical coherence tomography (OCT) is thought to represent retinal capillary non-perfusion (CNP) in eyes with diabetic retinopathy. This study was designed to evaluate the ability of DRIL to accurately predict CNP.

DESIGN

Retrospective masked reliability and diagnostic accuracy study performed in the National Institute for Health Research (NIHR) Moorfields Biomedical Research Centre, London, UK SAMPLES: Retinal images of patients with diabetic retinopathy

METHODS

The OCT images from 90 separate areas of angiographically confirmed perfused and non-perfused areas of the macula from 37 eyes of 31 patients were anonymized and coded. Two masked graders independently graded these OCT scans for the presence or absence of DRIL to determine the intergrader reliability. The diagnostic accuracy of DRIL in identifying CNP was evaluated from the results obtained.

MAIN OUTCOME MEASURES

Sensitivity and specificity of DRIL in accurately detecting CNP RESULTS: The intergrader agreement was high with a Cohen's kappa of 0.909. DRIL was present in 84.4% (38/45) of non-perfused retina and none in perfused retina (0/45). The sensitivity and specificity of DRIL in detecting angiographic evidence of CNP was 84.4% and 100%, respectively. The positive predictive value was 100% and the negative predictive value was 86.5%.

CONCLUSIONS

The presence of DRIL is a reliable predictor of areas of macular CNP. However, DRIL is not a universal finding of non-perfusion, with some cases exhibiting absence of DRIL despite angiographic CNP.

The relationship between area deprivation and contact with community intellectual disability psychiatry

BACKGROUND

People with intellectual disabilities (ID) have high rates of psychiatric illness and are known to live in more deprived areas than the general population. This study investigated the relationship between area deprivation and contact with ID psychiatry.

METHOD

Psychiatric case notes and electronic records were used to identify all patients who had face-to-face contact with community ID psychiatric services over 1 year in the North East Community Health Partnership of Greater Glasgow and Clyde (estimated population 177,867). The Scottish Index of Multiple Deprivation (SIMD) were determined for the patient sample and for the general population living in the same area.

RESULTS

Between 1 June 2012 and 1 June 2013, 184 patients were seen by ID psychiatry over a total of 553 contacts, with valid SIMD data for 179 patients and 543 contacts. Fifty-two per cent of patients (n = 93) lived in the most deprived SIMD decile, and 90.5% (n = 152) in the lowest 5 deciles. Compared with the general population, there were significantly more patients than expected living in the most deprived decile (Fisher's Exact test, P = 0.009) and in the most deprived 5 deciles (Fisher's Exact test, P = 0.001). The median number of contacts was 2 (interquartile range = 1-3). There was no significant association between the number of contacts and SIMD decile. Forty-eight point one per cent (n = 261) of all contacts were with patients living in the most deprived decile and 88.6% (n = 481) in the most deprived 5 deciles. This was significantly more than expected compared with general population data (Fisher's Exact test, P = 0.008 and Fisher's Exact test, P ≤ 0.001).

CONCLUSIONS

In the area under study, contact with ID psychiatry was greater in more deprived areas. Given the high psychiatric morbidity of people with ID, if services do not adjust for deprivation, this may lead to further discrimination in an already disadvantaged population.

Lateral rectus palsy following coronary angiography and percutaneous coronary intervention

We present a rare case of unilateral lateral rectus palsy following an elective coronary angiography and percutaneous coronary intervention in a 78-year-old woman. Ophthalmoplegia following coronary angiography is extremely rare and this is the first case of a unilateral lateral rectus palsy following the procedure.

Intestinal location of necrotizing enterocolitis among infants with congenital heart disease

OBJECTIVE

To determine whether differences exist in the location of necrotizing enterocolitis (NEC) in infants with congenital heart disease (CHD) versus those without CHD.

STUDY DESIGN

Retrospective cohort study utilizing 11 years of patient data. Inclusion criterion was surgical exploration for NEC. Presence or absence of CHD was determined. Surgical and/or pathology reports were reviewed to identify the location of NEC. Data were analyzed by t-tests and χ(2) analyses.

RESULT

One hundred and sixty-seven patients met the inclusion criteria. CHD infants had a higher percentage of mortality. There was no difference in the location of NEC between non-CHD and CHD patients, with the predominant location being the small intestine in both. In addition, there was no difference in the location of NEC between preterm non-CHD patients and full-term CHD patients with the small intestine again being the primary site.

CONCLUSION

Despite differences in gestational age between non-CHD and CHD patients, the location of NEC in these infants did not differ.

Bilateral cystoid macular oedema and cotton wool spots associated with Henoch-Schonlein purpura

We report a case of a male patient having bilateral cystoid macular oedema and cotton wool spots associated with Henoch-Schonlein purpura. He presented with decreased vision bilaterally measuring 0.2 (6/9.5) on the right and 0.5 (6/19) on the left. He has chronic hypertension with blood pressure averaging 150/90. His blood pressure was raised at 180/110 and with treatment reduced to 164/99. There were no other signs of malignant hypertensive retinopathy. He was treated with oral prednisolone and noticed a significant improvement the following day. An objective measurement performed 2 days later was -0.10 (6/4.8) bilaterally with resolution of macular oedema.

Recruitment to intellectual disability research: a qualitative study

BACKGROUND

Difficulties in the recruitment of adults with intellectual disability (ID) to research studies are well described but little studied. The aim of this study was to investigate the difficulties in recruiting to a specific research project, in order to inform future recruitment to ID research.

METHODS

Individual semi-structured interviews were held between September 2009 and May 2010 with people who had been involved as intermediaries in recruitment to the research project. These were transcribed verbatim and were independently analysed by two researchers using the Framework approach, who then agreed upon the key emerging themes.

RESULTS

Ten interviews were analysed. A number of themes arose, including participant factors (interview anxiety, difficulties in understanding the concept of research, worry about negative feedback), the importance of the researcher (using a personal approach, meeting potential participants prior to recruitment) and motivators [enjoyment of the research interview (participant), obtaining a medical assessment (carer)]. The themes were then used to generate strategies to improve recruitment to ID research: these include the research team applying a more personal approach, developing the recruitment process to allow for multiple meetings with potential participants, and considering motivators for both participants and carers.

CONCLUSIONS

This study has used the experiences of intermediaries to identify strategies for improving recruitment to future ID research. This has implications in terms of both time and money. However, successful recruitment is essential to ID research, and we hope that the study will be used by ID researchers to review and improve their recruitment processes.