Phacoemulsification with implantation of a trifocal intraocular lens in eyes with asteroid hyalosis and synchysis scintillans

PURPOSE

To compare the visual outcomes in both eyes of patients who undergo phacoemulsification and trifocal intraocular lens (IOL) implantation and have asteroid hyalosis (AH) or synchysis scintillans (SS) in only one eye.

METHODS

A retrospective comparative case series was performed. We evaluated uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), uncorrected intermediate visual acuity (UIVA), uncorrected near visual acuity (UNVA), predictability, safety, efficacy, and satisfaction after implantation of the same model of trifocal IOL in both eyes (PhysIOL FineVision Pod-F and Micro-F and Rayner RayOne Trifocal).

RESULTS

A total of 164 eyes of 82 patients (41 females, 50%) met the inclusion criteria. There were no statistically significant differences in sphere, cylinder, spherical equivalent, UDVA, UIVA, or UNVA between the groups. Postoperative CDVA was slightly better in the control group (logMAR 0.03) than in the AH/SS group (logMAR 0.04) (P: 0.014). There were no statistically significant differences in predictability, safety index, or efficacy index between the groups. Overall subjective satisfaction was good (98.2%).

CONCLUSIONS

Visual outcomes and satisfaction are good after implantation of trifocal IOLs in eyes with AH or SS. Therefore, trifocal IOLs should not be ruled out in these patients when no other vitreoretinal disorder is present.

Macular Neovascularization Type Influence on Anti-VEGF Intravitreal Therapy Outcomes in Age-Related Macular Degeneration

PURPOSE

To evaluate the influence of macular neovascularization (MNV) lesion type on 12-month clinical outcomes in treatment-naive eyes with neovascular age-related macular degeneration (nAMD) treated with anti-VEGF drugs nationwide.

DESIGN

Multicenter national nAMD database observational study.

SUBJECTS

One thousand six hundred six treatment-naive nAMD eyes (1330 patients) undergoing anti-VEGF therapy for 12 months nationwide.

METHODS

Demographics, visual acuity (VA) in logarithm of the minimum angle of resolution letters, number of injections and visits were was collected using a validated web-based tool. Neovascular lesion phenotype was classified as type 1 (T1, n = 711), type 2 (T2, n = 505), type 3 (T3, n = 315), and aneurysmal type 1 (A-T1, n = 75), according to the new proposed consensus classification.

MAIN OUTCOME MEASURES

Mean VA change at 12 months, final VA at 12 months, number of injections, time to lesion inactivation.

RESULTS

A total of 1606 treatment-naive nAMD eyes (1330 patients) received a median of 7 injections over 12 months. Mean (± standard deviation) baseline VA was significantly lower for T2 (49.4 ± 23.5 letters) compared with T1 (57.8 ± 20.8) and T3 (58.2 ± 19.4) (both P < 0.05) lesions. Mean VA change at 12 months was significantly greater for A-T1 (+9.5 letters) compared with T3 (+3.1 letters, P < 0.05). Patients with T3 lesions had fewer active visits (24.9%) than those with other lesion types (T1, 30.5%; T2, 32.6%; A-T1, 27.5%; all P < 0.05). Aflibercept was the most used drug in A-T1 lesions (70.1%) and ranibizumab in T1 (40.7%), T2 (57.7%), and T3 (47.6%) lesions.

CONCLUSIONS

This study highlights the relevance of MNV type on clinical outcomes in nAMD and reports significant differences in baseline VA, VA change, and lesion activity at 12 months. This report provides data about lesion-specific clinical features, which may guide the management of nAMD cases and potentially support personalized clinical decision making for these patients.

FINANCIAL DISCLOSURE(S)

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

Natural History and Surgical Outcomes of Lamellar Macular Holes

PURPOSE

To assess the natural history and surgical outcomes of lamellar macular holes (LMHs).

DESIGN

Retrospective and consecutive case series.

SUBJECTS

Patients with LMHs from multiple tertiary care centers.

METHODS

Clinical charts and OCT scans were reviewed.

MAIN OUTCOME MEASURES

The visual acuity (VA) changes and the occurrence rate of full-thickness macular hole (FTMH) were studied in both groups. Within the operated group, factors associated with 6-month VA and development of FTMH were explored.

RESULTS

One hundred seventy-eight eyes were included, of which 89 were monitored and 89 underwent surgery. In the observation group, the mean VA decreased from 0.25 ± 0.18 to 0.28 ± 0.18 logarithm of the minimum angle of resolution (logMAR; P = 0.13), with 14 eyes (15.7%) that lost ≥ 0.2 logMAR VA, after 45.7 ± 33.3 months. Nine eyes (10.1%) spontaneously developed an FTMH. In the operated group, the mean VA increased from 0.47 ± 0.23 to 0.35 ± 0.25 logMAR at 6 months (P < 0.001) and 0.36 ± 0.28 logMAR (P = 0.001) after 24.1 ± 30.1 months. By multivariate analysis, better baseline VA (P < 0.001), the presence of an epiretinal membrane (P = 0.03), and the peeling of the internal limiting membrane (ILM; P = 0.02), with a greater effect of ILM perihole sparing, were associated with a greater 6-month VA. Perihole epiretinal proliferation sparing was associated with a better postoperative VA by univariate analysis (P = 0.03), but this was not significant by multivariate analysis. Eight eyes (9.0%) developed a postoperative FTMH. Using Cox proportional hazard ratios [HRs], pseudophakia at baseline (HR, 0.06; 95% confidence interval [CI], 0.00-0.75; P = 0.03) and peeling of the ILM (HR, 0.05; 95% CI, 0.01-0.39; P = 0.004) were protective factors, while ellipsoid zone disruption (HR, 10.5; 95% CI, 1.04-105; P = 0.05) was associated with an increased risk of FTMH.

CONCLUSION

Observed eyes with LMH experienced, on average, progressive VA loss. Patients with LMH and altered vision may benefit from surgery. Internal limiting membrane peeling, with perihole ILM sparing, represents a crucial step of the surgery associated with a greater VA and a lower risk of postoperative FTMH.

FINANCIAL DISCLOSURE(S)

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

Impact of retinal fluid-free months on outcomes in nAMD: a treatment agnostic analysis of the HAWK and HARRIER studies

PURPOSE

To assess the effect of the total number of fluid-free months after loading on visual and anatomical outcomes in neovascular age-related macular degeneration (nAMD) patients receiving anti-vascular endothelial growth factor (anti-VEGF) therapy.

METHODS

This post-hoc analysis pooled patient-level data from the brolucizumab 6 mg (n=718) and aflibercept 2 mg (n=715) arms of the HAWK and HARRIER randomized clinical trials. Based on data from Weeks 12 to 96, patients were assigned to one of 5 categories based on fluid-free visits (FFV; the total number of monthly visits at which they were observed to be without retinal fluid). Three definitions of 'fluid-free' were explored based on the location of the fluid observed.

RESULTS

Patients allocated to categories 4 (15-21 FFV) and 5 (22 FFV, always dry) consistently had the best visual and anatomical outcomes at Week 96, while patients allocated to categories 1 (0 FFV, never dry) and 2 (1-7 FFV) consistently had the worst visual and anatomical outcomes. Variability in retinal thickness over time was lowest in categories 4 and 5.

CONCLUSION

Absence of retinal fluid at more visits after loading has a positive association with visual and anatomic outcomes in nAMD patients, regardless of fluid type.

Guidance on brolucizumab management recommendations

PURPOSE

Brolucizumab, a new generation anti-VEGF, has demonstrated efficacy and safety in AMD in the pivotal HAWK and HARRIER trials. Post-marketing, previously undetected adverse events related to intraocular inflammation have been reported. An independent post hoc review of the pivotal trials puts the rate of IOI at 4.6%. The aim of this paper is to propose a set of recommendations for implementing the management of brolucizumab in clinical practice.

METHODS

The recommendations made by the authors are based on their clinical experience, critical review of (i) the pivotal trials, the post-hoc analysis of the Safety Review Committee, (ii), and (iii) the published literature.

RESULTS

In the pivotal trials, brolucizumab showed sustained functional gains, superior anatomical outcomes with potentially longer intervals between injections and a well-tolerated overall safety profile. Adverse events reported post-marketing include retinal vasculitis and retinal vascular occlusion. Based on the available information, experts recommend (i) ruling out non-recommended patient profiles (prior history of ORI), (ii) screening the patient prior to each injection to rule out active ORI, (iii) monitoring the patient for early warning signs, and (iv) treating immediately should any adverse events develop.

CONCLUSIONS

The adverse events reported are rare, but may be associated with severe and irreversible loss of visual acuity. The recommendations made are intended to facilitate the management of brolucizumab in the routine practice of retinologists, to ensure patient safety and, should any adverse events occur, to minimise their impact on vision.

Efficacy, durability, and safety of intravitreal faricimab up to every 16 weeks for neovascular age-related macular degeneration (TENAYA and LUCERNE): two randomised, double-masked, phase 3, non-inferiority trials

BACKGROUND

Faricimab is a bispecific antibody that acts through dual inhibition of both angiopoietin-2 and vascular endothelial growth factor A. We report primary results of two phase 3 trials evaluating intravitreal faricimab with extension up to every 16 weeks for neovascular age-related macular degeneration (nAMD).

METHODS

TENAYA and LUCERNE were randomised, double-masked, non-inferiority trials across 271 sites worldwide. Treatment-naive patients with nAMD aged 50 years or older were randomly assigned (1:1) to intravitreal faricimab 6·0 mg up to every 16 weeks, based on protocol-defined disease activity assessments at weeks 20 and 24, or aflibercept 2·0 mg every 8 weeks. Randomisation was performed through an interactive voice or web-based response system using a stratified permuted block randomisation method. Patients, investigators, those assessing outcomes, and the funder were masked to group assignments. The primary endpoint was mean change in best-corrected visual acuity (BCVA) from baseline averaged over weeks 40, 44, and 48 (prespecified non-inferiority margin of four letters), in the intention-to-treat population. Safety analyses included patients who received at least one dose of study treatment. These trials are registered with ClinicalTrials.gov (TENAYA NCT03823287 and LUCERNE NCT03823300).

FINDINGS

Across the two trials, 1329 patients were randomly assigned between Feb 19 and Nov 19, 2019 (TENAYA n=334 faricimab and n=337 aflibercept), and between March 11 and Nov 1, 2019 (LUCERNE n=331 faricimab and n=327 aflibercept). BCVA change from baseline with faricimab was non-inferior to aflibercept in both TENAYA (adjusted mean change 5·8 letters [95% CI 4·6 to 7·1] and 5·1 letters [3·9 to 6·4]; treatment difference 0·7 letters [-1·1 to 2·5]) and LUCERNE (6·6 letters [5·3 to 7·8] and 6·6 letters [5·3 to 7·8]; treatment difference 0·0 letters [-1·7 to 1·8]). Rates of ocular adverse events were comparable between faricimab and aflibercept (TENAYA n=121 [36·3%] vs n=128 [38·1%], and LUCERNE n=133 [40·2%] vs n=118 [36·2%]).

INTERPRETATION

Visual benefits with faricimab given at up to 16-week intervals demonstrates its potential to meaningfully extend the time between treatments with sustained efficacy, thereby reducing treatment burden in patients with nAMD.

FUNDING

F Hoffmann-La Roche.

Role of intraretinal and subretinal fluid on clinical and anatomical outcomes in patients with neovascular age-related macular degeneration treated with bimonthly, treat-and-extend and as-needed ranibizumab in the In-Eye study

PURPOSE

To assess the effect of fluid status at baseline (BL) and at the end of the loading phase (LP) of three different ranibizumab regimens: treat-and-extend (T&E), fixed bimonthly (FBM) injections and pro re nata (PRN), in patients with neovascular age-related macular degeneration (nAMD).

DESIGN

Post hoc analysis of the In-Eye study (phase IV clinical trial).

METHODS

Patients were randomized 1:1:1 to the three study arms and were treated accordingly. The presence and type of fluid, intraretinal fluid (IRF) or subretinal fluid (SRF) and the anatomical and visual outcomes were analysed.

MAIN OUTCOME MEASURES

Best-corrected visual acuity (BCVA), the mean change from baseline BCVA (BL BCVA), and the proportion of eyes gaining more than 15 letters or losing more than five letters were analysed. Morphological characteristics including the subtype of choroidal neovascular membrane and the development of atrophy and fibrosis were also evaluated.

RESULTS

Patients with SRF at LP had better visual outcomes than patients with IRF. The persistence of SRF did not affect the mean change from BL BCVA among the three treatment regimens. However, in patients with IRF mean change from BL BCVA was significantly lower in the FBM group. The presence of IRF at BL and at the end of the loading phase was associated with the development of fibrosis at the end of the study; this result was contrary to that observed for patients with SRF.

CONCLUSIONS

While SRF is compatible with good visual and anatomical outcomes, IRF leads to worse results in patients with nAMD; our results suggest that patients with IRF have better outcomes when individualized treatment regimens are used (PRN or T&E) in contrast with a FBM regimen.

A new standardised nomenclature in ophthalmology: Criteria and quantitative evaluation indicators of medical procedures

PURPOSE

To create a new list of medical procedures in ophthalmology based on the International Classification of Diseases ICD-9-CM. To establish the general principles that define criteria, quantitative indicators, and scales. To develop the algorithms needed to calculate fees for medical procedures.

METHODS

The out-of-date processes were removed from the list, and new techniques were added, descriptors were modified, procedures with similar descriptions were grouped together, and others were relocated to other group according to surgical complexity conditions. The criteria to calculate the medical fees were defined: training and complexity (U), proficient responsibility (R), and health value (V), with their respective quantitative indicators: period of training necessary to master a technique, frequency of complications that worsen the preoperative situation, and days of incapacity for work due to the process. The Relative Value Unit (RVU) was defined as the score sum of R, V and U. The final fee per medical procedure was calculated as the product of the RVU by its unit cost and by the weighting coefficient (WC).

RESULTS

A new catalogue was prepared with 161 medical procedures, grouped into consultations, diagnostic procedures (DX.PR), therapeutic procedures (TX.PR), and surgical interventions, increasing in complexity from group 0 to group 8. The following characters were described for each one of the procedures: OMC and ICD-9-MC code, descriptor term, group, proposed modification: no changes or minimums in the descriptors, grouping of acts by similar definitions, change of origin group, new procedures, and procedures removed. The indicators for assessment were also scored: U between 1-4 points, and R and V between 0-3 points. Using their sum, the number of RVUs per medical procedure (between 1 and 10) was calculated which, together with the unit cost of the RVU and the WC (between 0.05 and 1), will determine the final rate.

CONCLUSIONS

The new standardised ophthalmological nomenclature updates and improves the old classification, adapting the procedures to the descriptors included in the ICD-9-CM, and incorporating all the new techniques. Additionally, the declaration of the general principles allows defining new criteria, quantitative indicators, rating scales, and algorithms to calculate fees for medical procedures.

Long-term results of autologous plasma as adjuvant to pars plana vitrectomy in the treatment of high myopic full-thickness macular holes

Background:

To analyse the feasibility and efficacy of a novel autologous plasma rich in growth factor (PRGF) preparation as adjuvant to pars plana vitrectomy and internal limiting membrane peel in high myopic full-thickness macular hole (FTMH).

Methods:

Single-centre, single-surgeon retrospective chart review of consecutive patients with high myopic FTMH who underwent surgery with a minimum follow-up of 12 months. Patients were divided in group 1 (naïve) and group 2 (persistent). Quantitative and qualitative variables were analysed, compared among groups and correlated with best corrected visual acuity (BCVA).

Results:

Postoperatively, FTMH resolved in 28/31 eyes in group 1 (90%) and in 10/11 eyes in group 2 (91%), without significant differences ( p = 0.954). None of the preoperative anatomical variables analysed showed significant association with preoperative BCVA. Intraoperatively, no significant complications were registered. Postoperatively, BCVA improved significantly in the studied population ( p < 0.001). Preoperative factors associated with better postoperative BCVA were the presence of intraretinal cystoid spaces ( p = 0.028) and elevated FTMH borders ( p = 0.005). Preoperative dome-shaped macula was associated with significantly worse postoperative BCVA ( p = 0.049).

Conclusion:

The use of PRGF as adjuvant to vitrectomy showed to be reproducible, straightforward and efficient, with primary anatomical success rate comparable to other surgical approaches and lower risk of complications.

Clinical-Decision Criteria to Identify Recurrent Diabetic Macular Edema Patients Suitable for Fluocinolone Acetonide Implant Therapy (ILUVIEN®) and Follow-Up Considerations/Recommendations

Current management of diabetic macular edema (DME) predominantly involves treatment with short-acting intravitreal injections of anti-vascular endothelial growth factors (anti-VEGFs) and/or corticosteroids; however, short-acting therapies (lasting between 1 and 6 months) require frequent injections to maintain efficacy, meaning a considerable treatment burden for diabetic patients with multiple comorbidities. Continuous injections needed in some cases are an economic burden for patients/healthcare system, so real-life clinical practice tends to adopt a reactive approach, ie, watch and wait for worsening symptoms, which consequently increases the risk of undertreatment and edema recurrence. On March 7th 2019, a group of experts in retinal medicine and surgery held a roundtable meeting in Madrid, Spain to discuss how to (1) optimize clinical outcomes through earlier use of fluocinolone acetonide (FAc) implant (ILUVIEN^®) in patients with persistent or recurrent DME despite therapy; and, (2) to provide guidance to assist physicians in deciding which patients should be treated with ILUVIEN. In this regard, a 36-month follow-up consensus protocol is presented. In conclusion, patients that achieve a complete or partial anatomical, and preferably functional, response following one or two intravitreal dexamethasone implants, but with recurrence of edema after 3-4 months, are deemed by the authors most likely to benefit from ILUVIEN, and the switch to FAc implant should not be delayed more than 12 months after the initiation of at least the first dexamethasone implant.

Optical coherence tomography-based consensus definition for lamellar macular hole

BACKGROUND

A consensus on an optical coherence tomography definition of lamellar macular hole (LMH) and similar conditions is needed.

METHODS

The panel reviewed relevant peer-reviewed literature to reach an accord on LMH definition and to differentiate LMH from other similar conditions.

RESULTS

The panel reached a consensus on the definition of three clinical entities: LMH, epiretinal membrane (ERM) foveoschisis and macular pseudohole (MPH). LMH definition is based on three mandatory criteria and three optional anatomical features. The three mandatory criteria are the presence of irregular foveal contour, the presence of a foveal cavity with undermined edges and the apparent loss of foveal tissue. Optional anatomical features include the presence of epiretinal proliferation, the presence of a central foveal bump and the disruption of the ellipsoid zone. ERM foveoschisis definition is based on two mandatory criteria: the presence of ERM and the presence of schisis at the level of Henle's fibre layer. Three optional anatomical features can also be present: the presence of microcystoid spaces in the inner nuclear layer (INL), an increase of retinal thickness and the presence of retinal wrinkling. MPH definition is based on three mandatory criteria and two optional anatomical features. Mandatory criteria include the presence of a foveal sparing ERM, the presence of a steepened foveal profile and an increased central retinal thickness. Optional anatomical features are the presence of microcystoid spaces in the INL and a normal retinal thickness.

CONCLUSIONS

The use of the proposed definitions may provide uniform language for clinicians and future research.

Optimization of Diabetic Macular Edema Management in the Real World: A Model of Excellence in Retina Units: The EMUREX Initiative

PURPOSE

To define and develop a model of excellence for the clinical management of diabetic macular edema (DME) patients in a real-world setting.

METHODS

A multidisciplinary joint commission (5 ophthalmologists, 1 nurse, and 1 pharmaceutic) established a series of preliminary recommendations based on clinical guidelines and DME activity results from 8 Pilot Hospitals (PH). These were validated by members of each PH and a group of DME patients in discussion workshops. Thus, the validated guideline (VG) took into consideration different aspects, namely, main core points (ranging 0-100), criteria, and indicators. Finally, each PH own setting was compared to the VG in order to settle down a starting point to clinical excellence.

RESULTS

Mean PH score was 51.5 (range 30-65). As compared to their maximum, main points that showed best scores were Clinical Guidelines and Protocols (78%) and Portfolio of Services (73%). Topics reaching close to 50% scoring included Resources (55%), Innovation (54%), Care Process (53%), Organization (52%), and Leadership (50%). Lowest scores were observed in the Strategic Alliances (46%) and Staff (37%) points.

CONCLUSIONS

Analysis of each PH by the VG delivered a global vision of the starting situation, especially focused in the identification of the different improvement areas. In order to further extend this model into the Public Health System, the effect of implementing it in different hospitals should be assessed to analyze its impact on daily clinical practice and health economics.

The role of Müller cells in tractional macular disorders: an optical coherence tomography study and physical model of mechanical force transmission

BACKGROUND

To explore the role of foveal and parafoveal Müller cells in the morphology and pathophysiology of tractional macular disorders with a mathematical model of mechanical force transmission.

METHODS

In this retrospective observational study, spectral-domain optical coherence tomography images of tractional lamellar macular holes and patients with myopic foveoschisis were reviewed and analysed with a mathematical model of force transmission. Parafoveal z-shaped Müller cells were modelled as a structure composed of three rigid rods, named R1, R2 and R3. The angle formed between the rods was referred to as θ . R1, R2 and R3 lengths as well as the variation of the angle θ were measured and correlated with best corrected visual acuity (BCVA).

RESULTS

In tractional lamellar macular holes, there was a significant reduction of the angle θ towards the foveal centre (p<0.001). By contrast, there were no significant differences in θ in myopic foveoschisis (p=0.570). R2 segments were more vertical in myopic foveoschisis. There was a significant association between lower θ angles at 200 µm temporal and nasal to the fovea and lower BCVA (p<0.001 and p=0.005, respectively). The stiffness of parafoveal Müller cells was predicted to be function of the angle θ , and it grew very rapidly as the θ decreased.

CONCLUSION

Parafoveal Müller cells in the Henle fibre layer may guarantee structural stability of the parafovea by increasing retinal compliance and resistance to mechanical stress. Small values of the angle θ were related to worse BCVA possibly due to damage to Müller cell processes and photoreceptor's axons.

Phaco-non-penetrating deep sclerectomy in ocular hypertension secondary to dexamethasone intravitreal implant

PURPOSE

To evaluate the characteristics and progression of patients treated with a 0.7mg dexamethasone intravitreal implant (Ozurdex^®) and required glaucoma filtering surgery (phaco-non-penetrating deep sclerectomy) to control ocular hypertension (OHT).

METHODS

A retrospective observational study including patients treated with Ozurdex^® in a tertiary-care university hospital from May 2011 to April 2016.

RESULTS

In five years of follow-up, 1.10% (4/363) of patients treated with 0.7mg dexamethasone intravitreal implant required phaco-non-penetrating deep sclerectomy (PNPDS) to control OHT refractory to topical treatment. All four patients started or increased previous antihypertensive topical treatment since the first dexamethasone intravitreal implant. Three or more dexamethasone intravitreal implants were injected in the four cases before intraocular pressure (IOP) became uncontrolled and PNPDS was performed. All four patients have a successfully controlled IOP without treatment after PNPDS. Two patients required additional treatment with dexamethasone intravitreal implants after PNPDS, maintaining IOP under control without treatment.

CONCLUSIONS

To the best of our knowledge, this is the first study describing the successful results of PNPDS in OHT secondary to dexamethasone intravitreal implant. All four patients have achieved controlled IOP without treatment. Re-treatment with dexamethasone intravitreal implant in those patients who underwent PNPDS is also possible, and IOP remains controlled.

Clinical Decision-Making when Treating Diabetic Macular Edema Patients with Dexamethasone Intravitreal Implants

Diabetes mellitus (DM) is a metabolic disease frequently associated with comorbidities that include diabetic macular edema (DME). The current medical approach to treating DME involves intravitreal injections with either anti-vascular endothelial growth factors or steroids. However, the burden associated with intravitreal injections and DM-derived complications is high, underlining the need to find optimal treatment regimens. In this article we describe the considerations we apply when treating DME patients with dexamethasone intravitreal implants (Ozurdex®), particularly those that influence the clinical decision-making process during the follow-up period. These considerations are based both on the available medical literature and on our clinical experience following the use of these implants in this type of patient, the goal being to optimize the number of injections and the clinical outcome of this therapy. We also provide a general overview of the pathophysiology of DME, highlighting the inflammatory component as a rationale to use steroids in these patients.

Long-Term Follow-up of Tacrolimus Treatment in Immune Posterior Uveitis

PURPOSE

To study the efficacy of tacrolimus in immune posterior uveitis.

METHODS

Twenty-one eyes of 11 patients with immune posterior uveitis under tacrolimus treatment were prospectively followed for 1 to 5 years. Tacrolimus dosage was adjusted to maintain blood levels in the range of 7 to 10 ng/mL. Systemic and ophthalmic evaluations were performed at baseline and during follow-up.

RESULTS

After a mean follow-up of 45 months, no treatment other than tacrolimus was necessary to control the inflammation in 6 cases (54.5%). The number of annual recurrences decreased from 3.2 to 1.29 during tacrolimus treatment (p=0.021). In four patients, tacrolimus was suspended after a treatment period of 27+/-3.5 months and a follow-up period of 12 months free of uveitis relapses. All four were free from relapses following tacrolimus withdrawal. Visual acuity remained unchanged in 16/21 (76%) eyes, deteriorated in 4/21 (19%), and improved in 1/21 (5%). Renal function transiently deteriorated in four patients from basal serum creatinine levels of 0.84, 1.1, 0.88, and 0.78 mg/dL to maximum levels of 1.33, 2.48, 1.38, and 1.39 mg/dL, respectively. This deterioration was directly related with elevated tacrolimus serum levels, returning to normal when doses were reduced. During the overall controlled evolution period, a slight increase of serum creatinine from a basal value of 0.89+/-0.2 mg/dL to a final of 1+/-0.19 mg/dL was detected, which was not statistically significant. All secondary effects were mild, transient, and did not require interruption of long-term treatment to be controlled.

CONCLUSIONS

Tacrolimus was well tolerated and useful in controlling posterior immune uveitis. Tacrolimus could be considered a real alternative to cyclosporine, and not only in cases of cyclosporine resistance or toxicity.

Comparative Study of Vitrectomy with and without Vein Decompression for Branch Retinal Vein Occlusion: A Pilot Study

Purpose

To report the clinical outcomes in patients undergoing pars plana vitrectomy with and without vein decompression for treatment of branch retinal vein occlusion (BRVO).

METHODS

Thirty-five eyes with macular edema and visual acuity worse than 20/100 secondary to BRVO were prospectively evaluated. Vitrectomy with posterior hyaloid removal and vein decompression at the arteriovenous crossing was performed on 15 eyes (Group 1); consecutively, the same technique without vein decompression was performed on 20 eyes (Group 2). Primary outcome was visual acuity and secondary outcomes were resolution of macular edema and development of neovascularization.

Results

No differences were found between groups in either patient age (p=0.566) or preoperative visual acuity (p=0.505). No differences were found in visual acuity at 3 (p=0.651), 6 (p =0.697), 9 (p =0.763), 12 (p=0.881), or 18 (p=0.748) months. Mean time for macular edema resolution and visual acuity improvement was 9 months in both groups, with a mean improvement of 3.5 ± 2.35 lines in Group 1 and 3.2 ± 2.97 lines in Group 2. No eyes in either group developed new vessels.

CONCLUSIONS

Results suggest that vitrectomy with posterior hyaloid removal without vein decompression can resolve macular edema, improve vision, and prevent development of new vessels in BRVO.

Prevalence of Vitreoretinal Interface Abnormalities on Spectral-Domain OCT in Healthy Participants over 45 Years of Age

PURPOSE

To assess the prevalence of vitreoretinal interface abnormalities in a general population of healthy adults ≥45 years of age.

DESIGN

Cross-sectional study carried out at 17 ophthalmology services throughout Spain.

PARTICIPANTS

Between September 2015 and March 2016, all consecutive healthy persons aged ≥45 years who were accompanying patients to ophthalmology services were invited to take part in the study. Exclusion criteria were known retinal disease, uveitis, history of ocular trauma or previous intraocular surgery (including cataract surgery and intravitreal injections), severe myopia (>-6 dioptres), and poor ocular media transparency.

METHODS

Spectral-domain OCT or swept-source OCT was performed on all participants. Diseases of the vitreomacular interface were classified according to the OCT-based anatomic classification system of the International Vitreomacular Traction Study Group. All pathologic and borderline images as well as doubtful cases were evaluated blindly in a central reading center.

MAIN OUTCOME MEASURES

Prevalence of vitreomacular interface abnormalities (vitreomacular traction epiretinal membrane, lamellar hole).

RESULTS

The study included 2257 participants with a mean age of 59.5 years (range 45-90), and a total of 4490 eyes (right eyes 2242, left eyes 2248). Vitreoretinal interface abnormalities were detected in 70 eyes, with a prevalence of 1.6%. Vitreomacular adhesion was observed in 1317 eyes (29.3%). Results of spectral-domain OCT or swept-source OCT examination were unrevealing in 3103 eyes. Vitreoretinal interface abnormalities were found in 61 participants, with a prevalence in the study population of 2.7%. Vitreomacular traction was observed in 14 participants (0.6%), epiretinal membrane in 44 (1.9%), and lamellar macular hole in 3 (0.1%). The prevalence of both vitreomacular traction and epiretinal membrane increased significantly with age. The presence of vitreoretinal interface abnormalities was unrelated to concomitant diabetes mellitus or hypertension.

CONCLUSIONS

An important percentage of healthy participants from the general population ≥45 years of age showed vitreoretinal interface abnormalities. Screening with OCT is advisable at any first routine consultation or preoperative assessment, particularly in older participants.

Insights Into Epiretinal Membranes: Presence of Ectopic Inner Foveal Layers and a New Optical Coherence Tomography Staging Scheme

PURPOSE

To describe the presence of continuous ectopic inner foveal layers associated with epiretinal membranes (ERMs) and to present a new optical coherence tomography (OCT) staging system of ERMs.

DESIGN

Retrospective multicenter observational case series.

METHODS

Clinical charts and spectral-domain OCT images of 194 eyes of 172 consecutive patients diagnosed with ERMs were reviewed and analyzed.

RESULTS

The presence of continuous ectopic inner foveal layers was identified in 63 out of 194 eyes (32.5%) and this morphology was significantly associated with lower visual acuity. ERMs were divided into 4 stages. Stage 1 (43 out of 194 eyes, 22.1%) ERMs were mild and thin and a foveal depression was present. Stage 2 (88 out of 194 eyes, 45.4%) ERMs were associated with widening of the outer nuclear layer and loss of the foveal depression. Stage 3 (51 out of 194 eyes, 26.3%) ERMs were associated with continuous ectopic inner foveal layers crossing the entire foveal area. In stages 1, 2, and 3 all retinal layers were clearly defined on OCT. Stage 4 ERMs (12 out of 194 eyes, 6.2%) were thick and associated with continuous ectopic inner foveal layers. In addition, retinal layers were disrupted. Visual acuity progressively declined from stage 1 through stage 4 (P < .001).

CONCLUSIONS

The presence of continuous ectopic inner foveal layers in ERMs is a newly described OCT finding associated with significant vision loss and is an essential element of a novel OCT-based grading scheme of ERMs that may influence visual prognosis.

Choroidal thickness in non-neovascular versus neovascular age-related macular degeneration: a fellow eye comparative study

PURPOSE

To investigate the possible differences in choroidal thickness (CT) between non-neovascular (NNV) and neovascular (NV) age-related macular degeneration (AMD).

METHODS

A retrospective, observational chart review of consecutive patients diagnosed with NNV AMD in one eye and with NV AMD in the fellow eye was carried out. NNV AMD was classified into four subgroups according to the Beckman Initiative for Macular Research AMD Classification Committee Meeting. CT was manually assessed using enhanced depth imaging optical coherence tomography from 1500 µm nasal to 1500 µm temporal to the fovea. Parametric and non-parametric tests were used to compare quantitative variables, a χ² test was used to compare categorical variables and logistic regression was used to evaluate associations of CT with other variables of interest.

RESULTS

In this study, 322 eyes from 161 patients were included and 102 (63.35%) were female and 59 (36.65%) were male, with a mean age of 80.80±8.45 years (range 58-99 years). Mean follow-up was 11.2±10.8 months (range 1-38 months). In NNV AMD eyes, the choroid was significantly thicker in the subfoveal and temporal regions of the macula, if compared with NV AMD fellow eyes. Differences in CT between NNV AMD and NV AMD fellow eyes were higher at earlier stages of NNV AMD.

CONCLUSIONS

Subfoveal and temporal choroid was significantly thicker in NNV AMD compared with NV AMD fellow eyes. There was a significant choroidal thinning at advanced stages of NNV AMD.

Treatment of Exudative Age-related Macular Degeneration: Focus on Aflibercept

A formulation of aflibercept for intravitreal injection (Eylea) is approved for the treatment of patients with exudative age-related macular degeneration (AMD). Aflibercept has a significantly higher affinity for Vascular endothelial growth factor (VEGF)-A compared with other monoclonal anti-VEGF antibodies. In addition to binding all VEGF-A isoforms, aflibercept also blocks other proangiogenic factors such as VEGF-B and placental growth factor. The VIEW 1 and 2 trials showed this drug achieves improved results in patients with exudative AMD similar to those obtained with monthly ranibizumab, using a bimonthly treatment regimen after a loading dose of three intravitreal injections, which translates to less use of healthcare resources. There is a subgroup of patients that present with persistent fluid after the loading dose that could benefit from monthly injections or personalized proactive treatment after the first year. In the second year of treatment, the Treat and Extend patterns can permit even more lengthening of the time between injections. More data are needed to confirm the optimal monitoring and retreatment dosing, to maintain long-term efficacy. Other preliminary data suggest that patients that do not respond to other anti-angiogenics and patients with special pathologies such as polypoidal choroidopathy or retinal angiomatous proliferation can improve upon switching to aflibercept. To date, the safety profile of aflibercept is excellent and is comparable to other anti-angiogenic treatments.

Autologous platelet concentrate in surgery for macular detachment associated with congenital optic disc pit

Purpose

To evaluate the anatomical and functional results obtained with pars plana vitrectomy (PPV) plus autologous platelet concentrate (APC) as a treatment for macular detachment associated with optic disc pit (ODP).

Methods

We performed a prospective interventional study of 19 eyes of 19 consecutive patients with posterior macular detachment due to ODP. All patients underwent PPV, posterior hyaloid peeling, fluid–air exchange, injection of 0.05 mL of APC over the ODP and 15% perfluoropropane (C3F8) endotamponade. Postoperative measures included face-up positioning for 2 hours and then avoidance of the face-up position during the ensuing 10 days. All patients underwent complete ophthalmologic examination and optical coherence tomography preoperatively at 1 month, 3 months, 6 months, 9 months, and 12 months postoperatively and then annually. Outcome measures were best corrected visual acuity (BCVA) by logMAR, improvement of quality of vision, macular attachment, and resolution of intraretinal schisis-like separation.

Results

Preoperatively, the median BCVA was 0.70 (range: 0.30–1.70) and all patients showed improved visual acuity after surgery; BCVA was 0.22 (range: 0.07–0.52) at 12 months follow-up. All patients showed complete reabsorption of intraretinal fluid (median time: 3.5 months [range: 2–8 months]) and macular attachment at the end of follow-up (median: 60 months [range: 12–144 months]), with stable or improved visual acuity. No reoperations were needed and no major adverse events were recorded.

Conclusion

For macular detachment associated with ODP, the combination of PPV, posterior hyaloid peeling, APC, and C3F8 tamponade is a highly effective alternative technique with stable anatomical and functional results.

[New perspectives in the approach to central retinal vein occlusion]

OBJECTIVE

The COPERNICUS and GALILEO trials were designed to evaluate the safety and efficacy of intravitreal injection of 2mg of aflibercept in the treatment of macular edema secondary to central retinal vein occlusion.

MATERIAL AND METHOD

Two phase III randomized, double-masked trials: COPERNICUS in North America (188 patients) and galileo in Europe and Asia (177 patients). In COPERNICUS, the patients in the treatment group received monthly injections of 2mg aflibercept for 6 months and later continued with strict PRN treatment with monthly follow-up every 6 months and with a minimum of 3-monthly follow up for 1 year. Patients in the placebo group could receive treatment after the sixth month, with similar treatment regimens and follow-up to the treatment group. In contrast, in galileo, the placebo group received no PRN treatment until 1 year of follow-up and during the first 6 months, followup visits were bi-monthly.

RESULTS

The treatment group in COPERNICUS showed a mean improvement of 13 letters versus the placebo group (1.5 letters) at week 100 of follow-up. In galileo, the mean best corrected visual acuity at 76 weeks were 13.7 and 6.6 in the treatment and placebo groups, respectively.

CONCLUSIONS

Early treatment with intravitreal afliberceptin achieves better results than when treatment is delayed by 6 months or 1 year. The visual benefits obtained with the drug are affected by the reduction in the frequency of monitoring during follow-up.

A delphi study to detect deficiencies and propose actions in real life treatment of neovascular age-related macular degeneration

Purpose. Spanish retina specialists were surveyed in order to propose actions to decrease deficiencies in real-life neovascular age macular degeneration treatment (nv-AMD). Methods. One hundred experts, members of the Spanish Vitreoretinal Society (SERV), were invited to complete an online survey of 52 statements about nv-AMD management with a modified Delphi methodology. Four rounds were performed using a 5-point Linkert scale. Recommendations were developed after analyzing the differences between the results and the SERV guidelines recommendations. Results. Eighty-seven specialists completed all the Delphi rounds. Once major potential deficiencies in real-life nv-AMD treatment were identified, 15 recommendations were developed with a high level of agreement. Consensus statements to reduce the burden of the disease included the use of treat and extend regimen and to reduce the amount of diagnostic tests during the loading phase and training technical staff to perform these tests and reduce the time between relapse detection and reinjection, as well as establishing patient referral protocols to outside general ophthalmology clinics. Conclusion. The level of agreement with the final recommendations for nv-AMD treatment among Spanish retinal specialist was high indicating that some actions could be applied in order to reduce the deficiencies in real-life nv-AMD treatment.

[BRAVO and CRUISE: ranibizumab for the treatment of macular edema secondary to retinal vein occlusion]

This article summarizes the results of the BRAVO and CRUISE trials, two randomized multicenter studies in patients with macular edema secondary to branch and central retinal vein occlusion, respectively. Randomization was 1:1:1 to 0.3 mg of ranibizumab, 0.5 mg of ranibizumab or placebo. Monthly injections were administered for 6 months followed by a 6-month observation period in which treatment on an on-demand (PRN) basis was applied with 0.5 mg ranibizumab. Patients in the control group were also eligible for 0.5 mg ranibizumab treatment in the observation period. The results showed a significant anatomical and visual improvement in both treatment groups 7 days after the intravitreal injection. PRN treatment with monthly follow-up maintained the visual improvements achieved after the first 6 months of treatment. Patients in the control group who received PRN treatment after the first 6 months showed an anatomical improvement similar to that in the treatment groups but less visual improvement.

Safety of ranibizumab in routine clinical practice: 1-year retrospective pooled analysis of four European neovascular AMD registries within the LUMINOUS programme

Purpose

Evaluation of 1-year safety profile of intravitreal ranibizumab 0.5 mg in neovascular age-related macular degeneration (NV-AMD) within routine clinical practice.

Methods

The LUMINOUS programme comprises a prospective observational study assessing ranibizumab ‘real-world’ safety and clinical effectiveness across licensed indications worldwide and an annual retrospective pooled safety analysis from completed NV-AMD ranibizumab registries. 1-year data from four European registries are available. This retrospective pooled safety analysis assessed 1-year incidence rates for safety events of particular interest (key ocular or systemic events possibly related to the injection procedure or vascular endothelial growth factor inhibition) together with treatment exposure. Patients were treated according to local protocols within the ranibizumab licence.

Results

Data of 4444 patients from registries in Germany (n=3470), the Netherlands (n=243), Belgium (n=260) and Sweden (n=471) were retrospectively pooled. Between 70.4% and 84.4% of enrolled patients completed 1 year of follow-up. Most frequent overall ocular events of particular interest were retinal pigment epithelial tears (27 patients; <1%) and intraocular pressure-related events (12 patients; <0.3%). Most frequent non-ocular event of particular interest was stroke (19 patients; 0.4%); annual incidence of stroke was low across all registries (0.0–0.5%).

Conclusions

Ranibizumab demonstrated favourable 1-year safety profile for NV-AMD in this routine clinical practice sample, consistent with previous reported trial data. Additional data from a larger patient population are needed to better describe the long-term safety profile of ranibizumab in routine clinical practice and further evaluate risk for infrequent but serious events in ‘real-life’ settings. The 5-year LUMINOUS prospective observational study will address this need.

Potential anti-vascular endothelial growth factor therapies for central retinal vein occlusion

Central retinal vein occlusion (CRVO) remains an important cause of visual loss. Impaired venous drainage leads to retinal hypoxia with upregulation and release of vascular endothelial growth factor (VEGF). VEGF increases vascular permeability and leads to the breakdown of the blood-retinal barrier, with the development of macular oedema. Treatment strategies for macular oedema in CRVO currently under evaluation focus on VEGF blockage. Bevacizumab is a humanized monoclonal antibody that blocks VEGF. It has been evaluated in a clinical trial that compared intravitreal injections of bevacizumab 1.25 mg with sham injections every 6 weeks. At the end of a 24-week follow-up period, 60.0% of patients in the bevacizumab group had gained ≥ 15 letters compared with 20.0% in the control group (p=0.003). Aflibercept (previously VEGF Trap-Eye) is a 115  kD decoy receptor fusion protein. Aflibercept is capable of binding both VEGF and placental growth factor (PlGF). By blocking both VEGF and PlGF, aflibercept could be more effective than other anti-VEGF drugs. Two clinical trials have evaluated the efficacy of aflibercept for the treatment of macular oedema in CRVO: COPERNICUS and GALILEO. Both included a similar 6-month phase, during which patients were randomized to receive either an intravitreal injection of aflibercept 2 mg or a sham injection every month. In a second 6-month phase of the GALILEO study, patients in the treatment group were treated on an as needed (PRN) basis with aflibercept, while patients in the placebo group continued with sham injections. In the second 6-month phase in the COPERNICUS study, all patients were treated with aflibercept on a PRN basis. Treatment with aflibercept led to an improvement in visual acuity of ≥ 15 letters in 55.3% (COPERNICUS) and 60.2% of patients (GALILEO). Patients initially in the placebo group and then treated PRN gained only a mean of 3.8 letters, with 30.1% achieving a visual gain of ≥ 15 letters (COPERNICUS). The percentage of patients that improved by ≥ 15 letters was 32.4% for the group receiving sham injections throughout the GALILEO study. In summary, VEGF blockage has been proven to improve visual outcomes in patients with macular oedema due to CRVO. However, an important disadvantage of anti-VEGF drugs is the need for frequent reinjections and even more frequent control visits. Further advances are needed in order to improve quality of life and reduce the burden to healthcare systems.

Rhegmatogenous retinal detachment treatment guidelines

This paper outlines general guidelines following the initial diagnosis of rhegmatogenous retinal detachment. These include preoperative evaluation, treatment, possible intra- and post-operative complications, retinal re-detachment, and all therapeutic options available for each case. Treatment of the traumatic retinal detachment is also described, due to its importance and peculiarities. Treatment or prophylactic guidelines are suggested for the different types of retinal detachment described. These are based on both the experience of the ophthalmologists that have participated in preparing the guidelines, and also on evidence-based grading linked to bibliographical sources. However, these guidelines should not be interpreted as being mandatory. Given that there is a wide spectrum of options for treatment of retinal detachment, the surgeons' experience with one or other surgical technique will be of utmost importance in obtaining the best surgical result. As guidelines, they are intended as an additional aid to the surgeon during the decision-making process, with the expectation that the final choice will still be left to the surgeon's judgment and past experience.

Results of bevacizumab as the primary treatment for retinal vein occlusions

BACKGROUND

The purpose of this study is to evaluate the efficacy of intravitreal bevacizumab as the primary treatment of macular oedema due to retinal vein occlusions.

METHODS

Patients diagnosed as having central retinal vein occlusion (CRVO) or branch retinal vein occlusion (BRVO) with visual acuity of less than 20/40 and macular oedema with more than 300 microm central retinal thickness were recruited. Patients that had received any prior treatment were excluded. After an initial intravitreal injection of bevacizumab, re-treatment was performed if intraretinal or subretinal fluid with distortion of the foveal depression was found in optical coherence tomography.

RESULTS

18 eyes with CRVO and 28 eyes with BRVO were included. During a 6-month period, the mean number of injections per patient was 3.7 (BRVO group) and 4.6 (CRVO group). In the BRVO group, mean baseline logMAR visual acuity was 0.80 (SD 0.38) and macular thickness was 486.9 microm (SD 138.5 microm). After 6 months, mean logMAR visual acuity improved significantly to 0.44 (SD 0.34), p<0.001. Mean macular thickness decreased significantly to 268.2 microm (SD 62.5 microm), p<0.001. In the CRVO group, mean baseline logMAR visual acuity was 1.13 (SD 0.21) and macular thickness was 536.4 microm (SD 107.1 microm). Mean final logMAR visual acuity improved significantly to 0.83 (SD 0.45), p<0.001. Mean macular thickness decreased significantly to 326.17 microm (SD 96.70 microm), p<0.001.

CONCLUSIONS

Intravitreal bevacizumab seems to be an effective primary treatment option for macular oedema due to retinal occlusions. Its main drawback is that multiple injections are necessary to maintain visual and anatomic improvements.

[Anatomical and functional outcomes of vitrectomy for the treatment of pseudophakic regmatogenous retinal detachment]

PURPOSE

To report the results obtained in a non-comparative series of pseudophakic patients with retinal detachment (RD) treated with vitrectomy with no associated scleral procedures.

METHODS

The clinical records of all pseudophakic patients with RD treated with vitrectomy were evaluated by one of the authors. Patients with primary regmatogenous RD with no signs of proliferative vitreoretinopathy were included. Patients with associated ocular pathologies or with less than 3 months follow-up were excluded. Main outcome measures were anatomical reattachment rate after one surgery, visual acuity change and surgical complications. The surgical procedure consisted of 20 g pars plana vitrectomy, with removal of peripheral vitreous up to the ora serrata. Laser photocoagulation of all retinal breaks was performed and 14% C3F8 was used as tamponade.

RESULTS

Thirty-one patients were included in the study. In 18 patients the macula was affected. Mean follow-up was 6.45 months (range 3 to 18). Retinal reattachment was achieved in all patients and only one patient experienced a re-detachment, 3 months after surgery. Visual acuity improved by a mean of 2.5 Snellen lines and 61.3% of patients reached a final visual acuity of 0.5 or better. Eight patients had an intraocular pressure rise after surgery, which was controlled with topical medication. No other complications were recorded.

DISCUSSION

Our results support the hypothesis that vitrectomy alone is a useful technique for the treatment of RD in pseudophakic eyes.

Anti-angiogenic drugs as an adjunctive therapy in the surgical treatment of diabetic retinopathy

Anti-VEGF drugs may be employed in the surgical treatment of diabetic retinopathy: 1. Prior to surgery. The intravitreal injection of anti-VEGF drugs leads to a significant reduction of neovascularization, with a reduction in the adherence of the fibrovascular complex to the retina. This simplifies viscodelamination and reduces intraoperative bleeding during delamination and segmentation. To minimize the risk of tractional retinal detachment due to the contraction of fibrovascular tissue, vitrectomy must be performed within one week after the injection. 2. To decrease the risk of postoperative bleeding. Recurrent vitreous hemorrhages after vitrectomy are often due to small bleeding from persistent neovascularization. The injection of anti-VEGF drugs at the end of vitrectomy could prevent bleeding from these vessels by blocking the pro-inflammatory stimulus of the surgical procedure. 3. To treat postoperative vitreous hemorrhage. The intravitreal injection of anti-VEGF drugs in patients with postoperative bleeding leads to resolution of the hemorrhage. 4. To treat rubeosis iridis. In eyes with complete panretinal photocoagulation, the combination of cryotherapy and intravitreal anti-VEGF injection in the same surgical procedure produces a disappearance of iris neovascularization together with a long term effect with no recurrences. In neovascular glaucoma, anti-VEGF drugs can also facilitate filtrating surgery.

[Evaluation of trypan-blue toxicity in macular hole surgery with electroretinography]

PURPOSE

Concern has been raised about the retinal toxicity of vital dyes. We designed a prospective study to determine the possible toxicity of trypan-blue (TB) in macular hole surgery with TB-assisted internal limiting membrane (ILM) peeling through the performance of electroretinograms (ERGs).

METHODS

Patients diagnosed with a macular hole underwent ophthalmological evaluation prior to surgery and at 6 months follow-up. All patients underwent vitrectomy and ILM-staining under air. All phakic patients underwent phacoemulsification and IOL implantation simultaneously. There were two study groups: In group 1, ILM-staining was performed with 0.06% TB, while in group 2 the procedure was performed with 0.15% TB. Preoperative ERG recordings were measured in the week prior to surgery. Postoperative ERGs were measured 3 to 6 months after surgery. The ERG data between eyes with macular hole and fellow eyes were compared in the pre- and post-operative stages. Visual acuity (VA) changes in both groups were evaluated.

RESULTS

Nine patients were recruited in each group. VA improved significantly in both groups, with more than 65% of patients improving more than 2 lines. There were no statistical differences in VA gain between groups or in ERG values between affected and fellow eyes.

CONCLUSION

No significant retinal toxicity of TB staining could be clinically detected.

Inferior sclerotomies without subretinal fluid drainage for exudative retinal detachment in diffuse retinal pigment epitheliopathy

PURPOSE

To evaluate the efficacy of inferior sutureless sclerotomies without subretinal fluid drainage for the treatment of bullous exudative retinal detachment secondary to diffuse retinal pigment epitheliopathy.

METHODS

A retrospective interventional case series of eyes treated with two inferior postequatorial full-thickness sclerotomies without subretinal fluid drainage. Patients were placed in an upright position 24 hours after surgery. Main outcomes were visual acuity and retinal reattachment rate.

RESULTS

Three eyes with recent diagnoses of diffuse retinal pigment epitheliopathy and bullous inferior retinal detachment were included in the study. In all cases, a very thick sclera was evident during surgery. The day after surgery the retina was completely attached in the three eyes. Preoperative visual acuity was light perception, 20/200, and counting fingers. After surgery, visual acuity improved to 20/200, 20/70, and 20/50, respectively. No intra- or postoperative complications occurred.

CONCLUSIONS

The performance of inferior sutureless sclerotomies without a draining procedure in cases of diffuse retinal pigment epitheliopathy with inferior bullous retinal detachment is a simple and effective technique. It achieves retinal reattachment the day after surgery, allowing laser photocoagulation of the leaking lesions disclosed in fluorescein angiography.

Treatment of bilateral candidal endophthalmitis with intravenous caspofungin

PURPOSE

Fungal resistances to drugs are increasing. Caspofungin is a new antifungal agent effective in the treatment of invasive candidiasis. We report a case of candidal endophthalmitis that responded adequately to caspofungin.

METHODS

A 24-year-old man with acute myeloid leukemia presented with vision loss in both eyes. Visual acuity was 20/50 in the right eye and counting fingers in the left eye. Fundus examination revealed multiple, premacular, vitreous, pearl stringshaped condensations in the right eye and a subretinal abscess in the left eye. Treatment with 50 mg of intravenous caspofungin once daily was started.

RESULTS

After 1 month, inflammation in both eyes had decreased, although the left eye developed macular scarring. Medication at discharge was intravenous caspofungin once daily for another 6 weeks. Nine months after presentation, the patient had residual vitreous condensations in the premacular region of the right eye with visual acuity of 20/25 and severe macular scarring in the left eye with visual acuity of 20/100.

CONCLUSION

This case adds support for the use of caspofungin as monotherapy for candidal endophthalmitis. Further studies are necessary to determine treatment options for the new antifungal agents.

Toxic keratolysis from combined use of nonsteroid anti-inflammatory drugs and topical steroids following vitreoretinal surgery

PURPOSE

To evaluate the corneal complications associated with the combined use of non-steroid anti-inflammatory drugs (NSAIDs) and topical steroids following vitreoretinal surgery.

METHOD

Description of corneal lesions in three patients after vitrectomy with use of topical ketorolac and prednisolone acetate.

RESULTS

Three eyes of three patients developed an atrophic central corneal ulcer with stromal thinning following a pars plana vitrectomy under local anesthesia. Lesions were asymptomatic and were found during a routine examination 2, 3, and 8 weeks after surgery, respectively. Surgical indications were as follows: a preretinal membrane, choroidal neovascularization, and massive uveal effusion following cataract surgery. Topical postoperative treatment was as follows: ketorolac 4 times a day, a combination of prednisolone acetate, polymyxin B, and neomycin 6 times a day, and 1% cyclopentolate 3 times a day. Suspension of ketorolac and ocular occlusion led to the resolution of corneal lesions between 2.5 and 3 months later, yielding a central superficial scarring, which showed no changes after a follow-up of 3 years.

CONCLUSIONS

Toxic keratolysis may appear as a secondary effect of the combined use of topical NSAIDs and steroids following vitreo retinal surgery and must be taken into account in the differential diagnosis of postoperative corneal lesions.

Scleral buckling technique without retinopexy for treatment of rhegmatogeneous: a pilot study

PURPOSE

To evaluate the role of retinopexy in the surgical management of primary rhegmatogenous retinal detachment (RD) without proliferative vitreoretinopathy. The primary outcome was retinal attachment, and secondary outcomes were visual acuity results and complications.

METHODS

A randomized controlled trial including 60 patients with RD caused by a break or a group of breaks no larger than one clock hour. Thirty eyes received no retinopexy (group 1), and 30 eyes received transscleral cryotherapy (group 2). An encircling buckle was placed in all eyes. In eyes with posterior breaks, segmental buckles were also added. In some eyes, subretinal fluid drainage or anterior chamber paracentesis and/or intravitreal air bubble injection was performed.

RESULTS

No differences were found between the groups in terms of the preoperative clinical variables evaluated: age; sex; axial length; lens status; type, number, and location of breaks; extension of detachment; and macula status. There were no differences in the surgical procedures performed. The reattachment rate in group 1 was 90%, and in group 2, it was 87% (a difference that was not significant [P = 1.00]). Final visual acuity improved by two lines or more in 22 patients in group 1 and in 20 patients in group 2 (P = 0.317).

CONCLUSIONS

Our results indicate that primary rhegmatogenous RD can be successfully treated with scleral buckling without retinopexy.

Multifocal choroiditis after allogenic bone marrow transplantation

PURPOSE

To describe the clinical manifestations of multifocal choroiditis presumed to be secondary to allogenic bone marrow transplantation after development of self-tolerance to chronic graft-versus-host disease (GVHD).

METHODS

Case report. A 17-year-old male who received an allogenic bone marrow transplant (BMT) from his HLA-identical sister.

RESULTS

One year after BMT, grade II chronic GVHD developed. Two years later, vision deteriorated to 20/50 R.E. and 20/400 L.E. Ophthalmoscopic examination showed multiple chorioretinal punched-out scars throughout the posterior pole and mid-periphery of both eyes. Fluorescein angiography showed four choroidal neovascular membranes (CNVMs) in the right eye that were surgically removed, and a subfoveal disciform scar in the left eye.

CONCLUSIONS

Multifocal choroiditis is a possible complication related to allogenic BMT. It should be included as a late cause of BMT-associated choroidopathy. Surgical removal of vision-threatening CNVMs is a reasonable approach.

Diagnostic value of polymerase chain reaction in blood and aqueous humor in immunocompetent patients with ocular toxoplasmosis

PURPOSE

To evaluate the diagnostic value of polymerase chain reaction (PCR) in blood and aqueous humor samples from immunocompetent patients with reactivated ocular toxoplasmosis.

METHODS

Group 1 was composed of seven patients with a clinical diagnosis of reactivated ocular toxoplasmosis. Group 2 consisted of 33 controls. In each subject, blood and aqueous humor samples were obtained for detection of Toxoplasma gondii DNA by means of simple PCR, seminested PCR, and Southern blot hybridization.

RESULTS

Group 1: Simple PCR was positive in 3 of 7 blood samples (42%) and in 2 of 7 (28%) aqueous humor samples. Seminested PCR was positive in 4 of 7 (57%) blood samples and in 3 of 7 (42%) aqueous humor samples. Group 2: Simple and seminested PCR were positive in both samples in 2 of 33 (6%) and 4 of 33 (12%), respectively. Sensitivity 57% (18.41-90.10), specificity 87% (71.80-96.60); positive and negative likelihood ratio 4.38 and 0.49, respectively.

CONCLUSIONS

Polymerase chain reaction can be useful for confirming the diagnosis of ocular toxoplasmosis, especially in those eyes where fundus examination does not yield conclusive results. The detection of T. gondii DNA in blood suggests that reactivation of ocular toxoplasmosis cannot be considered a local event.

Treatment of multiple evanescent white dot syndrome with cyclosporine

PURPOSE

To report the seven-year follow-up of a patient with multiple evanescent white-dot syndrome (MEWDS).

METHODS

CASE REPORT

A 46-year-old woman presented recurrent episodes of bilateral MEWDS.

RESULTS

During the seven-year follow-up there were nine episodes of MEWDS. After four bouts in the first two, cyclosporine therapy was started. During two years of treatment there were no recurrences except when the dose was reduced or discontinued.

CONCLUSIONS

The etiology of MEWDS is still unknown but the absence of new episodes during cyclosporine treatment and the recurrence immediately after decreasing or discontinuing the drug suggests an autoimmune origin, with the involvement of cellular immunity in the pathogenic process.

Value of PCR for detection of Toxoplasma gondii in aqueous humor and blood samples from immunocompetent patients with ocular toxoplasmosis

Toxoplasma gondii infection is an important cause of chorioretinitis in the United States and Europe. Most cases of Toxoplasma chorioretinitis result from congenital infection. Patients are often asymptomatic during life, with a peak incidence of symptomatic illness in the second and third decades of life. Diagnosis is mainly supported by ophthalmological examination and a good response to installed therapy. However, establishment of a diagnosis by ophthalmological examination alone can be difficult in some cases. To determine the diagnostic value of PCR for the detection of T. gondii, 56 blood and 56 aqueous humor samples from 56 immunocompetent patients were examined. Fifteen patients with a diagnosis of ocular toxoplasmosis had increased serum anti-T. gondii immunoglobulin G levels but were negative for anti-T. gondii immunoglobulin M (group 1), and 41 patients were used as controls (group 2). Samples were taken before antiparasitic therapy was initiated, and only one blood sample and one aqueous humor sample were obtained for each patient. Single nested PCRs and Southern blot hybridization were performed with DNA extracted from these samples. The results obtained showed sensitivity and specificity values of 53. 3 and 83%, respectively. Interestingly, among all patients with ocular toxoplasmosis, a positive PCR result with the aqueous humor sample was accompanied by a positive PCR result with the blood sample. This result suggests that ocular toxoplasmosis should not be considered a local event, as PCR testing of blood samples from patients with ocular toxoplasmosis yielded the same result as PCR testing of aqueous humor samples. PCR testing may be useful for discriminating between ocular toxoplasmosis and other ocular diseases, and also can avoid the problems associated with ocular puncture.

Laser photocoagulation for macular soft drusen. Updated results

PURPOSE

To update the results of a study on the disappearance of macular soft drusen after laser treatment in the natural evolution of age-related macular degeneration.

METHODS

A total of 46 patients with confluent soft drusen and pigmentary changes were studied prospectively. Group 1 was composed of 30 patients with bilateral drusen; the authors randomly assigned one eye of each patient for treatment and the fellow eye for the control. In 16 patients a choroidal neovascular membrane was present in one eye, and treatment was applied to the fellow eye (group 2). Argon green laser treatment was applied directly to the soft drusen in the temporal macula.

RESULTS

All treated drusen disappeared in a mean of 3.5 months after treatment, and untreated drusen disappeared in all but three patients in an average of 8.5 months. After an average period of 3 years, only one control eye and none of the treated eyes in group 1 developed a choroidal neovascular membrane (P = 0.500). In group 2, neovascularization occurred in 18% of the patients. The initial improvement in Snellen acuity after subfoveal drusen disappearance diminished as a consequence of cataract progression.

CONCLUSIONS

Although no definitive conclusions should be made because of the small number of patients studied, results seem to show that this treatment does not reduce the risk of choroidal neovascularization in the treated eye of patients with a history of exudative disease in the fellow eye. It may be effective in patients with high-risk bilateral soft drusen, that is, in less advanced stages of the disease.

Famciclovir for the treatment of acute retinal necrosis (ARN) syndrome

PURPOSE

To document a case of acute retinal necrosis syndrome in an immunocompetent patient who was successfully treated with famciclovir after unsuccessful treatment with acyclovir.

METHODS

After diagnosing acute retinal necrosis syndrome in the patient's left eye, we treated him with 13 mg/kg/24 hours of intravenous acyclovir in three daily doses for 14 days, followed by 800 mg of acyclovir five times per day orally. New areas of retinitis developed within the posterior pole despite treatment with the maximum dosage of acyclovir; thus, we used a new antiviral agent, famciclovir.

RESULTS

When we administered 500 mg of famciclovir orally every 8 hours for 3 months, the retinitis regressed within 1 month, leaving atrophic granular pigmented scars.

CONCLUSION

Famciclovir can effectively treat acute retinal necrosis syndrome in immunocompetent patients.