The Reinforced Treat-and-Extend Protocol for Exudative Age-Related Macular Degeneration: Retrospective Assessment of 24-Month Real-World Outcomes in France

INTRODUCTION

The aim of this work is to evaluate the real-world outcomes of the reinforced treat-and-extend (RTE) protocol for the treatment of exudative age-related macular degeneration with intravitreal injections of aflibercept or ranibizumab (anti-vascular endothelial growth factor therapies).

METHODS

This was a retrospective review of patients from two tertiary ophthalmology centers in France initiating the RTE protocol between February 2018 and June 2021. The primary outcome was change in best-corrected visual acuity (BCVA) after 24 months. Secondary outcomes were change in central retinal thickness (CRT), recurrence, and management-related factors (injection interval, number of injections/consultations). Outcomes were additionally evaluated after protocol changes (strict versus modified RTE protocol groups).

RESULTS

Sixty-eight patients (72 eyes) were included (68% females; mean age 82.2 ± 7.8 years). After 24 months, mean BCVA significantly improved (65.22 ± 14 vs. 71.96 ± 13 Early Treatment Diabetic Retinopathy Study letters; p < 0.001) and CRT significantly decreased (388.6 ± 104 vs. 278.8 ± 51 μM; p < 0.001) with 21% of eyes showing signs of exudation. Over the 24 months, a mean total of 14.9 ± 4.0 injections and 8.6 ± 1.4 consultations were performed. Mean 24-month injection interval was 7.9 ± 2.3 weeks. Initial and 24-month ophthalmic outcomes for eyes in the strict (47%) versus modified (53%) groups were not significantly different, but mean time interval to first recurrence of disease activity was significantly shorter for the modified group (7.3 ± 2.4 vs. 9.9 ± 2.5 weeks; p < 0.001). Patients in the strict RTE group received significantly less injections (13.9 ± 3.6 vs. 16.5 ± 3.9; p = 0.006) and mean 24-month injection interval was significantly longer (9.5 ± 2.7 vs. 6.5 ± 2.1 weeks; p < 0.001). Consultation number was similar (8.5 ± 1.9 vs. 8.8 ± 1.6; p = 0.93). Treatment with aflibercept versus ranibizumab did not influence ophthalmic or management outcomes.

CONCLUSIONS

The RTE protocol, even when modified, reduced consultations but improved ophthalmic outcomes. The RTE protocol could reduce hospital visits and overall burden while also encouraging better patient compliance. Video Abstract available for this article.

VIDEO ABSTRACT

Vincent Soler and François-Philippe Roubelat summarize the Reinforced Treat-and-Extend Protocol and main results (MP4 225022 KB).

[Limitations of outpatient vitreoretinal surgery at the Toulouse University hospital between 2016 and 2020: Causes for traditional hospitalization]

INTRODUCTION

Currently, the majority of patients undergoing vitreoretinal surgery (VRS) are managed on an outpatient basis; this has been made possible by major surgical and anesthetic advances over the past decades. Nevertheless, the conversion to "all outpatient" surgery still poses some problems that are interesting to identify, and traditional hospitalization remains the solution in many situations.

METHODS

All patients undergoing VRS at the Toulouse University Hospital between 2016 and 2020 were included retrospectively. For each patient, we analyzed the entire medical, anesthesia and demographic records. We performed a simple descriptive analysis of all parameters studied, followed by a bi-variate analysis between the "Outpatient/Hospitalization" parameter and all other parameters.

RESULTS

Three thousand patients were included over the study period; 79.4% of patients were managed on an outpatient basis compared to 20.6% by traditional hospitalization. Failure of ambulatory care was the cause of 41.9% of the traditional hospitalizations, with the absence of an accompanying person on the evening of the surgery being the main reason (47.8%).

DISCUSSION

Social isolation is found to be one of the main causes of failure of ambulatory care; improvements might be made at this level, in order to reduce the burden on the inpatient hospital system.

Use of the heads-up NGENUITY 3D Visualization System for vitreoretinal surgery: a retrospective evaluation of outcomes in a French tertiary center

Heads-up three-dimensional (3D) surgical visualization systems allow ophthalmic surgeons to replace surgical microscope eyepieces with high-resolution stereoscopic cameras transmitting an image to a screen. We investigated the effectiveness and safety of the heads-up NGENUITY 3D Visualization System in a retrospective evaluation of 241 consecutive vitreoretinal surgeries performed by the same surgeon using conventional microscopy (CM group) over a 1-year period versus the NGENUITY System (3D group) over a consecutive 1-year period. We included for study vitreoretinal surgeries for treatment of retinal detachment (RD) (98 surgeries), macular hole (MH) (48 surgeries), or epiretinal membrane (ERM) (95 surgeries). A total of 138 and 103 eyes were divided into 3D and CM groups, respectively. We found no differences in 3-month postoperative rates of recurrence of RD (10% versus 18%, p = 0.42), MH closure (82% versus 88%, p = 0.69), or decrease in central macular thickness of ERMs (134 ± 188 µm versus 115 ± 105 µm, p = 0.57) between the 3D and CM groups, respectively. Surgery durations and visual prognosis were also similar between both groups. We consolidate that the NGENUITY System is comparable in terms of visual and anatomical outcomes, giving it perspectives for integration into future robotized intervention.

[A series of 20 cases of endogenous endophthalmitis]

BACKGROUND

The purpose of this case series was to evaluate both the visual and systemic prognosis of patients with endogenous endophthalmitis.

MATERIAL AND METHODS

We reported a series of 20 cases of endogenous endophthalmitis occurring between 2012 and 2015 at the university medical center in Toulouse.

RESULTS

The mean age was 67 (±43.3) years with a male predominance (n=11). The site of entry was found in 14 cases (87.5%). In 11 cases (69%), the causative agent was a bacterium; a fungal infection was found in five cases. Visual acuity after maximal medical and surgical treatment was limited to "no light perception" in 7 cases (35%), "hand motion" in 2 cases (10%), "finger counting" in 3 cases (15%) and 10/10 in 2 cases (10%). One case had no final data. The main site of entry was found to be associated endocarditis (n=7), central venous line or venipuncture (n=6). The main local complications were retinal detachment (n=6), cataract (n=5) and choroidal neovascularization secondary to scarring (n=2).

CONCLUSIONS

Endogenous endophthalmitis is associated with poor visual prognosis. It is also often associated with systemic complications that may be life-threatening.

[Multimodal imaging in the diagnosis of acute macular neuroretinopathy]

INTRODUCTION

Acute macular neuroretinopathy is a retinal disease, usually presenting with a "normal fundus". Thus, this condition can be mistaken for optic neuropathy. Herein we present five clinical cases of patients affected with acute macular neuroretinopathy; one of them is a retrospective diagnosis while the others were diagnosed on initial examination. In the five cases, multimodal imaging with infrared photography and OCT helped to establish the diagnosis.

MATERIAL AND METHODS

Retrospective study of five clinical cases. Initial and final best visual acuities as well as infrared and OCT imaging were collected for all patients.

RESULTS

All patients initially reported a visual disturbance associated with a more or less severe decrease in visual acuity. Infrared imaging showed a dark, perifoveolar appearance of the lesions. In all cases, OCT images showed thickening and hyperreflectivity of the outer plexiform layer, extending towards the outer retinal layers.

CONCLUSION

Acute macular neuroretinopathy is a clinical entity that has been long-described, which now benefits widely from new imaging technologies, allowing an earlier and more accurate diagnosis, but calling into question the actual name of this condition. The exact pathophysiology of the condition remains nonetheless incompletely elucidated.

[Recurrent bilateral anterior uveitis due to Leishmania infantum in a patient with immune deficiency related to HIV infection: a case report and literature review]

We report the case of a 56-year-old patient, presenting with bilateral hypertensive anterior uveitis due to Leishmania infantum, in the setting of immune deficiency related to HIV infection. The etiology of the uveitis was diagnosed following detection of L. infantum DNA on anterior chamber paracentesis. Initially, the patient received an intravitreal injection of liposomal amphotericin B, systemic antiparasitic treatment, topical steroid and ocular hypotensive treatment. Due to unfavourable disease progression in the right eye, we re-evaluated the anti-inflammatory, antiretroviral and antiparasitic medications (beginning meglumine antimoniate): the uveitis in the left eye was thus able to be controlled. We followed the efficacy of treatment with weekly quantification of Leishmania DNA in the aqueous humor. Uveitis secondary to leishmaniasis is rare and serious. Physicians must be aware of this cause of uveitis, particularly in immunodeficient patients. The quantitation of Leishmania DNA in the aqueous humor is an indispensible tool for monitoring the disease.

[Intravitreal bevacizumab pretreatment in vitrectomy for severe diabetic retinopathy: a series of six cases]

INTRODUCTION

Bevacizumab (Avastin(®), Roche) is a full-length humanized monoclonal antibody applicable to all subtypes of vascular endothelial growth factor (VEGF). The purpose of this study was to report the results of its use as a surgical additive in severe cases of proliferative diabetic retinopathy (PDR).

PATIENTS AND METHOD

This retrospective study focused on six eyes of six patients with complicated diabetic retinopathy. A vitrectomy was performed within 13.6 days after an intravitreal bevacizumab injection of 0.1 mL (2.5mg), with dissection of the fibrovascular proliferation using a mono- or bimanual delamination technique.

RESULTS

The mean follow-up after intravitreal injection was 13.3 months. The mean surgery time was 64 minutes. The bimanual technique was not necessary. Only one iatrogenic retinal tear was repaired. The intraoperative bleeding was negligible. No adverse events resulting from the drug nor recurrence were observed throughout the follow-up period.

CONCLUSION

Intravitreal bevacizumab is useful as a surgical additive in severe cases of PDR, significantly improving surgical conditions. Nevertheless, its use beyond approved indications should be reserved for complex surgical cases.

[Pars plana vitrectomy, subretinal injection of recombinant tissue plasminogen activator and fluid-gas exchange in the management of massive submacular hemorrhages secondary to age-related macular degeneration]

INTRODUCTION

The natural prognosis of eyes with subretinal hemorrhage resulting from age-related macular degeneration is generally poor. A variety of therapeutic approaches have been developed but no consensus was found. Therefore, we evaluated a technique consisting of pars plana vitrectomy and subretinal rt-PA injection followed by evacuation of the liquid blood using sulfur hexafluoride (SF6).

PATIENTS AND METHODS

This study was a retrospective clinical case series examining 18 eyes of 16 patients with age-related macular degeneration and thick submacular hemorrhage treated with vitrectomy, subretinal injection of rt-PA (0.5mg), and fluid-gas exchange.

RESULTS

The subretinal hemorrhage was displaced in all 18 cases, revealing a choroidal lesion in 17 eyes. A treatable lesion accountable for the bleeding was identified in ten eyes, which all received a secondary treatment (intravitreal injection or photodynamic therapy). After a mean follow-up of 6 months, the final visual acuity improved in ten eyes. Complications consisted of one case of retinal detachment and one case of hyphema.

CONCLUSION

This surgical technique seems useful in displacing thick submacular hemorrhage secondary to age-related macular degeneration, allowing postoperative fluorescein angiography testing and, potentially, subsequent treatments. However, further controlled and multicentric studies will be required to assess its efficacy and safety in the management of this difficult clinical problem.

[Treatment of central retinal vein occlusion by isovolemic hemodilution]

PURPOSE

Evaluate the effects of hemodilution in the treatment of central retinal vein occlusion (CRVO).

PATIENTS AND METHODS

We carried out a retrospective, noncomparative study of 25 patients presenting unilateral CRVO, treated with one to three hemodilution sessions. The patients were re-examined in the 1st, 2nd, 3rd, 6th and 12th months following treatment with measurement of visual acuity, fluorescein angiography, and optical coherence tomography.

RESULTS

Our study included 17 men and eight women, averaging 63 years of age (range, 35-87 years), and monitored for an average of 7 months (range, 3-12 months). After the 6th month following treatment, average visual acuity improved compared to initial visual acuity. Initial visual acuity of less than 1/10, with the existence of poorly irrigated areas in the angiography, presented negative prognosis factors. The number of hemodilutions did not produce a significant difference in final visual acuity. No serious complications due to hemodilution were observed.

DISCUSSION

Treatment of CRVO is subject to debate. Some practitioners recommend against treatment, while others advocate intervention and offer laser-induced chorioretinal venous anastomosis. Surgical vitrectomy and radial optical neurotomy, with or without injection of triamcinolone, await evaluation. Hemodilution may offer a therapeutic approach to this pathology, in which the etiopathogenesis is not yet recognized, but in which blood viscosity plays a key role. This treatment is well tolerated.

CONCLUSION

Hemodilutions appear to have beneficial effects in treating CRVO, whatever the number of hemodilutions used. This study should be confirmed by a prospective study using an untreated control group.

[Management of complicated retinal detachment using a heavy silicon oil as temporary tamponade]

PURPOSE

To assess the efficacy and safety of a heavy silicon oil (a silicon oil-RMN3 mixture, a mixed fluorinated and hydrocarbonated olefin) as temporary internal tamponade in selected cases of retinal detachment with inferior breaks.

PATIENTS AND METHODS

Forty-six patients were operated on (inferior and/or posterior breaks: 38; proliferative vitreoretinopathy > or =C2: 18; anterior proliferative vitreoretinopathy: 14), with a mean follow-up of 39 months. Seventeen patients were operated on with a heavy silicon oil of a 1.03 g/cm3 density and 29 patients with a silicon oil of a 1.02 g/cm3 density. Heavy silicon oil was removed in 41 patients after a mean of 9.3 weeks.

RESULTS

Anatomic success was achieved in 35 cases after a mean follow-up of 39 months. Recurrent retinal detachment with proliferative vitreoretinopathy occurred in eight cases during heavy silicon oil tamponade. The removal was difficult in three cases with the 1.02 g/cm3 density silicon oil. Complications included glaucoma (eight eyes), major emulsification (two eyes), and an intraocular inflammation reaction to topical steroids (five eyes).

CONCLUSION

Heavy silicon oil (Oxane Hd) is as safe and effective as standard silicon oil in the treatment of selected retinal detachment, but intraocular manipulations are quite difficult. A prospective study is necessary to compare the efficacy of Oxane Hd and standard silicon oil in selected cases of retinal detachment with inferior breaks and in cases of large inferior retinectomy.

Particularités du traitement chirurgical du décollement de rétine du myope fort de plus de 10 dioptries et son risque hémorragique

INTRODUCTION

We report a series of 79 eyes undergoing primary surgery for rhegmatogenous retinal detachment associated with severe myopia greater than 10 diopters. Specific surgical procedures are recommended for these patients in order to minimize the high incidence of postoperative hemorrhagic complications.

MATERIALS AND METHODS

Seventy-nine eyes of 76 patients treated for retinal detachment with severe myopia greater than 10 diopters were reviewed. Scleral buckling was performed in 21 eyes and pars plana vitrectomy in 58 eyes.

RESULTS

After a mean follow-up period of 23.8 months, the final anatomical success rate was 93.7% (74 cases). Postoperative hemorrhagic complications (suprachoroidal hemorrhage and vitreous hemorrhage) occurred in four cases after scleral buckling and in ten cases after vitrectomy.

DISCUSSION

In this study, primary scleral buckling for retinal detachment was less frequently performed than vitrectomy. Broad scleral buckling may not be associated with higher postoperative hemorrhagic complications, when the buckle does not extend over six clock hours. Postoperative hemorrhagic complications also occurred after vitrectomy; however, scleral buckling associated with vitrectomy does not seem to increase the complication rate.

CONCLUSION

This retrospective study of 79 cases of rhegmatogenous retinal detachment with severe myopia higher than 10 diopters suggests that vitrectomy is often considered a primary procedure. Broad scleral buckling associated with vitrectomy is a safe and effective procedure, with an acceptable incidence of complications when not extending over six clock hours.

[Surgical treatment of inferior retinal detachment: advantages of postoperative traction of the right inferior muscle]

AIM

To evaluate the advantages of keeping the right inferior muscle in traction during external surgery for inferior retinal detachment.

PATIENTS AND METHODS

This was a prospective study involving ten patients consecutively operated on for rhegmatogenous retinal detachment at the Toulouse-Rangueil Teaching Hospital. Internal plugging by air or a C2F6-air mixture was systematically performed, together with external indentation and total subretinal fluid puncture. At the end of surgery, a 2.0 silk thread was set beneath the right inferior muscle and kept in traction from the forehead for a few days. The patient was maintained feet up, in a dorsal decubitus posture.

RESULTS

Results proved excellent, with ten anatomical successes. However, one patient had to have gas reinjected and in another subretinal fluid persisted for 3 months.

DISCUSSION

The risk of surgical failure in inferior retinal detachment is greater because dabbing is more difficult to perform. To make this dabbing easier, we propose maintaining the ocular globe rearward by maintaining traction on the right inferior muscle, which produced excellent results.

CONCLUSION

The technique proposed is easy to perform, and combined with internal dabbing and adequate patient positioning, it should help improve the surgical outcome of inferior retinal detachments.

Décollement de rétine par déchirure inférieure, facteur de mauvais pronostic ?

AIM

To determine whether a lower location of retinal wounds is a factor for poor prognosis in retinal detachment.

PATIENTS AND METHOD

This retrospective study involved 248 medical records of patients who were operated on for retinal detachment in 2001 at the Toulouse-Rangueil Hospital Ophthalmology Department. We excluded retinal detachment of very short-sighted patients, diabetic patients and detachment secondary to trauma or relapses. We compared the incidence of surgical failure according to various parameters: condition of the crystalline lens, operative technique, operator, vitreoretinal proliferation, retinal wound location, patient age and the operative side. Thirty-six patients presented with lower wounds; 17 patients obtained incomplete results and relapsed within 1 year of surgery.

RESULTS

Vitreoretinal proliferation and inferior location of the retinal detachment were found to be poor prognostic factors. No significant differences were found between the other parameters studied.

DISCUSSION

A variety of prognostic factors of retinal detachment surgery are now clearly identified (vitreoretinal proliferation, old detachment). A lower location of the detachment constitutes an additional difficulty for retinal applications. Indeed, it is more difficult to perform effective buffering in this type of case. We recommend that retinal detachment be operated internally, to reduce the risk of relapse.

CONCLUSION

An inferior location of the retinal wound during retinal detachment appears to be a factor of poor prognosis, but this remains to be ascertained through an ongoing, prospective study.

[Retinal complications of cataract surgery]

Main retinal complications of cataract extraction are retinal detachment and cystoid macular edema. The incidence of retinal detachment after ex traction is 1 %, and may increase after Nd: YAG laser capsulotomy to 4 %. Cystoid macular edema in aphakic or pseudophakic patients is unusually transient, with a decrease of visual acuity in about 3 % of cases; a long lasting cystoid macular edema with prolonged visual deficiency is described in only 1 % of cases. The incidence of photic macular injuries is estimated at between 7 and 28 % of cases; most photoretinal injuries are asymptomatic or minimally symptomatic because of their extrafoveolar location. Finally, the visual prognosis after cataract surgery is poor in diabetic patients, because of the frequency of cystoid macular edema and progression of diabetic retinopathy.