Prognostic factors for visual acuity improvement after treatment of submacular hemorrhage secondary to exudative age-related macular degeneration

PURPOSE

To recognize prognostic factors for better final visual acuity (VA) in patients presenting with submacular hemorrhage (SMH) secondary to exudative age-related macular degeneration.

METHODS

This retrospective study included patients who presented to a tertiary ophthalmology department between 2012 and 2019 with SMH and were treated by pars plana vitrectomy (PPV) or injection of tissue plasminogen activator (tPA) with pneumatic displacement. Baseline characteristics included demographic data, VA and optical coherence tomography (OCT) characteristics of the SMH. Patients were divided into groups by improvement of at least 2 lines in BCVA (best corrected visual acuity), and by having a final BCVA better than 20/200.

RESULTS

Forty-three eyes of 43 patients were included. Mean age was 86.72 ± 7.18. Prognostic factors for final VA better than 20/200 included better VA at presentation (1.25 vs 1.90 logMAR, p < 0.001), smaller area of SMH in the infra-red image (19.47 mm2 vs 38.45 mm2, p = 0.024), and lower height of SMH as measured by OCT (713.5 µm vs 962.5 µm, p = 0.03). Third of the patients improved in ≥2 lines from presentation, all in the group of the pneumatic and TPA displacement.

CONCLUSION

Smaller SMHs with good VA at presentation have a better chance for improvement and result in a better final VA. These patients may benefit the most from pneumatic displacement of the SMH with intravitreal tPA and gas.

Minimally invasive micro sclerostomy (MIMS) procedure in the treatment of open-angle glaucoma

BACKGROUND

To evaluate the safety and efficacy of the Minimally Invasive Micro Sclerotomy (MIMS) procedure in the management of uncontrolled open-angle glaucoma.

METHODS

A prospective, open-label, single-arm clinical evaluation with intra-subject comparisons performed at the Ophthalmologic Center after S.V. Malayan, Yerevan, Armenia. Included were adults with primary open-angle glaucoma (OAG) (N = 114) or exfoliative glaucoma (N = 6) who were uncontrolled (IOP > 21) on tolerated topical medication. Mild (N = 7), moderate (N = 66) and severe (n = 47) cases were prospectively included without preselection. Following subconjunctival Mitomycin C, an ab-interno MIMS procedure was performed alone (N = 100) or combined with phacoemulsification (N = 20). Patients were followed for 52 weeks. Procedure-related complications and adverse events were recorded. Success criteria were defined as -5 < IOP ≤ 21mmHg OR a reduction in IOP of ≥ 20% from baseline with (qualified success) or without (complete success) hypotensive medications.

RESULTS

Mean patient age was 69 ± 10.1 years. The mean duration of the procedure was 2:01 ± 0:41 min:sec. Scleral drainage channels were achieved in all cases. No device malfunctions, intraoperative complications, or serious adverse events were reported. Iris plugging of the sclerostomy site and early spikes in IOP were the most common adverse events. The only reason for failure was final IOP > 21 mmHg on tolerated medication. At 52 weeks (n = 93), mean IOP decreased by 38% from baseline (P < 0.001), from 27.9 ± 3.7 to 17.5 ± 5.3 mmHg, a difference of 10.5 mmHg (95% CI: -11.7, -9.3). One-year qualified success was documented in 82.1% (95% CI: 72.9%,89.2%) of the patients and complete success, in 70.5% (60.3-79.4%). 60% (95 CI:49.4%,69.9%) of the patients achieved maximum IOP level of 14 mmHg or at least 30% reduction in IOP.

CONCLUSIONS

MIMS procedure is a relatively simple, short and safe minimally invasive bleb-forming procedure. Its efficacy, as found in this short-term evaluation, lends it suitable for mild and moderate uncontrolled open-angle glaucoma patients.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT04503590 2019-05-29.

Recurrent and chronic anterior uveitis: Long-term outcome and treatment strategies

PURPOSE

To study the long-term clinical outcome and treatment strategies of recurrent and chronic non-infectious anterior uveitis.

METHODS

Multicenter study of anterior uveitis patients from 2001 to 2022. Outcome measures included ocular complications, medical and surgical therapies, and visual acuity measured at the beginning of follow-up and at 1, 2, and 5 years thereafter.

RESULTS

In total, 76 patients were included, with a mean follow-up of 6.8 years. Idiopathic anterior uveitis was the most common etiology (56%). Immunomodulatory agents (IMAs) were used in almost half of the cohort. Early initiation of IMAs was associated with a lower risk of developing glaucoma ( P = 0.019). Mean best corrected visual acuity (BCVA) improved after 5 years in both groups. Early use of immunomodulation was correlated with a better visual outcome at 2 years ( P = 0.024).

CONCLUSION

Chronic and recurrent anterior uveitis were associated with greater risk than expected for ocular complications, surgeries, and vision impairment. Early initiation of immunomodulation should be strongly considered to improve clinical course and outcome.

Anatomical and Functional Outcomes with Prompt versus Delayed Initiation of Anti-VEGF in Exudative Age-Related Macular Degeneration

PURPOSE

To investigate the correlation between time from diagnosis of treatment-naïve exudative age-related macular degeneration (AMD) to the introduction of anti-VEGF treatment and anatomical and functional outcomes.

DESIGN

Retrospective cohort study.

METHODS

Included were treatment-naïve exudative AMD patients who presented to a single tertiary medical center between 2012 and 2018. All patients were treated within the first 30 days of their diagnosis with three monthly intravitreal injections of bevacizumab. Patients were divided into three groups: group 1 (prompt anti-VEGF) were injected with bevacizumab within ten days, group 2 (intermediate anti-VEGF) within 11-20 days, and group 3 (delayed anti-VEGF) within 21-30 days from diagnosis. Baseline characteristics and clinical outcomes were compared up to two years from treatment.

RESULTS

146 eyes of 146 patients were included. Sixty-eight patients were in the prompt anti-VEGF group, 31 in the intermediate anti-VEGF group, and 47 in the delayed anti-VEGF group. Following the induction phase of three intravitreal bevacizumab injections, the mean central subfield macular thickness (328.0 ± 115.4 µm vs. 364.6 ± 127.2 µm vs. 337.7 ± 150.1 µm, p = 0.432) and the best-corrected visual acuity (0.47 ± 0.38 vs. 0.59 ± 0.48 vs. 0.47 ± 0.44 logMAR units, p = 0.458) were comparable between the prompt, intermediate and delayed anti-VEGF groups. Anatomical and functional outcomes, treatment burden, number of relapses and eyes with second-line anti-VEGF therapy were comparable between the groups at both 1-year and 2-year timepoints.

CONCLUSIONS

Our real-world evidence data emphasize that even if anti-VEGF induction cannot be initiated promptly within ten days from diagnosis of naïve exudative AMD, the visual and anatomical prognosis of the patients may not worsen if the treatment is started within one month of diagnosis.

Post-refractive surgery of Israeli Defense Forces recruits in 2005-2018-prevalence, combat unit drop-out rates and utilization of eye-care services

PURPOSE

To assess the number of recruits for military service in the Israeli Defense Force (IDF) who underwent refractive surgery prior to enlistment and examine whether the procedure affected their ability to accomplish combat training.

SETTING

Medical records of IDF recruits.

DESIGN

Retrospective analysis of medical records of recruits with ametropia who underwent or did not undergo refractive surgery prior to enlistment.

METHODS

Recruits were categorized into ametropes and recruits who underwent refractive surgery. Fitness and assignment to combat units and completion status of combat training were compared between the two groups.

RESULTS

The study included 334,688 (182,969 males, 151,719 females) ametropes of which 5231 (4753 males, 478 females) underwent refractive surgery prior to recruitment. Refractive surgery prevalence increased from 9/1000 ametropes in 2005 to 18.5/1000 ametropes in 2018 (r = 0.912, p < 0.001); 2643 of the operated recruits (50.5%) had their surgery at the age of 17-18. Dropout rates from combat training were significantly lower in the refractive surgery group during the study period (1.68% vs. 6.14%, respectively, p < 0.001). Soldiers in the operated group were more frequently referred to ophthalmologists than those in the ametropes group and less frequently referred to optometrists.

CONCLUSIONS

The prevalence of refractive surgery in IDF recruits has increased substantially during the last decade with more of them applying to combat units. Refractive surgery opened new possibilities for recruits who were unfit for combat duty prior to surgery and did not appear to impair the chances of successfully completing combat training.

Academic benchmark of highly influential ophthalmologists listed in the ophthalmology power list

OBJECTIVE

To review the academic benchmark of highly influential ophthalmologists listed in the ophthalmology '2020 Power List'.

METHODS

In this cross-sectional study, the academic profiles, achievements, and bibliometric profiles of all ophthalmologists listed in the 'Power List of 2020', regarded as the most influential figures in ophthalmology today, were analysed.

RESULTS

Ninety-five ophthalmologists were studied, after excluding 10 non-ophthalmologist figures that are also listed. Their mean age is 63 ± 11.7 years, with a strong male predominance (84.2%, n = 80 males, P < 0.001). All have a medical doctorate degree, and 31% (n = 29) have a Philosophy Doctor (PhD) degree. Fifty-three percent (n = 51) are graduates of medical schools in the United States (US). However, non-US ophthalmologists have a higher percentage of PhD degrees (41%, 18/44) vs. US ophthalmologists (22%, 11/51, P = 0.069), and also a longer duration of post-residency training (5.8 ± 3.1 vs. 1.8 ± 0.9 years, P < 0.001). The most common subspecialty was cataract and anterior segment surgery (42%, n = 40). The mean and standard deviation of the total number of papers published by ophthalmologists were 307.4 ± 226.3, with a mean citation record of 11,835.7 ± 13,330.5, and a mean h-index of 46.9 ± 27.9.

CONCLUSIONS

The ophthalmologists listed on the 'Power List of 2020' are leaders with high accomplishments and an established interest in research evidenced by a high record of publications and an exceptional bibliometric profile. The list contains more US figures with a gender disparity, demonstrating a greater difficulty for international ophthalmologists, especially women, in achieving this high level of recognition.

Optical coherence tomography angiography patterns of type 1 macular neovascularization in age-related macular degeneration patients

PURPOSE

To compare morphologic characteristics of type 1 macular neovascularization (MNV) flow pattern in treatment-naïve and previously treated patients with age-related macular degeneration (AMD) as assessed by optical coherence tomography angiography (OCTA).

STUDY DESIGN

Cross-sectional study.

MATERIALS AND METHODS

Macular OCT angiography images were acquired using RTVue XR Avanti with AngioVue. Distinct morphologic biomarkers and quantifiable features of the neovascular membranes were studied on en-face projection images comparing treatment-naïve and previously treated patients.

RESULTS

The study included 68 eyes of 58 patients. Among them, 24 eyes were treatment-naïve, and the remaining eyes had received a mean of 19.6 injections. Immature lesions were more associated with treatment-naïve eyes and hyper-mature lesions were associated with previously treated eyes (p = 0.005). Tangle pattern was associated with treatment-naïve eyes (p = 0.013), whereas mature core vessels and sea fan pattern were associated more with previously treated eyes (p = 0.001 and p = 0.044, respectively). Vascular density of the neovascular membrane was higher in the treatment-naïve group (p = 0.036) and the average MNV area was similar between the 2 groups (p = 0.683).

CONCLUSIONS

Based on OCTA, morphologic biomarkers of type 1 MNV might be an indication of previous treatment. The MNV pattern can improve our understanding of its maturation under anti-VEGF treatment and might be valuable to better guide therapeutic decisions and provide more personalized care to patients with AMD.

Postoperative complications of combined phacoemulsification and pars plana vitrectomy in diabetic retinopathy patients

Purpose

To compare intra- and postoperative complications in combined phacoemulsification and pars plana vitrectomy surgeries performed in patients with non-proliferative diabetic retinopathy (NPDR) vs. proliferative diabetic retinopathy (PDR).

Methods

Retrospective, case series of patients with diabetic retinopathy who underwent combined phacovitrectomy surgery between 2008 and 2017. We compared intraoperative complications including posterior capsular rupture and retinal tear, and postoperative complications including corneal edema, macular edema (ME), epiretinal membrane (ERM), neovascular glaucoma and persistent inflammation.

Results

A total of 104 eyes of 104 patients were included in this study. Twenty-four eyes (23.1%) were categorized as NPDR and 80 eyes (76.9%) as PDR. The most common indications for surgery in the NPDR group were ERM (67%) and rhegmatogenous retinal detachment (12.5%), while in the PDR group, indications were vitreous hemorrhage (56%) and tractional retinal detachment (19%). The most common intraoperative complication was retinal tear (8% in NPDR and 19% in PDR, p = 0.195) and postoperative complication was ME (29% in NPDR and 26% in PDR, p = 0.778). There were no statistically significant differences in intra- and postoperative complication rates between the NPDR and PDR groups, even after adjusting for confounders; patient age at surgery and indication for surgery.

Conclusion

After combined phacovitrectomy in NPDR and PDR patients, new-onset ME was found in about a quarter of eyes in both groups. Intraoperative anti-VEGF or steroid administration, and intense postoperative anti-inflammatory medication and follow-up should be regarded after phacovitrectomy regardless of the DR level.

Where Did the Patients Go? The IDF Medical Corps Medical Services Experience during the COVID-19 Outbreak: Lessons Learned

BACKGROUND

Coronavirus disease 2019 (COVID-19) led to two nationwide lockdowns in Israel, reducing both supply and demand for medical services in the Israel Defense Force (IDF). IDF soldiers serve on bases within Israel, and most of them return home at the end of the day, similar to other armies in the world.

OBJECTIVES

To analyze the health services provided by the IDF with regard to policy changes during lockdowns.

METHODS

We compared medical encounters between different services provided by the IDF Medical Corps. We related them to specific time periods: pre-first lockdown, first lockdown (and corresponding timeframes of the previous 3 years), between lockdowns, second lockdown, and post-second lockdown.

RESULTS

Compared to past periods, we found a similar reduction of 27-30% in primary care medical encounter rates during the two lockdowns: 42-43% in sick days and 50-54% in referrals to the emergency department. Referral rates to all specialist medical encounters and elective surgeries decreased significantly during the first lockdown period and increased 1.2-3.5 times during the second lockdown.

CONCLUSIONS

A continuance of the shift to telehealth is required to withstand a future lockdown, with a full supply of secondary medical services attuned to core medical issues relevant for combat personnel. A liberal sick leave policy is required to eliminate unnecessary in-person visits, thus reducing the risk of infection.

Intravitreal Tissue Plasminogen Activator Injection for the Treatment of Proliferative Vitreoretinopathy in a Rabbit Model

INTRODUCTION

The purpose of this study was to evaluate the effect of intravitreal injection of tissue plasminogen activator (tPA) on proliferative vitreoretinopathy (PVR).

METHODS

PVR was induced in a rabbit model by intraocular injection of dispase (0.05 U/0.1 mL). Progression of PVR was followed by indirect ophthalmic examination. Following 6 weeks, 5 animals received intravitreal injection of 25 µg/0.1 mL tPA and four were injected with balanced salt solution (BSS). Animals were euthanized at 48 h following tPA/BSS injection, and eyes were enucleated for histological evaluation and staining with α-smooth muscle actin (αSMA) and Sirius Red.

RESULTS

Following tPA injection, one eye had a reduction in PVR from grade 2 to 1 and three eyes remained stable. Following BSS, PVR grade was unchanged in three eyes. In one eye in each group, the severity of PVR could not be assessed due to limited view. Staining with αSMA showed reduced presence of fibroblasts in eyes injected with tPA compared with those injected with BSS. Collagen type I and III, demonstrated by Sirius Red staining, was reduced in the tPA group in comparison with controls.

CONCLUSION

Our results suggest that intravitreally injected tPA may show an inhibitory effect on PVR progression. Further exploration in clinical trials is desired.

Thickness measurements taken with the spectralis OCT increase with decreasing signal strength

BACKGROUND

Optical coherence tomography (OCT) is used worldwide by clinicians to evaluate macular and retinal nerve fiber layer (RNFL) characteristics. It is frequently utilized to assess disease severity, progression and efficacy of treatment, and therefore must be reliable and reproducible.

OBJECTIVE

To examine the influence of signal strength on macular thickness parameters, macular volume measurement and RNFL thickness measured by spectral-domain optical coherence tomography (SD-OCT).

METHODS

Macular thickness parameters, macular volume measurement and RNFL thickness were measured by the Spectralis® OCT (Heidelberg Engineering, Heidelberg, Germany). In each eye, the focusing knob was adjusted to obtain 4 images with different signal strengths - Low (below 15), Moderate (15-20), Good (20-25) and Excellent (above 25). The relationship between signal strength and measured data was assessed using the mixed model procedure.

RESULTS

A total of 71 eyes of 41 healthy subjects were included. Central macular thickness, macular volume and mean RNFL thickness increased with decreasing signal strength. Specifically, eyes with excellent signal strength showed significantly thinner central macular thickness (p = 0.023), macular volume (p = 0.047), and mean RNFL thickness (p = 0.0139).

CONCLUSIONS

Higher signal strength is associated with lower macular thickness, macular volume and RNFL thickness measurements. The mean differences between excellent and low-quality measurements were small implicating that SD-OCT is a reliable imaging tool even at low quality scans. It is imperative that the physician compares the signal strength of all scans, as minute differences may alter results.

Functional and Structural Findings in Infants Treated for Retinopathy of Prematurity Using Optical Coherence Tomography Angiography

BACKGROUND AND OBJECTIVE

To assess the foveal microvascular structure of children with retinopathy of prematurity (ROP) treated with diode laser photocoagulation using optical coherence tomography angiography (OCTA).

PATIENTS AND METHODS

OCTA was performed at a tertiary medical center in 17 children (27 eyes) aged 4 to 16 years with a history of diode laser photocoagulation treated ROP. OCTA parameters were compared with those of 12 healthy age-matched controls (23 eyes) attending the orthoptics clinic and correlated with clinical factors.

RESULTS

Compared with controls, the ROP group had a smaller foveal avascular zone area (P < .001), lower deep vascular plexus density (P < .001), lower flow density (P = .025), and greater central macular thickness (P < .001). High intraventricular hemorrhage grade correlated with smaller foveal avascular zone area (P = .008) and greater inner macular thickness (P = .047). There was no impact of gestational age, birth weight, or refractive status.

CONCLUSION

OCTA can identify significant quantifiable long-term macular microvascular and structural changes in this patient population. [Ophthalmic Surg Lasers Imaging Retina. 2022;53(4):194-201.].

Minimally Invasive Micro Sclerostomy (MIMS) Procedure: A Novel Glaucoma Filtration Procedure

PRCIS

Intermediate-term results suggest that ab interno Minimally Invasive Micro Sclerostomy (MIMS) stent-less subconjunctival filtration procedure is a promising treatment option for patients with open-angle glaucoma (OAG).

PURPOSE

MIMS is a novel ab interno, stent-less, subconjunctival filtration procedure. This study set to investigate the safety, performance, and efficacy of MIMS in OAG patients.

METHODS

Prospective, open-label, single arm clinical trial with intrasubject comparisons. Study participants were adults with OAG who were candidates for a filtration procedure. Patients were operated by a single surgeon (A.A.) in Chennai, India. Following mitomycin-C pretreatment, ab interno MIMS procedure was performed alone or combined with phacoemulsification surgery. Procedure-related complications and adverse events were assessed. Primary outcomes: patients (%) achieving an intraocular pressure (IOP) ≥5 mm Hg and ≤18 mm Hg, and an IOP reduction of >20% as compared with baseline, with or without hypotensive medications, with no need for recurrent surgery.

RESULTS

Twenty-one phacoemulsification-MIMS and 10 standalone MIMS procedures were performed. Mean age was 63.94±6.33 years. Mean duration of MIMS was 1:58±0:25 (min:s). Scleral tunnels were achieved in all cases. No device malfunctions, intraoperative complications, or serious adverse events were reported. Five (16.12%) patients presented with iris clogging 1 to 24 weeks following procedure. Two were treated with laser and 3 required trabeculectomy. Mean IOP change from baseline at 24 weeks was 47.4% (31.2 to 16.4 mm Hg, P<0.0001, n=23). The mean difference was -14.8 mm Hg (95% confidence interval: -17.6, -11.9) with no statistically significant differences between groups. Qualified success was achieved in 21 (84%), 17 (74%), and 13 (93%) after 12, 24, and 52 weeks, respectively. Complete success was achieved in 17 (68%), 13 (57%), and 8 (57%) after 12, 24, and 52 weeks, respectively.

CONCLUSIONS

The interim results suggest that MIMS procedure may be a simple and effective surgical option for early OAG patients requiring target IOP in high teens although iris clogging of incision site is the major concern with this procedure.

WhatsApp Tele-Medicine - usage patterns and physicians views on the platform

BACKGROUND

Telemedicine has become an integral part of health care delivery in recent years. One of the leading applications for this use is WhatsApp - a free smartphone application that allows instant messaging with pictures and videos. This study analyzed the emerging role of WhatsApp on reducing the need for referrals to medical specialists and to compare the views of physicians regarding WhatsApp consultations.

METHODS

A cross-sectional study based on an anonymous web-survey was conducted among PCPs and medical specialists working in the Israel Defense Forces Medical-Corps during September and October, 2019.

RESULTS

Of 201 participants, 153 were PCPs and 48 were medical specialists. 86.9 % of PCPs and 86.5 % of specialists used WhatsApp every day in professional settings. Added workload, potential breaching of patient confidentiality and lack of full documentation of consultations were the main concerns among physicians using the application. 60.7 % of PCPs and 95.7 % of specialists stated that these consultations have reduced the need for in-person appointments at least once a week.

CONCLUSIONS

In times of COVID-19 that require social distancing, WhatsApp provides a simple, readily available platform for consultations between healthcare providers, even to the extent of rendering some in-person appointments unnecessary. Healthcare organizations should address the matters troubling healthcare providers, mainly patient confidentiality and lack of documentation in patients' medical records, while providing adequate compensation for those providing the service during and after work hours.

Ophthalmologists and WhatsApp: Teleophthalmology is already here

PURPOSE

To estimate the extent of WhatsApp utilization using text and media messages for inter-physician consultations among ophthalmologists (residents and specialists) at various clinical settings and its perceived benefits for ophthalmologists and their patients. We also aimed to detect obstacles that concern ophthalmologists when using WhatsApp as a consultation platform.

METHODS

This was a cross-sectional study using a self-administered survey through Google Forms, which was sent to 660 practicing ophthalmologists during April to May 2020.

RESULTS

One hundred and ninety-two ophthalmologists completed the questionnaire, 151 of which (78.6%) were specialists and 41 (21.4%) were residents. Most ophthalmologists reported using WhatsApp at least once a day for both personal and professional use. Residents reported lower rates of contacting patients using WhatsApp than specialists (1.51 ± 0.98 vs 2.72 ± 1.32, p < 0.001). Respondents reported WhatsApp consultations frequently replaced referrals of patients to other physicians, with a median of once a week. 97.8% of residents and 91.4% of specialists reported the ability to share media is a major advantage of WhatsApp over other medias, followed by rapid responses for consultations.

CONCLUSION

Many ophthalmologists already use WhatsApp as a tool for professional consultations with other providers, mainly thanks to its simplicity and wide availability. Residents use it more frequently than specialists, and ranked it higher when asked how much WhatsApp has improved the clinical setting. Policy makers should address concerns brought up by physicians, such as documentation in medical records and proper compensation for consulting ophthalmologists during and after work hours.

Changes in Prices and Eye-Care Providers Prescribing Patterns of Glaucoma Medications in the United States Between 2013 and 2019

PRECIS

Brand glaucoma medication prices vastly increased in the United States over the past 7 years, despite a reduction in eye-care providers' tendency to prescribe brand medications over generics.

PURPOSE

Determine the changes in prices of brand and generic glaucoma medications and to identify changes in eye-care providers prescribing patterns since 2013.

MATERIALS AND METHODS

The National Average Drug Acquisition Cost (NADAC) database (2013-2019) was used analyze per-unit drug price. Medicare Part D prescriber profile was used to identify eye-care providers prescribing patterns between 2013 and 2017.

RESULTS

Brand-name medication prices increased by 59% between 2013 and 2019, while generic medications decreased by 22%. Brand-name drugs were 13 to 162 times more expensive than their generic counterparts. Eye-care Providers prescribed 25% less brand name medications in 2017 compared with 2013.

CONCLUSION

Brand glaucoma medication prices vastly increased in the United States over the past 7 years, despite a reduction in eye-care providers' tendency to prescribe brand medications over generics. A change in government policy, allowing Medicare medication prices negotiations, could greatly reduce health expenditure on glaucoma treatment.