Home Optical Coherence Tomography Monitoring for Neovascular Age-Related Macular Degeneration: Transformative Technology or Cool Toy?

The pending introduction of home-based optical coherence tomography (OCT) in managing neovascular age-related macular degeneration (nAMD) has sparked interesting debates. Advocates assert that home-based OCT will revolutionize care of patients with nAMD, while skeptics question its real-world viability and point out its potential drawbacks. This article delves into the dichotomy, presenting the "pro" argument highlighting the transformative potential of home OCT and the "con" perspective, which scrutinizes the limitations and challenges to adapting the technology to the real-world setting. By exploring both sides of the discourse, we aim to address the promises and complexities surrounding the role of home OCT in the management of nAMD.

SUSTAINED BIWEEKLY AFLIBERCEPT FOR REFRACTORY NEOVASCULAR AGE-RELATED MACULAR DEGENERATION: The Prospective TRISTAR Study

PURPOSE

To assess the safety and efficacy of biweekly (every 2 weeks) intravitreal aflibercept injections (IAI) 2 mg in eyes with refractory neovascular age-related macular degeneration (NVAMD).

METHODS

A prospective, single-arm, interventional study was conducted. Eyes with refractory NVAMD received six biweekly IAIs through week 12, followed by a 4-week treatment pause until week 16. Eyes with residual subretinal fluid (SRF) at week 16 were randomized 1:1 to either four additional biweekly IAIs or to 4-week (q4W) IAI dosing through week 24. All eyes were subsequently treated q4W through week 52.

RESULTS

Enrolled eyes (n = 22) had persistent SRF despite a mean of 11.8 injections over the prior 12 months. One patient developed endophthalmitis at week 12. There were no additional drug/procedure-related adverse events. Best-corrected visual acuity (BCVA) improved significantly from baseline to week 14 (2.52 letters, P < 0.001). The mean central subfield thickness (CST) was also significantly improved at week 14 (-31.9 µ m, P < 0.001) with eight of 22 eyes achieving complete SRF resolution. Only two of eight eyes remained free of SRF at week 16, with a corresponding increase in mean CST of 26.7 µ m compared with week 14. By week 52, improvements in BCVA and CST were lost.

CONCLUSION

In patients with refractory NVAMD-related SRF, sustained biweekly IAIs resulted in significant functional and anatomical improvements during biweekly dosing. These gains, however, were lost on return to monthly dosing. These findings suggest that efforts to reduce refractory SRF in NVAMD with biweekly dosing may provide added benefit compared with standard of care treatment if biweekly dosing is sustained.

A Comparison of Peel-Induced Maculopathy Following ILM Peeling Using a Microvacuum Pick Versus Forceps

OBJECTIVE

To compare peel-induced maculopathy (PIM) using surgical forceps versus the microvacuum pick (MVP).

METHODS

Consecutive eyes undergoing internal limiting membrane (ILM) peeling using either the MVP or forceps were assessed. En face optical coherence tomography (OCT) images at the level of the nerve fiber layer were generated for 6-month postoperative visit. The percentage of the imaged area showing PIM was termed the PIM index. PIM severity was additionally measured using a qualitative PIM severity scale.

RESULTS

Seventy-four consecutive eyes underwent ILM peeling with either the MVP (36/74; 49%) or forceps (38/74; 51%). At month-6 postoperatively, the mean PIM index for forceps was 7.7% vs 4.7% for the MVP (P < 0.001, R² = 0.15). At 6 months, 26/38 eyes (68.5%) in the forceps group had either moderate or severe PIM compared to 12/36 eyes (33.3%) in the MVP group (P = 0.001).

CONCLUSIONS

ILM peeling with the MVP resulted in lower PIM severity compared to forceps. [Ophthalmic Surg Lasers Imaging Retina 2023;54:37-42.].

Brolucizumab-associated intraocular inflammation in eyes without retinal vasculitis

Purpose

To analyze a series of eyes with brolucizumab-associated intraocular inflammation (IOI) without retinal vasculitis reported to the American Society of Retina Specialists (ASRS).

Methods

The ASRS Research and Safety in Therapeutics (ReST) Committee analyzed clinical characteristics from submitted reports of IOI after brolucizumab. Eyes with retinal vasculitis or that received intraocular antibiotics were excluded.

Results

Forty-nine eyes of 45 patients were collected. Mean visual acuity (VA) at baseline was 20/49 (range 20/20 - 5/200). Patients presented with IOI a mean of 24 (range 3-63) days after most recent brolucizumab injection; 61% presented for an unscheduled visit while 39% presented at routine follow-up. Mean VA at IOI presentation was 20/67 (range 20/20 - 3/200). Most common symptoms were floaters (78%) and blurry vision (76%). Pain (20%) and redness (16%) were less common; 3 (6%) eyes were asymptomatic. IOI was anterior only in 18%, posterior only in 31%, and both anterior and posterior in 51% of eyes. Treatment included topical steroids alone in 67% eyes, while 10% eyes received no treatment. Mean VA at last follow-up was 20/56 (range 20/20 - 1/200). Three (6%) eyes lost 3 or more lines and 1 (2%) eye lost 6 or more lines.

Conclusions

Brolucizumab-associated IOI without retinal vasculitis typically presented with a delayed onset of a few weeks. Often, visual acuity decline was relatively mild. Most symptoms resolved and nearly all had a return to baseline VA, but a small percentage of patients had a significant decrease in VA at last follow-up.

Occlusive Retinal Vasculitis Following Intravitreal Brolucizumab

Purpose

To analyze a case series of retinal vasculitis reported to the American Society of Retina Specialists (ASRS) following Food and Drug Administration approval of brolucizumab for treatment of neovascular age-related macular degeneration.

Methods

The ASRS Research and Safety in Therapeutics Committee analyzed clinical and imaging characteristics from submitted reports of retinal vasculitis after brolucizumab.

Results

Retinal vasculitis was reported in 26 eyes of 25 patients (22 [88%] female) after treatment with brolucizumab. Imaging studies were available for 24 of 26 eyes. Most cases (92%) were associated with intraocular inflammation, which presented at a mean of 25 days (range, 3-63 days) after the most recent brolucizumab injection. Mean visual acuity (VA) was 20/52 (range, 20/25-4/200) before the adverse event, 20/151 (range, 20/25-hand motion) at presentation of the adverse event, and 20/243 (range, 20/30-light perception) at last follow-up. Twelve eyes (46%) had a greater than 3-line decrease in VA at final follow-up, and 12 eyes (46%) had a final VA of 20/200 or worse. Analysis of retinal imaging identified vasculopathy that involved retinal arteries (91%), retinal veins (79%), and choroidal vessels (48%). Occlusive disease was apparent on imaging in 83% of eyes. Treatment approaches were varied.

Conclusions

Retinal vasculitis has been identified in a series of eyes following brolucizumab. Although a few eyes in this series were asymptomatic or minimally symptomatic, some eyes had significant vision loss. A careful examination for signs of active inflammation prior to brolucizumab injection is recommended. Once vasculopathy is suspected, angiographic imaging may help define the spectrum of involvement. Optimal treatment strategies remain unknown.

Reported Complications Following Laser Vitreolysis

Importance

Use of laser vitreolysis for symptomatic floaters has increased in recent years, but prospective studies are not available and the complication profile is poorly understood.

Objective

To analyze cases of complications following laser vitreolysis as voluntarily reported to the American Society of Retina Specialists Research and Safety in Therapeutics (ASRS ReST) Committee, an independent task force formed to monitor device-related and drug-related safety events.

Design, Setting, and Participants

A retrospective assessment was performed of all cases of complications following laser vitreolysis that were voluntarily reported by practitioners throughout the United States to the ASRS ReST Committee from the first report on September 19, 2016, through March 16, 2017, the date of data analysis and manuscript writing.

Main Outcomes and Measures

Complications reported to the ASRS ReST Committee following laser vitreolysis were analyzed by type to gain an understanding of the spectrum of potential complications.

Results

A total of 16 complications following laser vitreolysis were reported in 15 patients by 7 US vitreoretinal specialists during the study period. Complications included elevated intraocular pressure leading to glaucoma; cataracts, including posterior capsule defects requiring cataract surgery; retinal tear; retinal detachment; retinal hemorrhages; scotomas; and an increased number of floaters.

Conclusions and Relevance

This report presents a spectrum of complications reported to the ASRS ReST Committee across 6 months. The rate of complications cannot be determined because the denominator of total cases is unknown. Also, these findings cannot determine whether there is a causal association between these complications and laser vitreolysis. Prospective studies are warranted to better understand the efficacy of this procedure and the frequency of attendant complications. Until then, practitioners should be aware of the profile of potential complications to properly inform patients during the consent process. The ASRS ReST Committee will continue to monitor device-related and drug-related adverse events and encourages active surveillance and reporting by all physicians.

Retained Intraocular Perfluoro-n-octane After Valved Cannula Pars Plana Vitrectomy for Retinal Detachment

BACKGROUND AND OBJECTIVE

To investigate cases of retained intraocular perfluoro-n-octane (PFO) after pars plana vitrectomy (PPV) for retinal detachment (RD).

PATIENTS AND METHODS

Retrospective, noncomparative case series of six eyes with retained intraocular PFO after RD repair. Clinical data were supplemented with an experimental silicone eye model.

RESULTS

A cluster of six cases of retained intraocular PFO after PPV for RD repair were noted shortly after transitioning to valved cannulas. PFO was noted in the anterior chamber (AC) and/or vitreous and removed with AC paracentesis, AC wash-out, and/or PPV. A silicone eye model demonstrated that PFO levels are maintained anterior to cannula insertion with valved cannulas only.

CONCLUSION

The authors hypothesize that anterior PFO fill using valved cannulas can lead to sequestration within the AC, zonules, ciliary sulcus, ciliary teeth, and/or capsular bag. They suggest vigilance in not overfilling PFO, particularly when transitioning to use of valved cannulas, to minimize the risk of intraocular retention.

Reduced fluorescein angiography and fundus photography use in the management of neovascular macular degeneration and macular edema during the past decade

PURPOSE

We assessed recent trends in the use of diagnostic testing for neovascular age-related macular degeneration (NVAMD) and macular edema (ME).

METHODS

Claims data from a managed-care network were analyzed on patients with NVAMD (n = 22,954) or ME (n = 31,810) to assess the use of fluorescein angiography (FA), fundus photography (FP), and optical coherence tomography (OCT) from 2001 to 2009. Repeated-measures logistic regression was performed to compare patients' odds of undergoing these procedures in 2001, 2005, and 2009. In addition, the proportions of patients with an incident NVAMD or ME diagnosis in 2003 or 2008 who underwent FA, FP, and OCT were compared.

RESULTS

From 2001 to 2009, among patients with NVAMD, the odds of undergoing OCT increased 23-fold, whereas the odds of receiving FA and FP decreased by 68% and 79%, respectively. Similar trends were observed for ME. From 2003 to 2008, the proportion of patients undergoing OCT within 1 year of initial diagnosis increased by 315% for NVAMD and by 143% for ME; the proportion undergoing OCT without FA within 1 year increased by 463% for NVAMD and by 216% for ME.

CONCLUSIONS

Use of OCT increased dramatically during the past decade, whereas use of FA and FP declined considerably, suggesting that OCT may be replacing more traditional diagnostic testing in patients with NVAMD or ME. Future studies should evaluate whether this increased reliance on OCT instead of FA and FP affects patient outcomes.

Repair of Primary Noncomplex Rhegmatagenous Retinal Detachment

With the development of pars plana vitrectomy in the 1970s and pneumatic retinopexy in the 1980s, the primacy of scleral buckling for repair of rhegmatogenous retinal detachment (RRD) came under challenge. While a degree of consensus exists for certain forms of complex RRD, there remains little agreement concerning the optimal treatment of primary noncomplex RRD. This debate is further muddied by application of adjuvant procedures to supplement the primary surgical approach. This article aims to present the current evidence regarding repair of primary noncomplex RRD. A brief summary of primary surgical approaches—pneumatic retinopexy, scleral buckling, and pars plana vitrectomy—will be presented along with a short discussion on potential adjuvant procedures. The remainder of the article focuses on reported outcomes for the different treatment modalities for primary noncomplex RRD.

Emerging nonsurgical methods for the treatment of vitreomacular adhesion: a review

With the dissemination of optical coherence tomography over the past two decades, the role of persistent vitreomacular adhesion (VMA) in the development of numerous macular pathologies - including idiopathic macular hole, vitreomacular traction syndrome, cystoid and diabetic macular edema, neovascularization in diabetic retinopathy and retinal vein occlusion, exudative age-related macular degeneration, and myopic traction maculopathy - has been established. While invasive vitreoretinal procedures have long been utilized to address complications related to these disorders, such an approach is hampered by incomplete vitreoretinal separation and vitreous removal, surgical complications, and high costs. In light of such limitations, investigators have increasingly looked to nonsurgical means for the treatment of persistent pathologic VMA. Chief among these alternative measures is the intravitreal application of pharmacologic agents for the induction of vitreous liquefaction and/or vitreoretinal separation, an approach termed pharmacologic vitreolysis. This article aims to review the available evidence regarding the use of pharmacologic agents in the treatment of VMA-related pathology. In addition, a discussion of vitreous molecular organization and principles of physiologic posterior vitreous detachment is provided to allow for a consideration of vitreolytic agent mode of action and molecular targets.

Lubricant degradation and related wear of a steel pin in lubricated sliding against a steel disc

In lubricated sliding contacts, components wear out and the lubricating oil ages with time. The present work explores the interactive influence between lubricant aging and component wear. The flat face of a steel pin is slid against a rotating steel disk under near isothermal conditions while the contact is immersed in a reservoir of lubricant (hexadecane). The chemical changes in the oil with time are measured by vibrational spectroscopy and gas chromatography. The corresponding chemistry of the pin surface is recorded using X-ray photoelectron spectroscopy while the morphology of the worn pins; surface and subsurface, are observed using a combination of focused ion beam milling and scanning electron microscopy. When compared to thermal auto-oxidation of the lubricant alone, steel on steel friction and wear are found to accentuate the decomposition of oil and to reduce the beneficial impact of antioxidants. The catalytic action of nascent iron, an outcome of pin wear and disk wear, is shown to contribute to this detrimental effect. Over long periods of sliding, the decomposition products of lubricant aging on their own, as well as in conjunction with their products of reaction with iron, generate a thick tribofilm that is highly protective in terms of friction and wear.