1
|
Wolf RM, Liu TYA, Thomas C, Prichett L, Zimmer-Galler I, Smith K, Abramoff MD, Channa R. The SEE Study: Safety, Efficacy, and Equity of Implementing Autonomous Artificial Intelligence for Diagnosing Diabetic Retinopathy in Youth. Diabetes Care 2021; 44:781-787. [PMID: 33479160 DOI: 10.2337/dc20-1671] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 12/23/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Diabetic retinopathy (DR) is a leading cause of vision loss worldwide. Screening for DR is recommended in children and adolescents, but adherence is poor. Recently, autonomous artificial intelligence (AI) systems have been developed for early detection of DR and have been included in the American Diabetes Association's guidelines for screening in adults. We sought to determine the diagnostic efficacy of autonomous AI for the diabetic eye exam in youth with diabetes. RESEARCH DESIGN AND METHODS In this prospective study, point-of-care diabetic eye exam was implemented using a nonmydriatic fundus camera with an autonomous AI system for detection of DR in a multidisciplinary pediatric diabetes center. Sensitivity, specificity, and diagnosability of AI was compared with consensus grading by retinal specialists, who were masked to AI output. Adherence to screening guidelines was measured before and after AI implementation. RESULTS Three hundred ten youth with diabetes aged 5-21 years were included, of whom 4.2% had DR. Diagnosability of AI was 97.5% (302 of 310). The sensitivity and specificity of AI to detect more-than-mild DR was 85.7% (95% CI 42.1-99.6%) and 79.3% (74.3-83.8%), respectively, compared with the reference standard as defined by retina specialists. Adherence improved from 49% to 95% after AI implementation. CONCLUSIONS Use of a nonmydriatic fundus camera with autonomous AI was safe and effective for the diabetic eye exam in youth in our study. Adherence to screening guidelines improved with AI implementation. As the prevalence of diabetes increases in youth and adherence to screening guidelines remains suboptimal, effective strategies for diabetic eye exams in this population are needed.
Collapse
Affiliation(s)
- Risa M Wolf
- Division of Endocrinology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - T Y Alvin Liu
- Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, MD
| | - Chrystal Thomas
- Division of Endocrinology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Laura Prichett
- Biostatistics, Epidemiology, and Data Management Core, Johns Hopkins School of Medicine, Baltimore, MD
| | | | - Kerry Smith
- Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, MD
| | - Michael D Abramoff
- Department of Ophthalmology and Visual Sciences, The University of Iowa, Iowa City, IA.,IDx, Coralville, IA.,Iowa City VA Medical Center, Iowa City, IA.,Department of Biomedical Engineering, The University of Iowa, Iowa City, IA.,Department of Electrical and Computer Engineering, The University of Iowa, Iowa City, IA
| | - Roomasa Channa
- Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, MD .,Department of Ophthalmology and Visual Sciences, University of Wisconsin, Madison, WI
| |
Collapse
|
2
|
Horton MB, Brady CJ, Cavallerano J, Abramoff M, Barker G, Chiang MF, Crockett CH, Garg S, Karth P, Liu Y, Newman CD, Rathi S, Sheth V, Silva P, Stebbins K, Zimmer-Galler I. Practice Guidelines for Ocular Telehealth-Diabetic Retinopathy, Third Edition. Telemed J E Health 2020; 26:495-543. [PMID: 32209018 PMCID: PMC7187969 DOI: 10.1089/tmj.2020.0006] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 01/11/2020] [Accepted: 01/11/2020] [Indexed: 12/24/2022] Open
Abstract
Contributors The following document and appendices represent the third edition of the Practice Guidelines for Ocular Telehealth-Diabetic Retinopathy. These guidelines were developed by the Diabetic Retinopathy Telehealth Practice Guidelines Working Group. This working group consisted of a large number of subject matter experts in clinical applications for telehealth in ophthalmology. The editorial committee consisted of Mark B. Horton, OD, MD, who served as working group chair and Christopher J. Brady, MD, MHS, and Jerry Cavallerano, OD, PhD, who served as cochairs. The writing committees were separated into seven different categories. They are as follows: 1.Clinical/operational: Jerry Cavallerano, OD, PhD (Chair), Gail Barker, PhD, MBA, Christopher J. Brady, MD, MHS, Yao Liu, MD, MS, Siddarth Rathi, MD, MBA, Veeral Sheth, MD, MBA, Paolo Silva, MD, and Ingrid Zimmer-Galler, MD. 2.Equipment: Veeral Sheth, MD (Chair), Mark B. Horton, OD, MD, Siddarth Rathi, MD, MBA, Paolo Silva, MD, and Kristen Stebbins, MSPH. 3.Quality assurance: Mark B. Horton, OD, MD (Chair), Seema Garg, MD, PhD, Yao Liu, MD, MS, and Ingrid Zimmer-Galler, MD. 4.Glaucoma: Yao Liu, MD, MS (Chair) and Siddarth Rathi, MD, MBA. 5.Retinopathy of prematurity: Christopher J. Brady, MD, MHS (Chair) and Ingrid Zimmer-Galler, MD. 6.Age-related macular degeneration: Christopher J. Brady, MD, MHS (Chair) and Ingrid Zimmer-Galler, MD. 7.Autonomous and computer assisted detection, classification and diagnosis of diabetic retinopathy: Michael Abramoff, MD, PhD (Chair), Michael F. Chiang, MD, and Paolo Silva, MD.
Collapse
Affiliation(s)
- Mark B. Horton
- Indian Health Service-Joslin Vision Network (IHS-JVN) Teleophthalmology Program, Phoenix Indian Medical Center, Phoenix, Arizona
| | - Christopher J. Brady
- Division of Ophthalmology, Department of Surgery, Larner College of Medicine, University of Vermont, Burlington, Vermont
| | - Jerry Cavallerano
- Beetham Eye Institute, Joslin Diabetes Center, Massachusetts
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Michael Abramoff
- Department of Ophthalmology and Visual Sciences, The University of Iowa, Iowa City, Iowa
- Department of Biomedical Engineering, and The University of Iowa, Iowa City, Iowa
- Department of Electrical and Computer Engineering, The University of Iowa, Iowa City, Iowa
- Department of Ophthalmology, Stephen A. Wynn Institute for Vision Research, The University of Iowa, Iowa City, Iowa
- Iowa City VA Health Care System, Iowa City, Iowa
- IDx, Coralville, Iowa
| | - Gail Barker
- Arizona Telemedicine Program, The University of Arizona, Phoenix, Arizona
| | - Michael F. Chiang
- Department of Ophthalmology, Casey Eye Institute, Oregon Health and Science University, Portland, Oregon
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon
| | | | - Seema Garg
- Department of Ophthalmology, University of North Carolina, Chapel Hill, North Carolina
| | | | - Yao Liu
- Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison, Madison, Wisconsin
| | | | - Siddarth Rathi
- Department of Ophthalmology, NYU Langone Health, New York, New York
| | - Veeral Sheth
- University Retina and Macula Associates, University of Illinois at Chicago, Chicago, Illinois
| | - Paolo Silva
- Beetham Eye Institute, Joslin Diabetes Center, Massachusetts
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Kristen Stebbins
- Vision Care Department, Hillrom, Skaneateles Falls, New York, New York
| | | |
Collapse
|
3
|
Iftikhar M, Mir TA, Hafiz G, Zimmer-Galler I, Scott AW, Solomon SD, Sodhi A, Wenick AS, Meyerle C, Jiramongkolchai K, Liu TYA, Arevalo JF, Singh M, Kherani S, Handa JT, Campochiaro PA. Loss of Peak Vision in Retinal Vein Occlusion Patients Treated for Macular Edema. Am J Ophthalmol 2019; 205:17-26. [PMID: 30954469 PMCID: PMC10019499 DOI: 10.1016/j.ajo.2019.03.029] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 03/26/2019] [Accepted: 03/27/2019] [Indexed: 01/14/2023]
Abstract
PURPOSE To evaluate long-term visual and anatomic outcomes in patients with retinal vein occlusion (RVO) treated with anti-vascular endothelial growth factor (VEGF) agents. DESIGN Prospective, interventional case series. PARTICIPANTS Patients with central RVO (CRVO) or branch RVO (BRVO). METHODS Number of anti-VEGF injections and improvement from baseline best-corrected visual acuity (BCVA) and central subfield thickness (CST) were prospectively recorded in 40 eyes of 39 CRVO patients and 50 eyes of 47 BRVO patients. RESULTS Mean follow-up was 58 months for BRVO and 78 months for CRVO. Within 6 months of last follow-up, 58% of BRVO patients and 75% of CRVO patients required anti-VEGF injections to control edema. Analysis of the course of each patient over time showed that for BRVO patients, BCVA letter score increased by a mean of 24, from baseline of 52 (20/100) to peak of 76 (20/32), and subsequently decreased by 13, to 63 (20/50), at final visit; and for CRVO patients, BCVA letter score increased by a mean of 26, from baseline of 48 (20/100) to peak of 74 (20/32), and subsequently decreased by 18, to 56 (20/80), at last follow-up. Loss from peak BCVA occurred primarily owing to persistent/recurrent edema and related foveal damage. CONCLUSIONS Patients with RVO showed large improvements in BCVA after initiation of anti-VEGF injections, but in many patients some visual gains were lost over time owing to bouts of recurrent edema. Sustained suppression of VEGF may help to provide optimal outcomes in RVO and reduce treatment burden.
Collapse
Affiliation(s)
- Mustafa Iftikhar
- Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland, USA
| | - Tahreem A Mir
- Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland, USA
| | - Gulnar Hafiz
- Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Adrienne W Scott
- Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sharon D Solomon
- Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland, USA
| | - Akrit Sodhi
- Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland, USA
| | - Adam S Wenick
- Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland, USA
| | - Catherine Meyerle
- Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - T Y Alvin Liu
- Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland, USA
| | - J Fernando Arevalo
- Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland, USA
| | - Mandeep Singh
- Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland, USA
| | - Saleema Kherani
- Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland, USA
| | - James T Handa
- Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland, USA
| | | |
Collapse
|
4
|
Campochiaro PA, Mir TA, Han YS, Kherani S, Hafiz G, Krispel C, Liu TYA, Wang J, Scott AW, Zimmer-Galler I. Reply. Am J Ophthalmol 2017; 183:163-164. [PMID: 28941645 DOI: 10.1016/j.ajo.2017.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 09/01/2017] [Indexed: 10/18/2022]
|
5
|
Campochiaro PA, Han YS, Mir TA, Kherani S, Hafiz G, Krispel C, Liu TA, Wang J, Scott AW, Zimmer-Galler I. Increased Frequency of Topical Steroids Provides Benefit in Patients With Recalcitrant Postsurgical Macular Edema. Am J Ophthalmol 2017; 178:163-175. [PMID: 28392176 DOI: 10.1016/j.ajo.2017.03.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 03/24/2017] [Accepted: 03/29/2017] [Indexed: 11/27/2022]
Abstract
PURPOSE To compare standard and frequent topical steroids for postsurgical macular edema (ME). DESIGN Randomized clinical trial. METHODS Subjects with postsurgical ME stratified into post-cataract surgery ME (PCSME) and post-other surgery ME (POSME) were randomized to ketorolac 4 times a day (qid) + 1% prednisolone acetate (PA) every hour while awake (q1hWA, Group 1) or qid (Group 2). Mean change from baseline best-corrected visual acuity (BCVA) was determined at week 12, after which group 2 subjects with persistent edema were crossed over to PA q1hWA. RESULTS Twenty-two subjects (13 PCSME and 9 POSME) were randomized to Group 1 and 20 (12 PCSME and 8 POSME) to Group 2. At week 12, change from baseline BCVA (ETDRS letters) in Group 1 vs 2 was +11.6 vs +8.5 (P = .32) and for subgroups was +10.6 vs +7.8 (P = .23) for PCSME and +13.1 vs +9.4 (P = .47) for POSME. Mean change from baseline central subfield thickness (CST, μm) at week 12 in Group 1 vs 2 was -100.8 vs -63.9 (P = .30). Mean change from baseline intraocular pressure was +2.6 vs +1.7 mm Hg (P = .52). Eight subjects in Group 2 with residual ME at week 12 were switched to PA q1hWA and at week 24, the mean changes from week 12 BCVA and CST were +7.0 letters (P = .01) and -108.25 μm (P = .04). CONCLUSIONS Our data suggest that patients with postsurgical ME should initially be treated with ketorolac and PA qid, but if edema does not resolve after 12 weeks, a switch to ketorolac qid and PA q1hWA may provide benefit.
Collapse
|
6
|
Campochiaro PA, Hafiz G, Mir TA, Scott AW, Zimmer-Galler I, Shah SM, Wenick AS, Brady CJ, Han I, He L, Channa R, Poon D, Meyerle C, Aronow MB, Sodhi A, Handa JT, Kherani S, Han Y, Sophie R, Wang G, Qian J. Reply. Am J Ophthalmol 2016; 170:245-246. [PMID: 27561424 DOI: 10.1016/j.ajo.2016.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 07/15/2016] [Indexed: 10/21/2022]
|
7
|
Campochiaro PA, Hafiz G, Mir TA, Scott AW, Zimmer-Galler I, Shah SM, Wenick AS, Brady CJ, Han I, He L, Channa R, Poon D, Meyerle C, Aronow MB, Sodhi A, Handa JT, Kherani S, Han Y, Sophie R, Wang G, Qian J. Pro-permeability Factors in Diabetic Macular Edema; the Diabetic Macular Edema Treated With Ozurdex Trial. Am J Ophthalmol 2016; 168:13-23. [PMID: 27130369 PMCID: PMC5482180 DOI: 10.1016/j.ajo.2016.04.017] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 04/14/2016] [Accepted: 04/20/2016] [Indexed: 01/14/2023]
Abstract
PURPOSE The Diabetic Macular Edema Treated with Ozurdex (DMEO) Trial measured aqueous pro-permeability factors (PPFs) in diabetic macular edema (DME) patients before and after injection of dexamethasone implant or vascular endothelial growth factor (VEGF)-neutralizing protein and correlated changes in levels with changes in excess foveal thickness (EFT) to identify potential PPFs contributing to DME. DESIGN Prospective, randomized crossover clinical trial. METHODS Twenty DME patients randomized to dexamethasone implant or VEGF-neutralizing protein had aqueous taps and spectral-domain optical coherence tomography (SDOCT) at baseline and every 4 weeks for 28 weeks. Aqueous levels of 55 vasoactive proteins were measured with protein array. Crossover at week 16 provided changes in protein levels after each intervention in all 20 patients. RESULTS After dexamethasone implant there was significant correlation between changes in levels of 13 vasoactive proteins with changes in EFT, including 3 known PPFs: angiopoietin-2 (r = 0.40, P = .001), hepatocyte growth factor (HGF; r = 0.31, P = .02), and endocrine gland-VEGF (EG-VEGF, r = 0.43, P < .001). Reduction of prolactin, insulin-like growth factor binding protein-3, and matrix metalloproteinase-9 correlated with edema reduction after injection of a VEGF-neutralizing protein as well as dexamethasone implant, suggesting their modulation is likely secondary to changes in edema rather than causative. CONCLUSIONS Correlation of edema reduction with reduction in the PPFs angiopoietin-2, HGF, and EG-VEGF provides potential insight into the multifactorial molecular mechanism by which dexamethasone implants reduce edema and suggest that additional study is needed to investigate the contributions of these 3 factors to chronic DME.
Collapse
Affiliation(s)
- Peter A Campochiaro
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Gulnar Hafiz
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tahreem A Mir
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Adrienne W Scott
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ingrid Zimmer-Galler
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Syed M Shah
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Adam S Wenick
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christopher J Brady
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ian Han
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lingmin He
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Roomasa Channa
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - David Poon
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Catherine Meyerle
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mary Beth Aronow
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Akrit Sodhi
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - James T Handa
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Saleema Kherani
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Yong Han
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Raafay Sophie
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Guohua Wang
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jiang Qian
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
8
|
Campochiaro PA, Hafiz G, Mir TA, Scott AW, Solomon S, Zimmer-Galler I, Sodhi A, Duh E, Ying HS, Wenick AS, Shah SM, Do DV, Nguyen QD, Kherani S, Sophie R. Reply. Ophthalmology 2016; 123:e33-4. [DOI: 10.1016/j.ophtha.2015.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 11/18/2015] [Indexed: 11/25/2022] Open
|
9
|
Mir TA, Kherani S, Hafiz G, Scott AW, Zimmer-Galler I, Wenick AS, Solomon S, Han I, Poon D, He L, Shah SM, Brady CJ, Meyerle C, Sodhi A, Linz MO, Sophie R, Campochiaro PA. Changes in Retinal Nonperfusion Associated with Suppression of Vascular Endothelial Growth Factor in Retinal Vein Occlusion. Ophthalmology 2016; 123:625-34.e1. [PMID: 26712560 PMCID: PMC5482175 DOI: 10.1016/j.ophtha.2015.10.030] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 10/09/2015] [Accepted: 10/12/2015] [Indexed: 01/14/2023] Open
Abstract
PURPOSE To assess changes in retinal nonperfusion (RNP) in patients with retinal vein occlusion (RVO) treated with ranibizumab. DESIGN Secondary outcome measure in randomized double-masked controlled clinical trial. PARTICIPANTS Thirty-nine patients with central RVO (CRVO) and 42 with branch RVO (BRVO). METHODS Subjects were randomized to 0.5 or 2.0 mg ranibizumab every month for 6 months and then were re-randomized to pro re nata (PRN) groups receiving either ranibizumab plus scatter laser photocoagulation or ranibizumab alone for an additional 30 months. MAIN OUTCOME MEASURES Comparison of percentage of patients with increased or decreased area of RNP in patients with RVO treated with 0.5 versus 2.0 mg ranibizumab, during monthly injections versus ranibizumab PRN, and in patients treated with ranibizumab PRN versus ranibizumab PRN plus laser. RESULTS In RVO patients given monthly injections of 0.5 or 2.0 mg ranibizumab for 6 months, there was no significant difference in the percentage who showed reduction or increase in the area of RNP. However, regardless of dose, during the 6-month period of monthly injections, a higher percentage of patients showed a reduction in area of RNP and a lower percentage showed an increase in area of RNP compared with subsequent periods of ranibizumab PRN treatment. After the 6-month period of monthly injections, BRVO patients, but not CRVO patients, randomized to ranibizumab PRN plus laser showed significantly less progression of RNP compared with patients treated with ranibizumab PRN. CONCLUSIONS Regardless of dose (0.5 or 2.0 mg), monthly ranibizumab injections promote improvement and reduce progression of RNP compared with PRN injections. The addition of scatter photocoagulation to ranibizumab PRN may reduce progression of RNP in patients with BRVO, but a statistically significant reduction was not seen in patients with CRVO.
Collapse
Affiliation(s)
- Tahreem A Mir
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Saleema Kherani
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Gulnar Hafiz
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Adrienne W Scott
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ingrid Zimmer-Galler
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Adam S Wenick
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sharon Solomon
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ian Han
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - David Poon
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lingmin He
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Syed Mahmood Shah
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christopher J Brady
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Catherine Meyerle
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Akrit Sodhi
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Marguerite O Linz
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Raafay Sophie
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Peter A Campochiaro
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| |
Collapse
|
10
|
Campochiaro PA, Hafiz G, Mir TA, Scott AW, Sophie R, Shah SM, Ying HS, Lu L, Chen C, Campbell JP, Kherani S, Zimmer-Galler I, Wenick A, Han I, Paulus Y, Sodhi A, Wang G, Qian J. Pro-Permeability Factors After Dexamethasone Implant in Retinal Vein Occlusion; the Ozurdex for Retinal Vein Occlusion (ORVO) Study. Am J Ophthalmol 2015; 160:313-321.e19. [PMID: 25908486 PMCID: PMC6600806 DOI: 10.1016/j.ajo.2015.04.025] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 04/14/2015] [Accepted: 04/15/2015] [Indexed: 01/14/2023]
Abstract
PURPOSE To correlate aqueous vasoactive protein changes with macular edema after dexamethasone implant in retinal vein occlusion (RVO). DESIGN Prospective, interventional case series. METHODS Twenty-three central RVO (CRVO) and 17 branch RVO (BRVO) subjects with edema despite prior anti-vascular endothelial growth factor (VEGF) treatment had aqueous taps at baseline and 4 and 16 weeks after dexamethasone implant. Best-corrected visual acuity (BCVA) and center subfield thickness were measured every 4 weeks. Aqueous vasoactive protein levels were measured by protein array or enzyme-linked immunosorbent assay. RESULTS Thirty-two vasoactive proteins were detected in aqueous in untreated eyes with macular edema due to RVO. Reduction in excess foveal thickness after dexamethasone implant correlated with reduction in persephin and pentraxin 3 (Pearson correlation coefficients = 0.682 and 0.638, P = .014 and P = .003). Other protein changes differed among RVO patients as edema decreased, but ≥50% of patients showed reductions in hepatocyte growth factor, endocrine gland VEGF, insulin-like growth factor binding proteins, or endostatin by ≥30%. Enzyme-linked immunosorbent assay in 18 eyes (12 CRVO, 6 BRVO) showed baseline levels of hepatocyte growth factor and VEGF of 168.2 ± 20.1 pg/mL and 78.7 ± 10.0 pg/mL, and each was reduced in 12 eyes after dexamethasone implant. CONCLUSIONS Dexamethasone implants reduce several pro-permeability proteins providing a multitargeted approach in RVO. No single protein in addition to VEGF can be implicated as a contributor in all patients. Candidates for contribution to chronic edema in subgroups of patients that deserve further study include persephin, hepatocyte growth factor, and endocrine gland VEGF.
Collapse
|
11
|
Campochiaro PA, Hafiz G, Mir TA, Scott AW, Solomon S, Zimmer-Galler I, Sodhi A, Duh E, Ying H, Wenick A, Shah SM, Do DV, Nguyen QD, Kherani S, Sophie R. Scatter Photocoagulation Does Not Reduce Macular Edema or Treatment Burden in Patients with Retinal Vein Occlusion: The RELATE Trial. Ophthalmology 2015; 122:1426-37. [PMID: 25972260 PMCID: PMC10020833 DOI: 10.1016/j.ophtha.2015.04.006] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 04/06/2015] [Accepted: 04/06/2015] [Indexed: 01/14/2023] Open
Abstract
PURPOSE To determine whether scatter and grid laser photocoagulation (laser) adds benefit to ranibizumab injections in patients with macular edema from retinal vein occlusion (RVO) and to compare 0.5-mg with 2.0-mg ranibizumab. DESIGN Randomized, double-masked, controlled clinical trial. PARTICIPANTS Thirty-nine patients with central RVO (CRVO) and 42 with branch RVO (BRVO). METHODS Subjects were randomized to 0.5 mg or 2.0 mg ranibizumab every 4 weeks for 24 weeks and re-randomized to pro re nata ranibizumab plus laser or ranibizumab alone. MAIN OUTCOME MEASURES Mean change from baseline best-corrected visual acuity (BCVA) at week 24 for BCVA at weeks 48, 96, and 144 for second randomization. RESULTS Mean improvement from baseline BCVA at week 24 was 15.5 and 15.8 letters in the 0.5-mg and 2.0-mg CRVO groups, and 12.1 and 14.6 letters in the 0.5-mg and 2.0-mg BRVO groups. For CRVO, but not BRVO, there was significantly greater reduction from baseline mean central subfield thickness (CST) in the 2.0-mg versus 0.5-mg group (396.1 vs. 253.5 μm; P = 0.03). For the second randomization in CRVO patients, there was no significant difference from week 24 BCVA in the ranibizumab plus laser versus the ranibizumab only groups at week 48 (-3.3 vs. 0.0 letters), week 96 (+0.69 vs. -1.6 letters), or week 144 (+0.4 vs. -6.7 letters), and a significant increase from week 24 mean CST at week 48 (+94.7 vs. +15.2 μm; P = 0.05) but not weeks 96 or 144. For BRVO, there was a significant reduction from week 24 mean BCVA in ranibizumab plus laser versus ranibizumab at week 48 (-7.5 vs. +2.8; P < 0.01) and week 96 (-2.0 vs. +4.8; P < 0.03), but not week 144, and there were no differences in mean CST change from week 24 at weeks 48, 96, or 144. Laser failed to increase edema resolution or to reduce the ranibizumab injections between weeks 24 and 144. CONCLUSIONS In patients with macular edema resulting from RVO, there was no short-term clinically significant benefit from monthly injections of 2.0-mg versus 0.5-mg ranibizumab injections and no long-term benefit in BCVA, resolution of edema, or number of ranibizumab injections obtained by addition of laser treatment to ranibizumab.
Collapse
Affiliation(s)
- Peter A Campochiaro
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Gulnar Hafiz
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tahreem A Mir
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Adrienne W Scott
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sharon Solomon
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ingrid Zimmer-Galler
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Akrit Sodhi
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elia Duh
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Howard Ying
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Adam Wenick
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Syed Mahmood Shah
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Diana V Do
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Quan D Nguyen
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Saleema Kherani
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Raafay Sophie
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
12
|
Byrne MM, Parker DF, Tannenbaum SL, Ocasio MA, Lam BL, Zimmer-Galler I, Lee DJ. Cost of a community-based diabetic retinopathy screening program. Diabetes Care 2014; 37:e236-7. [PMID: 25342836 DOI: 10.2337/dc14-0834] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Margaret M Byrne
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Dorothy F Parker
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL
| | - Stacey L Tannenbaum
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL
| | - Manuel A Ocasio
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL
| | - Byron L Lam
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL
| | | | - David J Lee
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL
| |
Collapse
|
13
|
Sophie R, Hafiz G, Scott AW, Zimmer-Galler I, Nguyen QD, Ying H, Do DV, Solomon S, Sodhi A, Gehlbach P, Duh E, Baranano D, Campochiaro PA. Long-term outcomes in ranibizumab-treated patients with retinal vein occlusion; the role of progression of retinal nonperfusion. Am J Ophthalmol 2013; 156:693-705. [PMID: 24053892 DOI: 10.1016/j.ajo.2013.05.039] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 05/24/2013] [Accepted: 05/28/2013] [Indexed: 11/30/2022]
Abstract
PURPOSE To determine the percentage of ranibizumab-treated patients with retinal vein occlusion (RVO) who had resolution of edema for at least 6 months after the last injection, along with factors and outcomes that correlate with resolution. DESIGN Post hoc analysis of open-label clinical trial. METHODS Twenty patients with branch RVO (BRVO) and 20 with central RVO (CRVO) received ranibizumab monthly for 3 months and as needed for recurrent/persistent macular edema, no more frequently than every 2 months. Patients still requiring injections after month 40 received scatter and grid laser photocoagulation to try to reduce the need for injections. Main outcome measures included the percentage of patients who had resolution of edema, change in best-corrected visual acuity (BCVA) from baseline, and change in area of retinal nonperfusion in central subfields. RESULTS Nine patients with BRVO (45%) had edema resolution from injections alone after a mean of 20.2 months, 4 resolved after addition of laser, 4 were unresolved through 72 months, and 3 exited prior to resolution. Five patients with CRVO (25%) resolved from injections alone after a mean of 14.0 months, 8 remained unresolved through 72 months despite addition of laser, and 7 exited prior to resolution. For BRVO or CRVO, there was a negative correlation between posterior retinal nonperfusion area and BCVA at months 18, 24, and 36 (P < .05). CONCLUSIONS In patients with RVO, infrequent ranibizumab injections to control edema may not be sufficient to prevent progression of retinal nonperfusion, which may contribute to loss of visual gains.
Collapse
Affiliation(s)
- Raafay Sophie
- Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Li HK, Horton M, Bursell SE, Cavallerano J, Zimmer-Galler I, Tennant M, Abramoff M, Chaum E, DeBuc DC, Leonard-Martin T, Winchester M. Telehealth practice recommendations for diabetic retinopathy, second edition. Telemed J E Health 2011; 17:814-37. [PMID: 21970573 PMCID: PMC6469533 DOI: 10.1089/tmj.2011.0075] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Revised: 04/25/2011] [Accepted: 04/25/2011] [Indexed: 12/18/2022] Open
Abstract
Ocular telemedicine and telehealth have the potential to decrease vision loss from DR. Planning, execution, and follow-up are key factors for success. Telemedicine is complex, requiring the services of expert teams working collaboratively to provide care matching the quality of conventional clinical settings. Improving access and outcomes, however, makes telemedicine a valuable tool for our diabetic patients. Programs that focus on patient needs, consider available resources, define clear goals, promote informed expectations, appropriately train personnel, and adhere to regulatory and statutory requirements have the highest chance of achieving success.
Collapse
Affiliation(s)
- Helen K. Li
- Department of Ophthalmology, Weill Cornell Medical College/The Methodist Hospital, Houston, Texas
- School of Biomedical Informatics, University of Texas Health Science Center, Houston, Texas
- Department of Ophthalmology, Jefferson Medical College, Philadelphia, Pennsylvannia
| | - Mark Horton
- Phoenix Indian Medical Center, Phoenix, Arizona
| | - Sven-Erik Bursell
- Telehealth Research Institute, John A. Burns School of Medicine, Honolulu, Hawaii
| | - Jerry Cavallerano
- Joslin Diabetes Center, Beetham Eye Institute, Boston, Massachusetts
| | | | - Mathew Tennant
- Department of Ophthalmology, University of Alberta, Edmonton, Canada
| | - Michael Abramoff
- Department of Ophthalmology and Visual Sciences, The University of Iowa Hospital and Clinics, Iowa City, Iowa
| | - Edward Chaum
- Hamilton Eye Institute, University of Tennessee Health Science Center, Memphis, Tennessee
| | | | | | | |
Collapse
|
15
|
Campochiaro PA, Hafiz G, Channa R, Shah SM, Nguyen QD, Ying H, Do DV, Zimmer-Galler I, Solomon SD, Sung JU, Syed B. Antagonism of Vascular Endothelial Growth Factor for Macular Edema Caused by Retinal Vein Occlusions: Two-Year Outcomes. Ophthalmology 2010; 117:2387-2394.e1-5. [DOI: 10.1016/j.ophtha.2010.03.060] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2009] [Revised: 03/23/2010] [Accepted: 03/26/2010] [Indexed: 10/19/2022] Open
|
16
|
Moscaritolo M, Knezevich FP, Zimmer-Galler I, Jampel H, Zeimer R. A Machine Vision Method for Automated Alignment of Fundus Imaging Systems. Ophthalmic Surg Lasers Imaging Retina 2010; 41:607-13. [DOI: 10.3928/15428877-20100929-05] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2009] [Accepted: 07/29/2010] [Indexed: 11/20/2022]
|
17
|
Campochiaro PA, Shah SM, Hafiz G, Heier JS, Lit ES, Zimmer-Galler I, Channa R, Nguyen QD, Syed B, Do DV, Lu L, Monk J, Cooke JP, Kengatharan MK, Hsu HH. Topical mecamylamine for diabetic macular edema. Am J Ophthalmol 2010; 149:839-51.e1. [PMID: 20189159 PMCID: PMC3143041 DOI: 10.1016/j.ajo.2009.12.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2009] [Revised: 11/28/2009] [Accepted: 12/01/2009] [Indexed: 10/19/2022]
Abstract
PURPOSE Stimulation of nicotinic acetylcholine (nACh) receptors on vascular endothelial cells promotes angiogenesis and vascular permeability in animal models. The safety and bioactivity of topical mecamylamine, an antagonist of nACh receptors, was tested in patients with diabetic macular edema. DESIGN A multicenter phase I/II clinical trial. METHODS Twenty-three patients with chronic diabetic macular edema received 1% mecamylamine topically twice daily for 12 weeks, the primary end point. Patients underwent safety assessments, measurement of best-corrected visual acuity (BCVA), and measurement of foveal thickness using optical coherence tomography at baseline, 1, 4, 8, 12, and 16 weeks. RESULTS Mecamylamine drops were well tolerated and there were no drug-related safety problems. Mean improvement in BCVA at 1, 4, 8, 12, and 16 weeks was 2.8, 1.9, 2.4, 0.8, and 3.1 letters, respectively. There was little change in mean excess foveal thickness. There was substantial heterogeneity in response, because 8 patients showed convincing improvement in BCVA, foveal thickness, or both, 9 patients showed equivocal or no substantial changes, and 4 patients showed worsening. Five patients showed a substantial improvement in BCVA, foveal thickness, or both between their last visit while receiving mecamylamine and 1 month after stopping mecamylamine. CONCLUSIONS This study suggested that administration of topical mecamylamine, a nonspecific nACh receptor blocker, may have heterogeneous effects in patients with diabetic macular edema. Variable expression of nACh receptor subtypes on endothelial cells that have different effects on permeability would provide an explanation for these results and should be investigated, because more specific nACh receptor blockers may dissociate antipermeability and propermeability effects.
Collapse
Affiliation(s)
- Peter A Campochiaro
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287-9277, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Moscaritolo M, Jampel H, Zimmer-Galler I, Knezevich F, Zeimer R. A Computer Algorithm to Quantitatively Assess Quality of Digital Optic Disc Images. Ophthalmic Surg Lasers Imaging Retina 2010; 41:279-84. [DOI: 10.3928/15428877-20100303-21] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2009] [Indexed: 11/20/2022]
|
19
|
Patel SJ, Petrarca R, Shah SM, Zimmer-Galler I, Janjua KA, Do DV, Nguyen QD. AtypicalBartonella hensalaeChorioretinitis in an Immunocompromised Patient. Ocul Immunol Inflamm 2009; 16:45-9. [DOI: 10.1080/09273940801899780] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
20
|
Campochiaro PA, Hafiz G, Shah SM, Nguyen QD, Ying H, Do DV, Quinlan E, Zimmer-Galler I, Haller JA, Solomon SD, Sung JU, Hadi Y, Janjua KA, Jawed N, Choy DF, Arron JR. Ranibizumab for Macular Edema Due to Retinal Vein Occlusions: Implication of VEGF as a Critical Stimulator. Mol Ther 2008; 16:791-9. [PMID: 18362932 DOI: 10.1038/mt.2008.10] [Citation(s) in RCA: 235] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
|
21
|
Campochiaro PA, Hafiz G, Shah SM, Nguyen QD, Ying H, Do DV, Quinlan E, Zimmer-Galler I, Haller JA, Solomon SD, Sung JU, Hadi Y, Janjua KA, Jawed N, Choy DF, Arron JR. Ranibizumab for Macular Edema Due to Retinal Vein Occlusions; Implication of VEGF as a Critical Stimulator. Mol Ther 2008. [DOI: 10.1038/sj.mt.6300416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
|
22
|
Do DV, Cho M, Nguyen QD, Shah SM, Handa JT, Campochiaro PA, Zimmer-Galler I, Sung JU, Haller JA. Impact of optical coherence tomography on surgical decision making for epiretinal membranes and vitreomacular traction. Retina 2007; 27:552-6. [PMID: 17558315 DOI: 10.1097/iae.0b013e31802c518b] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To compare retina surgeons' recommendations for management of epiretinal membranes (ERM) and vitreomacular traction (VMT) based on clinical assessment alone with management based on clinical evaluation supplemented by optical coherence tomography (OCT). METHODS A prospective, masked clinical case series was conducted. Surgeons first performed a complete history and physical examination on patients referred with the macular disorders under study without the benefit of adjunctive OCT, determined whether ERM, VMT, and/or macular edema were present, questionably present, or absent, and made a provisional management recommendation. The retina specialists then reviewed the OCT images for the presence or absence of ERM, VMT, and/or associated macular edema and reconsidered the final management recommendation in light of clinical evaluation combined with OCT findings. RESULTS Eighty-four eyes of 73 patients were examined. ERM was identified in 66 (78.6%) of 84 eyes using clinical examination compared with 72 (85.7%) of 84 eyes using OCT (P = 0.06). VMT was identified in 5 (6%) of 84 eyes using clinical examination compared with 18 (21.4%) of 84 eyes using OCT (P < 0.005). Macular edema was identified in 57 (67.9%) of 84 eyes using clinical examination compared with 70 (83.3%) of 84 eyes using OCT (P = 0.003). Surgical intervention was recommended in 33 cases: 19 (57.6%) based on the history and clinical examination findings without OCT information and an additional 14 (42.4%) based on the combination of clinical evaluation and OCT findings. CONCLUSIONS OCT is more sensitive than clinical examination in detecting ERM, VMT, and associated macular edema. Taken together with careful clinical evaluation, OCT findings influenced surgeons to recommend consideration of surgery to an additional 14 patients (42.2%) in this series.
Collapse
Affiliation(s)
- Diana V Do
- Retina Division, The Wilmer Eye Institute, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Shah SM, Tatlipinar S, Quinlan E, Sung JU, Tabandeh H, Nguyen QD, Fahmy AS, Zimmer-Galler I, Symons RCA, Cedarbaum JM, Campochiaro PA. Dynamic and quantitative analysis of choroidal neovascularization by fluorescein angiography. Invest Ophthalmol Vis Sci 2007; 47:5460-8. [PMID: 17122137 DOI: 10.1167/iovs.06-0012] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
PURPOSE In this study, the authors sought to develop and characterize techniques for measuring changes in choroidal neovascularization (CNV) lesion size and fluorescence over time for quantitative analysis of fluorescein angiograms. METHODS Initial assessment of the quantitative technique was made by retrospectively analyzing digital fluorescein angiograms taken before and 3 months after photodynamic therapy (PDT) for CNV (6 patients, group 1). The method was then applied prospectively to digital fluorescein angiograms (baseline and day 71) obtained on 12 patients taking part in a clinical trial investigating the effect of vascular endothelial growth factor (VEGF) Trap in CNV (group 2). Two masked observers, with the use of image processing, measured the area of hyperfluorescence and fluorescence intensity above background. Values for each image were plotted against time after dye injection to generate curves, and each area under the curve (AUC) was calculated. RESULTS The physician who treated the patients in group 1 judged the condition of three patients to be improved and of three to be worse 3 months after PDT. Masked retrospective grading of fluorescein angiograms showed an 11% decrease in AUC for fluorescence area and a 32% decrease in AUC for fluorescence intensity in the three patients whose conditions clinically improved but increases of 131% and 292% in the three patients whose conditions clinically worsened. In group 2, a 38% decrease in AUC for fluorescence intensity and a 19% decrease in AUC for fluorescence area were observed in patients who received VEGF Trap compared with increases of 66% (P = 0.004, Mann-Whitney U test) and 21% (P = 0.07) for patients who received placebo. Macular volume decreased by 11% in VEGF Trap-treated patients and increased by 10% in placebo-treated patients (P = 0.03). CONCLUSIONS This study reports a technique for analysis of change in fluorescence area and intensity over time during fluorescein angiography (FA) using a continuous scale and its application in a clinical setting and a clinical trial. Compared with previous techniques making use of categorical scales, this approach provides an advantage for evaluating responses to treatment that may improve the value of FA as an outcome measure in clinical trials.
Collapse
Affiliation(s)
- Syed Mahmood Shah
- Retinal Imaging Research and Reading Center, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287-9277, USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Nguyen QD, Tatlipinar S, Shah SM, Haller JA, Quinlan E, Sung J, Zimmer-Galler I, Do DV, Campochiaro PA. Vascular endothelial growth factor is a critical stimulus for diabetic macular edema. Am J Ophthalmol 2006; 142:961-9. [PMID: 17046701 DOI: 10.1016/j.ajo.2006.06.068] [Citation(s) in RCA: 263] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2006] [Revised: 06/23/2006] [Accepted: 06/29/2006] [Indexed: 01/21/2023]
Abstract
PURPOSE The role of vascular endothelial growth factor (VEGF) in diabetic macular edema (DME) was tested with ranibizumab, a specific antagonist of VEGF. DESIGN A nonrandomized clinical trial. METHODS Ten patients with chronic DME received intraocular injections of 0.5 mg of ranibizumab at baseline and at one, two, four, and six months. The primary outcome was change in foveal thickness between baseline and seven months, and the secondary outcome measures were changes from baseline in visual acuity and macular volume. RESULTS Mean values at baseline were 503 microm for foveal thickness, 9.22 mm3 for macular volume, and 28.1 letters (20/80) read on an Early Treatment Diabetic Retinopathy Study (ETDRS) visual acuity chart. At seven months (one month after the fifth injection), the mean foveal thickness was 257 microm, which was a reduction of 246 microm (85% of the excess foveal thickness present at baseline; P = .005 by Wilcoxon signed-rank test for likelihood that this change is due to ranibizumab rather than chance). The macular volume was 7.47 mm3, which was a reduction of 1.75 mm3 (77% of the excess macular volume at baseline; P = .009). Mean visual acuity was 40.4 letters (20/40), which was an improvement of 12.3 letters (P = .005). The injections were well-tolerated with no ocular or systemic adverse events. CONCLUSION Intraocular injections of ranibizumab significantly reduced foveal thickness and improved visual acuity in 10 patients with DME, which demonstrated that VEGF is an important therapeutic target for DME. A randomized, controlled, double-masked trial is needed to test whether intraocular injections of ranibizumab provide long-term benefit to patients with DME.
Collapse
Affiliation(s)
- Quan Dong Nguyen
- The Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21287-9277, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Abstract
Approximately 50% of patients with diabetes in the United States do not undergo recommended ocular evaluations for diabetic retinopathy. The DigiScope (EyeTel Imaging, Inc., Columbia, MD) was developed as a cost-effective and practical telemedicine digital imaging system to screen for diabetic retinopathy in the primary care physician's (PCP) office. The DigiScope has been validated against seven-field stereo color fundus photography for the detection of diabetic retinopathy. This study reports on the implementation of the DigiScope for diabetic retinopathy assessment in the primary care environment. In PCP's offices, patients with diabetes who had not undergone an eye examination in the past year were imaged with the DigiScope. The images were transmitted to a reading center where the need for referral to an ophthalmologist was determined. Nonurgent referral was recommended for patients with diabetic retinopathy greater than a few micro-aneurysms, other ocular pathology, or unreadable images. Referral was deemed "urgent" for patients with sight-threatening disease and evaluation by an ophthalmologist within 72 hours was recommended. Between October 1, 2002 and March 31, 2771 patients with diabetes underwent DigiScope imaging at multiple sites. Nonurgent referral was recommended for 468 patients (17%). Urgent referral was recommended for 71 patients (3%). The images were unreadable in 295 cases (11%). This study indicates that implementation of the DigiScope in the primary care setting is practical and allows screening of patients with diabetes who are otherwise not receiving recommended eye examinations.
Collapse
Affiliation(s)
- Ingrid Zimmer-Galler
- Ophthalmic Physics Laboratory, Wilmer Eye Institute, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287, USA.
| | | |
Collapse
|
26
|
Do DV, Cho M, Nguyen QD, Shah SM, Handa JT, Campochiaro PA, Zimmer-Galler I, Sung JU, Haller JA. The impact of optical coherence tomography on surgical decision making in epiretinal membrane and vitreomacular traction. Trans Am Ophthalmol Soc 2006; 104:161-6. [PMID: 17471336 PMCID: PMC1809924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
PURPOSE To compare retinal surgeons' recommendations for management of epiretinal membranes (ERM) and vitreomacular traction syndrome (VMT) based on clinical examination alone, with management based on examination supplemented by optical coherence tomography (OCT). METHODS A prospective, masked clinical case series was conducted. Surgeons first assessed, on the basis of clinical examination only, whether ERM, VMT, or macular edema was present, questionably present, or absent and made a provisional management recommendation. The retina specialist then reviewed the OCT images, determined the presence or absence of ERM, VMT, or associated macular edema, and made a final management recommendation. RESULTS Eighty-four eyes of 73 patients were examined. ERM was identified in 66 (78.6%) of 84 using clinical examination compared to 72 (85.7%) of 84 using OCT (P = .06). VMT was identified in five (6%) of 84 using clinical examination compared to 18 (21.4%) of 84 using OCT (P < .005). Macular edema was identified in 57 (67.9%) of 84 using clinical examination compared to 70 (83.3%) of 84 using OCT (P =.003). Surgical intervention was recommended in 33 cases: 19 (57.6%) based on clinical examination alone and 14 (42.4%) based on the combination of clinical examination and OCT findings. CONCLUSIONS OCT is more sensitive than clinical examination in detecting ERM, VMT, and associated macular edema. OCT influenced the recommendation for surgical intervention in 42.4% of patients scheduled for surgery.
Collapse
Affiliation(s)
- Diana V Do
- Retina Division, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Cavallerano J, Lawrence MG, Zimmer-Galler I, Bauman W, Bursell S, Gardner WK, Horton M, Hildebrand L, Federman J, Carnahan L, Kuzmak P, Peters JM, Darkins A, Ahmed J, Aiello LM, Aiello LP, Buck G, Cheng YL, Cunningham D, Goodall E, Hope N, Huang E, Hubbard L, Janczewski M, Lewis JWL, Matsuzaki H, McVeigh FL, Motzno J, Parker-Taillon D, Read R, Soliz P, Szirth B, Vigersky RA, Ward T. Telehealth practice recommendations for diabetic retinopathy. Telemed J E Health 2005; 10:469-82. [PMID: 15689653 DOI: 10.1089/tmj.2004.10.469] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Telehealth holds the promise of increased adherence to evidenced-based medicine and improved consistency of care. Goals for an ocular telehealth program include preserving vision, reducing vision loss, and providing better access to medicine. Establishing recommendations for an ocular telehealth program may improve clinical outcomes and promote informed and reasonable patient expectations. This document addresses current diabetic retinopathy telehealth clinical and administrative issues and provides recommendations for designing and implementing a diabetic retinopathy ocular telehealth care program. The recommendations also form the basis for evaluating diabetic retinopathy telehealth techniques and technologies. Recommendations in this document are based on careful reviews of current evidence, medical literature and clinical practice. They do not, however, replace sound medical judgment or traditional clinical decision-making. "Telehealth Practice Recommendations for Diabetic Retinopathy" will be annually reviewed and updated to reflect evolving technologies and clinical guidelines.
Collapse
|
28
|
Polito A, Shah SM, Haller JA, Zimmer-Galler I, Zeimer R, Campochiaro PA, Vitale S. Comparison between retinal thickness analyzer and optical coherence tomography for assessment of foveal thickness in eyes with macular disease. Am J Ophthalmol 2002; 134:240-51. [PMID: 12140031 DOI: 10.1016/s0002-9394(02)01528-3] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To use the retinal thickness analyzer (RTA) and optical coherence tomography (OCT) scanners for quantitative measurement of retinal thickness in eyes with macular disease. DESIGN In a cross-sectional study, 44 patients (55 eyes) with macular disease and sufficient media clarity to visualize the fundus using clinical biomicroscopy underwent an ophthalmologic examination, fluorescein angiography, RTA, and OCT during the same visit. METHODS Foveal and foveal center (foveolar) retinal thickness measurements were obtained by RTA and by OCT. RESULTS Retinal thickness measurements were obtained by OCT in all 55 eyes and by RTA in 34 eyes (62%, primarily due to interference from media opacities). In the 34 eyes in which measurements were obtained by both instruments, mean foveal thickness was 291 and 269 microm for OCT and RTA, respectively; foveolar thickness was 277 and 265 microm, respectively. OCT and RTA measurements of foveal thickness were strongly correlated (intraclass correlation coefficient = 0.89), as were measurements of the foveolar thickness (intraclass correlation coefficient = 0.94). Topographic maps generated by the two techniques yielded qualitatively similar information. CONCLUSIONS Overall, there was excellent agreement between RTA and OCT measurements. Each technique has advantages that may make its use preferable in a particular subgroup of eyes or to describe a particular disease process. An important consideration is that media opacities create less interference for OCT than for RTA, so that in study populations with a moderate-to-high prevalence of media opacity, images can be obtained in a greater percentage of eyes by OCT than by RTA.
Collapse
Affiliation(s)
- Antonio Polito
- Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21287-9277, USA
| | | | | | | | | | | | | |
Collapse
|
29
|
Abstract
OBJECTIVE To report the third known and documented occurrence of malignant disease as a complication of immunosuppression associated with low-dose methotrexate therapy for rheumatoid arthritis. MATERIAL AND METHODS We present a case report of a 64-year-old woman with rheumatoid arthritis who had received low-dose methotrexate therapy for 16 months in whom blurred vision occurred. An ophthalmologic examination was performed, and prednisone was administered. Subsequently, she complained of sore throat, weakness, and fever. An axillary lymph node biopsy and immunologic studies were done. RESULTS Funduscopic examination revealed severe bilateral choroidal thickening. Findings on the biopsy disclosed a large cell, B-cell phenotype non-Hodgkin's lymphoma. Immunologic studies performed on frozen and paraffin-embedded tissue samples showed that the neoplastic cells were positive for CD20 and CD22 and without definite immunoglobulin light chain expression. CONCLUSION Although the occurrence of lymphoma may be associated with autoimmune diseases, low-dose methotrexate therapy has also been implicated. Because of the increasing use of low-dose methotrexate therapy for classic and juvenile rheumatoid arthritis, an increased risk of lymphoproliferative disease is possible.
Collapse
Affiliation(s)
- I Zimmer-Galler
- Department of Ophthalmology, Mayo Clinic Rochester, Minnesota
| | | |
Collapse
|
30
|
Abstract
Infantile leukocoria, a white pupillary reflex, is the result of various neoplastic, inflammatory, hemorrhagic, or congenital ocular conditions. Combined B and A scan ultrasonography is a safe, easily performed, highly informative diagnostic technique which aids in the identification of ocular pathology (even when ophthalmoscopic examination is precluded). This report summarizes the clinical course, pathologic findings, and acoustic characteristics of retinoblastoma, persistent hyperplastic primary vitreous, Coats' disease, retrolental fibroplasia, vitreous hemorrhage, congenital cataract, and ocular toxocariasis.
Collapse
Affiliation(s)
- Barrett G. Haik
- Department of Ophthalmology, 1430 Tulane Avenue, New Orleans, LA 70112
| | | | - Mary E. Smith
- Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, Louisiana
| |
Collapse
|