About Chlamydia trachomatis. Reply to Garcia-Teillard et al. Trachoma and the Importance of Sexual Infective Route in Developed Countries. Comment on "Gallenga et al. Why the SAFE-S Strategy for Trachoma? Are Musca sorbens or Scatophaga stercoraria Really the Culprit?-A Brief Historical Review from an Italian Point of View. Pathogens 2023, 12, 1419"

The confirmatory comment of Garcia-Teillard et al [...].

Use of 6-minute walk distance to predict lung transplant-free survival in fibrosing non-IPF interstitial lung diseases

BACKGROUND AND OBJECTIVE

The identification of progression in patients with fibrosing non-idiopathic pulmonary fibrosis (IPF) interstitial lung diseases (ILDs) represents an ongoing clinical challenge. Lung function decline alone may have significant limitations in the detection of clinically significant progression. We hypothesized that longitudinal changes of 6-min walk distance (6MWD) from baseline, simultaneously considered with measures of lung function, may independently predict survival and identifying clinically significant progression of disease.

METHODS

Forced vital capacity (FVC), diffusing lung capacity (DLCO) and 6MWD were considered both at baseline and at 1 year in a discovery cohort (n = 105) and in a validation cohort (n = 138) from different centres. The primary endpoint was lung transplant (LTx)-free survival.

RESULTS

Average follow-up was 3 years in both cohorts. Combined incidence of deaths and LTx was 29% and 21%, respectively. No collinearity and no strong correlations were observed among FVC, DLCO and 6MWD longitudinal changes. While age, gender and BMI were not significant, 6MWD decline ≥24 m predicted LTx-free-survival significantly and independently from FVC and DLCO declines, with high sensitivity and specificity, in both the discovery and the validation cohorts. Although FVC and DLCO declines remained significant predictors of LTx-free survival, 6MWD decline was more accurate than the proposed ATS/ERS/JRS/ALAT functional criteria. Results were confirmed after stratifying patients by baseline FVC.

CONCLUSION

Longitudinal declines of 6MWD are associated with poor survival in fibrosing ILDs across a wide range of baseline severity, with high accuracy. 6MWD longitudinal decline is largely independent from lung function decline and may be integrated into the routine assessment of progression.

Intravitreal Aflibercept for the Treatment of Diabetic Macular Edema in Routine Clinical Practice: Results from the 24-Month AURIGA Observational Study

INTRODUCTION

AURIGA is the largest real-world study to date to evaluate intravitreal aflibercept (IVT-AFL) in the treatment of diabetic macular edema (DME) or macular edema secondary to retinal vein occlusion in routine clinical practice. The 24-month outcomes in the DME cohort from across 11 participating countries are reported here.

METHODS

AURIGA (NCT03161912) was a prospective observational study. The study enrolled eligible patients with DME for whom the decision to treat with IVT-AFL had previously been made by the attending physician. Patients were treated with IVT-AFL for up to 24 months at physician discretion according to local practice. The primary endpoint was mean change in visual acuity (VA; Early Treatment Diabetic Retinopathy Study [ETDRS] letters) from baseline to month 12 (M12). All statistical analyses were descriptive.

RESULTS

In 1478 treatment-naïve and 384 previously treated patients with DME, the mean (95% confidence interval) change in VA from baseline was +6.7 (5.7, 7.6) and +7.4 (5.5, 9.4) letters by M12 and +5.9 (4.9, 6.9) and +8.1 (6.1, 10.1) letters by M24 (baseline [mean ± standard deviation]: 56.0 ± 19.8 and 50.8 ± 19.5 letters), respectively; 25.9% of treatment-naïve and 32.8% of previously treated patients achieved ≥ 15-letter gains by M24. The mean change in central retinal thickness from baseline to M24 was -110 (-119, -102) µm in treatment-naïve patients and -169 (-188, -151) µm in previously treated patients. By M6, M12, and M24, treatment-naïve patients had received 3.8 ± 1.7, 4.9 ± 2.8, and 5.7 ± 3.9 injections, respectively, and previously treated patients had received 3.9 ± 1.5, 4.9 ± 2.4, and 6.2 ± 3.6 injections, respectively. The safety profile of IVT-AFL was consistent with previous studies.

CONCLUSION

In AURIGA, treatment-naïve and previously treated patients with DME achieved clinically relevant functional and anatomic improvements following IVT-AFL treatment for up to 24 months in routine clinical practice. Even with the decreasing injection frequency observed, these gains were largely maintained throughout the study, suggesting long-term durability of the positive effects of IVT-AFL treatment. Infographic available for this article.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03161912 (May 19, 2017). INFOGRAPHIC.

Effects of cannabis smoking on the respiratory system: A state-of-the-art review

The diminished perception of the health risks associated with the consumption of cannabis (marijuana) lead to a progressive increase in its inhalational use in many countries. Cannabis can be smoked through the use of joints, spliffs and blunts, and it can be vaporised with the use of hookah or e-cigarettes. Delta-9 tetrahydrocannabinol (THC) is the main psychoactive component of cannabis smoke but contains numerous other substances. While the recreational use of cannabis smoking has been legalised in several countries, its health consequences have been underestimated and undervalued. The purpose of this review is to critically review the impact of cannabis smoke on the respiratory system. Cannabis smoke irritates the bronchial tree and is strongly associated with symptoms of chronic bronchitis, with histological signs of airway inflammation and remodelling. Altered fungicidal and antibacterial activity of alveolar macrophages, with greater susceptibility to respiratory infections, is also reported. The association with invasive pulmonary aspergillosis in immunocompromised subjects is particularly concerning. Although cannabis has been shown to produce a rapid bronchodilator effect, its chronic use is associated with poor control of asthma by numerous studies. Cannabis smoking also represents a risk factor for the development of bullous lung disease, spontaneous pneumothorax and hypersensitivity pneumonitis. On the other hand, no association with the development of chronic obstructive pulmonary disease was found. Finally, a growing number of studies report an independent association of cannabis smoking with the development of lung cancer. In conclusion, unequivocal evidence established that cannabis smoking is harmful to the respiratory system. Cannabis smoking has a wide range of negative effects on respiratory symptoms in both healthy subjects and patients with chronic lung disease. Given that the most common and cheapest way of assumption of cannabis is by smoking, healthcare providers should be prepared to provide counselling on cannabis smoking cessation and inform the public and decision-makers.

Why the SAFE-S Strategy for Trachoma? Are Musca sorbens or Scatophaga stercoraria Really the Culprit?-A Brief Historical Review from an Italian Point of View

The biological history of Chlamydia trachomatis is intertwined with the evolution of the man. Infecting Elemental Bodies (EBs), having penetrated mucosal epithelial cells, wrap themselves in a cloak (ĸλαμις) of glycogen that ensures their obligatory intracellular survival and protects this differentiation into Reticulate Bodies (RBs) that feed on cellular ATP. Multiple chemokines and cytokines are involved under the direction of IL-6 in the florid phase and IL-17A in the scar phase. The WHO has successfully identified the SAFE strategy against trachoma (Surgery, Antibiotics, Facial cleansing, Environment) as the blueprint to eliminate the disease by 2020. Recently, interest has been increasingly focused on changing sexual attitudes in different areas of the world, leaving Musca sorbens, Scatophaga stercoraria, and stepsisters fairly blameless, but extolling the role of Chlamydia trachomatis in apparently "sterile" chronic prostatitis or conjunctivitis or, less frequently, in oropharyngitis and proctitis. The addition of an S (SAFE-S) standing for "sexual behavior" was then proposed to also attract the interest and attention not only of Ophthalmologists and Obstetricians/Gynecologists, Urologists/Andrologists, and the School Authorities for information on the prevention of sexually transmitted diseases, but also of Social Physicians and Pediatricians. This means that sexually transmitted infections should be screened in asymptomatic patients with risky sexual behavior or sexual contact with people diagnosed with a transmitted infection.

Risk of retinal vein occlusion following COVID-19 vaccination: a self-controlled case series

BACKGROUND

To evaluate the association between COVID-19 vaccination and retinal vein occlusion (RVO).

METHODS

This multicentre self-controlled case series included patients with RVO seen in five tertiary referral centres in Italy. All adults who received at least one dose of the BNT162b2, ChAdOx1 nCoV-19, mRNA-1273 or Ad26.COV2.S vaccine and had a first diagnosis of RVO between January 01, 2021, and December 31, 2021 were included. Incidence rate ratios (IRRs) of RVO were estimated using Poisson regression, comparing rates of events in a 28-day period following each dose of vaccination and in the unexposed control periods.

RESULTS

210 patients were included in the study. No increased risk of RVO was observed after the first dose (1-14 days IRR: 0.87, 95% CI: 0.41-1.85; 15-28 days IRR: 1.01, 95% CI: 0.50-2.04; 1-28 days IRR: 0.94, 95% CI: 0.55-1.58) and second dose of vaccination (1-14 days IRR: 1.21, 95% CI: 0.62-2.37; 15-28 days IRR: 1.08, 95% CI: 0.53-2.20; 1-28 days IRR: 1.16, 95% CI: 0.70-1.90). No association between RVO and vaccination was found in subgroup analyses by type of vaccine, gender and age.

CONCLUSIONS

This self-controlled case series found no evidence of an association between RVO and COVID-19 vaccination.

The State of Intraoperative OCT in Vitreoretinal Surgery: Recent Advances and Future Challenges

Since its first introduction more than 30 years ago, optical coherence tomography (OCT) has revolutionized ophthalmology practice, providing a non-invasive in vivo cross-sectional view of the structures of the eye. Mostly employed in the clinical setting due to its tabletop configuration requiring an upright patient positioning, the recent advent of microscope-integrated systems now allows ophthalmologists to perform real-time intraoperative OCT (iOCT) during vitreoretinal surgical procedures. Numerous studies described various applications of this tool, such as offering surgeons feedback on tissue-instrument interactions in membrane peeling, providing structural images in macular hole repair, and showing residual subretinal fluid or perfluorocarbon in retinal detachment surgery. This narrative review aims at describing the state of the art of iOCT in vitreoretinal procedures, highlighting its modern role and applications in posterior segment surgery, its current limitations, and the future perspectives that may improve the widespread adoption of this technology.

Long-term functional and structural outcomes after large chorioretinectomy for ruptured globe following blunt trauma

BACKGROUND

The purpose of this study was to present a modified surgical technique involving pars plana vitrectomy with large chorioretinectomy for eyes with rupture of the globe due to severe ocular blunt trauma.

METHODS

This retrospective study included consecutive patients with rupture of the globe due to blunt trauma who were treated at the King Khaled Eye Specialist Hospital (Riyadh, Saudi Arabia). All patients underwent 25-gauge pars plana vitrectomy with large chorioretinectomies involving all the tissue around the posterior scleral wounds. Outcome measures included best-corrected visual acuity (BCVA), anatomical success and globe survival, rates of complications.

RESULTS

15 eyes of 15 patients were included. Mean BCVA was 2.88 ± 0.13 logMAR at presentation, and significantly improved to 0.83 ± 0.28 logMAR (P < 0.001), with 10 patients (67%) achieving a final BCVA ≥ 20/200. Anatomical success and globe survival were achieved in 11 (73%) and 15 (100%) of eyes, respectively. Postoperative complications included retinal detachment in 6 eyes (40%), epiretinal membrane in 6 (40%), hypotony in 4 (26%), PVR in 2 (13%).

CONCLUSIONS

Pars plana vitrectomy with large chorioretinectomy is an effective treatment for globe rupture following severe blunt trauma, yielding good visual outcomes and anatomical success rates.

Macrophage Activation in Follicular Conjunctivitis during the COVID-19 Pandemic

Among the symptoms of SARS-CoV-2, follicular conjunctivitis has become relevant. The conjunctiva acts as an open lymph node, reacting to the viral antigen that binds the epithelial cells, forming follicles of B cells with activated T cells and NK cells on its surface, which, in turn, talk to monocyte-derived inflammatory infected macrophages. Here, the NLRP3 inflammasome is a major driver in releasing pro-inflammatory factors such as IL-6 and caspase-1, leading to follicular conjunctivitis and bulbar congestion, even as isolated signs in the 'asymptomatic' patient.

Cone dystrophy associated with autoimmune polyglandular syndrome type 1

To report the association of autoimmune polyglandular syndrome type 1 (APS1) with cone dystrophy in a large Saudi family. This is a Retrospective chart review and prospective genetic testing and ophthalmic examination of a large multiplex consanguineous family. Genetic testing was performed on 14 family members, seven of whom had detailed ophthalmic examinations. Medical history, ocular history and evaluation, visual field testing, full-field electroretinogram (ERG), and Whole Exome Sequencing (WES) results were analyzed. Three family members were homozygous for c.205_208dupCAGG;p.(Asp70Alafs*148) in AIRE and homozygous for c.481-1G>A in PDE6C. One additional family member was homozygous for only the AIRE variant and another additional family member was homozygous for only the PDE6C variant. All patients with homozygosity for the PDE6C variant had cone dystrophy, and all patients with homozygosity for the AIRE variant had APS1. In addition, two of the family members who were homozygous for the PDE6C and AIRE variants had reduced rod function on ERG. We report the co-inheritance for APS1 and PDE6C-related cone dystrophy, an unusual example of two seemingly independent recessive conditions coinciding within a family. Dual molecular diagnosis must be taken into account by ophthalmologists facing unusual constellations of findings, especially in consanguineous families.

Cluster analysis of transcriptomic datasets to identify endotypes of idiopathic pulmonary fibrosis

BACKGROUND

Considerable clinical heterogeneity in idiopathic pulmonary fibrosis (IPF) suggests the existence of multiple disease endotypes. Identifying these endotypes would improve our understanding of the pathogenesis of IPF and could allow for a biomarker-driven personalised medicine approach. We aimed to identify clinically distinct groups of patients with IPF that could represent distinct disease endotypes.

METHODS

We co-normalised, pooled and clustered three publicly available blood transcriptomic datasets (total 220 IPF cases). We compared clinical traits across clusters and used gene enrichment analysis to identify biological pathways and processes that were over-represented among the genes that were differentially expressed across clusters. A gene-based classifier was developed and validated using three additional independent datasets (total 194 IPF cases).

FINDINGS

We identified three clusters of patients with IPF with statistically significant differences in lung function (p=0.009) and mortality (p=0.009) between groups. Gene enrichment analysis implicated mitochondrial homeostasis, apoptosis, cell cycle and innate and adaptive immunity in the pathogenesis underlying these groups. We developed and validated a 13-gene cluster classifier that predicted mortality in IPF (high-risk clusters vs low-risk cluster: HR 4.25, 95% CI 2.14 to 8.46, p=3.7×10-5).

INTERPRETATION

We have identified blood gene expression signatures capable of discerning groups of patients with IPF with significant differences in survival. These clusters could be representative of distinct pathophysiological states, which would support the theory of multiple endotypes of IPF. Although more work must be done to confirm the existence of these endotypes, our classifier could be a useful tool in patient stratification and outcome prediction in IPF.

Denuded Descemet's membrane supports human embryonic stem cell-derived retinal pigment epithelial cell culture

Recent clinical studies suggest that retinal pigment epithelial (RPE) cell replacement therapy may preserve vision in retinal degenerative diseases. Scaffold-based methods are being tested in ongoing clinical trials for delivering pluripotent-derived RPE cells to the back of the eye. The aim of this study was to investigate human embryonic stem cell-derived retinal pigment epithelial (hESC-RPE) cells survival and behaviour on a decellularized Descemet's Membrane (DM), which may be of clinical relevance in retinal transplantation. DMs were isolated from human donor corneas and treated with thermolysin. The DM surface topology and the efficiency of the denudation method were evaluated by atomic force microscope, scanning electron microscopy and histology. hESC-RPE cells were seeded onto the endothelial-side surface of decellularized DM in order to determine the potential of the membrane to support hESC-RPE cell culture, alongside maintaining their viability. Integrity of the hESC-RPE monolayer was assessed by measuring transepithelial resistance. RPE-specific gene expression and growth factors secretion were assessed to confirm maturation and functionality of the cells over the new substrate. Thermolysin treatment did not affect the integrity of the tissue, thus ensuring a reliable method to standardize the preparation of decellularized DM. 24 hours post-seeding, hESC-RPE cell attachment and initial proliferation rate over the denuded DM were higher than hESC-RPE cells cultured on tissue culture inserts. On the new matrix, hESC-RPE cells succeeded in forming an intact monolayer with mature tight junctions. The resulting cell culture showed characteristic RPE cell morphology and proper protein localization. Gene expression analysis and VEGF secretion demonstrate DM provides supportive scaffolding and inductive properties to enhance hESC-RPE cells maturation. Decellularized DM was shown to be capable of sustaining hESC-RPE cells culture, thus confirming to be potentially a suitable candidate for retinal cell therapy.

Retinal periphlebitis associated with branch retinal vein occlusion and complicated by subfoveal hemorrhage: a case report

Retinal periphlebitis is a subtype of retinal vasculitis affecting the retinal veins. We report a case of bilateral branch retinal vein occlusion (BRVO) associated with idiopathic retinal periphlebitis and complicated by subfoveal hemorrhage (SFH). An 18-year-old woman presented with best-corrected visual acuity of 20/20 in the right eye and 20/30 in the left eye. Examination revealed bilateral retinal vascular sheathing predominantly involving the retinal veins and bilateral BRVO. Fundus fluorescein angiography revealed localized vascular leakage in the right eye and diffuse vascular leakage in the left eye. Spectral-domain optical coherence tomography showed mild nasal thickening with subfoveal fluid in the left eye. Oral steroids were started on a tapering dosage as well as oral methotrexate. A year later, she presented with regressed vascular sheathing in both eyes with 5/200 vision and SFH in the left eye. Pars plana vitrectomy, subretinal tissue plasminogen activator, intravitreal ranibizumab, laser photocoagulation, and gas injection were performed. The SFH resolved and the visual acuity improved to 20/100. Good vision was preserved in both eyes with no active inflammation. Timely management of SFH in idiopathic retinal periphlebitis can achieve a favorable visual outcome.

The role of the mTOR pathway in diabetic retinopathy

The retina, the part of the eye, translates the light signal into an electric current that can be sent to the brain as visual information. To achieve this, the retina requires fine-tuned vascularization for its energy supply. Diabetic retinopathy (DR) causes alterations in the eye vascularization that reduce the oxygen supply with consequent retinal neurodegeneration. During DR, the mammalian target of rapamycin (mTOR) pathway seems to coordinate retinal neurodegeneration with multiple anabolic and catabolic processes, such as autophagy, oxidative stress, cell death, and the release of pro-inflammatory cytokines, which are closely related to chronic hyperglycemia. This review outlines the normal anatomy of the retina and how hyperglycemia can be involved in the neurodegeneration underlying this disease through over activation or inhibition of the mTOR pathway.

Management of complicated proliferative diabetic retinopathy in a patient with oculocutaneous albinism

Purpose

To describe the management and outcome of a patient with oculocutaneous albinism and complicated proliferative diabetic retinopathy, as well as to discuss treatment challenges and strategies in this patient population.

Observation

A 52-year-old patient with oculocutaneous albinism and diabetes presented with light perception vision in her right eye and 20/300 vision in her left eye. Examination showed a diabetic tractional retinal detachment in the right eye and high-risk proliferative diabetic retinopathy (PDR) in the left eye. In the right eye, the patient underwent pars plana vitrectomy, membrane delamination, endolaser therapy, and silicone oil tamponade, with follow-up evaluations showing a flat retina under silicone oil with regressed retinopathy in this eye. In her left eye, pan-retinal photocoagulation was attempted without success, with persistent PDR and absence of laser marks in this eye. Subsequently, the patient underwent six intravitreal anti-VEGF injections, after which she developed a tractional retinal detachment necessitating treatment cessation and a planned surgical intervention.

Conclusion and Importance

This case highlights the difficulty of using standard medical and surgical treatment strategies when caring for patients with oculocutaneous albinism and complicated proliferative diabetic retinopathy. If medical treatments fail in these patients, surgical approaches should be planned with extreme care due to the risks and challenges posed by hypopigmented fundi.

Method

Interventional case report.

Radiographic Progression and Survival of the Different HRCT Patterns of Idiopathic Pulmonary Fibrosis

INTRODUCTION

Idiopathic pulmonary fibrosis (IPF) is a chronic disease with a peculiar (typical) HRCT pattern, but biopsy can demonstrate usual interstitial pneumonia in patients with atypical patterns. It is unknown how progression pattern varies among different radiographic presentations of IPF. We sought to investigate the longitudinal radiographic evolution and survival of typical and non-typical patterns.

MATERIALS AND METHODS

One-hundred-twenty-three patients diagnosed with IPF in 2 tertiary referral hospitals were included in the study. Longitudinal evolution of non-typical patterns was considered. The HRCT visual fibrosis score was used as a reliable evaluation tool of disease progression. HRCTs were scored by 2 senior chest radiologists with ILD expertise. The primary endpoint was the evolution of the presentation pattern to probable or typical. The secondary endpoint was lung transplant (LTx)-free survival from the time of diagnosis.

RESULTS

Average interval between HRCTs was 16±5 months; average follow-up after the 2^nd HRCT was 17±11 months. Four out of 45 (8.9%) patients with probable pattern "evolved" to a typical pattern of IPF, while 5 out of 31 (16.1%) with indeterminate/alternative pattern "evolved" to probable pattern. An average HRCT fibrosis score increase of 9±11% was observed with typical (n=49), 6±5% with probable (n=43) and 7±8% (n=31) with indeterminate/alternative presentation pattern. LTx-free survival and lung function declines did not show any difference related to presentation HRCT patterns.

CONCLUSIONS

The evolution of a non-typical UIP pattern to a typical one is infrequent. All presentation HRCT patterns of IPF evolve in similar way and are associated with comparable survival time.[/sc].

Digital quantification of p16-positive foci in fibrotic interstitial lung disease is associated with a phenotype of idiopathic pulmonary fibrosis with reduced survival

BACKGROUND

Idiopathic pulmonary fibrosis (IPF) is associated with increased expression of cyclin-dependent kinase inhibitors such as p16 and p21, and subsequent induction of cell cycle arrest, cellular senescence, and pro-fibrotic gene expression. We sought to link p16-expression with a diagnosis of IPF or other fibrotic interstitial lung diseases (ILDs), radiographic pattern, senescent foci-specific gene expression, antifibrotic therapy response, and lung transplant (LTx)-free survival.

METHODS

Eighty-six cases of fibrosing ILD were identified with surgical lung biopsy. Immunohistochemistry for p16 was performed on sections with the most active fibrosis. p16-positive foci (loose collection of p16-positive fibroblasts with overlying p16-positive epithelium) were identified on digital slides and quantified. Cases were scored as p16-low (≤ 2.1 foci per 100 mm²) or p16-high (> 2.1 foci per 100 mm²). Twenty-four areas including senescent foci, fibrotic and normal areas were characterized using in situ RNA expression analysis with digital spatial profiling (DSP) in selected cases.

RESULTS

The presence of p16-positive foci was specific for the diagnosis of IPF, where 50% of cases expressed any level of p16 and 26% were p16-high. There was no relationship between radiographic pattern and p16 expression. However, there was increased expression of cyclin-dependent kinase inhibitors, collagens and matrix remodeling genes within p16-positive foci, and cases with high p16 expression had shorter LTx-free survival. On the other hand, antifibrotic therapy was significantly protective. DSP demonstrated that fibroblastic foci exhibit transcriptional features clearly distinct from that of normal-looking and even fibrotic areas.

CONCLUSIONS

We demonstrated the potential clinical applicability of a standardized quantification of p16-positive fibroblastic foci. This method identifies an IPF phenotype associated with foci-specific upregulation of senescence-associated and matrix remodeling gene expression. While these patients have reduced LTx-free survival, good response to antifibrotic therapies was observed in those who were treated.

P182 VALSARTAN LIMITS PULMONARY AND CARDIAC DAMAGE INDUCED BY SARS–COV–2 IN EXPERIMENTAL MODELS BY REDUCING THE EXPRESSION OF ACE2

Background

SARS–CoV–2 primarily affects the respiratory system, but cardiac complications also occur very often. The entry of SARS–CoV–2 into host cells is mediated by the interaction between the viral glycoprotein Spike (S) and the host angiotensin–converting enzyme 2 (ACE2) protein. The use of ACE inhibitors (ACEIs) and angiotensin II type 1 receptor blockers (ARBs) might influence both ACE2 expression and viral infection, but our knowledge about these possible interactions is limited. Aim. To evaluate the effects of ACEIs and ARBs during active viraemia.

Methods

We tested the effects of exposure to the ACEI Lisinopril (100nM and 500nM) and the ARB Valsartan (10µM and 50µM) on three different cell types: green monkey–derived epithelial cells (VERO E6) which are used to replicate SARS–CoV–2, cardiomyocytes derived from hiPSC (iPSC–CMs) as heart model and a lung epithelial cancer cell line (16HBE) as pulmonary model. The SARS–CoV–2 wild strain was inoculated on cell lines for 1 hour. Cell viability was measured 72 hours after infection. The supernatants of the infected cells were collected and titrated by the micro–neutralization assay on VERO E6 cells to verify the presence of the virus. Levels of ACE2 mRNA and protein content on cell lysates were quantified after each treatment by RT–qPCR and western blot, respectively.

Results

ACEI and ARB at both concentrations do not affect the viability of the 3 cell lines. Vice versa, viral infection significantly decreases the viability of VERO E6 (–60%, p < 0.0001) and iPSC–CMs (–44%, p < 0.001), while 16HBE cells do not show a cytopathic effect after infection. Viral titration shows that SARS–CoV–2 replicated in cell lines and was actively released into supernatants. Valsartan 50µM decreased virus release in the three cell lines and increased the viability of VERO E6 (+69%, p < 0.01) and iPSC–CMs (+20.5%, p < 0.05) after the infection. Valsartan 50µM also decreases both mRNA (–65% in VERO E6, p < 0.001; –50% in iPSC–CMs, p < 0.05; –60.5% in 16HBE, p < 0.01) and protein levels of ACE2 in all 3 cell lines.

Conclusion

The data suggest that ACEIs and ARBs do not worsen the SARS–CoV–2 infection and that Valsartan, by reducing the levels of ACE2 expression, might result protective.

Re-Vitrectomy versus Combined Re-Vitrectomy with Scleral Buckling for Pediatric Recurrent Retinal Detachment

Purpose

To compare re-vitrectomy versus combined re-vitrectomy with scleral buckling (SB) for pediatric recurrent rhegmatogenous retinal detachment (RRD) following failed primary pars plana vitrectomy (PPV).

Methods

This was a retrospective, comparative case series of pediatric patients (under 18 years) who underwent secondary RRD procedures after failed primary PPV. Patients were divided into the re-vitrectomy and the combined re-vitrectomy with SB groups. The primary outcome was the anatomical success rate for each procedure. The secondary outcomes were changes in best-corrected visual acuity (BCVA) and postoperative complications.

Results

In the re-vitrectomy group (30 eyes), the final anatomical success rate was 83.3% (25/30) after a mean follow-up of 21.7 + 6.9 months. The final anatomical success rate in the combined re-vitrectomy/SB group (23 eyes) was 73.9% (17/23) after a mean follow-up of 26.5 + 7.7 months. There was no statistically significant difference in the final anatomical success rate (P = 0.41) and the mean change in BCVA (P = 0.37) between the two groups. Even though not statistically significant, the combined re-vitrectomy/SB group had a lower incidence of postoperative complications (P = 0.25).

Conclusion

Re-vitrectomy alone provides similar anatomical and functional outcomes to combined re-vitrectomy/SB for pediatric recurrent RRD after failed primary PPV.

Vitrectomy versus Vitrectomy with Scleral Buckling in the Treatment of Giant Retinal Tear Related Retinal Detachments: An International Multicenter Study

PURPOSE

To determine the practice pattern for treating giant retinal tear (GRT) related detachments, and their anatomic and visual outcomes with pars plana vitrectomy (PPV) with or without scleral buckling (SB).

DESIGN

Retrospective cohort study.

SUBJECTS

Eyes with GRT detachments repaired from 2008-2020 with at least 6 months of follow-up from seven institutions in North and South America, Europe, and Asia.

METHODS

Eyes repaired using PPV versus PPV/SB were compared.

MAIN OUTCOME MEASURES

Anatomic and functional outcomes.

RESULTS

A comparable number of eyes underwent PPV (n=101) and PPV/SB (n=99). Except for prior intraocular surgery and lens status, no differences in baseline demographics, ocular characteristics, or intraoperative surgical adjuncts were observed. Overall single surgery anatomic success (SSAS) at 6 months and 1 year was similar between the groups (82.2% and 77.2% of PPV, and 87.9% and 85.7% of PPV/SB). However, when stratified by age, the 1-year SSAS rate was higher for PPV/SB (88.5%) than PPV (56.3%) (p=0.03) for children < 18 years. For both children and adults, mean best corrected visual acuity (BCVA) at baseline did not differ between the PPV and PPV/SB groups. However, for children, mean BCVA at 1 year was better in the PPV/SB than PPV groups (p=0.001) while for adults, no difference was found between the two groups. The mean time to first redetachment was 7.9 months in the PPV group and 5.5 months in the PPV/SB group (p=0.8). PVR was the most common cause for redetachment (70.4% of PPV and 93.8% of PPV/SB in redetached eyes; p=0.1). Postoperative complications were also similar between the two groups including ocular hypertension, epiretinal membrane, and cataract.

CONCLUSIONS

PPV and PPV/SB are equally popular among surgeons globally for managing GRT detachments and have comparable anatomic and visual outcomes in adults. In children, PPV/SB is superior to PPV for anatomic and functional success at one year. In adults, the relief of traction by the GRT may reduce peripheral traction and obviate the need for a SB. However, in children, a supplemental SB can be beneficial as complete vitreous shaving and posterior hyaloid detachment, and postoperative positioning are difficult in this group.

Adjunctive Intravitreal Triamcinolone Acetonide for Exudative Retinal Detachment in Coats Disease

Purpose:

This work aims to assess the value of intravitreal triamcinolone acetonide (IVTA) as an adjunctive therapy in advanced Coats disease with exudative retinal detachment (ERD).

Methods:

A retrospective review was conducted of patients with Coats disease stage 3 or higher who received IVTA to decrease subretinal fluid (SRF), facilitate retinal ablative therapy, and avoid surgical drainage. Primary outcomes were SRF resolution and avoidance of surgical SRF drainage.

Results:

Seventeen eyes of 17 patients (mean, [SD] age, 3.9 [3.4] years) met the inclusion criteria. ERD configuration was bullous in 7 and shallow in 10 eyes. Following a single IVTA injection, ablative therapy was achieved after a mean (SD) of 2.1 (3.0) weeks. Complete SRF resolution was observed in 13 eyes (76.4%) after a mean of 1.3 IVTA injections and a mean of 2 (SD, 1.27) laser sessions, and none of these eyes required SRF drainage up to last follow-up (mean [SD], 50.5 [26.24] months). In 4 eyes with bullous ERD at presentation, SRF persisted ( P = .015) despite additional measures including surgical drainage. Final visual acuity ranged from 20/100 to no light perception. Cataract developed in 12 of the 17 eyes (70.5%). None developed an increase in intraocular pressure at final follow-up.

Conclusions:

IVTA injection can be a helpful adjunctive modality to address SRF in advanced Coats disease. It may obviate the need to surgically drain SRF to effectively treat the condition, particularly when the ERD is not highly bullous.

Immunomodulatory treatment of interstitial lung disease

Interstitial lung diseases (ILDs) other than idiopathic pulmonary fibrosis (IPF) have an array of immunomodulatory treatment options compared with IPF, due to their inflammatory component. However, there is a relative paucity of guidance on the management of this heterogeneous group of diseases. In ILDs other than IPF, immunosuppression is the cornerstone of therapy, with varying levels of evidence for different immunomodulatory agents and for each specific ILD. Classification of ILDs is important for guiding treatment decisions. Immunomodulatory agents mainly include corticosteroids, mycophenolate mofetil (MMF), azathioprine, methotrexate, cyclophosphamide and rituximab. In this review, the available evidence for single agents in the most common ILDs is first discussed. We then reviewed practical therapeutic approaches in connective tissue disease-related ILD and interstitial pneumonia with autoimmune features, scleroderma-related ILD, vasculitis and dermatomyositis with hypoxemic respiratory failure, idiopathic non-specific interstitial pneumonia, hypersensitivity pneumonitis sarcoidosis, fibrosing organizing pneumonia and eosinophilic pneumonia. The treatment of acute exacerbations of ILD is also discussed. Therapy augmentation in ILD is dictated by the recognition of progression of disease. Criteria for the evaluation of progression of disease are then discussed. Finally, specific protocol and measures to increase patients' safety are reviewed as well, including general monitoring and serologic surveillance, Pneumocystis jirovecii prophylaxis, patients' education, genetic testing for azathioprine, MMF serum levels and cyclophosphamide administration protocols. Immunomodulatory therapies are largely successful in the management of ILDs and can be safely managed with the application of specific protocols, precautions and monitoring.

Validation of the risk stratification score in idiopathic pulmonary fibrosis: study protocol of a prospective, multi-centre, observational, 3-year clinical trial

BACKGROUND

Idiopathic pulmonary fibrosis (IPF) is characterized by a poor prognosis, with a progressive decline in lung function and considerable variability in the disease's natural history. Besides lung transplantation (LTx), the only available treatments are anti-fibrosing drugs, which have shown to slow down the disease course. Therefore, predicting the prognosis is of pivotal importance to avoid treatment delays, which may be fatal for patients with a high risk of progression. Previous studies showed that a multi-dimensional approach is practical and effective in the development of a reliable prognostic score for IPF. In the RIsk Stratification scorE (RISE), physiological parameters, an objective measure of patient-reported dyspnea and exercise capacity are combined to capture different domains of the complex pathophysiology of IPF.

METHODS

This is an observational, multi-centre, prospective cohort study, designed to reflect common clinical practice in IPF. A development cohort and a validation cohort will be included. Patients newly diagnosed with IPF based on the ATS/ERS criteria and multi-disciplinary discussion will be included in the study. A panel of chest radiologists and lung pathologists will further assess eligibility. At the first visit (time of diagnosis), and every 4-months, MRC dyspnea score, pulmonary function tests (FEV1, FVC and DLCO), and 6-min walking distance will be recorded. Patients will be prospectively followed for 3 years. Comorbidities will be considered. The radiographic extent of fibrosis on HRCT will be recalculated at a 2-year interval. RISE, Gender-Age-Physiology, CPI and Mortality Risk Scoring System will be calculated at 4-month intervals. Longitudinal changes of each variable considered will be assessed. The primary endpoint is 3-year LTx-free survival from the time of diagnosis. Secondary endpoints include several, clinically-relevant information to ensure reproducibility of results across a wide range of disease severity and in concomitance of associated pulmonary hypertension or emphysema.

DISCUSSION

The objective of this study is to validate RISE as a simple, straightforward, inexpensive and reproducible tool to guide clinical decision making in IPF, and potentially as an endpoint for future clinical trials.

TRIAL REGISTRATION

U.S National Library of Medicine Clinicaltrials.gov, trial n. NCT02632123 "Validation of the risk stratification score in idiopathic pulmonary fibrosis". Date of registration: December 16th, 2015.

Comparison of 3D Digitally Assisted Visualization System with Current Standard Visualization for the Removal of Vitreous in a Preclinical Model

Purpose

Novel 3D digital display systems, such as NGENUITY 3D digitally assisted visualization system (DAVS), can provide enhanced illumination, depth of field, and digital filtering. This study compared vitreous removal using NGENUITY 3D DAVS with a standard surgical microscope.

Methods

This was an in vivo, 2-arm laboratory study in 15 Yorkshire pig eyes. The LuxOR LX3 microscope with NGENUITY 3D DAVS (arm 1) and the LuxOR LX3 microscope alone (arm 2) were used with 5× optical magnification and Oculus BIOM 200 mm optics. Standard core and peripheral vitrectomy without scleral depression was performed using the CONSTELLATION Vision System. Residual vitreous weight was assessed in enucleated eyes by a masked observer. Axial length and vitreous weight of contralateral eyes were compared from an additional 14 Yorkshire pigs to confirm that eyes from a single animal were essentially identical.

Results

After vitrectomy, mean ± SD residual vitreous was significantly smaller with NGENUITY versus standard microscope (0.143 ± 0.146 versus 0.580 ± 0.269 g, respectively; P < 0.0001). Based on a mean initial vitreous weight of 2.5 g, as determined by assessment in contralateral eyes from an additional 14 Yorkshire pigs, the mean percentage vitreous removal was 94% ± 6% versus 77% ± 11%, respectively. Further, vitreous weight and axial length for contralateral eyes from any single animal in these additional 14 animals were essentially identical, as mean differences were 0.046 ± 0.035 g and 0.11 ± 0.08 mm, respectively.

Conclusion

Vitrectomy with NGENUITY 3D DAVS resulted in significantly less residual vitreous in pig eyes compared with standard microscopy. NGENUITY may improve vitreous removal during vitreoretinal surgery by enhancing visualization.

Comparison of heads up three dimensional visualization system to conventional microscope in retinopathy of prematurity related tractional retinal detachment

To report the outcomes, advantages and disadvantages of a heads-up three-dimensional (3D) visualization system compared to the conventional microscope in pediatric tractional retinal detachment (TRD) surgery secondary to advanced stage retinopathy of prematurity (ROP). Medical records of patients with ROP stage 4 or 5 who underwent surgery for tractional retinal detachment at King Khaled Eye Specialist Hospital between September 2017 and July 2019 were identified and reviewed. Eyes were divided into 2 groups, eyes that underwent surgery with a 3D heads-up platform (3D group) and eyes that underwent surgery with a conventional microscope (conventional group). Data were collected on neonatal history, visual acuity, intraoperative complications and success rates between groups.Eighteen eyes of 14 patients who underwent surgical repair of TRD related to ROP. Postoperative outcomes were compared between 10 eyes (7 patients) in the 3D group and 8 eyes (7 patients) in the conventional group There was no statistically significant difference in success rate between both groups (75% conventional group vs 70% 3D group). Partial or complete reattachment was achieved in 7 eyes in 3D group compared to 6 eyes in conventional group. Lower postmenstrual age at the time of the first surgery and presence of retinal breaks were associated with poorer surgical outcome. Heads up 3D visualization system is feasible in tractional retinal detachment related to ROP with similar success rate and no increased risk of complications when compared to conventional microscope. This system may be advantageous in advanced pediatric tractional retinal detachment surgeries.

Comparison of Posterior Hyaloid Assessment Using Preoperative Optical Coherence Tomography and Intraoperative Triamcinolone Acetonide Staining During Vitrectomy

Purpose

To compare the specificity of diagnosing posterior vitreous detachment (PVD) using preoperative optical coherence tomography (OCT) versus intraoperative triamcinolone acetonide (TA) staining in patients undergoing vitrectomy.

Patients and Methods

This retrospective cohort study included patients undergoing pars plana vitrectomy for diverse retinal pathologies. Intraoperatively, surgeons evaluated the posterior hyaloid status with TA staining and compared it with preoperative OCT findings.

Results

One hundred six patients underwent intraoperative assessments of posterior hyaloid status, with 72% (76/106) of the eyes showing positive staining. Sixty-two patients had also undergone preoperative OCT. Of the patients diagnosed with PVD on preoperative OCT, 50% (15/30) showed positive TA staining intraoperatively. The sensitivity of preoperative OCT assessment was 83.3%, and its specificity was 65.9%.

Conclusion

Preoperative OCT imaging is associated with lower sensitivity and specificity for diagnosing PVD when compared to intraoperative TA staining.

Immunization on the French Armed Forces: Impact, organization, limits and perspectives

Vaccination plays a key role in the prevention of the infectious diseases, which the armed forces are exposed to during overseas deployments. Historically, the French military health service have always contributed greatly to progress in vaccination. The military immunization schedule has often been used as a model for the national schedule. It is a powerful tool, which is constantly evolving to take into account the risks of infection inherent in deployment and to include new scientific data, while still remaining aware of the limitations of vaccination from an individual and collective standpoint. In the current context of increasingly fast emergence or re-emergence of pathogens with a high epidemic potential, developing preventive medical measures is more necessary than ever before, and the French military health service is actively participating.

Surgical Management of Hemorrhagic Retinal Detachment Secondary to Peripheral Exudative Hemorrhagic Chorioretinopathy

The purpose of the study is to report a case of peripheral exudative hemorrhagic chorioretinopathy (PEHCR), managed surgically with favorable visual outcome. A 66-year-old female presented with painless visual loss due to dense vitreous and subretinal hemorrhage extending from the far periphery to the macula. Pars plana vitrectomy (PPV) with subretinal tissue plasminogen activator (TPA) injection was performed resulting in good anatomical and visual outcome. PEHCR can present with severe visual loss. Surgical management with PPV and subretinal TPA injection might result in favorable anatomical and visual outcome.

Endophthalmitis Post Pars Plana Vitrectomy Surgery: Incidence, Organisms' Profile, and Management Outcome in a Tertiary Eye Hospital in Saudi Arabia

PURPOSE

To determine the incidence of endophthalmitis after pars plana vitrectomy (PPV), organisms' profile, and management outcomes at a tertiary eye hospital in a Middle East country.

METHODS

In this single-arm cohort study conducted in 2020, medical records of patients who underwent PPV not accompanied by any other intraocular surgery were reviewed; those with a diagnosis of acute endophthalmitis in the immediate postoperative period (within 6 weeks) during the past 6 years were analyzed.

RESULTS

A total of 8153 records of PPV surgeries were reviewed. Five cases had endophthalmitis post-PPV with an incidence of 0.061%. Three (0.037%) had positive cultures, all of them for Staphylococcus epidermidis. The interval between PPV and diagnosis of endophthalmitis ranged from 3 to 25 days (mean, 15.8 days). Final vision after treatment ranged from 20/400 to no light perception, and one eye was eviscerated.

CONCLUSION

The incidence of endophthalmitis post PPV is low. Despite prompt diagnosis and standard management, visual prognosis seems to be poor. The infective agents for endophthalmitis were commensals from the ocular surface.

Exercise capacity and its relationship with body composition and nutrition status in patients with interstitial lung disease

BACKGROUND

Patients with interstitial lung disease (ILD) are known to have diminished exercise ability. This study aimed to explore the relationship between nutrition status and body composition parameters with exercise capacity in ILD patients. A second aim focused on assessing the appropriateness of surrogate markers of nutrition status in ILD patients.

METHODS

Disease severity was determined by the percentage of predicted forced vital capacity. Exercise capacity was determined using 6-minute walk distance. Nutrition status was assessed using the subjective global assessment (SGA), standardized phase angle (SPhA), and impedance ratio z-score (z-IR). Bioelectrical impedance analysis estimated body composition parameters.

RESULTS

45 of 79 participants (57%) were malnourished according to the SGA. FFM index z-score (z-FFMI) (r = 0.42, P = .02) and SGA (r = 0.49, P < .01) were significant predictors of exercise capacity independent of disease severity. Age (odds ratio [OR] = 1.1; 95% CI, 1.01-1.25; P = .04), low body mass index (OR = 0.73; 95% CI, 0.57-0.92; P = .01), z-FFMI (OR = 0.34; 95% CI, 0.17-0.68; P < .01), and body fat mass index z-score (OR = 0.39; 95% CI, 0.17-0.91; P = .03) were significantly associated with severe malnutrition. There was no significant difference in SPhA across SGA groups; however, a higher z-IR (poorer cell health) significantly increased the odds of severe malnutrition (OR = 2.75; 95% CI, 1.27-6.03; P = .02).

CONCLUSION

In ILD patients, malnutrition and loss of FFM negatively impact the ability to perform activities of daily living.

Fat-Free Mass Index Controlled for Age and Sex and Malnutrition Are Predictors of Survival in Interstitial Lung Disease

BACKGROUND

Literature focusing on nutritional variables and survival in interstitial lung disease (ILD) is limited by its focus on weight and BMI and has not considered body composition.

OBJECTIVES

The primary objective of this study was to examine whether body composition measures, specifically fat-free mass index z-score (z-FFMI) and body fat mass index z-score (z-BFMI), were predictors of survival in fibrotic ILD patients. The second objective was to examine if nutrition status was a predictor of survival.

METHOD

Seventy-eight outpatients diagnosed with fibrotic ILD were recruited in this cross-sectional study. Body composition data using dual frequency bioelectrical impedance analysis (BodyStat 1500MD; UK) and nutrition status using the subjective global assessment (SGA) were determined. To control for age and sex, z-FFMI and z-BFMI were calculated using population means. Participant charts were reviewed for diagnosis, age, disease severity, and exercise capacity.

RESULTS

Age (HR 1.08, 95% CI [1.03-1.13], p < 0.01), BMI (HR 0.90, 95% CI [0.84-0.97], p < 0.01]), z-FFMI (HR 0.70, 95% CI [0.56-0.87], p = 0.02), z-BFMI (HR 0.74, 95% CI [0.57-0.96], p < 0.01), 6-min walk distance (6MWD) (HR 0.99, 95% CI [0.99-1.00], p < 0.01), percent predicted diffusing capacity for carbon monoxide (%DLco) (HR 0.93, 95% CI [0.89-0.97], p < 0.01), and severe malnutrition (SGA-C) (HR 6.98, 95% CI [2.00-24.27], p < 0.01) were significant predictors of survival. When controlled for exercise capacity and disease severity, z-FFMI and severe malnutrition were significant predictors of survival independent of %DLco.

CONCLUSION

z-FFMI and severe malnutrition were significant predictors of survival in fibrotic ILD patients independent of disease severity.

Incidence and Natural History of Retinochoroidal Neovascularization in Enhanced S-Cone Syndrome

OBJECTIVE

We examined the incidence and natural history of macular retinochoroidal neovascularization (RCN) in enhanced S-cone syndrome (ESCS).

DESIGN

Retrospective case series.

METHODS

This single-center study included 14 of 93 patients with ESCS who had signs of active or inactive RCN in ≥1 eye. We conducted multimodal retinal imaging, full-field electroretinography, and molecular genetic analysis of NR2E3 gene. Our main outcome measures included the cumulative incidence of RCN in ESCS, type of RCN, and mode of evolution of RCN.

RESULTS

Fourteen (15.1%) of 93 patients with ESCS had RCN in ≥1 eye at 2 to 27 years of age. All 22 RCNs (21 eyes of 14 patients) were macular. Twelve of the RCNs were active with exudates/hemorrhages. Of these, 5 appeared de novo in a subretinal location, with photographic evidence of no pre-existing lesions. The latter were compatible with type 3 neovascularization or retinal angiomatous proliferation and subsequently evolved into unifocal fibrotic nodules. The remaining active lesions all had some degree of pre-existing fibrosis and remained stable. Ten inactive fibrotic nodules, identical to end-stage de novo lesions, were found and were presumed to represent healed RCNs.

CONCLUSIONS

RCN, a treatable condition, may occur as early as 2 years of age and may be much more common in patients with ESCS than previously estimated. It may be the primary cause of the unifocal submacular fibrosis that is commonly observed in this condition. Additional research is needed to establish the pathogenesis of RCN in patients with ESCS and its optimal management.

Tobacco Worker's Lung: A Neglected Subtype of Hypersensitivity Pneumonitis

Tobacco worker's lung (TWL) is a type of hypersensitivity pneumonitis (HP) affecting workers exposed to tobacco leaves and molds in the humidified environment of the tobacco production industry. Limited epidemiological data point to a prevalence of TWL that is not negligible and probably underestimated. As in other types of HP, an acute vs. chronic presentation depends on the pattern of the exposure. Therefore, the clinical presentation can vary from an acute influenza-like syndrome, mostly self-limiting with the removal of the exposure, to an insidious onset of cough, exertional dyspnea, fatigue and weight loss in chronic presentations, where fibrotic changes may be observed. The main treatment strategy is the removal of the exposure to tobacco dust and molds, while the main aim of corticosteroid therapy is to reduce morbidity and prevent complications, namely the development of pulmonary fibrosis and permanent lung dysfunction. Despite the fact that TWL is quite well described, preventive measures are not usually adopted in the tobacco production industry. We present here a state of the art review of this neglected, preventable, but still prevalent and occupational-related subtype of HP.

TPMT and HLA-DQA1-HLA-DRB genetic profiling to guide the use of azathioprine in the treatment of interstitial lung disease: First experience

BACKGROUND

The choice of immunosuppressive therapy in interstitial lung disease (ILD) other than idiopathic pulmonary fibrosis (IPF) is based on safety profile and expected efficacy. Azathioprine is one of the most commonly used agents to treat ILD. The immunosuppressive effect and pancreatitis risk of azathioprine are influenced by the activity of the enzyme thiopurine methyltransferase (TPMT) and by the genetic mutations in HLA-DQA1-HLA-DRB locus, respectively. We hypothesized that systematic genotyping prior to starting azathioprine improves the rate of discontinuation of immunosuppressive therapy and the total incidence of adverse drug reactions (ADRs).

METHODS

Eighty-two patients with ILD other than IPF were included in the study. The rate of immunosuppressive therapy discontinuation due to major ADRs and the total incidence of ADRs were compared between a cohort of genotyped patients (n = 49) and an untested cohort of patients (n = 33).

RESULTS

Thirty-seven out of 49 patients in the genotyped cohort and 27 out of 33 patients in the untested cohort were started on azathioprine. The rate of immunosuppressive therapy discontinuation due to major ADRs was significantly lower (6/49) in the genotyped cohort compared to the untested cohort (11/33; p = 0.0276). All but one discontinuation due to severe ADRs occurred within a month of therapy. However, the total incidence rate of ADRs was very similar in the 2 cohorts (0.025 in the genotyped cohort vs. 0.023 in the untested cohort).

CONCLUSION

In patients with ILD other than IPF, genotyping for azathioprine metabolism prior to starting therapy is associated with a significantly reduced rate of immunosuppressive therapy discontinuation due to major ADRs, with prevention of bone marrow suppression and pancreatitis, but without a reduction of the total incidence of ADRs. While these data support the use of genetic profiling prior to starting azathioprine to treat ILD, its cost effectiveness remains to be established.

Use of nintedanib in interstitial lung disease other than idiopathic pulmonary fibrosis: much caution is warranted

Interstitial lung disease (ILD) other than idiopathic pulmonary fibrosis (IPF) is currently treated with immunosuppressive therapy, with a dynamic algorithm based on continued clinical surveillance. Published results on mycophenolate mofetil, cyclophosphamide and azathioprine showed either stabilization or improvement of lung function with these therapies. However, despite treatment optimization, progression of disease in ILD other than IPF is often observed, and a role for antifibrotic drug nintedanib has been hypothesized. The present article first reviews relevant aspects when considering anti-fibrotic therapy in progressing ILD other than IPF, including accuracy of the diagnosis, optimization of disease-modifying, immunosuppressive therapy and optimal timing. Next, a critical appraisal of published results on nintedanib in ILD other than IPF considers the design of the studies, inclusion criteria, used definition of "progression" of disease, frequency and severity of side effects observed and cost of the therapy. There currently is a strong and legitimate interest in additional therapies that can help controlling progressing ILD other than IPF. When the studies on the use of nintedanib are carefully considered, however, caution should be exercised before prematurely endorsing and applying this therapy. The conduction of studies that will clarify and justify its potential role as switch vs. add-on therapy and, at the same time, a more rigorous definition of disease progression are both strongly encouraged.

Minimally interface vitrectomy for rhegmatogenous retinal detachment with a single break in young patients

Purpose

This study evaluates a new surgical technique consisting of minimal vitreous removal under air (minimal interface vitrectomy; MIV) to reduce postoperative complications while preserving the ability to address surgical factors at the retinal break.

Methods

This retrospective analysis examined the outcomes of minimal interface vitrectomies in consecutive cases, with a minimum 12-month follow-up period, of primary rhegmatogenous retinal detachment (RRD), recurrent RRD after pars plana vitrectomy (PPV), or failed surgery after primary scleral buckling surgery (SBS).

Results

Twelve eyes of 12 patients with RRD underwent MIV. The total surgical duration was 190–300 s (mean, 245.25 s). Eight (66.7%) eyes were treated with cryotherapy, and 4 (33.3%) with endolaser to seal the retinal break. Successful, complete retinal reattachment was achieved in all eyes and maintained during follow-up. No intra- or postoperative complications occurred and no patients developed inflammation or cataract during follow-up.

Conclusion and Importance

We effectively removed traction and subretinal fluid and treated breaks with endolaser or cryotherapy by using a novel minimal interface vitrectomy technique in this selected population.

A novel variant in DOCK6 gene associated with Adams-Oliver syndrome type 2

BACKGROUND

Adams-Oliver syndrome (AOS) is a rare, inherited multi-systemic malformation syndrome characterized by a combination of aplasia cutis congenita and transverse terminal limb defects along with variable involvement of the central nervous system, eyes, and cardiovascular system. AOS can be inherited as both autosomal-dominant and recessive traits. Pathogenic variants in the DOCK6, ARHGAP31, EOGT, RBPJ, DLL4, and NOTCH1 genes have been associated with AOS.

PURPOSE

To report a novel homozygous variant in the DOCK6 gene associated with Adams-Oliver syndrome type 2.

MATERIALS AND METHODS

Case report.

RESULTS

We report a case of a 4-month-old male who presented with microcephaly, global developmental delay, truncal hypotonia, and limb reduction defects. Ophthalmic examination revealed bilateral nystagmus and retinal detachment with mild cataractous changes in addition to retrolental plaque in the left eye. Next generation sequencing analysis identified a novel homozygous frameshift likely pathogenic variant (c.1269_1285dup (p.Arg429Glnfs*32)) in the DOCK6 gene. The constellation of the clinical findings and the genetic mutation were consistent with a diagnosis of AOS type 2.

CONCLUSION

The discovery of this new likely pathogenic variant enriches the genotypic spectrum of DOCK6 gene and contributes to genetic diagnosis and counseling of families with AOS. Neurologic and ocular findings appear to be consistent with AOS type 2 for which multidisciplinary clinical evaluation is crucial.

Longitudinal functional changes with clinically significant radiographic progression in idiopathic pulmonary fibrosis: are we following the right parameters?

Background

Progression of the disease in idiopathic pulmonary fibrosis (IPF) is difficult to predict, due to its variable and heterogenous course. The relationship between radiographic progression and functional decline in IPF is unclear. We sought to confirm that a simple HRCT fibrosis visual score is a reliable predictor of mortality in IPF, when longitudinally followed; and to ascertain which pulmonary functional variables best reflect clinically significant radiographic progression.

Methods

One-hundred-twenty-three consecutive patients with IPF from 2 centers were followed for an average of 3 years. Longitudinal changes of HRCT fibrosis scores, forced vital capacity (FVC), total lung capacity and diffusing lung capacity for carbon monoxide were considered. HRCTs were scored by 2 chest radiologists. The primary outcome was lung transplant (LTx)-free survival after the follow-up HRCT.

Results

During the follow-up period, 43 deaths and 11 LTx occurred. On average, the HRCT fibrosis score increased significantly, and a longitudinal increase > 7% predicted LTx-free survival significantly, with good specificity, but limited sensitivity. The correlation between radiographic and functional progression was moderately significant. HRCT progression and FVC decline predicted LTx-free survival independently and significantly, with better sensitivity, but worse specificity for a ≥ 5% decline of FVC. However, the area under the curve towards LTx-survival were only 0.61 and 0.62, respectively.

Conclusions

The HRCT fibrosis visual score is a reliable and responsive tool to detect clinically meaningful disease progression. Although no individual pulmonary function test closely reflects radiographic progression, a longitudinal FVC decline improves sensitivity in the detection of clinically significant disease progression. However, the accuracy of these methods remains limited, and better prognostication models need to be found.

Retinal relaxation following membrane peeling: Effect on vision, central macular thickness, and vector analysis of motion

BACKGROUND

Epiretinal membranes (ERM) form as a result of an inward displacement of retinal structures. Removal of an ERM leads to the outward displacement of retinal vessels and visual improvement.

PURPOSE

The aim of the study was to evaluate the direction and extent of displacement of retinal/superficial vascular structures after a membrane peeling procedure by means of image comparison and in selected cases, a vector analysis of displacement.

METHODOLOGY

Scanning laser ophthalmoscope images of the retina of eyes undergoing ERM peeling were compared before and 6 months after surgery. Stratification was made between prominent and limited displacement, with assessment of visual acuity (VA), and central macular thickness (CMT). In three cases, using the optic nerve as reference, 50 landmarks were chosen within the posterior pole along large and small vascular structures allowing the construction of a vector map of displacement over 1 year.

RESULTS

Nine eyes with prominent and six with limited displacement were assessed. Improvement in VA was similar for both groups, while CMT drop was greatest for the worst group. Vector analysis showed that most vascular movement occurs over the first 6 months, covers most of the posterior retina, is centered around distinct nodes, and may lead to several hundred micrometers of displacement.

CONCLUSIONS

Superficial retinal relaxation has no direct implication on visual recovery. It originates in nodes of retinal contraction. Its extent can be significant, covering most of the posterior pole.

RELEVANCE FOR PATIENTS

A better understanding of retinal relaxation following the peeling of ERM may help better understand when intervention is required and which part of the membrane is critical to surgical success.

Apolipoprotein AI-Derived Vitreous Amyloidosis: An Elusive Diagnosis

A 56-year-old female presented with vitreous opacity with gradual visual disturbance in her right eye of 1-year duration. A Non-Hodgkin's lymphoma had been treated 15 years before. Presenting best-corrected visual acuity (BCVA) was 20/200 in her right eye and 20/25 in her left eye. Intraocular pressure was 18 mm Hg bilaterally. Slit-lamp examination revealed no abnormal findings in the anterior segment of both eyes, including the absence of cells and flare. Fundoscopic examination indicated hazy media with the typical glass-wool-like appearance in her right eye. B-scan ultrasound demonstrated that the vitreous was full of middle-echo spots, vitreous opacities, and posterior vitreous detachment occurred. The patient underwent vitreous biopsy and a standard 25-gauge pars plana vitrectomy (diagnostic and therapeutic). Intraoperatively, the eye was noted to have severe diffuse debris and very strong vitreoretinal adhesions. Cytospin smears prepared from the vitreous aspirate indicated amorphous acellular material that stained positively with Congo Red and showed apple green birefringence on polarized microscopy, consistent with the diagnosis of amyloidosis. A genetic evaluation of tongue tissue demonstrated apolipoprotein AI-derived amyloidosis. The BCVA was 20/25 OU at 3 months postoperatively.

Macular Hole-Related Retinal Detachment in Children with Knobloch Syndrome

PURPOSE

To describe the findings and the management of macular hole (MH)-related retinal detachment (RD) in children with Knobloch syndrome.

DESIGN

Retrospective interventional case series.

PARTICIPANTS

Patients with Knobloch syndrome who presented with MH-related RD.

METHODS

Retrospective chart review of patients with Knobloch syndrome who presented with MH-related RD from January 2012 to December 2018. Interventions included pars plana vitrectomy and silicone oil tamponade with or without scleral buckle, drainage retinotomy, or relaxing retinectomy.

MAIN OUTCOME MEASURES

MH characteristics and surgical anatomical outcome.

RESULTS

The study included 9 eyes of 5 patients (age range 2 months to 5 years; median age 5.5 months). Presenting symptoms were poor fixation and nystagmus. The fellow eye of 1 patient had RD due to peripheral breaks. The MH was clinically visible in 8 eyes and detected only by OCT in 1 eye. The RD was shallow and extended to the anterior equator in 7 eyes and localized to a punched-out atrophic lesion in 1 eye. Seven eyes underwent surgical repair. At the last follow-up examination (follow-up range 11 to 42 months; mean 24 months, standard deviation 11.8 months), retinal reattachment with MH closure was achieved in 5 eyes along with marked improvement in fixation.

CONCLUSION

Patients with Knobloch syndrome may develop MH-related RD as early as infancy. The condition may be easily overlooked in children but should be suspected in the setting of high myopia, vitreoretinal degeneration, and encephalocele.