Adrienne W. Scott

Imaging the Infant Retina with a Hand-held Spectral-Domain Optical Coherence Tomography Device

PURPOSE To evaluate and treat infant retina through the use of a hand-held spectral-domain optical coherence tomography (SD OCT) device in selected cases of Shaken Baby syndrome (SBS). DESIGN Observational case series. METHODS A novel SD OCT system was optimized and evaluated for infant imaging. An adult eye was imaged with both a standard clinical SD OCT system and the hand-held system. Four eyes of two infants with a history of SBS were imaged with the hand-held system. One infant was imaged again during follow-up examinations. Robust image processing algorithms were developed to create high-quality images. Images were assessed for usefulness in demonstrating pertinent morphologic features. RESULTS The novel SD OCT unit proved effective for data acquisition and comparable with conventional chin-rest SD OCT. Rapid data acquisition limited motion artifact within the B-scan, although there was slight motion between B scans. The SD OCT images provided previously unseen details with regard to the morphologic features of retinal lesions in these infant eyes. This information influenced prognosis and management. CONCLUSIONS As with adults, the hand-held customized SD OCT proved to be an invaluable tool in the differentiation of disease processes or injury in these eyes under study. SD OCT imaging systems may be considered a useful adjunct to RetCam fundus photography for assessment and clinical management in cases of SBS.

Scatter Photocoagulation Does Not Reduce Macular Edema or Treatment Burden in Patients with Retinal Vein Occlusion The RELATE Trial

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.

Long-term Outcomes in Ranibizumab-Treated Patients With Retinal Vein Occlusion; The Role of Progression of Retinal Nonperfusion

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.

Macular Vascular Abnormalities Identified by Optical Coherence Tomographic Angiography in Patients With Sickle Cell Disease

IMPORTANCE Patients with sickle cell disease may develop various macular vascular abnormalities that have not been described previously and can be seen using optical coherence tomographic angiography. OBSERVATIONS Ten eyes from 5 consecutive patients (3 men and 2 women) with sickle cell disease (4 patients with hemoglobin SS disease and 1 patient with hemoglobin SC disease) were included. The mean age was 37.6 years. Five of 10 eyes (50%) had retinal thinning that was identified using spectral-domain optical coherence tomography. Each of these eyes had corresponding loss of vascular density in the superficial or deep retinal plexus (or both). CONCLUSIONS AND RELEVANCE Optical coherence tomographic angiography provides a novel way to view the retinal vasculature, including the superficial and deep capillary plexus, and may provide a sensitive method for identifying macular vascular abnormalities in patients with sickle cell disease.

Public Attitudes About Eye and Vision Health

Importance Understanding the importance of eye health to the US population across ethnic and racial groups helps guide strategies to preserve vision in Americans and inform policy makers regarding priority of eye research to Americans. Objective To understand the importance and awareness of eye health in the US population across ethnic and racial groups. Design, Setting, and Participants Online nationwide poll created by experienced policy makers in August 2014 designed to understand the importance of eye health in the US population, although the poll was not subjected previously to formal construct-validity testing. The population survey comprised 2044 US adults including non-Hispanic white individuals and minority groups with minority oversampling to provide predicted margins of error no greater than 5%. Main Outcomes and Measures Respondent attitudes on the importance of eye health, concerns about losing vision, support for eye health research, and awareness of eye diseases and risk factors. Results Of the 2044 survey respondents, the weighten mean age was 46.2 years, 48% were male, and 11% were uninsured. Sixty three percent reported wearing glasses. Most individuals surveyed (87.5%; 95% CI, 84.5%-90%) believed that good vision is vital to overall health while 47.4% (95% CI, 43.7%-51.1%) rated losing vision as the worst possible health outcome. Respondents ranked losing vision as equal to or worse than losing hearing, memory, speech, or a limb. When asked about various possible consequences of vision loss, quality of life ranked as the top concern followed by loss of independence. Nearly two-thirds of respondents were aware of cataracts (65.8%) or glaucoma (63.4%); only half were aware of macular degeneration; 37.3% were aware of diabetic retinopathy; and 25% were not aware of any eye conditions. Approximately 75.8% and 58.3%, respectively, identified sunlight and family heritage as risk factors for losing vision; only half were aware of smoking risks on vision loss. Conclusions and Relevance In this well-characterized survey across all US ethnic and racial groups, vision health was a priority with high support for ongoing research for vision and eye health. Many Americans were unaware of important eye diseases and their behavioral or familial risk factors. The consistency of these findings among the varying ethnic/racial groups underscores the importance of educating the public on eye health and mobilizing public support for vision research.

CORRELATION OF MULTIMODAL IMAGING IN SICKLE CELL RETINOPATHY

Purpose: To correlate macular findings on spectral domain optical coherence tomography (SDOCT) and optical coherence tomography angiography (OCTA) with quantitative ischemic index calculations on ultra-wide-field fluorescein angiography (UWFFA) in patients with sickle cell retinopathy. Methods: In this retrospective case series, SDOCT, OCTA, and UWFFA images of patients with sickle cell retinopathy were evaluated. Eyes were staged based on the Goldberg classification of proliferative sickle cell retinopathy. Focal areas of macular thinning were assessed on SDOCT, macular vessel density was derived from OCTA, and peripheral ischemic index was calculated from UWFFA. Results: Eighteen eyes of 10 patients were included. Mean age was 36.8 ± 16.8 years, and 6 patients (11 eyes) were SS, 3 patients (5 eyes) were SC, and 1 patient (2 eyes) was S&bgr; thalassemia in hemoglobin electrophoresis. Abnormal macular findings included inner retinal atrophy in 11 eyes (61%) on SDOCT, vascular remodeling and nonperfusion in the superficial and deep retinal capillary plexus in 12 eyes (67%) on OCTA, and macular microvascular abnormalities in 9 eyes (50%) on UWFFA. Sickle cell retinopathy Stage I was identified in 4 eyes (22.2%), Stage II in 8 eyes (44.4%), and Stage III in 6 eyes (33.3%). Mean ischemic index was 14.1 ± 9.1%. Ischemic index was significantly correlated with hemoglobinopathy subtype (23.7 ± 9.8%, 9.3 ± 5.4%, and 16.3 ± 3.2%, for SC, SS, and S&bgr; thalassemia disease, respectively), stage of sickle cell retinopathy (22.5 ± 9.2%, 12.5 ± 4.9%, and 4.5 ± 0.73% for Stages III, II, and I, respectively), and presence of retinal thinning on SDOCT (17.4 ± 9.7% vs. 8.8 ± 5.1%, respectively). Conclusion: Multimodal imaging can provide a more complete description of the microvascular and structural alterations associated with sickle retinopathy. The correlation between the severity of peripheral nonperfusion and stage and subtype of retinopathy suggests that UWF imaging may be a useful tool in the evaluation of these patients.PURPOSE To correlate macular findings on spectral domain optical coherence tomography (SDOCT) and optical coherence tomography angiography (OCTA) with quantitative ischemic index calculations on ultra-wide-field fluorescein angiography (UWFFA) in patients with sickle cell retinopathy. METHODS In this retrospective case series, SDOCT, OCTA, and UWFFA images of patients with sickle cell retinopathy were evaluated. Eyes were staged based on the Goldberg classification of proliferative sickle cell retinopathy. Focal areas of macular thinning were assessed on SDOCT, macular vessel density was derived from OCTA, and peripheral ischemic index was calculated from UWFFA. RESULTS Eighteen eyes of 10 patients were included. Mean age was 36.8 ± 16.8 years, and 6 patients (11 eyes) were SS, 3 patients (5 eyes) were SC, and 1 patient (2 eyes) was Sβ thalassemia in hemoglobin electrophoresis. Abnormal macular findings included inner retinal atrophy in 11 eyes (61%) on SDOCT, vascular remodeling and nonperfusion in the superficial and deep retinal capillary plexus in 12 eyes (67%) on OCTA, and macular microvascular abnormalities in 9 eyes (50%) on UWFFA. Sickle cell retinopathy Stage I was identified in 4 eyes (22.2%), Stage II in 8 eyes (44.4%), and Stage III in 6 eyes (33.3%). Mean ischemic index was 14.1 ± 9.1%. Ischemic index was significantly correlated with hemoglobinopathy subtype (23.7 ± 9.8%, 9.3 ± 5.4%, and 16.3 ± 3.2%, for SC, SS, and Sβ thalassemia disease, respectively), stage of sickle cell retinopathy (22.5 ± 9.2%, 12.5 ± 4.9%, and 4.5 ± 0.73% for Stages III, II, and I, respectively), and presence of retinal thinning on SDOCT (17.4 ± 9.7% vs. 8.8 ± 5.1%, respectively). CONCLUSION Multimodal imaging can provide a more complete description of the microvascular and structural alterations associated with sickle retinopathy. The correlation between the severity of peripheral nonperfusion and stage and subtype of retinopathy suggests that UWF imaging may be a useful tool in the evaluation of these patients.

Changes in Retinal Nonperfusion Associated with Suppression of Vascular Endothelial Growth Factor in Retinal Vein Occlusion

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.

Pro-Permeability Factors After Dexamethasone Implant in Retinal Vein Occlusion; the Ozurdex for Retinal Vein Occlusion (ORVO) Study

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.

Discrepancies in the Concordance of Self-Reported Vision Status and Visual Acuity in the Salisbury Eye Evaluation Study

PURPOSE To examine the association between self-rated vision and distance visual acuity by race and other factors. DESIGN Cross-sectional analysis within a longitudinal, population-based cohort study. PARTICIPANTS AND CONTROLS Two thousand five hundred twenty individuals, 65 to 84 years of age, including 666 black participants and 1854 white participants. METHODS All participants reported their self-rated vision score. Binocular distance visual acuity was assessed. Based on the level of visual acuity and the self-reported vision score, participants were placed into concordant and discrepant groups. MAIN OUTCOME MEASURES Multinomial logistic regression models were used to examine the characteristics associated with concordant and discrepant groups. RESULTS Black participants were more likely to be represented in the discordant group that reported good vision but had acuity worse than 20/40. In the multivariate analysis, a per-year decrement in years of education received increased the odds of being in both discrepant groups, one that reported good vision but had a visual acuity worse than 20/40 (odds ratio, 1.21; P<0.0001) and the other discrepant group that reported bad vision but had a visual acuity of 20/40 or better (odds ratio, 1.04; P<0.0001). A per-year decrement in years of education received also seemed to explain the excess risk of black race in the discrepant group that reported good vision but had a visual acuity worse than 20/40. CONCLUSIONS Given the socioeconomically driven discrepancies in self-reported vision status, self-reported vision status should be used cautiously in surveillance surveys, especially when assessing vision inequalities between socioeconomic groups. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Associations Between Self-Rated Vision Score, Vision Tests, and Self-Reported Visual Function in the Salisbury Eye Evaluation Study

PURPOSE We attempt to understand the determinants of self-rated vision status by examining associations with vision tests, self-reported visual function, demographic, and health-status characteristics. METHODS Participants included 2467 individuals, aged 65 to 84 years, in a longitudinal, population-based cohort study. Participants rated their vision status from 0 to 10. Visual acuity, contrast sensitivity, stereoacuity, and visual fields were assessed. The Activities of Daily Vision Scale (ADVS) questionnaire was administered. Multivariate ordinal and multinomial logistic-regression models examined the association of demographic, health-status characteristics, vision tests, and ADVS subscales with self-rated vision status score. Odds ratios described the association of these characteristics with reporting better vision status. RESULTS Better visual acuity, contrast sensitivity, stereoacuity, and visual fields were associated with increased odds of reporting better vision status. Among the vision tests, a 2-line increase in visual acuity was most likely to result in an individual reporting better vision status (odds ratio, 1.49; 95% confidence interval [CI], 1.30-1.70). A 5-point increase in the near vision and far vision ADVS subscale scores was associated with increased odds of reporting good versus poor vision status. A 5-point increase in the near vision subscale was most likely to result in an individual reporting good versus poor vision status (odds ratio, 1.38; 95% CI, 1.28-1.50). CONCLUSIONS Self-rated vision status is a multidimensional measure. Near-vision visual function, visual acuity, and contrast sensitivity are important determinants of self-rated vision status in an elderly population. This understanding may improve the ability of eye care providers to maximize self-rated vision status among their patients.