Andrew Chang

Prevalence and Associations of Epiretinal Membranes

PURPOSEnThe purpose of the study is to determine the prevalence and associations of epiretinal membranes in a defined older Australian population and to assess their influence on visual acuity.nnnMETHODSnThree thousand six hundred fifty-four persons 49 years of age or older, representing 88% of permanent residents from an area west of Sydney, underwent a detailed eye examination, including stereo retinal photography. Epiretinal membranes were diagnosed clinically and from photographic grading.nnnRESULTSnSigns of epiretinal membranes were found in 243 participants (7%; 95% confidence interval [CI], 6.1, 7.6), bilateral in 31%. The prevalence was 1.9% in persons younger than 60 years of age, 7.2% in persons 60 to 69 years of age, 11.6% in persons 70 to 79 years of age, and 9.3% in persons 80 years of age and older, with slightly higher rates in women. Two stages were identified: an early form without retinal folds, termed cellophane macular reflex present in 4.8%, and a later stage with retinal folds, termed preretinal macular fibrosis (PMF), found in 2.2% of the population. Preretinal macular fibrosis, but not cellophane macular reflex, had a small, significant effect on visual acuity. Preretinal macular fibrosis was significantly associated with diabetes, after age-gender adjustment, in subjects without signs of diabetic retinopathy (odds ratio, 3.2; 95% CI, 1.4, 7.2). Preretinal macular fibrosis also was associated with increased fasting plasma glucose (odds ratio, 1.2; 95% CI, 1.1, 1.3). Epiretinal membranes were found in 16.8% of persons who had undergone cataract surgery in one or both eyes (including PMF in 3.7%), in 16.1% of retinal vein occlusion cases (PMF in 12.5%), both significantly higher rates than in subjects without these conditions (P < 0.0001), and in 11% of persons with diabetic retinopathy (PMF in 3.6%), not significantly higher (P = 0.17).nnnCONCLUSIONSnThis study has documented the frequency and mild effect on vision of epiretinal membranes in an older population. Diabetes was associated significantly with idiopathic cases, whereas well-known associations with past cataract surgery and retinal disease were confirmed.

Visual outcomes following vitrectomy and peeling of epiretinal membrane

Background:u2002 Visual outcomes of patients following vitrectomy and peeling of visually significant epiretinal membranes were assessed to determine the influence of specific perioperative factors and surgical complications on final visual acuity and functional vision.

Intravitreal Aflibercept for Treatment-Resistant Neovascular Age-related Macular Degeneration

OBJECTIVEnTo assess the effectiveness of intravitreal aflibercept in patients with neovascular age-related macular degeneration (AMD) previously resistant to treatment with other anti-vascular endothelial growth factor agents.nnnDESIGNnProspective, open-label, noncontrolled, registered clinical trial.nnnPARTICIPANTSnForty-nine patients with treatment-resistant neovascular AMD.nnnINTERVENTIONnA dose of 2 mg intravitreal aflibercept was administered as 3 initial loading doses every 4 weeks (week 0, week 4, and week 8), followed by further injections every 8 weeks (weeks 16 and 24) across a 24-week period in total. All patients underwent a complete ophthalmic examination, including measurement of Early Treatment Diabetic Retinopathy Study (ETDRS) best-corrected visual acuity (BCVA), intraocular pressure assessment, adverse event monitoring, and spectral-domain optical coherence tomography at every visit. Baseline fluorescein angiography and indocyanine green angiography also were performed.nnnMAIN OUTCOME MEASURESnOutcomes assessed included proportions of patients with a gain or loss of more than 5 ETDRS letters and a decrease or increase in central retinal thickness (CRT) of more than 150 μm at week 24 compared with baseline, change in mean BCVA and CRT between baseline and week 24, and descriptive safety data.nnnRESULTSnThe BCVA improved and CRT was reduced significantly at all follow-up visits compared with baseline (Pu2009<u20090.001), with a mean improvement of 6.9 letters of BCVA and a decrease of 89.4 μm in CRT at week 24. Spacing of injections from every 4 weeks to 8 weeks resulted in an increase of 37.4 μm in CRT (Pu2009<u20090.001); however, this was not correlated with a significant change in vision. There was 1 (2%) patient who lost more than 5 ETDRS letters, and 27 (55%) patients who gained more than 5 letters. Two (4%) patients had a more than 150xa0μm increase in CRT at week 24, and 10 (20%) patients showed a decrease in CRT of more than 150 μm.nnnCONCLUSIONSnIntravitreal aflibercept is effective in previously treatment-resistant neovascular AMD. Further follow-up is required to determine whether these improvements can be maintained.

Endophthalmitis following intravitreal injection versus endophthalmitis following cataract surgery: clinical features, causative organisms and post-treatment outcomes

Aims To describe and compare the causative organisms, clinical features and visual outcomes of endophthalmitis following intravitreal injection (IVI) to endophthalmitis following cataract surgery. Methods Patient population and setting: A retrospective case series of patients with acute endophthalmitis following either cataract surgery or IVI presenting to a tertiary referral centre—Sydney Eye Hospital—between 2007 and 2010. Main outcome measures: (1) identification of the causative organism; (2) time to presentation; (3) odds of improvement in visual acuity (VA) following treatment; (4) odds of final VA of counting fingers (CF) or less and (5) odds of enucleation. Results Of the 101 patients in our study, 48 had preceding cataract surgery and 53 had preceding IVI. There was an increased incidence of Streptococcus spp. endophthalmitis in post-IVI cases (24.53% vs 6.25%; OR 5.85; p=0.022). Endophthalmitis following IVI had increased likelihood of a final VA of CF or less (OR=6.0; p<0.01), decreased likelihood of any improvement in acuity following treatment (OR=0.13; p<0.01) and an increased likelihood of presenting within a week of the procedure (OR=3.93; p<0.01). Endophthalmitis caused by Streptococcus spp. was associated with increased likelihood of a final VA of CF or less (OR=10.2; p<0.01), decreased likelihood of any improvement in acuity following treatment (OR=0.06; p<0.01) and increased likelihood of enucleation (OR=17.11; p<0.01). Conclusions Endophthalmitis following IVI is associated with an increased incidence of Streptococcus spp. infection, earlier presentation and poorer visual outcomes when compared with endophthalmitis following cataract surgery.

The macular hole: report of an Australian surgical series and meta‐analysis of the literature

Purpose: To report an Australian series of macular hole surgery by pars plana vitrectomy and fluid‐gas exchange, and to identify factors influencing the outcome of the surgery through meta‐analysis of the literature.

Response Of Pigment Epithelial Detachments To Intravitreal Aflibercept Among Patients With Treatment-resistant Neovascular Age-related Macular Degeneration

Purpose: To assess the effect of intravitreal aflibercept on pigment epithelial detachment (PED) in patients with treatment-resistant neovascular age-related macular degeneration. Methods: Forty-six patients with vascularized PEDs participating in a wider, prospective clinical trial of treatment-resistant neovascular age-related macular degeneration received 2-mg aflibercept as 3 loading doses 1 month apart, followed by further 2-monthly doses over a total 12-month period. Change in PED dimensions and reflective properties were assessed by optical coherence tomography. Reflectivity was subclassified as solid (hyperreflective), hollow (hyporeflective), or mixed (elements of both). Results: Aflibercept reduced PED height, width, and length at 48 weeks compared with baseline values (P ⩽ 0.01 for all). Reductions in PED height were correlated with reductions in central macular thickness at 48 weeks (R2 = 0.36, P < 0.001). There was no significant correlation between PED height decrease and visual acuity changes at 48 weeks. Solid PEDs were less likely to experience reductions in all three dimensions than either hollow or mixed PEDs. Conclusion: Aflibercept is effective in reducing PED dimensions in treatment-resistant patients and is most effective in PEDs demonstrating some hyporeflective optical coherence tomography characteristics. Reduction in PED dimensions correlated with central macular thickness, but not with visual acuity changes. The role of PEDs as markers of disease requires further investigation; however, lesions should be monitored for retinal fluid recurrence.

Dietary modification and supplementation for the treatment of age-related macular degeneration

Age-related macular degeneration (AMD) causes a significant proportion of visual loss in the developed world. Currently, little is known about its pathogenesis, and treatment options are limited. Dietary intake is one of the few modifiable risk factors for this condition. The best-validated therapies remain oral antioxidant supplements based on those investigated in the Age-Related Eye Disease Study (AREDS) and the recently completed Age-Related Eye Disease Study 2 (AREDS2). In this review, current dietary guidelines related to AMD, along with the underlying evidence to support them, are presented in conjunction with current treatment recommendations. Both AREDS and AREDS2 are discussed, as are avenues for further research, including supplementation with vitamin D and saffron. Despite the considerable disease burden of atrophic AMD, few effective therapies are available to treat it, and further research is required.

Limited macular translocation for subfoveal choroidal neovascularization in age‐related macular degeneration

Purpose: To examine the safety and efficacy of limited macular translocation followed by laser photocoagulation in the management of subfoveal choroidal neovascularization (CNV) in age‐related macular degeneration (AMD).

Treating the untreatable patient: current options for the management of treatment-resistant neovascular age-related macular degeneration.

Anti‐vascular endothelial growth factor (anti‐VEGF) agents represent the current standard of care for neovascular age‐related macular degeneration (nAMD). Although effective in a majority of cases, a significant proportion of patients have persisting retinal exudation despite regular anti‐VEGF therapy. This exudation is considered to produce poorer visual outcomes in these patients. Some of these patients may have misdiagnosed nAMD variants such as polypoidal choroidal vasculopathy; however, the majority of these eyes have what has been termed treatment‐resistant nAMD. Currently, the best way to care for these patients is uncertain. Here, we review the evidence for different approaches to the management of treatment‐resistant nAMD, including high‐dose anti‐VEGF therapy, combination regimes and switching of anti‐VEGF agents, and discuss possible therapeutic approaches for patients with treatment‐resistant nAMD.

Sympathetic ophthalmia following ciliary body laser cyclophotocoagulation for rubeotic glaucoma.

A 60‐year‐old Asian man presented with left rubeotic glaucoma secondary to a central retinal vein occlusion. He was successfully treated with laser diode cyclophotocoagulation of the ciliary body. Nine months later he developed right progressive visual loss, headache, corneal oedema, anterior chamber cells, flare, mutton fat keratic precipitates, a swollen disc, and a minimal inferior visual field defect. A diagnosis of sympathetic ophthalmia was made, which was confirmed by characteristic findings seen on fluorescein and indocyanine green angiography.