Donald J D'Amico

Peripheral retinal ischaemia, as evaluated by ultra-widefield fluorescein angiography, is associated with diabetic macular oedema

Purpose To determine the relationship between retinal ischaemia and the presence of macular oedema (DMO) in patients with diabetic retinopathy (DR) using ultra-widefield fluorescein angiography (UWFA) imaging. Methods A retrospective review of 122 eyes of 70 treatment-naïve diabetic patients who underwent diagnostic UWFA using the Optos 200Tx imaging system. Two independent, masked graders quantified the area of retinal ischaemia. Based on clinical examination and optical coherence tomography (OCT), each patient was given a binary classification as either having DMO or no DMO. McNemars test (with Yates correction as indicated) and a two-sample test of proportions were used to determine the relationship between DMO and ischaemia for binary and proportional data, respectively. Linear and logistic models were constructed using generalised estimating equations to test relationships between independent variables, covariates and outcomes while controlling for inter-eye correlation, age, gender, haemoglobin A1c, mean arterial pressure and dependence on insulin. Results Seventy-six eyes (62%) exhibited areas of retinal ischaemia. There was a significant direct correlation between DMO and peripheral retinal ischaemia as seen on UWFA (p<0.001). In addition, patients with retinal ischaemia had 3.75 times increased odds of having DMO compared with those without retinal ischaemia (CI 1.26 to 11.13, p<0.02). Conclusion Retinal ischaemia is significantly correlated with DMO in treatment-naïve patients with DR. UWFA is a useful tool for detecting peripheral retinal ischaemia, which may have direct implications in the diagnosis, follow-up and treatment such as targeted peripheral photocoagulation.

Persistent suppression of ocular neovascularization with intravitreal administration of AAVrh.10 coding for bevacizumab.

Vascular endothelial growth factor (VEGF) plays an important role in the pathogenesis of neovascular age-related macular degeneration and diabetic retinopathy. Bevacizumab, an anti-VEGF monoclonal antibody, is efficacious for these disorders, but requires monthly intravitreal administration, with associated discomfort, cost, and adverse event risk. We hypothesized that a single intravitreal administration of adeno-associated virus (AAV) vector expressing bevacizumab would result in persistent eye expression of bevacizumab and suppress VEGF-induced retinal neovascularization. We constructed an AAV rhesus serotype rh.10 vector to deliver bevacizumab (AAVrh.10BevMab) and assessed its ability to suppress neovascularization in transgenic mice overexpressing human VEGF165 in photoreceptors. Intravitreal AAVrh.10BevMab directed long-term bevacizumab expression in the retinal pigmented epithelium. Treated homozygous mice had reduced levels of neovascularization, with 90±4% reduction 168 days following treatment. Thus, a single administration of AAVrh.10BevMab provides long-term suppression of neovascularization without the costs and risks associated with the multiple administrations required for the current conventional bevacizumab monoclonal drug delivery.

Retinal reperfusion in diabetic retinopathy following treatment with anti-VEGF intravitreal injections

Purpose The aim of this study is to report peripheral reperfusion of ischemic areas of the retina on ultra-widefield fluorescein angiography (UWFA) following anti-vascular endothelial growth factor (VEGF) intravitreal injections in patients treated for diabetic retinopathy. Methods This study is a retrospective review of 16 eyes of 15 patients with diabetic retinopathy, who received anti-VEGF intravitreal injections and underwent pre- and postinjection UWFA. The main outcome measured was the presence of reperfusion in postinjection UWFA images in areas of the retina that demonstrated nonperfusion in preinjection images. Images were analyzed for reperfusion qualitatively and quantitatively by two graders. Results Twelve of 16 eyes (75%) or 11 of 15 patients (73.3%) demonstrated reperfusion following anti-VEGF injection. On UWFA, reperfusion was detected both within the field of 7-standard field (7SF) fluorescein angiography and in the periphery outside the 7SF. Four of 16 eyes or 4 of 15 patients did not demonstrate reperfusion, one of which had extensive scarring from prior panretinal photocoagulation. Conclusion In patients with diabetic retinopathy, treatment with anti-VEGF agents can be associated with reperfusion of areas of nonperfusion, as demonstrated by UWFA.

A comparison of same setting versus delayed vitrectomy in the management of retained lens fragments after cataract surgery.

Purpose: Intravitreal retained lens fragments are a rare but potentially serious complication of phacoemulsification. The purpose of this study was to compare same setting (“no wait”) vitrectomy with delayed surgery in the management of retained lens fragments in a single academic setting. Methods: This study is a retrospective nonrandomized study of all patients undergoing pars plana vitrectomy for retained lens fragments after cataract surgery from 2007 to 2012. Outcomes included visual acuity and the development of various complications such as retinal detachment, elevated intraocular pressure >30 mmHg, and cystoid macular edema. Multivariate analysis was performed to adjust for potentially confounding variables such as age and preoperative visual acuity. Results: Twenty-eight consecutive eyes (13 same setting, 15 delayed setting) were included in the analysis. Patients in the same setting group were older than in the delayed group (81.00 vs. 72.87 years, P = 0.053). No other preoperative differences existed between the groups (axial length, preoperative vision, and intraocular pressure). The mean time to pars plana vitrectomy in the delayed group was 26.6 days (range, 1–91 days). The mean follow-up time was 363 days (same setting) and 643 days (delayed). At the most recent follow-up, no significant difference existed in mean vision between the same setting (logMAR, 0.42) and the delayed group (logMAR, 0.57) (P = 0.132). Multivariate analysis showed no difference in final vision when adjusting for age and preoperative vision. Although there was a trend for eyes in the same setting group to obtain good vision (≥20/40) faster, a higher percentage of eyes in the delayed group obtained good vision at the most recent follow-up (66.7 vs. 23.1%, P = 0.02). More eyes in the delayed group had an intraocular pressure >30 at any point (P = 0.055). There was no significant difference between the groups in any other complications such as retinal detachment, choroidal detachment, and cystoid macular edema during the follow-up. Conclusion: In this cohort, same setting pars plana vitrectomy offers no significant visual acuity advantage over delayed pars plana vitrectomy in patients with retained lens fragments. Fewer eyes in the same setting group “ever” had an intraocular pressure ≥30 during follow-up, whereas no other complication differences were seen between the groups.

Clinical Utility of Ultra-Widefield Imaging with the Optos Optomap Compared with Indirect Ophthalmoscopy in the Setting of Non-Traumatic Rhegmatogenous Retinal Detachment

Abstract Purpose: To evaluate the clinical utility of ultra-widefield imaging as an adjunctive tool in the diagnosis, management, and follow-up of eyes with non-traumatic rhegmatogenous retinal detachment. Methods: Retrospective chart review of patients with a rhegmatogenous retinal detachment who received ultra-widefield imaging with the Optos® Optomap® P200Tx. Comparisons were made between UWF imaging and indirect ophthalmoscopy for features of detachments, including extent of detachment, holes, retinopexy, and related pathology. Results: Thirty-six eyes of 34 patients were included. Preoperatively, ultra-widefield imaging more precisely documented the extent of retinal detachments in the superior, inferior, and nasal quadrants in 13.9% of cases. Ultra-widefield imaging failed to detect retinal holes in the superior and inferior quadrants in 11.1% and 19.4% of cases, respectively. In postoperative imaging, UWF photos did not detect retinopexy which was ophthalmoscopy-visible both superiorly and inferiorly in 19.4% of cases. The mean differences in clock hours of the detachments as documented on the clinical exam compared to ultra-widefield imaging in the superior, inferior, temporal, and nasal quadrants were −0.18u2009±u20090.84, 0.41u2009±u20091.16, 0.08u2009±u20091.08, and −0.13u2009±u20092.25 hours, respectively. Conclusion: Ultra-widefield imaging is a useful adjunct for documentation of rhegmatogenous retinal detachments and their postoperative repair. However, detection of retinal holes, tears, and postoperative scarring is poor, especially in the inferior and superior periphery.

Characteristics of intraretinal deposits in acute central serous chorioretinopathy

Purpose To describe the temporal and spatial characteristics of intraretinal deposits in patients with acute central serous chorioretinopathy (CSC) using spectral domain optical coherence tomography (OCT). Materials and methods We retrospectively reviewed the medical records of all patients that presented with acute CSC to Weill Cornell Medical College from January 2012 to May 2013. Acute CSC was defined as a diagnosis of CSC within 4 months of the onset of symptoms. Only one eye per patient was included in the study. Each patient was imaged with spectral domain OCT at the initial office visit. The decision to reimage these patients was made by the treating physician. Results A total of 25 patients (25 eyes; 17 men and eight nonpregnant women) were included in this review. Seven of 25 patients (28%) demonstrated intraretinal deposits within the outer plexiform layer during the initial OCT, with deposits appearing as early as the same day as the onset of symptoms. A total of 25 of 25 patients (100%) demonstrated intraretinal deposits in the outer nuclear layer upon initial (76%) or follow-up OCT, as early as 2 days after the onset of symptoms. A total of 24 of 25 patients (96%) demonstrated deposits in the external limiting membrane upon a follow-up OCT, as early as 7 days from symptoms appearing. A total of 24 of 25 patients (96%) developed intraretinal deposits in the inner segment/outer segment layer upon follow-up OCT, appearing as early as 14 days after symptom onset. At the time of resolution of subretinal fluid, 20 of 25 patients (80%) demonstrated intraretinal deposits. Conclusion Intraretinal deposits are present in the outer retinal layers in patients with acute CSC, with the deposits appearing progressively deeper within the retina as the condition evolves. Upon resolution of subretinal fluid, the deposits slowly resolve.

Pachychoroid neovasculopathy in extramacular choroidal neovascularization

Purpose To review a series of extramacular choroidal neovascular membranes (CNVMs) in the context of their choroidal features, as determined by optical coherence tomography (OCT). Methods Patients with extramacular CNVMs were identified from a tertiary care center through a review of records. The charts and cases were reviewed using multimodal imaging including fundus photography, OCT, fluorescein angiography (FA), and indocyanine angio-graphy (ICG). Results Of six patients with extramacular CNVMs evaluated in this series, four patients (66.7%) exhibited pachychoroidopathy on OCT imaging under or adjacent to the extramacular CNVM. All four of these patients also exhibited pachychoroidopathy in the macular OCT distant from the CNVM. Conclusion Pachychoroidopathy is implicated in some cases of extramacular CNVMs. This represents the first report, to our knowledge, of pachychoroidopathy in extramacular CNVM.

Reply: To PMID 24853687.

managing redetachments. However, I agree with the authors that a longer follow-up period in both groups could bring more differences. Therefore, it will be prudent if we do not infer on the basis of the available data that the two surgical techniques described here are comparable in treating primary noncomplex rhegmatogenous retinal detachment, and look forward to future studies with similar objective but with a larger sample size.