Felipe F. Conti

Outcomes Of Patients With Exudative Age-related Macular Degeneration Treated With Antivascular Endothelial Growth Factor Therapy For Three Or More Years: A Review of Current Outcomes

Purpose: To summarize the findings of long-term outcomes of anti-vascular endothelial growth factor (VEGF) therapy (≥36 months) in patients with exudative age-related macular degeneration. Methods: Studies reporting long-term outcomes (≥36 months) of anti-VEGF therapy (n = 11) were identified and analyzed for changes in visual acuity (VA), optical coherence tomography, and safety findings. Results: Six prospective extension studies of Phase 3 clinical trials and five retrospective evaluation studies were identified. The largest improvements in VA with anti-VEGF treatment were found in Years 1 to 2 after treatment initiation. In five studies, VA ultimately declined below patients pretreatment initial baseline; in three studies, VA ultimately returned to patients baseline; in three studies, VA decreased but ultimately remained improved over patients baseline. There was a trend demonstrating that a higher frequency of intravitreous injections showed a better maintenance in VA. Rates of adverse events were similar to previous registration studies of anti-VEGF drugs. Conclusion: The body of evidence to date regarding long-term anti-VEGF treatment indicates a variable course at greater than 36 months follow-up and seems to be dependent on the treatment protocol. Consistent dosing with fluid-free interval is suggested to maintain VA gains in patients with exudative age-related macular degeneration. There is no evidence suggesting that there are additional adverse events from long-term anti-VEGF use.

Association of Disorganization of Retinal Inner Layers With Visual Acuity Response to Anti–Vascular Endothelial Growth Factor Therapy for Macular Edema Secondary to Retinal Vein Occlusion

Importance Disorganization of retinal inner layers (DRIL) has demonstrated significant correlations with visual acuity (VA) in center-involved diabetic macular edema. In patients with retinal vein occlusion (RVO) and secondary macular edema, DRIL may be a useful biomarker in determining VA outcomes. Objective To examine whether DRIL at baseline and after treatment is associated with VA in RVO. Design, Setting, and Participants A retrospective review of records of 147 patients 18 years or older with treatment-naive branch RVO (BRVO), central RVO (CRVO), or hemispheric RVO (HRVO), with a minimum of 12 months of follow-up, who presented to a tertiary ophthalmic center from December 1, 2010, to January 1, 2016, was conducted. Data collection continued through January 2017. Exclusion criteria included active confounding retinal or ocular disease, history of pars plana vitrectomy, or prior intravitreal injections. Two masked graders calculated a DRIL score based on DRIL presence in 3 predefined regions on spectral-domain optical coherence tomography at baseline, 6 months, and 12 months. A third masked grader was used for discrepancies. Exposures Anti–vascular endothelial growth factor (AVF) therapy (ranibizumab, aflibercept, or bevacizumab) determined by the treating physician. Main Outcomes and Measures The DRIL score at baseline for determining VA outcomes and correlation of VA with changes in DRIL burden in response to AVF therapy. Results In the 147 patients (mean [SD] age, 68.9 [13.1] years; 75 [51.0%] female), baseline DRIL was seen in 91 eyes (61.9%). In the BRVO group but not the CRVO group, baseline DRIL was associated with lower baseline Early Treatment Diabetic Retinopathy Study (ETDRS) score (score of 66.7 for no DRIL vs 54.6 for DRIL, Pu2009=u2009.002). Absence of DRIL at baseline in the CRVO/HRVO group correlated with greater VA gains at 6 months, adjusting for baseline VA (score change of 19.50 for no DRIL vs 12.72 for DRIL; Pu2009=u2009.04). During 12 months, continued DRIL presence in BRVO was associated with less VA gain up to 6 months (score change of 6.2 for the DRIL increase group vs 18.6 for the DRIL decrease group vs 2.9 for the DRIL stable group; Pu2009=u2009.02). Increasing DRIL scores in CRVO/HRVO were associated with reduced VA improvement at 6 months (score change of –0.12 for the DRIL increase group vs 16.90 for the DRIL decrease group vs 8.45 for the DRIL stable group; Pu2009=u2009.002) and 12 months (score change of –1.91 for the DRIL increase group vs 17.83 for the DRIL decrease group vs 6.97 for the DRIL stable group; Pu2009<u2009.001). Conclusions and Relevance Baseline DRIL presence and DRIL burden changes with AVF therapy for macular edema secondary to RVO may be useful biomarkers of ETDRS score improvements.

Ellipsoid Zone Mapping Parameters in Retinal Venous Occlusive Disease with Associated Macular Edema

PurposenTo evaluate the association of baseline ellipsoid zone (EZ) parameters on optical coherence tomography (OCT) as calculated by a semi-automated computer algorithm with baseline visual acuity in eyes with retinal vein occlusion (RVO).nnnDesignnRetrospective consecutive case series.nnnSubjectsnPatients affected by RVO presenting from January 2011 to December 2014.nnnMethodsnBaseline demographics, clinical characteristics, and SD-OCT data at presentation were collected. Macular cube scans were exported into a retinal layer analysis software platform and outer retinal parameters were evaluated. Outer retinal/EZ parameters included EZ-retinal pigment epithelium (RPE) volume, central foveal EZ-RPE area, EZ-RPE central subfield thickness (CST), and EZ-RPE central foveal thickness (CFT). In addition, en face EZ mapping features were extracted including percent area with EZ attenuation (i.e., EZ-RPE thickness < 20 μm) and percent area with total EZ loss (i.e., EZ-RPE thickness = 0 μm).nnnMain Outcome MeasurenCorrelation of EZ parameters and baseline visual acuity (VA). Secondary outcome measures: Correlation of EZ parameters with other clinical characteristics and OCT measures of cube volume, cube average thickness, central subfield thickness.nnnResultsnOne hundred and twelve eyes were included in this analysis. Mean baseline VA was 56.53 ±17.68 ETDRS letters and was inversely associated with total EZ loss and EZ-RPE attenuation (r= - 0.33 and -0.38 respectively, p<0.001). VA was directly associated with all other EZ parameters (r=0.37 to 0.45, p<0.001). The presence of subretinal fluid was strongly linked to central parameters of central foveal EZ-RPE, EZ-RPE-CST, and EZ-RPE-CFT (Kruskal-Wallis test). Conventional OCT parameters (central subfield retinal thickness, cube volume and cube average thickness) did not have significant correlations with EZ measures (-0.30.05).nnnConclusionnBaseline EZ integrity is closely linked to presenting visual acuity in eyes with RVO and macular edema. EZ mapping provides an additional metric for evaluating RVO impact on retinal anatomy and potential function.

Surgical Repair of Traumatic Macular Holes With Extreme Macular Pathology Using an Internal Limiting Membrane Flap Technique

This report describes the use of inverted internal limiting membrane (ILM) flap technique as a treatment option for traumatic macular holes (MHs) with severe macular pathology. An interventional case series of two patients who experienced blunt trauma is reported. One patient developed two adjacent MHs and the second patient a MH with focal tissue avulsion in the fovea. Each patient underwent pars plana vitrectomy with ILM flap creation and intraocular gas tamponade. The ILM flap technique was successfully used for closure of MHs in one patient with a traumatic double MH and another patient with MH with foveal tissue avulsion. Visual acuity and symptoms improved in both patients. The ILM flap technique is a useful option for patients even with advanced pathologic findings subsequent to traumatic MH formation. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e143-e146.].

Beta-Thalassemia Minor Manifesting as Proliferative Retinopathy

Beta-thalassemia (β-thalassemia) minor is characterized by a mutation in one of the two β-globin genes (HBB) that produce the β-globin chains in the hemoglobin molecule. Although other hemoglobinopathies have been frequently associated with retinal disease, there are limited reports of retinal pathology with β-thalassemia minor. We report two patients with β-thalassemia minor presenting with decreased vision, vitreous hemorrhage, and proliferative retinopathy. This case report highlights that patients with β-thalassemia minor may require routine ocular examinations for peripheral retinal pathology, and β-thalassemia minor should be considered in the differential diagnosis for proliferative retinopathy. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e161-e164.].

Repeatability of Split-Spectrum Amplitude-Decorrelation Angiography to Assess Capillary Perfusion Density Within Optical Coherence Tomography

BACKGROUND AND OBJECTIVEnTo evaluate the repeatability of retinal thickness and vascular density measurements using split-spectrum amplitude-decorrelation angiography (SSADA) with optical coherence tomography (OCT).nnnPATIENTS AND METHODSnForty patients were divided into seven categories according to their diagnosis: no retinopathy (control), retinal vein occlusion, diabetes with no retinopathy, diabetes with retinopathy, non-exudative age-related macular degeneration (AMD), exudative AMD, and epiretinal membrane. Capillary density and retinal thickness measurements were taken and evaluated for reliability by determination of statistically significant differences and coefficient of variability (CoV) between measurements.nnnRESULTSnNo significant differences (P > .05) were found in any of the within-visit measurements. CoVs ranged from 0.26% to 52.76%, depending on the measure and the disease settings.nnnCONCLUSIONnThe SSADA OCT angiography analysis has a low level of variability between measurements and, thus, is a reliable tool for evaluation of retinal perfusion. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e9-e19.].

36-Month Evaluation of Intravitreous Aflibercept Injection for Wet Age-Related Macular Degeneration in Patients Previously Treated With Ranibizumab or Bevacizumab

BACKGROUND AND OBJECTIVEnIn the ASSESS study, patients with neovascular age-related macular degeneration transitioned from other anti-vascular endothelial growth factor therapies to intravitreous aflibercept (Eylea; Regeneron, Tarrytown, NY) injections (IAI). The purpose was to determine the 36-month outcomes following the change from a fixed 24-month IAI dosing regimen to a routine clinical practice regimen.nnnPATIENTS AND METHODSnPatients were treated with a fixed bimonthly regimen for the first 2 years. In the third year, patients were managed according to routine clinical practice.nnnRESULTSnA total of 18 patients completed the 36 months and were considered for statistical analyses. At 36 months, a nonsignificant decrease of -37.8 μm in central subfield thickness and a nonsignificant gain of 5.8 letters from baseline were observed.nnnCONCLUSIONnDespite the significant visual and anatomical gains observed in the 2 years of fixed-dosing IAI, there was gradual decline in these improvements when patients were transitioned to a variable regimen. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:179-185.].

Measuring outcomes in cataract surgery

Purpose of review The article presents a review of recently published studies reporting postcataract surgery outcomes and the use of electronic systems to track them. Recent findings Current publications report several parameters to measure cataract outcomes such as visual acuity, patient-reported visual function, contrast sensitivity, reading speed, residual refractive errors and complications (intraoperative and postoperative). Summary Cataracts currently afflict an estimated 94 million people worldwide, and surgical removal is the only effective therapy known. Tracking outcomes through registry databases has been shown to be a powerful tool for improving patient outcomes, understanding and adopting best clinical practices, reducing costs and increasing value delivered. Large datasets present in electronic registry systems are valuable resources for evaluating the quality of care by allowing researchers and healthcare providers to analyze, understand and adjust to ‘real-world’ best practices and adverse events.

Choriocapillaris and retinal vascular plexus density of diabetic eyes using split-spectrum amplitude decorrelation spectral-domain optical coherence tomography angiography

Background/aims Split-spectrum amplitude decorrelation angiography for spectral-domain optical coherence tomography has enabled detailed, non-invasive assessment of vascular flow. This study evaluates choriocapillaris and retinal capillary perfusion density (CPD) in diabetic eyes using optical coherence tomography angiography (OCTA). Methods Records of 136 eyes that underwent OCTA imaging at a single institution were reviewed. Eyes were grouped as non-diabetic controls (37 eyes), patients with diabetes mellitus (DM) without diabetic retinopathy (DM without DR, 31 eyes), non-proliferative diabetic retinopathy (NPDR, 41 eyes) and proliferative diabetic retinopathy (PDR, 27 eyes). Quantitative CPD analyses were performed on OCTA images for assessing perfusion density of the choriocapillaris and retinal plexus for all patients and compared between groups. Results Eyes with NPDR and PDR showed significantly decreased choriocapillaris CPD compared with controls, while DM eyes without DR did not show significant change. Choriocapillaris whole-image CPD was decreased by 8.3% in eyes with NPDR (p<0.01) and decreased by 7.1% in eyes with PDR (p<0.01). Choriocapillaris parafoveal CPD was decreased by 8.9% in eyes with NPDR (p<0.01) and decreased by 8.2% in eyes with PDR (p<0.01). Compared with controls, only eyes with PDR showed significantly decreased retinal CPD, as well as significantly increased foveal avascular zone (FAZ) area. In those patients, retinal whole-image CPD was decreased by 9.7% (p<0.01), retinal foveal CPD was decreased by 20.5% (p<0.01) and retinal parafoveal CPD was decreased by 11.4% (p<0.01). FAZ area was increased by 50.9% (p<0.01). Conclusions Choriocapillaris and retinal CPD are reduced in diabetic retinopathy, while FAZ area is increased in eyes with PDR. Vascular changes captured by new imaging modalities can further characterise diabetic choroidopathy.

Switching Anti-VEGF Drugs in the Treatment of Diabetic Macular Edema

Since their introduction in the late 2000s, anti-vascular endothelial growth factor (VEGF) agents have become the first-line choice for center-involved diabetic macular edema (DME). Even with its proven effectiveness, there are still cases that do not respond satisfactorily. In those cases, a treatment option is to change to another anti-VEGF drug. In this paper, the authors review studies on switching between different anti-VEGF drugs in the treatment of persistent DME. An extensive bibliographic review was done using PubMed, Embase, and Scopus. Fourteen studies published from March 2010 to April 2017 reporting switching from anti-VEGF drugs in DME treatment were included. All reported good anatomical results after conversion; however, visual acuity outcomes showed great variability between publications. Therefore, switching to other anti-VEGFs in patients with DME not responding to previous anti-VEGF therapy may be an option, but the results are still not well-known due to a lack of randomized clinical trials. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:748-754.].