Gernot Steinwender

A Systematic Review and Meta-Analysis on the Safety of Vascular Endothelial Growth Factor (VEGF) Inhibitors for the Treatment of Retinopathy of Prematurity.

Introduction Laser photocoagulation is the current gold standard treatment for proliferative retinopathy of prematurity (ROP). However, it permanently reduces the visual field and might induce myopia. Vascular endothelial growth factor (VEGF) inhibitors for the treatment of ROP may enable continuing vascularization of the retina, potentially allowing the preservation of the visual field. However, for their use in infants concern remains. This meta-analysis explores the safety of VEGF inhibitors. Methods The Ovid Interface was used to perform a systematic review of the literature in the databases PubMed, EMBASE and the Cochrane Library. Results This meta-analysis included 24 original reports (including 1.457 eyes) on VEGF inhibitor treatment for ROP. The trials were solely observational except for one randomized and two case-control studies. We estimated a 6-month risk of retreatment per eye of 2.8%, and a 6-month risk of ocular complication without the need of retreatment of 1.6% per eye. Systemic complications were only reported as isolated incidents. Discussion VEGF inhibitors seem to be associated with low recurrence rates and ocular complication rates. They may have the benefit of potentially allowing the preservation of visual field and lower rates of myopia. Due to the lack of data, the risk of systemic side effects cannot be assessed.

IL2RA gene polymorphism rs2104286 A>G seen in multiple sclerosis is associated with intermediate uveitis: possible parallel pathways?

PURPOSE Uveitis is a major cause for visual impairment. Inflammation-related gene polymorphisms have previously been shown to confer susceptibility to different types of uveitis. Recently, IL-2 receptor alpha (IL2RA, also called CD25) and IL-7 receptor alpha (IL7RA) gene variants (rs2104286, rs12722489, and rs6897932) have been identified to play an essential role in the pathogenesis of immune-mediated diseases. Their role in uveitis, however, has not yet been studied. The present study was set to investigate a hypothesized association of these gene polymorphisms and the presence of either intermediate or HLA-B27-associated acute anterior uveitis. METHODS One hundred forty-five patients with HLA-B27-associated acute anterior uveitis (AAU), 84 patients with intermediate uveitis, 132 HLA-B27-negative controls, and 61 HLA-B27-positive controls were enrolled. Determination of genotypes was done by polymerase chain reaction. RESULTS The frequency of carriers of the minor allele for rs2104286 was significantly lower in patients with intermediate uveitis compared with HLA-B27 positive and negative controls combined (P = 0.006). Frequencies of the minor allele for rs2104286 did not differ significantly in patients with HLA-B27-associated uveitis (28.3%) when compared with HLA-B27-negative controls (24.2%; P = 0.29) and HLA-B27-positive controls (30.3%; P = 0.72). The rs12722489 and rs6897932 polymorphisms were not significantly associated with either investigated uveitis entity (P > 0.005). CONCLUSIONS These findings suggest an association of the rs2104286 polymorphism with intermediate uveitis, but not with HLA-B27-associated acute anterior uveitis. Because this polymorphism was associated with multiple sclerosis in previous studies, the authors suggest possible parallel pathways between multiple sclerosis and intermediate uveitis but not HLA-B27-associated uveitis.

Association between Polymorphism of the Vitamin D Metabolism Gene CYP27B1 and HLA-B27-Associated Uveitis. Is a State of Relative Immunodeficiency Pathogenic in HLA B27-Positive Uveitis?

Objective Polymorphisms of the vitamin D metabolism gene CYP27B1 showed associations with multiple autoimmune diseases. The aim of this study was to investigate a possible association between the rs703842 A>G polymorphism of the CYP27B1 gene and HLA-B27-associated uveitis. Design One hundred fifty-nine patients with HLA-B27-associated uveitis, 138 HLA-B27-negative controls and 100 HLA-B27-positive controls were recruited for this retrospective case-control study. Main outcome parameters were genotype distribution and allelic frequencies determined by polymerase chain reaction. Results Carriers of the rs703842G allele were found significantly more often in patients with HLA-B27-associated uveitis than in HLA-B27-positive controls (p = 0.03). Between patients and HLA-B27-negative controls no significant difference in the genotype distribution of the rs703842 A>G polymorphism was found (p = 0.97). Conclusions Our data suggest that the rs703842 A>G polymorphism may play a role in HLA-B27-associated uveitis.

Use of true net power in intraocular lens power calculations in eyes with prior myopic laser refractive surgery

Intraocular lens (IOL) power calculation following laser refractive surgery is still one of the most challenging aspects in cataract surgery. This study was initiated to investigate the application of true net power (TNP; Pentacam, software version 6.02r10, Oculus, Germany) in IOL power calculations in eyes with prior laser refractive surgery. Our data contribute to the notion that the TNP of the Pentacam is a reliable alternative to determine the IOL power in cases where the historical data are missing. Based on our data, we recommend implementing the TNP to obtain the true corneal power and thus, reliable IOL power calculations.

Role of IL-10 gene polymorphisms in intermediate and HLA-B27-associated uveitis.

decreased from 20 of 40 to 20 of 100 during the last follow-up. Smith et al. (2009) evaluated 164 eyes after intravitreal ranibizumab injections and reported a RPE tear incidence of 5% in eyes with FVPED. 6% incidence of RPE tear was reported by Spandau and Jonas in their series of 63 eyes with FVPED treated with bevacizumab (Spandau & Jonas 2006). In the study of Chan et al. (2007), among 2785 intravitreal bevacizumab injections for 1064 eyes, the incidence of RPE tears was 17.1% in patients with PED. Chang and Sarraf (2007) have observed a 15% incidence (9 ⁄ 59) of RPE tears following anti-VEGF pharmacotherapy in eyes with a PED. Our result is markedly different from the results of Chan & Sarraf. The possible causes are the intravitreal administration of different drugs, small number of cases and short follow-up time. Short-term follow-up would detect the majority of tears developing secondary to treatment, while missing those evolving over the natural course of the disease (Smith et al. 2009). In our study, despite of the subfoveal RPE tear, VA decreased in only one of three patients. In the literature, most of the cases with a RPE tear after intravitreal ranibizumab injection retained stable vision. In the study of Bressler et al. (1990), it was suggested that there may be remaining RPE or pigment epithelium directly beneath the central macula is not required for maintenance of good VA. Limitations of our study are the small number of cases, its retrospective nature and the use of time domain (TD) OCT. The high-resolution spectral domain (SD) OCT image quality results in finer discrimination of retinal and subretinal layers. In addition, the sensitivity of SD OCT images of detecting FV components and the internal structures of PED are greater than TD-OCT. So, the diagnosis of FVPED would be more reliable if we used SD OCT. In conclusion, this study found that the presence of FVPED increases the risk of the RPE tear occurrence after intravitreal ranibizumab injection for neovascular AMD. The development of RPE tear is not a contraindication for the continuation of the anti-VEGF treatment. Despite of the subfoveal RPE tear, remaining stable VA or vision improvement can be possible. References

Early Tomographic Changes in the Eyes of Patients With Keratoconus

PURPOSE To identify tomographic variables best suited for detecting keratoconus before manifestation of ectatic changes and showing disease progression in the early stage. METHODS Twenty-seven patients with diagnosed unilateral keratoconus were followed up for their fellow eye, which had not yet shown any ectatic changes, to determine initial change indicators toward keratoconus disease. Variables were compared to 50 normal eyes without any known disease. A following receiver operating characteristic (ROC) analysis was performed to reveal the variables best used to discriminate healthy eyes from early ectatic eyes. RESULTS The calculated mean difference of the cylinder for total corneal refractive power was only 0.07 ± 0.32 diopters (D) (anterior astigmatism = 0.12 ± 0.28 D and posterior astigmatism = 0.02 ± 0.10 D). ROC revealed the index of height decentration with an area under the curve of 0.788 ± 0.054 as the most suitable to differentiate between eyes of healthy patients and the non-ectatic eye of patients with asymmetrical keratoconus, followed by the index of vertical asymmetry of 0.772 ± 0.057 and a keratoconus index of 0.743 ± 0.062. However, with progression of the eyes into early ectactic stages, the ROC showed the highest area under the curve for D-index (0.876 ± 0.039), followed by index of height decentration (0.855 ± 0.046) and index of vertical asymmetry (0.842 ± 0.046). CONCLUSIONS Early stages of keratoconus are hard to diagnose and best results can be achieved by using index of height decentration and index of vertical asymmetry. As the disease progresses, D-index is better suited to diagnose an ectasia. Astigmatism, keratometry, and pachymetry barely change in the early stages, so these values are not as fitting as corneal elevation parameters for early diagnosis. [J Refract Surg. 2018;34(4):254-259.].

Comparison of standard and accelerated corneal cross-linking for the treatment of keratoconus: a meta-analysis

To compare results between standard and accelerated corneal collagen cross‐linking (CXL) for the treatment of progressive keratoconus.

Refractive Outcomes After Femtosecond Laser–Assisted Cataract Surgery in Eyes With Anterior Chamber Phakic Intraocular Lenses

PURPOSE To report the efficacy, predictability, and safety of femtosecond laser-assisted cataract surgery (FLACS) in eyes with anterior chamber phakic intraocular lenses (IOLs). METHODS This retrospective case series included eyes with previous implantation of an angle-supported and an iris-fixated phakic IOL for the correction of myopia that underwent a combined procedure of phakic IOL ex-plantation and FLACS with in-the-bag implantation of a posterior chamber IOL. Postoperative corrected distance visual acuity (CDVA), predictability of refractive outcome, and occurrence of intraoperative and postoperative complications were analyzed. RESULTS Ten eyes of 7 patients with significant cataract were included: 5 eyes with an angle-supported foldable hydrophobic phakic IOL, 4 eyes with an angle-supported polymethylmethacrylate (PMMA) phakic IOL, and 1 eye with an iris-fixated PMMA phakic IOL. Mean follow-up after FLACS was 8.4 ± 5.8 months. Mean interval between phakic IOL implantation and FLACS was 11.9 ± 4.0 years. After the combined procedure of phakic IOL explantation and FLACS, mean manifest refractive spherical equivalent (MRSE) was -0.11 ± 0.49 diopters (D) and MRSE was within ± 0.75 D of target refraction in all eyes. Four eyes received a toric posterior chamber IOL after phacoemulsification. Mean preoperative CDVA of 0.40 ± 0.23 logMAR improved significantly to 0.22 ± 0.11 logMAR postoperatively (P = .027). No intraoperative or postoperative complications occurred. CONCLUSIONS The results in this series showed that FLACS in eyes with previous implantation of both rigid and foldable anterior chamber phakic IOLs offers good refractive outcomes with a high level of predictability and safety. [J Refract Surg. 2018;34(5):338-342.].

Impact of a Displaced Corneal Apex in Small Incision Lenticule Extraction

PURPOSE To evaluate the possible impact of a displaced corneal apex (point of maximum curvature) on visual results and tomographic parameters after small incision lenticule extraction (SMILE). METHODS In this retrospective evaluation, eyes with uncomplicated SMILE for myopia correction were classified in two groups based on their preoperative distance between the corneal apex and corneal vertex (corneal intercept with the patients line of sight) of 1 mm or greater (large A-V distance) or less than 1 mm (small A-V distance). All surgeries were performed during the early learning curve of two surgeons. Visual outcome parameters included uncorrected (UDVA) and corrected (CDVA) distance visual acuity, manifest refractive spherical equivalent (MRSE), and refractive astigmatism 3 months postoperatively. Scheimpflug-derived tomographic outcome parameters included mean keratometry value, root mean square higher order aberrations (RMS HOAs), and optical zone decentration. RESULTS The study comprised 94 eyes of 48 patients: 44 eyes in the large A-V distance group and 50 eyes in the small A-V distance group. Preoperative and postoperative RMS HOAs were significantly higher in the large A-V distance group than in the small A-V distance group (P = .002 and .008, respectively). Postoperative CDVA was significantly better in the small A-V distance group (P = .014). There were no statistically significant differences in postoperative UDVA, MRSE, refractive astigmatism, mean keratometry value, and optical zone decentration. CONCLUSIONS After SMILE, CDVA was significantly worse in eyes with a preoperatively displaced corneal apex compared to eyes with a more central corneal apex. However, good visual results were achieved in both groups. [J Refract Surg. 2018;34(7):460-465.].

Vitreous hyper-reflective dots in pseudophakic cystoid macular edema assessed with optical coherence tomography

Purpose This study compares the presence of vitreous hyper-reflective dots (VHDs) detected with optical coherence tomography (OCT) between eyes with pseudophakic cystoid macular edema (CME) and those with no CME after cataract surgery. In addition, we evaluated the impact of VHDs on the responsiveness of pseudophakic CME to cortisone treatment. Setting Department of Ophthalmology, Medical University of Graz, Austria. Design Retrospective, monocenter case-controlled study. Methods Inclusion criteria for the study group and the control group were CME and no CME within 12 weeks following uneventful phacoemulsification in otherwise healthy eyes, respectively. VHDs (number and size) and the macular thickness were assessed with OCT. Furthermore, the number of peribulbar or intravitreal steroid injections was assessed. Results A total of 284 eyes from 267 patients were analyzed, among which 119 met the inclusion criteria for the study (n = 63) and the control group (n = 56). VHDs were observed in 54 (85.7%) study eyes and 21 (37.5%, p = 0.013) control eyes. The number of VHDs was 3.9±3.4 in the study group and 0.7±1 in the control group (p<0.001). The size of the VHDs was 33.5±9.1 μm and 36.6±17.9 μm in the study and control groups, respectively (p = 0.978). Overall, the number of VHDs correlated with central subfield thickness (r = 0.584, p<0.001), cube volume (r = 0.525, p<0.001), and postoperative best-corrected visual acuity (BCVA) (r = -0.563, p<0.001). The number of VHDs did not correlate with the frequency of peribulbar or intravitreal steroid injections. Conclusion VHDs occurred more often in eyes with CME than in eyes without CME following cataract surgery. In addition, the number of VHDs had an impact on the extent of macular thickening and subsequently postoperative BCVA. No correlation was found between the number of VHDs and the frequency of required peribulbar or intravitreal steroid injections.