Nadia Mendoza

REPRODUCIBILITY OF MACULAR PIGMENT OPTICAL DENSITY MEASUREMENT BY TWO-WAVELENGTH AUTOFLUORESCENCE IN A CLINICAL SETTING.

Purpose: Macular pigment, composed of lutein, zeaxanthin, and meso-zeaxanthin, is postulated to protect against age-related macular degeneration, likely because of filtering blue light and its antioxidant properties. Macular pigment optical density (MPOD) is reported to be associated with macular function evaluated by visual acuity and multifocal electroretinogram. Given the importance of macular pigment, reliable and accurate measurement methods are important. The main purpose of this study is to determine the reproducibility of MPOD measurement by two-wavelength autofluorescence method using scanning laser ophthalmoscopy. Methods: Sixty-eight eyes of 39 persons were enrolled in the study, including 11 normal eyes, 16 eyes with wet age-related macular degeneration, 16 eyes with dry age-related macular degeneration, 11 eyes with macular edema due to diabetic mellitus, branch retinal vein occlusion or macular telangiectasia, and 14 eyes with tractional maculopathy, including vitreomacular traction, epiretinal membrane, or macular hole. MPOD was measured with a two-wavelength (488 and 514 nm) autofluorescence method with the Spectralis HRA + OCT after pupil dilation. The measurement was repeated for each eye 10 minutes later. The analysis of variance and Bland–Altman plot were used to assess the reproducibility between the two measurements. Results: The mean MPOD at eccentricities of 1° and 2° was 0.36 ± 0.17 (range: 0.04–0.69) and 0.15 ± 0.08 (range: −0.03 to 0.35) for the first measurement and 0.35 ± 0.17 (range: 0.02–0.68) and 0.15 ± 0.08 (range: −0.01 to 0.33) for the second measurement, respectively. The difference between the 2 measurements was not statistically significant, and the Bland–Altman plot showed 7.4% and 5.9% points outside the 95% limits of agreement, indicating an overall excellent reproducibility. Similarly, there is no significant difference between the first and second measurements of MPOD volume within eccentricities of 1°, 2°, and 6° radius, and the Bland–Altman plot showed 8.8%, 2.9%, and 4.4% points outside the 95% limits of agreement, respectively. The data for the reproducibility did not differ significantly among the various disease and normal eyes. Conclusion: Under routine examination conditions with pupil dilation, MPOD measurement by two-wavelength autofluorescence method showed a high reproducibility.

INTEGRITY OF OUTER RETINAL LAYERS AFTER RESOLUTION OF CENTRAL INVOLVED DIABETIC MACULAR EDEMA.

Purpose: To evaluate the integrity of outer retina layers after resolution of central involved diabetic macular edema (DME) and to demonstrate the effect of various baseline factors for the final vision and final external limiting membrane (ELM) integrity. Methods: Fifty-nine eyes of 48 patients with resolved DME were included. Several optical coherence tomography parameters including central subfield thickness, maximum foveal thickness, foveal center point thickness, and the extent of the ellipsoidal (ISe) layer and ELM damage were assessed at the time of DME and after resolution of DME. Eyes having laser scars near the fovea were excluded. Final visual acuity was classified as good (Snellen≥20/40, logarithm of the minimum angle of resolution ⩽0.3) or impaired (Snellen <20/40, logarithm of the minimum angle of resolution >0.3) for the logistic regression analysis. Zero Inflated Poison Regression model was used to find the best predictors for post-treatment ELM damage. Results: External limiting membrane and inner segment ellipsoidal band layers were disrupted in 16 eyes (27.2%) and 21 eyes (35.5%) at the final visit, respectively. Baseline ELM damage (p=0.001), baseline impaired vision (p= 0.013), and the most recent glycosylated hemoglobin level (p=0.018) were the best set of parameters for having impaired final visual acuity. Baseline vision, severity of diabetic retinopathy, absence of intravitreal injection, central subfield thickness, and history of extrafoveal macular laser (not within 1 mm of fovea) (p<0.001, for all parameters) were independent predictors for the final ELM damage. Conclusion: Outer retinal layers may be damaged even after complete resolution of DME, where inner segment ellipsoidal band layer damage appeared to be more common than ELM damage. Poorly controlled diabetic patients with damaged ELM and worse vision at the time of DME were more likely to have ELM damage and subsequent impaired vision after complete resolution of DME.

Rate and Pattern of Rim Area Loss in Healthy and Progressing Glaucoma Eyes

PURPOSE To characterize the rate and pattern of age-related and glaucomatous neuroretinal rim area changes in subjects of African and European descent. DESIGN Prospective longitudinal study. PARTICIPANTS Two hundred ninety-six eyes of 157 healthy subjects (88 patients of African descent and 69 of European descent) and 73 progressing glaucoma eyes of 67 subjects (24 patients of African descent and 43 of European descent) from the Diagnostic Innovations in Glaucoma Study and the African Descent and Glaucoma Evaluation Study were included. METHODS Global and sectoral rim areas were measured using confocal laser scanning ophthalmoscopy. Masked stereophotograph review determined progression of glaucomatous optic disc damage. The rates of absolute rim area loss and percentage rim area loss in healthy and progressing glaucomatous eyes were compared using multivariate, nested, mixed-effects models. MAIN OUTCOME MEASURES Rate of rim area loss over time. RESULTS The median follow-up time was 5.0 years (interquartile range, 2.0-7.4 years) for healthy eyes and 8.3 years (interquartile range, 7.5-9.9 years) for progressing glaucoma eyes. The mean rate of global rim area loss was significantly faster in progressing glaucomatous eyes compared with healthy eyes for both rim area loss (-10.2×10(-3) vs. -2.8×10(-3) mm(2)/year, respectively; P < 0.001) and percentage rim area loss (-1.1% vs. -0.2%/year, respectively; P < 0.001), but considerable overlap existed between the 2 groups. Sixty-three percent of progressing glaucoma eyes had a rate of change faster than the fifth quantile of healthy eyes. For both healthy and progressing eyes, the pattern of rim area loss and percentage rim area loss were similar, tending to be fastest in the superior temporal and inferior temporal sectors. The rate of change was similar in progressing eyes of patients of African or European descent. CONCLUSIONS Compared with healthy eyes, the mean rate of global rim area loss was 3.7 times faster and the mean rate of global percentage rim area loss was 5.4 times faster in progressing glaucoma eyes. A reference database of healthy eyes can be used to help clinicians distinguish age-related rim area loss from rim area loss resulting from glaucoma.

Outer retinal tubulations response to anti-VEGF treatment

Aim To review the longitudinal changes of outer retinal tubulations (ORTs) in wet age-related macular degeneration (AMD) and their response to anti-vascular endothelial growth factor (VEGF) therapy by spectral-domain optical coherence tomography (SD-OCT), and to correlate these observations with disease activity, presence or absence of fluid, and patients’ demographics. Methods Retrospective study of wet AMD eyes treated with anti-VEGF agents and showing ORTs on SD-OCT, and the patients’ fellow eye with wet AMD but without ORTs. Results Fifty-one wet AMD eyes from 31 patients diagnosed and treated for wet AMD were included in the review and analysis of data; 33 eyes showed ORTs at baseline, while 18 fellow eyes had no ORTs. During a median follow-up treatment period of 11 months, 23 eyes had stable ORTs and 10 eyes had ORT changes. Among the 10 eyes with ORTs changes, ORTs collapsed during anti-VEGF treatment in 5 eyes but then reappeared within 12 months after stopping treatment. In two eyes, ORTs increased in size during anti-VEGF treatment, while in two other eyes ORTs collapsed without any treatment. In a single eye, ORTs collapsed within 10 months of no treatment and did not reappear upon recurrence of fluid. Eyes with ORTs tended to have lower visual acuity than eyes with no ORTs due to greater disruption of the external limiting membrane in the fovea. Conclusions ORTs documented by SD-OCT may exhibit multiple types of longitudinal changes, such as collapse, recurrence or enlargement, which could be associated with anti-VEGF treatment or spontaneous. Some ORTs may have a vascular component or may be vascular in nature, considering their response to anti-VEGF treatment, while other ORTs are likely composed only of degenerating photoreceptor cells and may collapse independently from anti-VEGF treatments.

LONG-TERM REMISSION OF NEOVASCULAR AGE-RELATED MACULAR DEGENERATION WITH AS-NEEDED ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY.

Purpose: To determine the presenting characteristics of patients with neovascular age-related macular degeneration with long-term remission (LTR), which was defined as the absence of intraretinal/subretinal fluid, or hemorrhage, and absence of leakage on fluorescein angiography for longer than 6 months while on as-needed antivascular endothelial growth factor treatment. Methods: The presenting characteristics of patients with LTR were compared with a control group including 32 eyes of 28 age-, gender-, and ethnicity-matched patients who did not achieve LTR. Results: Seventy-four percent of patients in the LTR group had Type 1 choroidal neovascular membrane and 18.5% had retinal angiomatous proliferation. In the control group, 28 eyes had Type 1 choroidal neovascular membrane (87.5%), and none of the patients had retinal angiomatous proliferation; overall, there was a significant difference in lesion types between the 2 groups (P = 0.036). Eyes with LTR at presentation had significantly thinner subfoveal choroidal thickness (147 vs. 178 &mgr;m, P = 0.04). There was more intraretinal fluid and less subretinal fluid at the presentation in the remission group (59.3% intraretinal fluid and 11.1% subretinal fluid) compared with the control group (28.1% intraretinal fluid and 34.4% subretinal fluid, P = 0.03). Conclusion: The presence of retinal angiomatous proliferation, thinner choroidal thickness, more intraretinal fluid, and less subretinal fluid at presentation were associated with LTR in patients receiving as-needed treatment for age-related macular degeneration.

RECALCITRANT CYSTOID MACULAR EDEMA AFTER PARS PLANA VITRECTOMY.

Purpose: To evaluate the outcomes of different types of treatment of chronic cystoid macular edema (CME) after pars plana vitrectomy. Methods: Retrospective review of eyes that developed chronic CME after pars plana vitrectomy treated with intravitreal triamcinolone acetonide (TCA) with or without the addition of anti-vascular endothelial growth factor. Results: Thirty-nine eyes of 37 patients were included, with a median duration between pars plana vitrectomy and onset of CME of 5 months (interquartile range, 3–12). In most eyes (66.7%), the main indication for surgery was for vitreomacular interface disorders, such as epiretinal membrane, vitreomacular traction, and macular hole. With intravitreal TCA, there was a significant decrease in central foveal thickness at 3, 6, and 12 months, compared with baseline (P = 0.0171, 0.0401, and 0.0024, respectively). A significant gain in vision was noted at 1 month compared with baseline (P = 0.0169), but this was not sustained at 3, 6, and 12 months (P = 0.4862, 0.9098, and 0.4312, respectively). The addition of bevacizumab to TCA did not provide any additional benefit for central foveal thickness and visual acuity. Thirty-two eyes (82.1%) were started on prophylactic antiglaucoma drops 2 weeks after a TCA injection, and no eye needed laser or surgery to control intraocular pressure. Conclusion: Chronic CME after pars plana vitrectomy is recurrent and difficult to treat. Intravitreal TCA is effective in reducing CME, but there was only short-term visual acuity improvement even with continued reduction of central foveal thickness. Intraocular pressure did not significantly rise with the use of prophylactic antiglaucoma drops even with repeated injections.

CHARACTERISTICS OF EPIRETINAL MEMBRANE REMNANT EDGE BY OPTICAL COHERENCE TOMOGRAPHY AFTER PARS PLANA VITRECTOMY

Purpose: To evaluate the incidence, characteristics, and the progression of epiretinal membrane (ERM) remnant edge seen by optical coherence tomography after ERM peeling. Methods: A retrospective chart review was conducted for 86 eyes of 85 consecutive patients who were diagnosed with ERM and underwent pars plana vitrectomy for epiretinal membrane peeling between 2013 and 2014. Data collected and analyzed included age, gender, preoperative and postoperative visual acuity, use of indocyanine green dye to stain internal limiting membrane, tamponade used after vitrectomy, ERM edge boundaries, presence of cystoid macular edema, and central foveal thickness. Results: An ERM remnant edge was detected in 33/86 study eyes (38.4%) at the first postoperative optical coherence tomography scan. Compared with those without an ERM remnant, patients with an ERM remnant after surgery were significantly older at baseline and had a higher incidence of ERM recurrence at their last visit. They were not significantly different in terms of gender, preoperative and postoperative visual acuity, reduction of central foveal thickness from baseline, proportion of eyes with preoperative ERM elevation on optical coherence tomography, presence of macular edema before surgery, intraoperative use of indocyanine green staining for ILM peeling, or tamponade used. Based on the edge morphology, we classified the ERM remnant into three types: Type 1 was flat and blended with the retina (14/33 eyes, 42.4%), Type 2 was flat but stepped (17/33 eyes, 51.5%), and Type 3 was elevated (2/33 eyes, 6.0%). A significantly higher risk of ERM recurrence was seen in Type 2 and Type 3 ERM remnants (75% and 100%, respectively) than Type 1 ERM remnants (10%). Conclusion: An ERM remnant edge was detected by optical coherence tomography after ERM peeling in 38.4% of eyes. The presence of a postoperative ERM edge was associated with a higher risk of ERM recurrence, particularly in Type 2 and Type 3 ERM remnants.