Rukhsana G. Mirza

Visual and anatomical outcomes following intravitreal aflibercept in eyes with recalcitrant neovascular age-related macular degeneration: 12-month results

PurposeTo describe the efficacy of intravitreal aflibercept on 12-month visual and anatomical outcomes in patients with neovascular age-related macular degeneration (AMD) recalcitrant to prior monthly intravitreal bevacizumab or ranibizumab.MethodsNon-comparative case series of 21 eyes of 21 AMD patients with evidence of persistent exudation (intraretinal fluid/cysts, or subretinal fluid (SRF), or both) on spectral domain OCT despite ≥6 prior intravitreal 0.5 mg ranibizumab or 1.25 mg bevacizumab (mean 29.8±17.1 injections) over 31.6±17.4 months who were transitioned to aflibercept.ResultsAt baseline, best-corrected visual acuity (BCVA) was 0.42±0.28 logarithm of minimum-angle of resolution (logMAR), central foveal thickness (CFT) was 329.38±102.67 μm and macular volume (MV) was 7.71±1.32 mm3. After 12 months of aflibercept (mean 10.2±1.2 injections), BCVA was 0.40±0.28 logMAR (P=0.5), CFT decreased to 292.71±91.35 μm (P=0.038) and MV improved to 7.33±1.27 mm3 (P=0.003). In a subset of 15 eyes with a persistent fibrovascular or serous pigment epithelial detachment (PED), mean baseline PED greatest basal diameter (GBD) was 2350.9±1067.6 μm and mean maximal height (MH) was 288.7±175.9 μm. At 12 months, GBD improved to 1896.3±782.3 μm (P=0.028), while MH decreased to 248.27±146.2 μm (P=0.002).ConclusionIn patients with recalcitrant AMD, aflibercept led to anatomic improvement at 12 months, reduction in proportion of eyes with SRF and reduction in PED, while preserving visual acuity.

Imaging characteristics of neovascular pigment epithelial detachments and their response to anti-vascular endothelial growth factor therapy

Purpose To evaluate the imaging characteristics of macular neovascular pigment epithelial detachments (PEDs) and their response to anti-vascular endothelial growth factor (VEGF) therapy. Methods Patients with exudative age-related macular degeneration (AMD), idiopathic polypoidal choroidal vasculopathy, presumed ocular histoplasmosis syndrome (POHS) and central serous retinopathy (CSR) with choroidal neovascularisation (CNV) were included in the study. A retrospective chart review of 72 eyes of 64 patients was performed. Results Three types of PEDs were identified based on reflectivity of the material under the retinal pigment epithelium on optical coherence tomography: hollow (26 eyes with primarily hyporeflectivity under the PED), solid (30 eyes with primarily hyperreflective signal under the PED) and mixed (8 eyes with mixed reflectivity). The average number of anti-VEGF injections was 7 per eye and the average duration of follow-up was 16 months. Among eyes with exudative AMD, 7/21 hollow PEDs flattened, 1/19 solid PEDs flattened and 2/6 mixed PEDs flattened after anti-VEGF therapy. POHS and CSR with CNV were associated with subfoveal solid PEDs and were unchanged after therapy. Overall, 46% (12/26) with hollow PEDs, 25% (2/8) with mixed PEDs and 3% (1/30) with solid PEDs had flattening after anti-VEGF therapy. Conclusions The likelihood of PED flattening was inversely related to the reflectivity of the PED. The more reflective the PED, the less likely resolution with anti-VEGF therapy occurred.

Quantification of Change in Pigment Epithelial Detachment Volume and Morphology After Transition to Intravitreal Aflibercept in Eyes With Recalcitrant Neovascular AMD: 18-Month Results

BACKGROUND AND OBJECTIVE To quantitatively evaluate the change in pigment epithelial detachment (PED) morphology on spectral-domain optical coherence tomography (SD-OCT) 18 months after the transition to intravitreal aflibercept in patients with neovascular age-related macular degeneration (AMD) with PED recalcitrant to monthly intravitreal bevacizumab or ranibizumab. PATIENTS AND METHODS Retrospective case series examining patients with neovascular AMD who had a persistent fibrovascular or serous PED on SD-OCT. PED volume was calculated by manually outlining the PED on individual OCT slices of the raster scan and multiplying by the pixel dimensions. RESULTS Eleven eyes of 10 patients who had received an average of 25.7 ± 20.1 (range: 6 to 70) prior bevacizumab or ranibizumab injections over a period of 26.6 ± 19.8 months (range: 4 to 63) were included. PED volume decreased with aflibercept from 0.687 ± 0.837 mm(3) to 0.562 ± 0.705 mm(3) (P = .02), a decrease of 19% ± 12.27%. CONCLUSION After 18 months of aflibercept, recalcitrant PED volumes were reduced by 19% while preserving visual acuity in eyes with neovascular AMD.

Transitioning to intravitreal aflibercept following a previous treat-and-extend dosing regimen in neovascular age-related macular degeneration: 24-month results

Purpose:To evaluate frequency of injections, visual and anatomical outcomes of neovascular age-related macular degeneration (nAMD) patients transitioned to intravitreal aflibercept after failure to extend treatment interval beyond 8 weeks with prior intravitreal bevacizumab or ranibizumab.Methods:Retrospective review of patients with nAMD switched to aflibercept following ≥6 prior intravitreal ranibizumab or bevacizumab injections at 4–8-week intervals. Three monthly aflibercept injections were given followed by a treat-and-extend dosing regimen.Results:Twenty-one eyes of 18 patients who had received a mean of 23.8±18.8 (mean±SD; range 6–62) prior ranibizumab or bevacizumab injections were included. Over a mean follow-up of 24 months after the transition, 9.2±2.9 (range 4–21) aflibercept injections were required. Interval between aflibercept injections increased to 57.3 days (range 35–133 days), as compared with 37±6.1 days (range 29–54 days) with the prior agents (P=0.01). Mean best-corrected visual acuity was preserved (0.42±0.31 vs 0.42±0.23 logMAR; P=0.2). Mean OCT central subfoveal thickness (292.1±83.2 μm to 283.6±78.6 μm; P=0.4) and mean macular volume (7.9±0.95 mm3 to 7.67±0.94 mm3; P=0.16) remained stable.Conclusion:Patients requiring treatment more frequently than every 8 weeks with ranibizumab and bevacizumab were transitioned to >8-week treatment interval with aflibercept while maintaining the anatomic and visual gains.

RETICULAR PSEUDODRUSEN ON INFRARED IMAGING ARE TOPOGRAPHICALLY DISTINCT FROM SUBRETINAL DRUSENOID DEPOSITS ON EN FACE OPTICAL COHERENCE TOMOGRAPHY.

Purpose: To evaluate the quantitative and topographic relationship between reticular pseudodrusen (RPD) on infrared reflectance (IR) and subretinal drusenoid deposits (SDD) on en face volumetric spectral domain optical coherence tomography. Methods: Reticular pseudodrusen were marked on IR images by a masked observer. Subretinal drusenoid deposits were visualized on en face sections of spectral domain optical coherence tomography below the external limiting membrane and identified by a semiautomated technique. Control RPD lesions were generated in a random distribution for each IR image. Binary maps of control and experimental RPD and SDD were merged and analyzed in terms of topographic localization and quantitative drusen load comparison. Results: A total of 54 eyes of 41 patients diagnosed with RPD were included in this study. The average number of RPD lesions on IR images was 320 ± 44.62 compared with 127 ± 26.02 SDD lesions on en face (P < 0.001). The majority of RPD lesions did not overlap with SDD lesions and were located >30 &mgr;m away (92%). The percentage of total SDD lesions overlapping RPD was 2.91 ± 0.87% compared with 1.73 ± 0.68% overlapping control RPD lesions (P < 0.05). The percentage of total SDD lesions between 1 and 3 pixels of the nearest RPD lesion was 5.08 ± 1.40% compared with 3.33 ± 1.07% between 1 and 3 pixels of the nearest control RPD lesion (P < 0.05). Conclusion: This study identified significantly more RPD lesions on IR compared with SDD lesions on en face spectral domain optical coherence tomography and found that a large majority of SDD (>90% of lesions) were >30 &mgr;m away from the nearest RPD. Together, our findings indicate that RPD and SDD are two entities that are only occasionally topographically associated, suggesting that at some stage in their development, they may be pathologically related.

Fundus autofluorescence imaging in punctate inner choroidopathy with blind spot enlargement.

Purpose: To present a case report in which fundus autofluorescence (FAF) helped to diagnose and monitor the clinical course of a patient diagnosed with punctate inner choroidopathy (PIC). Methods: Retrospective chart review of patient data. Results: FAF showed multiple hypoautofluorescent spots in the posterior pole.It also showed an area of hypoautofluorescence surrounded by a ring of hyperautofluorescence, which corresponded to a larger lesion seen clinically. As the disease became inactive, the number of hypoautofluorescent spots decreased. The rim of hyperautofluorescence surrounding the macular lesion became attenuated.Persistent hypofluorescent areas grew in size. Conclusions: FAF is a useful imaging modality to better visualize and delineate the extent of damaged retinal pigment epithelium (RPE) in PIC. FAF also helps the clinician to assess the resolution of the disease by the appearance of the RPE.

Relentless placoid chorioretinitis.

Relentless placoid chorioretinitis (RPC) was first described by Jones et al in 2000. They reported on 6 patients who presented conditions resembling both acute posterior multifocal placoid pigment epitheliopathy (APMPPE) and serpiginous choroiditis (SC), but with an atypical time course and retinal distribution. The term ampiginous has also been used to describe such patients. Before the understanding of this as a distinct process, some previous descriptions of multifocal serpiginous and recurrent APMPPE have likely been misclassified. In the original report, patients’ age ranged from 17 to 51 years. There was no sex predilection. In a more recent series by Jyotirmay et al, a male preponderance was found, with a mean age of 34 years. Patients present with sudden painless blurred vision. Patients can also present with metamorphopsia and floaters. Conversely, they may be asymptomatic. Patients may not have any consistent medical disorder or any complaint of a viral prodrome. Patients have bilateral posterior creamy white lesions at the level of the retinal pigment epithelium. The lesions usually tend to be smaller than those of APMPPE and are approximately half disc area in size. Lesions can be active in both eyes simultaneously, and can persist and grow. Pigmented chorioretinal atrophy develops as these lesions heal. A hallmark of this entity is the eventual presence of >50 to hundreds of lesions with involvement anterior and posterior to the equator. This contrasts with APMPPE, which is limited to the posterior pole. It has been suggested that lesions more frequently appear in the periphery first and in the posterior pole later. The fovea commonly becomes involved. Other associated ocular findings include a mild vitritis, occasional subretinal fluid, and disc swelling. Subretinal fibrosis as well as epiretinal membranes can be seen. CNV has not been described in the presentation of this entity. Anterior segment examination may

Imaging of a Cilioretinal Artery Embolisation

Retinal artery occlusion can be the first indicator of a significant cardiovascular disorder and the need for treatment. We present the case of a 69-year-old man with a cilioretinal artery occlusion and retinal ischemia. Retinal imaging, in particular fundus autofluorescence, highlighted an intraluminal hyperautofluorescent lesion which led to the diagnosis of retinal emboli. Subsequently a severe, previously undiagnosed carotid occlusive disease was discovered. The patient underwent prompt endarterectomy.

OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY IN ADULT-ONSET FOVEOMACULAR VITELLIFORM DYSTROPHY

Purpose: To determine the ability of optical coherence tomography angiography (OCTA) to detect choroidal neovascularization (CNV) in the pseudohypopyon stage of adult-onset foveomacular vitelliform dystrophy. Methods: Prospective case series of eight consecutive patients with adult-onset foveomacular vitelliform dystrophy with at least one eye in the pseudohypopyon stage (a total of 14 eyes). Patients were assessed with spectral domain OCT, flourescein angiography, and OCTA. Main outcome measures were the presence or absence of CNV and any unifying patterns that could be identified on OCTA for adult-onset foveomacular vitelliform dystrophy. Results: One (12.5%) of eight eyes in the pseudohypopyon stage had CNV on OCTA, without definitive evidence of CNV on flourescein angiography. Twelve of 14 eyes (86%) had OCTA segmentation errors, giving the false appearance of deep capillary plexus drop out. All 14 eyes (100%) had blockage of flow signal under the vitelliform lesion on OCTA that presented as artifactual loss of flow in the choriocapillaris. Conclusion: Optical coherence tomography angiography may be superior to flourescein angiography in detecting CNV in adult-onset foveomacular vitelliform dystrophy, especially in the pseudohypopyon stage. There are common artifacts that must be considered when analyzing vitelliform lesions with OCTA, including segmentation errors and inability to visualize flow under the vitelliform lesion in the choriocapillaris.

Occipital lobe infarction following cardiac ablation.

A 60-year-old man presented with the chief complaint of seeing a blurred area just up and to the left of the center of his vision. The patient noted this visual field defect immediately after he awoke from a cardiac electrophysiologic study with a catheter ablation procedure. On neuro-ophthalmologic testing, a small scotoma was present superior and left of fixation in both eyes. MRI showed a small irregular area of abnormal signal in the right occipital lobe consistent with an ischemic lesion. To the best of our knowledge, this represents the first case report of a homonymous visual field defect secondary to an occipital lobe infarction following a cardiac catheter ablation procedure.