An efficacy comparison of combination of different anti-vascular endothelial growth factors and photodynamic therapy in patients with pachychoroid neovasculopathy

Purpose

To evaluate anatomical and visual outcomes in patients who received intravitreal anti-vascular endothelial growth factor (VEGF) agents in combination with full-dose photodynamic therapy (PDT) on eyes with choroidal neovascularization (CNV) secondary to naive pachychoroid neovasculopathy (PNV).

Materials and Methods

Medical records on 19 eyes of 19 patients whom intravitreal bevacizumab (IVB), intravitreal ranibizumab (IVR), and intravitreal aflibercept (IVA) injections were administered for CNV caused by PNV were enrolled into the study. The central macular thickness (CMT), best-corrected visual acuity (BCVA), and subfoveal choroidal thickness (SFCT) were recorded at the baseline, months 1, 3, 6, 12, and final control visit following treatment.

Results

The age average was 53.84?±?5.23 years (range, 46–62 years), and mean follow-up time was 33.42?±?9.43 months (range, 16–49 months). The change in BCVA was found statistically significant in the IVA group only during follow-up visits (p?=?0.007). Although there was no statistically significant change in CMT following IVR (360.60?±?75.64–252?±?75.04 µm) (p?=?0.077), significant changes were observed in IVB (397.14?±?122.59–275.28?±?63.82 µm) (p?=?0.004) and IVA (385.85?±?43.82–244.42?±?51.57 µm) (p?=?0.005) between the baseline and the final visit. SFCT significantly decreased following both IVR and IVA treatments (p?=?0.016, p?=?0.039, respectively). In consideration of the number of injections, significantly fewer injections were needed in the IVA group than the others (p?=?0.018).

Conclusions

Anti-VEGF agents with full-dose PDT were well tolerated for the first 3 months and were highly effective treatment option in order to naive PNV patients. However, in long-term follow-ups, the effectiveness of IVA was superior to other anti-VEGFs.

     

The combination of phacoemulsification surgery and intravitreal triamcinolone injection in patients with cataract and diabetic macular edema

Purpose

To assess the safety and efficiency of combined phacoemulsification (PHACO) surgery and intravitreal triamcinolone (IVTA) injection with or without macular grid laser photocoagulation in patients with cataract and diabetic macular edema.

Material and methods

This prospective study included 41 eyes of 36 diabetic patients with cataract and coexisting clinically significant macular edema (CSME). After PHACO and IVTA injection eyes were divided into two groups: the laser and IVTA group (Group 1) and only IVTA group (Group 2). Preoperative and postoperative best corrected visual acuity (BCVA), central macular thickness (CMT), and intraocular pressure (IOP) were recorded. Paired sample t-test was used to compare data in the groups and C square test for qualitative variables.

Results

Postoperative BCVA was significantly higher than the initial BCVA during the follow-up period in both groups (p < 0.01). The BCVA 6 months after surgery was significantly higher in group 1 than in group 2 (p < 0.01). There was no statistically significant difference in IOP between two groups preoperatively and postoperatively during the follow-up period (p > 0.05). There was no statistically significant difference between both groups in mean CMT preoperatively and 2nd week, 2nd month and 3rd month after surgery (p > 0.05). The mean CMT 6 months after surgery was statistically significantly lower in group 1 than in group 2 (p < 0.01).

Conclusions

PHACO surgery combined with IVTA injection improves BCVA and provides a decrease in CMT in diabetic patients with CSME. Additional macular grid laser photocoagulation after surgery helps to preserve this improvement in BCVA and decrease in CMT.     

Comparison of anatomical and functional outcomes of vitrectomy with internal limiting membrane peeling in recalcitrant diabetic macular edema with and without traction in Indian patients

Purpose:To study and compare the outcomes of pars plana vitrectomy (PPV) with the internal limiting membrane (ILM) peeling in the eyes with recalcitrant diabetic macular edema (DME) with and without vitreomacular traction.Methods:A comparative prospective interventional study was undertaken in which group 1 included 45 eyes of 45 patients with DME with vitreomacular tractional component and group 2 included 45 eyes of 45 patients with recalcitrant DME without a tractional component. Both groups underwent standard PPV with ILM peeling. All the patients were followed up for a minimum of 6 months. The parameters evaluated were changes in the best-corrected visual acuity (BCVA), central macular thickness (CMT), multifocal electroretinogram (mfERG) parameters, and occurrence of any intraoperative/postoperative surgical complication.Results:The mean CMT improved significantly from 540.6 and 490.2 μm at the baseline to 292.5 and 270.6 μm at 6 months in groups 1 and 2, respectively (P < 0.001). The mean BCVA logMAR improved from 0.78 ± 0.21 to 0.62 ± 0.22 in group 1 and 0.84 ± 0.19 to 0.65 ± 0.21 in group 2 at 6 months follow-up which was not statistically significant. The improvement in the mfERG was seen in group 2 as a significant increase in P1 wave amplitude in ring 2 (2–5°) (P < 0.004) and a significant decrease in P 1 wave implicit time in ring 1 (central 2°) (P < 0.001). None of the eyes suffered from the loss of BCVA or any major surgical complication in either group.Conclusion:PPV in recalcitrant DME provides good anatomical outcomes and the results are comparable in DME with and without a tractional component.     

Intravitreal Anti-vascular Endothelial Growth Factor for Newly Diagnosed Symptomatic Polypoidal Choroidal Vasculopathy with Extrafoveal Polyps

PurposeTo evaluate the 12-month outcome of anti-vascular endothelial growth factor (VEGF) treatment for extrafoveal polypoidal choroidal vasculopathy (PCV).MethodsThis retrospective observational study included 32 eyes of 32 patients newly diagnosed with extrafoveal PCV (polyps located more than 500 µm from the center of the fovea). Patients were treated with intravitreal ranibizumab, bevacizumab, or both. The best-corrected visual acuity (BCVA) and central foveal thickness (CFT) at diagnosis and at 12 months were compared. Eyes were divided into two groups according to the presence of submacular hemorrhage. The BCVA in each group was compared at baseline and at 12 months.ResultsDuring the 12-month study period, patients received an average of 4.0 ± 1.1 anti-VEGF injections. The BCVA at baseline, three-month post-diagnosis, and 12-month post-diagnosis was 0.59 ± 0.40, 0.34 ± 0.38, and 0.38 ± 0.38, respectively. The BCVA at 12 months was significantly better than the baseline value (p = 0.002). The CFT at baseline, three-month, and 12-month post-diagnosis was 477.1 ± 194.2 µm, 214.5 ± 108.8 µm, and 229.8 ± 106.1 µm, respectively. The CFT at 12 months was significantly lower than the baseline value (p < 0.001). A significant improvement in BCVA was noted in eyes with and without submacular hemorrhage (n = 13, p = 0.032 and n = 19, p = 0.007, respectively).ConclusionsAnti-VEGF therapy was beneficial in extrafoveal PCV, regardless of the presence of submacular hemorrhage.     

One-year Results of Aflibercept Treatment for Polypoidal Choroidal Vasculopathy with Good Visual Acuity

PurposeTo evaluate the one-year efficacy of intravitreal aflibercept injection in polypoidal choroidal vasculopathy (PCV) with best-corrected visual acuity (BCVA) of 20 / 40 or better.MethodsThis was a multicenter retrospective study. The medical records of patients diagnosed with treatment-naïve PCV were retrospectively reviewed. Patients with an initial BCVA of 20 / 40 or better and who had undergone intravitreal aflibercept injection were included. Patients were treated with three consecutive monthly injections, followed by pro re nata regimen according to the clinician’s discretion at variable interval visits. The proportions of eyes for which BCVA was maintained (≤ 0.2 logarithm of the minimum angle of resolution change) or improved at 12 months were evaluated. The changes of BCVA, central subfield macular thickness (CSMT), pigment epithelial detachment, and subretinal fluid also were assessed.ResultsA total of 86 eyes were included. The mean number of injections for 12 months of treatment was 5.4 ± 1.7. BCVA was maintained or improved in 94.2% (81 / 86) of cases. Mean BCVA (logarithm of the minimum angle of resolution) had changed from the baseline (0.23 ± 0.09) at 3 months (0.21 ± 0.14), 6 months (0.24 ± 0.22), and 12 months (0.20 ± 0.18), but with no statistical significance. CSMT had improved significantly from the baseline (336.1 ± 97.3 μm) at 3 months (223.6 ± 47.22 μm), 6 months (239.6 ± 64.2 μm), and 12 months (223.8 ± 47.9 μm). Pigment epithelial detachment was observed in 93% of cases at the baseline, 72.1% at 3 months, and 69.8% at 12 months, showing a significant decrease at all observation points. Subretinal fluid was observed in 91.9% of cases at the baseline, 20.9% at 3 months, and 29.1% at 12 months, showing a significant decrease at all observation points.ConclusionsIn cases of PCV with good visual acuity, intravitreal aflibercept injections decreased CSMT and were effective in maintaining visual acuity.     

Collateral Vessel Development in Central and Branch Retinal Vein Occlusions Are Associated With Worse Visual and Anatomic Outcomes

PurposeThe purpose of this study was to investigate the effects of the extension of collateral vessels on the outcomes of eyes affected by central retinal vein occlusion (CRVO) and branch retinal vein occlusion (BRVO).MethodsThe study was designed as a cross-sectional case series. Patients affected by CRVO and BRVO were progressively recruited, along with an age- and sex-matched control group of healthy subjects. Structural optical coherence tomography (OCT) and OCT angiography (OCTA; 4.5 × 4.5 mm and 9.0 × 9.0 mm acquisitions) were performed on all participants in order to assess the relationship between the presence of collateral vessels and final anatomical outcomes – central macular thickness (CMT), foveal avascular zone – and functional outcomes – best corrected visual acuity (BCVA).ResultsFifty-six eyes affected by CRVO and 47 eyes affected by BRVO were included. Baseline LogMAR BCVA was 0.41 ± 0.33 LogMAR in CRVO, and 0.39 ± 0.25 LogMAR in BRVO (P < 0.01), improving to 0.20 ± 0.26 LogMAR in CRVO (P < 0.01), and 0.19 ± 0.22 LogMAR in BRVO (P < 0.01). Baseline CMT was 511 ± 214 µm in CRVO and 482 ± 178 µm in BRVO (P > 0.05), decreasing to 328 ± 105 µm (P < 0.01) and 321 ± 78 µm in CRVO and BRVO, respectively (P < 0.01). Collateral vessels were detected in 16 of 56 eyes (29%) in CRVO and in 47 of 47 eyes (100%) in BRVO. Their extension was correlated with worse anatomic and visual outcomes. Remarkably, no correlation was found with peripheral capillary nonperfusion and vessel density impairment.ConclusionsThe present study demonstrates that collateral vessel extension is associated with worse anatomic and functional outcomes in patients affected by CRVO and BRVO.     

Outcomes of preoperative bevacizumab in diabetics with nonclearing vitreous hemorrhage without tractional detachment – A quasi-randomized retrospective study

Purpose:To assess whether preoperative bevacizumab (BVZ) in treatment-naïve eyes with proliferative diabetic retinopathy (PDR) and vitreous hemorrhage (VH) without tractional retinal detachment (TRD) leads to lesser macular edema and better visual outcome compared to eyes that do not receive BVZ.Methods:This quasi-randomized retrospective study included 217 treatment-naïve eyes with nonclearing VH without TRD that had vitrectomy with or without BVZ and had a minimum 6-months follow-up. Postoperative variables, including visual acuity (BCVA), central macular thickness (CMT) at 1 month, and need for additional anti-VEGF injections till 6 months follow-up, were recorded for analysis.Results:Of the 217 eyes, 107 eyes (49%) received preoperative BVZ and 110 (51%) did not. Groups were comparable in terms of preoperative characteristics. At 1 month, mean CMT was significantly higher in eyes without BVZ (310 ± 33 μ vs. 246 ± 34μ; P < 0.001). The likelihood of developing center-involving DME at 1 month after vitrectomy was 67% lower if the eye received preoperative BVZ (OR = 0.33, 95%CI = 0.18–2.54, P = 0.56). Though BCVA improved significantly in both groups at 1 month, it was 1/3^rd of a line better in the BVZ group (β coefficient = −0.035 logMAR, 95%CI = −0.04 to −0.008 logMAR, P = 0.01).Conclusion:Preoperative BVZ in treatment-naïve eyes with PDR and VH but without TRD lead to better macular status and marginally improved vision at 1 month, which was maintained at 6 months. In view of these results, patients may be offered BVZ only when it is readily affordable to them.     

Aflibercept Treatment for Neovascular Age-related Macular Degeneration and Polypoidal Choroidal Vasculopathy Refractory to Anti-vascular Endothelial Growth Factor

Purpose

To report the results of switching treatment to vascular endothelial growth factor (VEGF) Trap-Eye (aflibercept) in neovascular age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV) refractory to anti-VEGF (ranibizumab and bevacizumab).

Methods

This is a retrospective study involving 32 eyes from 29 patients; 18 were cases of neovascular AMD and 14 were cases of PCV. The best-corrected visual acuity (BCVA) and central macular thickness (CMT) of spectral-domain optical coherence tomography were evaluated.

Results

BCVA and CMT improved from 0.58 to 0.55 (p = 0.005) and from 404 to 321 µm (p < 0.001), respectively, after switching to aflibercept. The 14 eyes that received 6 or more aflibercept injections remained stable at 0.81 to 0.81 and 321 to 327 µm (p = 1.0, 0.29), respectively, after 3 aflibercept injections. The 10 eyes that received 3 or more bevacizumab injections after 3 or more aflibercept injections worsened, from 0.44 to 0.47 and from 332 to 346 µm (p = 0.06, 0.05), respectively. The results showed similar improvement of BCVA and CMT in neovascular AMD and PCV.

Conclusions

Aflibercept seems to be effective for improvement and maintenance of BCVA and CMT for neovascular AMD and PCV refractory to anti-VEGF. Switching from aflibercept back to bevacizumab treatment may not be a proper strategy.     

Management of Acute Submacular Hemorrhage with Intravitreal Injection of Tenecteplase,Anti-vascular Endothelial Growth Factor and Gas

PurposeTo evaluate the visual and anatomical outcomes for neovascular age-related macular degeneration with submacular hemorrhage after intravitreal injections of tenecteplase (TNK), anti-vascular endothelial growth factor (VEGF) and expansile gas.MethodsThis study was a retrospective clinical case series following 25 eyes of 25 patients. All patients received a triple injection using 0.05 mL TNK (50 µg), 0.05 mL anti-VEGF and 0.3 mL of perfluoropropane gas. Retreatment with anti-VEGF was performed as needed. Preoperative and postoperative best-corrected visual acuity and central retinal thickness were analyzed.ResultsThe mean logarithm of the minimum angle of resolution of best-corrected visual acuity improved significantly from 1.09 ± 0.77 at baseline to 0.52 ± 0.60 at 12 months (p < 0.001). The mean central retinal thickness also improved significantly from 545 ± 156 at baseline to 266 ± 107 at 12 months (p < 0.001). A visual improvement of 0.3 logarithm of the minimum angle of resolution unit or more was achieved in 15 eyes (60%). During the 12 postoperative months, an average of 4.04 intravitreal anti-VEGF injections was applied.ConclusionsA triple injection of TNK, anti-VEGF, and a gas appears to be safe and effective for the treatment of submacular hemorrhage secondary to neovascular age-related macular degeneration.     

Phase I/II randomized study of proton beam with anti-VEGF for exudative age-related macular degeneration: long-term results

Background/objectiveTo determine if treatment of exudative age-related macular degeneration (eAMD) using proton beam therapy (PBT) combined with intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy is safe and effective long term.Subject/methodsThirty eyes with newly diagnosed eAMD were enrolled in a phase I/II prospective, sham-controlled double-masked university study. Eyes were randomized 1:1:1–24 GyE, 16 GyE or sham radiation, and treated with three initial monthly intravitreal ranibizumab or bevacizumab. Subsequent anti-VEGF reinjection was based on monthly optical coherence tomography and examination for 2 years and standard of care thereafter.ResultsA total of 23 eyes completed 2-year study follow-up, of which 16 maintained monthly follow-up. Mean best-correct visual acuity (BCVA) at 2 years was similar among treatment groups (p > 0.05). The 24 GyE group required fewer anti-VEGF injections when compared with the sham group at 2 years (4.67 ± 1.9 vs 9.67 ± 3.5; p = 0.017). Extended follow-up (mean 4 years) available in 22 eyes showed persistent reduced need for anti-VEGF therapy among eyes treated with 24 GyE compared with sham radiation (2.0 ± 1.6 vs 4.84 ± 2.4 per year, p = 0.008). New and increasing geographic atrophy (GA), noted in some eyes in all treatment groups, resulted in decreased mean BCVA from baseline for the 24 GyE group on extended follow-up (p = 0.009). Possible mild radiation retinopathy noted in 15% of eyes was not visually significant.ConclusionsInitial treatment combining PBT (24 GyE) with intravitreal anti-VEGF therapy appears to decrease the need for anti-VEGF reinjection in eyes with newly diagnosed eAMD. Radiation retinopathy risk was low and does not appear visually significant. Long-term vision was limited by GA development especially in the 24 GyE group.Subject terms: Macular degeneration, Outcomes research     

Outcomes of early versus deferred laser after intravitreal ranibizumab in aggressive posterior retinopathy of prematurity

Purpose:The aim of this study was to report the treatment outcomes of early and deferred laser in infants of aggressive posterior retinopathy of prematurity (APROP) after initial treatment with intravitreal Ranibizumab (IVR).Methods:In a prospective, randomized, interventional study, infants with APROP received IVR (0.25 mg) and were randomized into two groups prior to laser. Laser was done at 1 week (group 1) or at 6 weeks or earlier if there was a recurrence of plus disease (group 2). The structural outcome, number of laser spots, duration of laser procedure and refractive error at 6 months were compared. Favorable structural outcome was defined as, complete regression of disease at 6 weeks after laser.Results:63 eyes of 32 infants with APROP were enrolled. Mean gestational age (GA) and birth weight (BW) were 30.2 ± 2.3 weeks and 1294 ± 372.8 grams respectively. GA, BW, and disease severity were comparable at baseline. 27 (90%) eyes in group 1 and 29 (93.5%) eyes in group 2 had favorable structural outcome (P = 0.61) at 6 weeks after laser. Eyes in group 2 (2149.8 ± 688.7) required lesser number of laser spots than group 1 (2570.8 ± 615) (P = 0.01). At six months, more eyes in group 1 had myopic refractive error (Mean spherical equivalent: –1.0D ± 1.3) than those in group 2 (Mean spherical equivalent: 0.5D ± 1.9) (P = 0.002).Conclusion:Infants with APROP receiving IVR have comparable structural outcomes after an early or deferred laser. Moreover, eyes undergoing deferred laser require less number of laser spots and have a less myopia at 6 months after laser.     

Postoperative microstructural re-modelling and functional outcomes in idiopathic full thickness macular hole

Purpose:To analyze the effect of various macular hole indices and postoperative microstructural changes of all retinal layers on postoperative functional outcomes in patients with idiopathic full-thickness macular hole (FTMH).Methods:In this prospective study, pre and post-operative optical coherence tomography (OCT) scans of 36 eyes with idiopathic FTMH were analyzed. Hole indices and microstructural changes of all retinal layers such as ellipsoid zone (EZ), external limiting membrane (ELM) integrity, outer and inner retinal defects, and cystoid resolution were studied on follow-up visits.Results:Out of 36 eyes, type-1 closure was achieved in 23 eyes (65.7%) and type-2 closure in 11 eyes (31.42%), one eye showed persistent hole, and one eye was lost to follow-up. The mean minimum diameter of hole (P = 0.026), mean MHI (P = 0.001), DHI (P = 0.158), THI (P = 0.001), and HFF (P < 0.001) showed statistical significance with the type of hole closure. Postoperatively, eyes with intact ELM and EZ had better BCVA at the final visit. The BCVA was better by logMAR 0.73 ± 0.38 (P < 0.001) in patients with absent outer retinal defects. There was a significant difference in BCVA of 0.52 ± 0.35 at 1 month and 0.64 ± 0.34 at 6 months in eyes without inner retinal defects (P < 0.001). At 6 months, cystoid resolution was observed in 28 (80%) eyes. BCVA was significantly better at 1 month (P < 0.001) and at 6 months (P = 0.001) in eyes with no DONFL.Conclusion:Macular hole indices determine the closure type. Postoperative regeneration of outer retinal layers and resolution of retinal defects significantly influence the final visual outcomes. ELM recovery is seen as a prerequisite for EZ regeneration with no new IRD after a period of 3 months.     

Short-term efficacy of intravitreal triamcinolone acetonide for macular edema secondary to retinal vein occlusion that is refractory to intravitreal bevacizumab

Aims:

To evaluate the 1-month efficacy of intravitreal triamcinolone acetonide (TA) in treating macular edema secondary to retinal vein occlusion (RVO) that was refractory to intravitreal bevacizumab.

Materials and Methods:

This retrospective, observational study included 23 eyes from 23 patients with macular edema secondary to RVO. Macular edema that did not respond to two or more consecutive intravitreal bevacizumab injections was treated with intravitreal TA. Central foveal thickness (CFT) and best-corrected visual acuity (BCVA) were compared before and one month after TA injection.

Results:

Fifteen eyes were diagnosed with central RVO, and eight eyes were diagnosed with branch RVO. All patients were previously treated with 2.4 ± 0.6 intravitreal bevacizumab injections. The TA injection was performed, on average, 5.8 ± 1.4 weeks after the last bevacizumab injection. The CFT before TA injection was 516.6 ± 112.4 μm and significantly decreased to 402.3 ± 159.7 μm after TA therapy (P < 0.001). The logarithm of the minimal angle of resolution BCVA was 0.72 ± 0.34 before TA therapy and was not significantly improved by the treatment (0.67 ± 0.35, P = 0.119), despite a decrease in CFT. However, seven eyes (30.4%) had a BCVA gain of one or more lines.

Conclusions:

Intravitreal TA therapy was beneficial in some patients with macular edema secondary to RVO that was refractory to intravitreal bevacizumab therapy. This study suggests that intravitreal TA should be considered as a treatment option for refractory macular edema.     

Two-year results of intravitreal ranibizumab for polypoidal choroidal vasculopathy with recurrent or residual exudation

Aim

To clarify the 2-year efficacy of ranibizumab for patients with polypoidal choroidal vasculopathy (PCV) with recurrent or residual exudation from branching vascular networks after previous photodynamic therapy (PDT).

Methods

We retrospectively reviewed 26 eyes of 26 Japanese patients (22 men, 4 women) in this pilot study. All eyes had PCV with complete regression of polypoidal lesions resulting from PDT detected by indocyanine green angiography (ICGA), but recurrent or residual leakage from branching vascular networks on fluorescein angiography and evidence of persistent fluid on optical coherence tomography (OCT). Three consecutive intravitreal injections of ranibizumab (0.5 mg/0.05 ml) were administered to all eyes.

Results

The mean logarithm of the minimum angle of resolution best-corrected visual acuity (BCVA) improved significantly from 0.55 at baseline to 0.35 at 12 months (P<0.0001) and 0.43 at 24 months (P=0.0012). The mean increases in the BCVA 12 and 24 months after baseline were 1.95 and 1.23 lines, respectively. The mean central retinal thickness significantly decreased from 295 μm at baseline to 189 μm at 12 months (P<0.0038) and 163 μm at 24 months (P<0.001). The mean numbers of intravitreal ranibizumab (IVR) injections at months 12 and 24, including the initial treatments, were 5.8 and 8.8, respectively. Five (19.2%) eyes had recurrent polypoidal lesions on ICGA at a mean of 15.7 months after baseline. At month 24, OCT showed no exudation in 17 (65.4%) of the 26 eyes. No adverse events developed.

Conclusions

IVR injections maintained or improved the VA and retinal thickness at 24 months in eyes with PCV with recurrent or residual exudation from branching vascular networks after previous PDT.     

Subjective and objective measures of the patient experience before,during, and after intravitreal anti–vascular endothelial growth factor injections

Purpose:To assess patient experience of intravitreal injections using vital-signs, visual-experience, pain-rating and emotional response during intravitreal anti-VEGF injections.Methods:A prospective observational study of patient experience of intravitreal anti-VEGF injections done following metrics were collected pre-injection, during injection, and post-injection: pain assessment using visual analog score, fear-response rating, visual-experience questionnaire, and vital-signs.Results:A total of one-hundred-and-seventy-four patients undergoing intravitreal anti-VEGF injections for retinal pathologies were included in the study. Mean age was 58.8 ± 10.4 years in <5 injection group (n = 133) and 59.02 ± 9.0 years in ≥5 injection group (n = 41) (P = 0.90).During injection, 90.2% of patients in <5 injection group reported moderate or severe pain compared to 78% of patients in ≥5 injection group. In pre and post-injection phases, mild-to-moderate pain was reported in both groups (P = <0.001). Ninety-two (52.9%) patients reported having a mild frightening experience. There was no statistical significance in patients assessment of fear with respect to age, sex, or number of injections. The Systolic Blood Pressure (SBP) during and following injection ((SBP 171.7 ± 21.1,150.8 ± 16.2) procedures was significantly higher in cases with <5 injections when comparing to cases with >5 injections (SBP 159.7 ± 26.4, 143.2 ± 17.0) (P = 0.003), (P = 0.011). DBP, heart rate, pulse rate measurements were similar among patients in all phases of the study.Conclusion:We report a large sample size with comprehensive assessments of the patient experience. Higher pain ratings in the <5 injection group, the increase in the SBP in the pre-and during injection phases, and the overall rating of mild-to-moderate fear during the procedure.     

Validation of choroidal hyperreflective foci in diabetic macular edema through a retrospective pilot study

Purpose:Choroidal hyperreflective foci (HCF) are novel spectral-domain optical coherence tomography (SDOCT) biomarkers in diabetic macular edema (DME). The present study intended to validate HCF and assess their role in the treatment outcome.Methods:It was a retrospective, longitudinal, records-based pilot study recruiting consecutive patients of nonproliferative diabetic retinopathy with treatment naïve DME. Patients were treated with three intravitreal anti-vascular endothelial growth factor injections and followed by a pro re nata regimen.Results:A total of 43 eyes of 28 patients were included in the study. Eyes were divided into two groups. Group A (n = 19) comprised eyes with retinal hyperreflective foci (HRF) and group B (n = 24) had eyes with both HRF and HCF. The mean age of patients in group A and B was 58.5 ± 2.1 years and 55.2 ± 8.8 years, respectively. Mean best-corrected visual acuity at presentation was 0.38 ± 0.25 in group A and 0.59 ± 0.29 in group B (P = 0.01). Final BCVA was 0.35 ± 0.39 in group A and 0.47 ± 0.34 in group B (P = 0.3). External limiting membrane was intact in 19 out of 19 eyes in group A and two (8.3%) eyes in group B (P = 0).Conclusion:Presence of HCF meant significantly worse initial BCVA compared to the eye that had HRF alone. The final BCVA was also worse in eyes with HCF compared to those with HRF and without HCF; however, the difference did not reach a significance level, probably pointing toward the fact that HCF and HRF are pathophysiologically identical. Further studies with a larger sample size and prospective design are needed to take these findings forward.     

One-year outcomes of Aflibercept for refractory diabetic macular edema in Bevacizumab nonresponders

Purpose:A sub-population of patients with diabetic macular edema (DME) responds less effectively to off-label use of Bevacizumab. Approval of Aflibercept for DME has offered Bevacizumab nonresponders an alternative therapeutic option. Herein, we investigate the anatomical and functional changes associated with Aflibercept treatment in Bevacizumab nonresponders with chronic DME in a Canadian setting.Methods:A retrospective study of eyes with persistent DME that were switched to Aflibercept due to nonresponse following ≥6 consecutive monthly Bevacizumab injections was performed. Anatomical and functional changes and the predictors of response were assessed using patients'' characteristics prior to receiving their first (baseline) and seventh consecutive Aflibercept injections (follow-up).Results:Twenty-four eyes were included, with a mean age of 63.9 ± 10.7 years, an average of 16.8 ± 8.5 Bevacizumab injections prior to switching to Aflibercept, and mean follow-up duration of 11.8 ± 1.7 months following switching to Aflibercept. Best-corrected visual acuity (BCVA) improved significantly from 0.49 ± 0.13 to 0.41 ± 0.11 logMAR (P < 0.001) and central subfield thickness (CST) decreased by 119.4 μm from 409.4 ± 85.8 μm to 290.0 ± 64.5 μm (P < 0.001), with 50% of eyes showing complete anatomical response. Worse BCVA and higher CST at baseline predicted greater vision improvements (P = 0.001 and P = 0.035, respectively) while a larger decrease in CST was associated with greater baseline CST (P = 0.001) and better glycemic control (P = 0.039).Conclusion:Our data from a real-world clinical setting highlight the efficacy of Aflibercept as an alternative therapeutic option for DME recalcitrant to Bevacizumab, with potential additional benefit to those with worse vision, greater CST, and better glycemic control at baseline.     

Foveal Microvascular Integrity Association With Anti-VEGF Treatment Response for Diabetic Macular Edema

PurposeTo investigate the association between foveal microvascular integrity and anti-vascular endothelial growth factor (VEGF) treatment response for diabetic macular edema (DME).MethodsThis retrospective study enrolled 58 eyes (from 45 patients) with DME. Treatment strategy was three to five monthly anti-VEGF injections followed by a PRN protocol. Treatment with an intravitreal corticosteroid would be considered for persistent DME after five consecutive anti-VEGF injections. Eyes achieving a treatment-free interval ≥ four months within two years were classified into the good clinical course group (group 1). Eyes with frequent recurrent edema (treatment-free interval < four months) or requiring an intravitreal corticosteroid within two years were classified into the suboptimal clinical course group (group 2). Foveal microvascular integrity was evaluated by two continuous variables, that is, vessel density (%) within a width of 300 µm around the foveal avascular zone (FD-300) on optical coherence tomography angiography (OCTA) and perifoveal leakage (area %) on fluorescein angiography (FA).ResultsThere were 37 eyes in group 1 and 21 eyes in group 2. FD-300 (odds ratio 0.733, 95% CI 0.620–0.867, P < 0.001) and perifoveal leakage (odds ratio 1.064, 95% CI 1.007–1.124, P = 0.027) were significantly associated with suboptimal clinical course. Area under curve (AUC) was 0.820 for FD-300 and 0.723 for perifoveal leakage in predicting clinical course. FD-300 was negatively correlated with perifoveal leakage (coefficient = −0.325, P = 0.014).ConclusionsCompromised foveal microvascular integrity, represented by lower FD-300 and more severe perifoveal fluorescein leakage, was associated with suboptimal clinical course in anti-VEGF treatment for DME. A negative correlation between FD-300 and perifoveal leakage existed.     

Role of Avastin in management of central serous chorioretinopathy

Purpose

To evaluate the short-term safety and efficacy of intravitreal bevacizumab for the treatment of intraretinal or subretinal fluid accumulation secondary to central serous chorioretinopathy (CSC).

Design

Prospective interventional series non-comparative study.

Setting

Department of Ophthalmology, Al-Minya University Faculty of Medicine, Egypt.

Methods

The study included 20 eyes of 20 patients with central serous chorioretinopathy (CSC), Out of them 10 eyes with acute CSC (group I), 6 eyes with chronic CSC (defined as symptoms present for longer than 6 months) and four eyes with recurrent (defined as more than one episode of the disease) chronic and recurrent cases are considered in one group (group II), all patients were injected with intravitreal Avastin (IVA) 1.25 mg (0.05 mL) of commercially available bevacizumab [Avastin; Genentech, Inc., San Francisco, CA] as a primary treatment. At baseline and follow up visits patients had best corrected visual acuity (BCVA), IOP assessment, dilated fundus examination, fundus photography, fluorescein angiography (FA) and optical coherence tomography (OCT) imaging is used for measurement of central retinal thickness (CRT). Main outcome measures were the resolution of neurosensory detachment, improvement in visual symptoms and visual acuity, and resolution of leakage in FA. Secondary outcome and measures were the need for re-injection and the adverse effects. The mean number of injections was 2 (range 1–3 injections) 6–8 weeks intervals and follow up for 6 months (range 5–7 months). All finding at baseline and each follow up visit were reported and compared.

Results

The mean age of all patients was 40.3 years ± 6.5 (range 25–50 years), 15 males and five females patients. In acute CSC group, the mean baseline BCVA was 20/60 (log MAR 0.48) and improved to 20/30 (log MAR 0.18) with statistically significance difference change (P < 0.003) and in (chronic and recurrent group), the mean baseline VA was 20/80 (log MAR 0.60) and improved to 20/40 (log MAR 0.30) with statistically significance difference change (P < 0.002). The mean baseline CRT for all patients was 486 ± 86 μm (range, 386–580), decreased to 316 ± 56 μm (range, 276–368) after 1 months with statistically significance difference change (P < 0.02) and to 272 ± 52 μm (range 220–338) at last follow up with statistically significance difference change from the baseline (P < 0.001).

Conclusions

Intravitreal Avastin (IVA) injection was associated with visual improvement and reduced neurosensory detachment without adverse events in patients with CSC. Although these results are promising, further randomized controlled studies would be helpful to understand this therapy for patients with CSC.     

Vitrectomy Combined with Intravitreal Triamcinolone Acetonide Injection and Macular Laser Photocoagulation for Nontractional Diabetic Macular Edema

Purpose

To evaluate the efficacy of vitrectomy combined with intravitreal injection of triamcinolone acetonide (IVTA) and macular laser photocoagulation for the treatment of nontractional diabetic macular edema (DME) refractory to anti-vascular endothelial growth factor (VEGF) therapy.

Methods

Twenty-eight eyes from 28 subjects who were diagnosed with nontractional DME refractory to three or more sequential anti-VEGF injections underwent sequential vitrectomy, IVTA, and macular laser photocoagulation. Changes in best-corrected visual acuity (BCVA) and central subfield thickness (CST) during the six months following vitrectomy were evaluated. Additionally, the CST and BCVA outcomes were compared with those of 26 eyes treated with the same triple therapy for nontractional DME refractory to conventional treatment, such as IVTA or macular laser photocoagulation, or both.

Results

The mean logarithm of the minimum angle of resolution BCVAs before and one, three, and six months after vitrectomy were 0.44 ± 0.15, 0.36 ± 0.18, 0.31 ± 0.14, and 0.34 ± 0.22, respectively. The mean CSTs were 433.3 ± 77.9, 329.9 ± 59.4, 307.2 ± 60.2, and 310.1 ± 80.1 microns, respectively. The values of both BCVA and CST at one, three, and six months were significantly improved from baseline (p < 0.05). The extent of CST reduction during the first month after triple therapy was greater in eyes refractory to conventional treatment than in eyes refractory to anti-VEGF (p = 0.012).

Conclusions

Vitrectomy combined with IVTA and macular laser photocoagulation had a beneficial effect on both anatomical and functional outcomes in eyes with nontractional DME refractory to anti-VEGF therapy.