Real-world experience of brolucizumab in nAMD.

PURPOSE: To evaluate real-world outcomes with neovascular age-related macular degeneration (nAMD) in relation to anatomical success, visual outcomes, and safety of intravitreal brolucizumab (IVBr) injection at 1.5 years. METHODS: Prospective, randomized, single-center study between December 2020 and December 2022 that included 71 eyes of 62 patients with nAMD, who received IVBr. Patients were divided into three groups, i.e., naïve choroidal neovascular membrane (CNVM), switched therapy (st) CNVM, and st polypoidal choroidal vasculopathy (stPCV). They were subdivided into dry, minimal fluid (fluid <50 microns)/pigment epithelial detachment (PED) and persistent fluid (fluid >100 microns)/PED subgroups depending upon the fluid level at the end of 1.5 years. Best-corrected visual acuity (BCVA), central macular thickness (CMT), status of fluid, and number of injections at 1.5 years were evaluated. From the beginning, patients were treated on pro re nata (PRN) basis. RESULTS: Of the 71 eyes, 27 eyes (38%) were naïve CNVM, 35 eyes (49.3%) were stCNVM, and 9 (12.7%) were stPCV cases. Significant vision improvement after 1.5 years was seen in the stCNVM category (P = 0.001), while CMT reduction was significant in all three groups (P < 0.05). The mean number of injections required in naïve CNVM and stCNVM groups was significantly less as compared to the stPCV group (P = 0.017). Further, vision improvement was significant in the "Minimal fluid" subgroup (P = 0.002), while the CMT improvement was significant in the "Minimal fluid" and "Dry" subgroups each with P < 0.0001. No ocular/systemic adverse events including intraocular inflammation (IOI) were noted. CONCLUSION: In a real-world scenario, with 203 procedures and 1.5-year follow-up, brolucizumab is found to be efficacious and safe with the need for a lesser number of injections and more interval-free period in the management of naïve CNVM, stCNVM, and stPCV patients.

Retro-mode: a newer insight into dry age-related macular degeneration (AMD).

The purpose of this study is to study the role of retro-mode (RM) in early detection and to compare it with other preexisting available modalities on multimodal imaging system in dry AMD. A prospective observational cross-sectional study was done between November 2020 and October 2021 which included 409 eyes of 207 patients. For study purpose, eyes were divided into 3 groups according to the size and number of the drusen, viz, group 1: No AMD, group 2: early AMD and group 3: intermediate AMD which was further divided into 2 subgroups, viz, subgroup A: eyes with drusen size 63-125 µm and subgroup B: eyes with drusen size 125-250 µm. Patients with active or treated wet AMD, scarred choroidal neovascular membrane (CNVM), other maculopathies, other retinopathies, high myopia, trauma and glaucoma were excluded from the study. In cases of No AMD and early AMD, a number of drusens detected on RM were statistically not significant compared to fundus autofluorescence (FAF) and color photo (CF), but in intermediate AMD cases, it was statistically significant. While the area involved by drusens calculated by RM was statistically significant compared to both other modalities. When all modalities were compared with enhanced depth imaging-optical coherence tomography (EDI-OCT) at the choroid and chorio-capillary (CC) level and vessel density (VD) on optical coherence tomography angiography (OCTA) at the choroid, capillaries, deep retinal and superficial retinal plexus level; it was only RM which was found to be in sync with these proven modalities in terms of pattern and trend. In the present scenario, RM is found to be a better diagnostic modality in detecting early and a greater number of drusens with area of involvement than other existing modalities. Though superior, as found in this study, this mode cannot replace other modalities at present but only acts as a complementary investigation in early detection of this disease.

Vessel density changes in choroid, chorio-capillaries, deep and superficial retinal plexues on OCTA in normal ageing and various stages of age-related macular degeneration.

PURPOSE: To study vessel density (VD) on optical coherence tomography angiography at choroid, chorio-capillaries (CC) and various retinal levels in normal population and various stages of dry AMD and how these changes progress with increase in severity of the disease. METHODS: Prospective, observational, cross-sectional study was done on 252 eyes of 132 patients (males: 61, females: 71) presenting to tertiary-care centre in Central India between February 2021 and January 2022. For study purpose, eyes were divided into five groups according to the size and number of the drusen, viz, Group 1: No AMD (< 50 years), Group 2: No AMD (> 50 years), Group 3: Early AMD, Group 4: Intermediate AMD and Group 5: Advanced AMD. In all eyes, VD was measured at choroid, CC, deep capillary plexus (DCP) of retina and superficial capillary plexus (SCP) of retina. RESULTS: The mean age in case cohort is 61.90 ± 7.97 years. The mean vascular density differed significantly across diagnosis types in all the quadrants (p < 0.05) at choroid, CC and DCP level. At SCP level, the differences were significant across the groups except at the central quadrant. Vessel density was found to be more in early AMD cohort when compared to No AMD (> 50 years) cohort at SCP and DCP level, while it showed continuous reduction later in intermediate and advanced AMD cohort. CONCLUSION: With increase in the severity of disease, significant reduction in VD is also seen in retinal plexuses, along with the changes in choroid and CC. These VD maps may play a role as non-invasive biomarkers for healthy and diseased ageing.

The All India Ophthalmological Society - Academic and Research Committee pan-India diabetic retinopathy project "Fixing the missing link": Prevalence data from Madhya Pradesh and Chhattisgarh.

Purpose: : To determine the prevalence of diabetic retinopathy (DR) and its risk factors among diabetic patients in the states of Madhya Pradesh (MP) and Chhattisgarh (CG). Methods: : Diabetic patients were screened in the treating diabetologist/physician's clinic by a team that included an ophthalmologist, an optometrist, and a counselor. Demographic details, diabetic control, compliance to eye checkup, awareness regarding diabetic blindness, and visual acuity were recorded using a questionnaire. DR was graded both by indirect ophthalmoscopy and fundus photo taken with a portable fundus camera. Results: : In total, 602 subjects were screened across five selected locations of MP and CG. The prevalence of DR was 13.62%. No significant difference with gender was seen. The presence and grade of DR were related to age, diabetic age, and diabetic control. Conclusion: : This study provides the prevalence data for DR among diabetic patients from the states of MP and CG and highlights important barriers to DR screening in our country.

Pre-operative optical coherence tomography predictors: Do they hold any relevance in the era of inverted internal limiting membrane flap in large macular holes?

Purpose: To study the relevance of preoperative OCT predictors in large macular holes (MH) treated using the inverted ILM peel technique. Methods: Prospective study of 95 patients undergoing vitrectomy for large MH between January 2019 and December 2020 was performed by dividing the patients into groups depending on various quantitative parameters and indices of MH such as base diameter (BD), hole form factor (HFF), macular hole index (MHI), diameter hole index (DHI), and tractional hole index (THI) by using parameters such as minimal hole diameter, hole height, nasal and temporal arm lengths. Depending upon the duration of symptoms, patients were divided into three groups: <3 months, 3-6 months, and >6 months. Anatomical success rate, type of closure, and postoperative vision gain were analyzed in relation to the abovementioned diameters, indices, and duration to see if any significance existed. Results: The mean age of patients included in the study was 60.48 ± 13.88 years, with female preponderance (males: females = 37:58). Change in logMAR was statistically significant individually with all studied parameters (P < 0.0001) without influence of size of hole and other indices. BD and DHI levels showed significant association with type of closure as indicated by P values of 0.017 and 0.048, respectively. Duration of symptoms showed no significance in terms of anatomical and functional success. Conclusion: OCT predictors of MH success seem to have lost relevance with inverted flap surgeries as 100% anatomical success is achieved with this technique, with 95.78% (91/95) achieving type 1 closure with statistically significant equivalent functional gain across the indices with no effect of duration of symptoms.

Reverse Swiss Roll technique for diabetic vitreous membranes.

Background: Diabetic membranes are always a challenge for a surgeon because of sticky nature and chances of iatrogenic break while removing. Purpose: To demonstrate a safe reverse swiss roll technique to dissect diabetic vitreous membranes. Synposis: Approaches and techniques for membrane dissection are segmentation, delamination and en-bloc dissection using various types of instruments and illumination. With vitreous cutte, picks and scissors, surgical steps are traditionallu performed by using classic lift and shave technique. After identifying the plane, tissue is lifted and then cut, which puts the retina at risk of break because of traction and active suction. Such a threat can be reduced by placing the cutter above the membrane thereby having the membrane itseld acting as a protective cushion to the retina. Port here, unlike lift and shave technique, doesn't face the edge of membrane but is exactly 180 degree opposite and membrane curls into port because of suction. Also, hemostasis is maintained by continuous aspiration and cutting as the instrument is moved side to side, retracting from the edge. Highlights: Reverse swiss roll technique is safer compared to lift and shave because of the safety cushion of the membrane between the port and the retina. There is inherently less chances of retinal break because the active suction from the port is directed away from the retina. The technique also minimises traction and localised pull on the atrophic macula. Video link: https://youtu.be/WNnSsP69ZLw.

The All India Ophthalmological Society - Academic and Research Committee pan-India diabetic retinopathy project "Fixing the missing link": Prevalence data from West Bengal.

PURPOSE: The aim of this study was to determine the prevalence of diabetic retinopathy (DR) and its risk factors among diabetic patients in rural and urban West Bengal (WB). METHODS: Patients were screened in the physician's clinic by a team of ophthalmologist, optometrist and counsellor. Demographic details, diabetic control, compliance to eye checkup, awareness regarding diabetic blindness, and visual acuity were recorded using a questionnaire. DR was graded both by indirect ophthalmoscopy and fundus photo taken with a portable fundus camera. RESULTS: A total of 1553 subjects were screened over 39 camps across 14 districts of WB over 17 months. The prevalence of DR was 21.51%, with a significant difference between rural (26.55%) and urban (13.89%) areas (P < 0.01). No significant difference with gender was seen (P = 0.99). Presence and grade of DR were related to age, loss of vision, diabetic age, diabetic control, awareness of diabetic blindness and last eye checkup. CONCLUSION: This study provides the first major prevalence data from WB, and gives valuable insight regarding modifiable risk factors for DR. It is also the first DR study in India to be conducted in the physician's clinic. The study results emphasise the need to "fix the missing link" between ophthalmologists and treating physicians to win the battle against DR.

Aggressive Posterior Retinopathy of Prematurity (APROP): LASER as the Primary Modality of Treatment.

PURPOSE: To study the success rate of LASER as a primary modality of treatment in aggressive posterior retinopathy of prematurity (APROP) cases. METHODS: This is a prospective case series of 56 eyes of 28 preterm babies (males = 21) with APROP who underwent laser therapy. Babies were divided into groups on the basis of gestational age (GA), birth weight (BW), and postmenstrual age (PMA) at which treatment was performed. GA (in weeks): < 28 (n = 7), 28-30 (n = 11), > 30 (n = 10). BW (in grams): < 1000 (n = 8), 1000-1200 (n = 10), > 1200 (n = 10). PMA (in weeks): < 32 (n = 6), 32-34 (n = 18), > 34 (n = 4). Success was calculated as complete regression of disease without need for any other modality of treatment such as anti-vascular endothelial growth factor (anti-VEGF) or pars plana vitrectomy. RESULTS: The overall success rate was 94.64% (53/56). Two babies who needed additional modality of treatment were < 28 weeks of GA (one eye) and 28-30 weeks (two eyes). One baby (one eye) was < 1000 gm and the other (two eyes) was > 1200 gm, while PMA at which additional treatment was needed was 30 weeks in one baby (one eye) and 33 weeks in the other (two eyes). CONCLUSION: In this era of anti-VEGF treatment, even in cases of APROP, LASER should still be considered as a primary modality of treatment, as it is a one-time treatment without the concern of systemic side effects and recurrent/persistent avascular zones.

Digitally assisted three-dimensional surgery - Beyond vitreous.

Purpose: The aim of this study was to evaluate the application and safety of three-dimensional (3D) visualization system in varied anterior segment procedures and Scleral Buckle. Methods: This was a prospective observational study of 313 eyes. Patients undergoing phacoemulsification (PE) with intraocular lens (IOL), trabeculectomies, glaucoma triple procedure (GTP), scleral fixated (SF) IOL, and scleral buckle (SB) were included in the study. Cases were randomly distributed in 3D visualization system (learning and post-learning phase) and conventional microscope group. Parameters studied were complications (intraoperative and early postoperative), surgical outcomes, and surgeon's perspective on various parameters (through a validated questionnaire) like surgical time, time lag, learning curve, ease of doing various steps and its value as an educational tool, for both groups [Questionnaires 1 and 2]. Results: Complications rates were not different in two groups. Surgical outcomes (anatomical and physiological) were similar in both the groups. Mean duration of surgery in PE+IOL, Trabeculectomy, GTP in learning stage by 3D was significantly higher than Microscope, which became insignificant in postlearning stage. For, SB and SFIOL, duration between two groups were insignificantly different. There was significant learning struggle in PE+IOL, SB, and Trabeculectomy. Image resolution, depth perception, illumination and postural comfort was graded higher for 3D surgery across the stages. Time lag, poor color contrast, and field of view were appreciated during the learning stage. Educational relevance of 3D was higher, as appreciated by resident and nurses. Conclusion: 3D surgery is as safe, faster, and predictable after initial learning struggle. Even in anterior segment procedure, no apparent lag was appreciated after learning curve.

Evaluation of ganglion cell-inner plexiform layer thickness in the diagnosis of preperimetric glaucoma and comparison to retinal nerve fiber layer.

Purpose: The aim of this study was to evaluate the diagnostic ability of optic nerve head (ONH), RNFL, and GC-IPL parameters in differentiating eyes with PPG from normals. Methods: This was a retrospective, cross-sectional, observational study. We studied 73 eyes of 41 patients and compared them to 65 eyes of 34 normal persons. Each patient underwent detailed ocular examination, standard automated perimetry, GC-IPL, ONH, and RNFL analysis. PPG was defined as eyes with normal visual field results and one or more localized RNFL defects that were associated with a glaucomatous disc appearance (e.g., notching or thinning of neuroretinal rim) and IOP more than 21 mm Hg. Diagnostic abilities of GC-IPL, ONH, and RNFL parameters were computed using area under receiver-operating curve (AUROC), sensitivity and specificity, and likelihood ratios (LRs). Results: All GC-IPL parameters differed significantly from normal. The ONH, RNFL, and GC-IPL parameters with best area under curves (AUCs) to differentiate PPG were vertical cup to disc ratio (0.76), inferior quadrant RNFL thickness (0.79), and inferotemporal quadrant GC-IPL thickness (0.73), respectively. Similarly, best LRs were found for clock hour 5, 6, and 12 thicknesses among RNFL; inferior sector and inferotemporal sector thicknesses among GC-IPL parameters. Conclusion: Diagnostic abilities of GC-IPL parameters were comparable to RNFL parameters in differentiating PPG patients from normals. The likelihood of ruling in a disease was greater with GC-IPL parameters.

Short-term outcomes of intravitreal dexamethasone in relation to biomarkers in diabetic macular edema.

PURPOSE: The purpose of this study was to determine the effects of dexamethasone implant (0.7 mg) on biomarkers such as hyper-reflective dots, external limiting membrane integrity and disorganization of retinal inner layers in treatment-naïve patients, patients who received less than three anti-vascular endothelial growth factor injections and non-responder cases with diabetic macular edema and its effects on edema and visual acuity. METHODS: This is a prospective study of treatment-naïve patients, patients who received less than three anti-vascular endothelial growth factor injections and non-responder patients with diabetic macular edema, treated with single dexamethasone implant. Pre- and post-injection-based best-corrected visual acuity, central macular thickness, hyper-reflective dots, external limiting membrane integrity and disorganization of retinal inner layers were assessed. RESULTS: A total of 27 diabetic macular edema eyes, including 9 non-responder eyes, 9 eyes which received less than three anti-vascular endothelial growth factor injections and 9 treatment-naïve eyes, were included in this study. Baseline hyper-reflective dots were 22.22 ± 11.76, 30 ± 7.91 and 19.44 ± 8.82 which reduced to 3.33 ± 1.32, 9 ± 8.35 and 8.78 ± 2.53 four months after implant in treatment-naïve patients, patients who received less than three anti-vascular endothelial growth factor injections and non-responder cases, respectively. Baseline central macular thickness was 589.44 ± 175.37, 537 ± 181.81 and 673.11 ± 138.24 and the central macular thickness after dexamethasone implant was 272.11 ± 39.00, 336.44 ± 132.88 and 524.00 ± 200.39 in treatment-naïve patients, patients who received less than three anti-vascular endothelial growth factor injections and non-responder cases, respectively. External limiting membrane integrity was restored in two patients in each group, whereas two patients with disorganization of retinal inner layers in treatment-naïve group showed reorganization of retinal structures after treatment with dexamethasone implant. CONCLUSION: Better response to dexamethasone implant in cases with more hyper-reflective dots shows that these hyper-reflective dots can be used as a predictive biomarker. Dexamethasone implant might help in restoring external limiting membrane integrity and resolution of disorganization of retinal inner layers.

Role of LASERS in stage 4A retinopathy of prematurity (ROP).

To study the anatomical success rate of light amplification by stimulated emission of radiation (LASERS) as first line of management in stage 4A retinopathy of prematurity (ROP). Observational, prospective case series of 14 eyes of 7 babies (males: 3, females: 4) with stage 4A ROP who underwent LASERS for stage 4A between January 2018 and July 2019. Gestation age (GA), birth weight (BW), and post-menstrual age (PMA) at which laser was done were noted in all cases. A number of clock hours of detachment at the time of presentation were noted in all babies. All babies were followed up up to 6 months after laser for any recurrence. Success was defined as complete regression of disease without the need of any other modality of treatment like anti-vascular endothelial growth factor (anti-VEGF) or pars plana vitrectomy. A total of 92.85% (13/14) showed complete regression of disease. One eye progressed to stage 4B ROP warranting lens-sparing vitrectomy (LSV). LASERS is an effective method of management without any need of anti-VEGF or surgical intervention even in babies with stage 4A ROP.

Evolving consensus on managing vitreo-retina and uvea practice in post-COVID-19 pandemic era.

The COVID-19 pandemic has brought new challenges to the health care community. Many of the super-speciality practices are planning to re-open after the lockdown is lifted. However there is lot of apprehension in everyone's mind about conforming practices that would safeguard the patients, ophthalmologists, healthcare workers as well as taking adequate care of the equipment to minimize the damage. The aim of this article is to develop preferred practice patterns, by developing a consensus amongst the lead experts, that would help the institutes as well as individual vitreo-retina and uveitis experts to restart their practices with confidence. As the situation remains volatile, we would like to mention that these suggestions are evolving and likely to change as our understanding and experience gets better. Further, the suggestions are for routine patients as COVID-19 positive patients may be managed in designated hospitals as per local protocols. Also these suggestions have to be implemented keeping in compliance with local rules and regulations.

Structural evaluation of preperimetric and perimetric glaucoma.

Purpose: To evaluate diagnostic ability of macular ganglion cell layer-inner plexiform layer (GCL-IPL) for detection of preperimetric glaucoma (PPG) and perimetric glaucoma and comparison with peripapillary RNFL. Methods: Three hundred and thirty seven eyes of 190 patients were enrolled (127 normals, 70 PPG, 140 perimetric glaucoma). Each patient underwent detailed ocular evaluation, standard automated perimetry, and spectral domain optical coherence tomography. Diagnostic abilities of GCL-IPL and RNFL parameters were determined. Data were compared using one-way analysis of variance, Pearson's Chi-square test, and area under the curve (AUC). Results: After adjusting for age, gender, and signal strength, all GCL-IPL and RNFL parameters except mean thickness and disc area differed significantly. Among GCL-IPL thicknesses, inferotemporal had the highest AUC (0.865) for classifying perimetric glaucoma from normals, inferior (0.746) for PPG from normals, and inferotemporal (0.750) for perimetric glaucoma from PPG. When using RNFL, inferior thickness had the highest AUC (0.922) in discriminating POAG from normal, while the same parameter had lower AUC (0.813) in discriminating PPG from normal. The average thickness had maximum AUC (0.775) for discriminating POAG from PPG. For discriminating perimetric glaucoma and normals, inferotemporal GCL-IPL had the highest strength (sensitivity 81.43% and specificity 77.96%), slightly lower than inferior RNFL thickness (sensitivity 87.85% and specificity 84.26%). The same parameters were sensitive in discriminating perimetric glaucoma from PPG (87.14% and 92.85%, respectively). However, their specificities were poor (56.43% both). Conclusion: RNFL had better diagnostic ability, when compared with GCL-IPL for detecting PPG and perimetric glaucoma. However, difference was small and may not be clinically relevant.

Structural evaluation of perimetrically normal and affected hemifields in open angle glaucoma.

Purpose: To study macular ganglion cell layer--inner plexiform layer complex (GCL + IPL) in relation to peripapillary retinal nerve fiber layer (RNFL) in glaucomatous eyes with superior or inferior hemifield defects (HD) and to study structural configuration in normal hemifield. Methods: This was an observational cross-sectional study. Data from consecutive 45 superior HD (SHD) and 50 inferior HD (IHD) eyes were analyzed. Each patient underwent detailed ocular examination, standard automated perimetry, and spectral domain optical coherence tomography (SD-OCT). After adjusting for age, gender, and signal strength, area under receiver operating characteristic curve (AUC) was calculated to determine diagnostic ability of GCL + IPL and peripapillary RNFL. Apparently normal hemifield was compared with true normal hemifield. Data were analyzed with SPSS, analysis of variance, t-test, Chi-square test, and receiver operating curve. Results: In the SHD glaucoma group, best parameters for discriminating normal eyes from glaucomatous eyes were inferotemporal GCL + IPL thickness (0.935) and inferior quadrant RNFL thickness (0.971). For IHD glaucoma, average GCL + IPL thickness (0.877) and average RNFL thickness (0.950) had best AUC values. When evaluating apparently normal hemifield in both groups, statistically significant difference was found in inferior GCL + IPL sector (0.865) and inferior quadrant RNFL (0.883) in IHD and superonasal GCL + IPL (0.725) and superior quadrant RNFL (0.842) in SHD groups. Conclusion: SD-OCT may be a useful ancillary diagnostic tool for evaluation of early macular and circumpapillary structural changes in glaucomatous eyes with localized visual field defects. Apparently normal hemifields show structural damage and should be considered in management of glaucoma.

Internal limiting membrane peel: Does it change the success rate of primary vitrectomy without belt buckle in rhegmatogenous retinal detachments?

Purpose: To compare the anatomic success of pars plana vitrectomy (PPV) after internal limiting membrane (ILM) peeling at macular area and macular plus peripapillary area versus no peeling in rhegmatogenous retinal detachments (RRD). Methods: A prospective observational study between July 2014 and March 2017 conducted on 289 eyes of 287 patients with RRD were randomly assigned to three treatment procedures, viz., PPV with no ILM peeling, PPV with macular peeling, and PPV with macular plus peripapillary peeling. Recurrent RD (ReRD) was treated as an event and accordingly the overall primary (PS) and final success (FS) rates were obtained. The risk of ReRD associated with peeling procedures after adjusting for risk factors were obtained using Cox-proportional hazard analysis. Results: The PS percentage for no peel, macular, and macular plus peripapillary procedures were 77.78% (70/90), 82.18% (83/101), and 94.89% (93/98; maximum), respectively, which was statistically significant with a P value of 0.003. The FS percentage for no peel, macular, and macular plus peripapillary were 93.33%, 95.04%, and 100%, respectively, which was significantly different with a P value of 0.048. With reference to no peeling, the adjusted hazard ratio for macular peeling was 0.841 [95% CI: 0.44-1.60] while 0.235 [95% CI: 0.088-0.626] for macular plus peripapillary peeling. Conclusion: The anatomic success rate of PPV with macular plus peripapillary ILM peeling was significantly higher as compared to no peel category. The hazard of ReRD in patients undergoing macular plus peripapillary peel was significantly reduced as compared to no peel procedure.