Real-World Outcomes of a Loading Phase with Intravitreal Faricimab in Neovascular Age-Related Macular Degeneration (n-AMD) and Diabetic Macular Edema (DME).

INTRODUCTION: The aims of this work were to evaluate the real-world efficacy and safety of a loading dose of intravitreal faricimab in eyes with active neovascular age-related macular degeneration (n-AMD) or diabetic macular edema (DME) and to analyze the treatment outcome in relation to specific biomarkers. METHODS: Patients with active n-AMD or DME, treated with four monthly intravitreal injections of faricimab, were enrolled in this retrospective, uncontrolled study. Best-corrected visual acuity (BCVA), central subfield thickness (CST), presence of retinal fluid (RF) on optical coherence tomography (OCT), and adverse events were assessed at baseline and at weeks 4, 8, 12, and 16. Predefined biomarkers were evaluated at baseline (BL) and at last visit. RESULTS: Sixteen eyes of 15 patients with n-AMD (n-AMD group) and 15 eyes of 12 patients with DME (DME group) were included. Mean (± standard deviation) logarithm of minimum angle of resolution (logMAR) BL BCVA changed from 0.68 (± 0.43) to 0.53 (± 0.36; P = 0.13) and from 0.51 (± 0.34) to 0.32 (± 0.24; P: 0.048) at week 16 in n-AMD and DME group, respectively. A statistically significant mean CST reduction was reported in both groups at last visit (n-AMD: - 166.5 µm; P = 0.0009/DME: - 110.8 µm; P = 0.0086). Seventy-five and 33% of eyes with n-AMD and DME respectively achieved complete RF resolution at last visit. Subfoveal inner and outer retinal damage correlated with a lower final BCVA in n-AMD group. The presence of large (> 100 µm) juxtafoveal microaneurysms (MAs) was significantly correlated with a higher chance of residual fluid in eyes with DME. CONCLUSIONS: Both n-AMD and DME groups achieved satisfactory anatomical results after a loading-dose of intravitreal faricimab. BCVA improvement might be hampered by pre-existing retinal damage in eyes with n-AMD. Large, juxtafoveal MAs might represent a hallmark of a slower anatomical response to the treatment in eyes with DME.

Comparative Study on Anti-VEGF in Wet Age-Related Macular Degeneration in the Setting Based on Lean Methodology from the Bari Intravitreal Injection Registry (BIVIR).

INTRODUCTION: Optimizing treatment protocols for wet age-related macular degeneration (wAMD) is an ongoing challenge, as it involves a delicate balance between achieving therapeutic efficacy and minimizing invasive procedures' frequency. This study aimed to apply the Lean methodology and evaluate the effectiveness of this new setting on intravitreal therapy for wAMD, employing different anti-vascular endothelial growth factors (VEGF) drugs (bevacizumab, brolucizumab, aflibercept, ranibizumab), drawing data from the Bari Intravitreal Injections Registry (BIVIR). METHODS: This was a retrospective, monocentric, nonrandomized, comparative study. Lean methodology was employed to design the new setting and the BIVIR collected information from electronic medical records. Clinical data of four groups, stratified based on the first-line anti-VEGF agents used, were compared. Best-corrected visual acuity (BCVA) and central retinal thickness (CRT) changes were compared between the four groups at 3 and 12 months. RESULTS: Out of 4990 eyes and 41,323 intravitreal injections (IVs) recorded in BIVIR, 1421 eyes of 1182 patients were included. The mean number of IVs in first year was 6.1 ± 2.5, with no significant differences among the four subgroups. The mean change in BCVA was + 6.2 letters [95% confidence interval (CI) 5.6-6.8] after two IVs, and + 5.9 (95% CI 5.1-6.8) letters after three IVs; at three months, brolucizumab was associated with a greater mean increase in BCVA than bevacizumab (p = 0.050); aflibercept (p = 0.044) and ranibizumab p = 0.047). At the 1-year follow-up, the mean change was + 6.3 letters (95% CI 5.4-7.2), brolucizumab and ranibizumab were associated with a superior improvement in BCVA compared to aflibercept (p = 0.033). Regarding the CRT, a significant reduction was observed in the subgroup treated with brolucizumab at the 3-month follow-up, compared to bevacizumab (p = 0.003), aflibercept (p = 0.015), and ranibizumab (p < 0.001); Aflibercept exhibited a superior effect than ranibizumab (p = 0.001). At 1-year follow-up, aflibercept resulted in a more significant reduction of macular thickness compared to ranibizumab (p = 0.016) while no significant differences were observed among the other drugs. CONCLUSIONS: Our practical experience showed the effectiveness of the new setting in the treatment of wAMD. This comparative study at 1 year suggested a predominant brolucizumab efficacy on functional outcomes. In addition, brolucizumab and aflibercept appeared to have similar efficacy in fluid control.

Choriocapillaris Reperfusion in Resolved Chronic Central Serous Chorioretinopathy Treated with Eplerenone: Long-Term Effects on the Fellow Eye.

INTRODUCTION: The aim of this work is to utilize swept-source optical coherence tomography angiography (SS-OCTA) to assess the long-term changes in the choroidal and choriocapillaris (CC) layers of the fellow unaffected eye of patients with unilateral resolved chronic central serous chorioretinopathy (cCSC) following treatment with continuous oral eplerenone (EPL). METHODS: The study included 35 patients with cCSC and subretinal fluid (SRF) in one eye. SS-OCTA imaging was performed on the fellow cCSC eyes at baseline, 6 months, and 12 months during eplerenone therapy. CC OCT angiography was analyzed to determine the percentage of choriocapillaris flow deficits (FD%), the number of flow deficits (FDn), and the average area of flow deficits (FDa). RESULTS: The results demonstrated significant changes in CC flow deficits from baseline to follow-up visits. Specifically, there was a significant decrease in FD% from 28.9 ± 2.2% at baseline to 26.4 ± 1.9% at 6 months (p = 0.023), and further to 24.9 ± 1.7% at 12 months (p = 0.001). Additionally, the FD area gradually contracted over the follow-up period (p < 0.05). Conversely, there was a significant increase in the number of flow deficits compared to baseline (p < 0.05). No statistically significant changes were observed in best-corrected visual acuity (BCVA) at the follow-up visits (p > 0.05). CONCLUSIONS: The findings of this study demonstrated long-term reperfusion of the choriocapillaris in unaffected fellow cCSC eyes during continuous oral eplerenone therapy. The beneficial effects of eplerenone therapy were observed after 6 months and maintained at 1 year. These results suggest that specific mineralocorticoid receptor (MR) antagonists may be effective in promoting choriocapillaris recovery in the unaffected eyes of patients with cCSC.

Microscope-assisted pneumatic retinopexy for the management of primary rhegmatogenous retinal detachment.

PURPOSE: Outcomes of pneumatic retinopexy (PnR) using surgical microscope, wide-angle viewing system, and chandelier endoilluminator (microscope-assisted pneumatic retinopexy) for primary rhegmatogenous retinal detachment (RRD). METHODS: Retrospective study. 43 consecutive eyes with RRD undergoing microscope-assisted PnR surgery (MAPR) were analysed. Inclusion criteria comprehend phakic eyes with single retinal break or a group of breaks in detached retina in the same quadrant above 8- and 4-o'clock meridians. Follow-up was at least 6 months. RESULTS: Of the 43 eyes, a total of 25 (58%) presented preoperatively a single retinal break, 15 (35%) had two retinal breaks in the same quadrant and 3 (7%) presented three or more retinal breaks in the same quadrant. Other retinal breaks not observed preoperatively were discovered intraoperatively in 12 eyes (28%). In 9 (21%) the missed retinal breaks were in the same quadrant as the main diagnosed break(s), while 3 (7%) had missed retinal breaks in a different one. These 3 eyes as no longer adhering to the PnR indication criteria switched intraoperatively to other surgical procedures and were excluded in the reattachment rate results. The total primary reattachment rate with MAPR was achieved in 37 eyes (92.5%). No significant BCVA changes were observed postoperatively. CONCLUSION: MAPR is an effective and safe surgical option, it allows to work with both hands free and provides an adequate visualization of the retina during the procedure minimizing the risk of missed retinal breaks potentially leading to surgical failure.

Polypoidal Choroidal Vasculopathy Based on Non-ICGA Criteria in White Patients With Neovascular Age-Related Macular Degeneration.

PURPOSE: To determine prevalence of probable polypoidal choroidal vasculopathy (PCV) among White patients with neovascular age-related macular degeneration (nAMD) using non-indocyanine green angiography (ICGA) criteria DESIGN: Multicenter, multinational, retrospective, cross-sectional study. METHODS: A total of 208 treatment-naive eyes from Hispanic and non-Hispanic White individuals diagnosed with nAMD were included. All underwent color fundus photography (CFP), optical coherence tomography (OCT), and fluorescein angiography (FFA). De-identified images of study eyes were sent to 2 groups of graders. Group 1 reviewed CFP, OCT, and FFA to confirm nAMD diagnosis. Group 2 reviewed CFP and OCT to determine highly suggestive features for PCV. Probable PCV diagnosis defined as the presence of ≥2 of 4 highly suggestive features for PCV: notched or fibrovascular pigment epithelial detachment (PED) on CFP, sharply-peaked PED, notched PED, and hyperreflective ring on OCT. RESULTS: Eleven eyes were excluded because of poor image quality (6) or non-nAMD diagnosis (5). Of 197 eligible eyes (197 patients), the mean age (SD) was 78.8 years (8.9), 44.2% were men, 26.4% were Hispanic, and 73.6% were non-Hispanic White individuals; 41.1%, 23.4%, 9.1%, and 2.5% had ≥1, ≥2, ≥3, and 4 highly suggestive features. Results showed that 23.4% (95% CI, 17.6%-29.9%) had probable PCV diagnosis. Predominantly occult CNV was more frequently found in probable PCV than nAMD subgroup (84.8% vs 64.9%, P = .01). Hispanic White individuals had a lower prevalence of probable PCV than non-Hispanic White individuals (9.6% vs 28.2%, P = .006) CONCLUSIONS: These findings suggest that probable PCV occurs between 17.6% and 29.9% in White individuals with nAMD, and more commonly in non-Hispanic than in Hispanic White individuals.

Standardized Flanged Intrascleral Intraocular Lens Fixation with the Double-Needle Technique for Cataract Luxation in the Vitreous Chamber during Phacoemulsification.

PURPOSE: To assess the visual and refractive outcome of immediate intraoperative vitrectomy and intrascleral intraocular lens implantation using a "standardized" sutureless Yamane technique during cataract luxation in the vitreous chamber as a complication of phacoemulsification. DESIGN: A prospective, interventional, consecutive case series. MATERIALS AND METHODS: Twelve patients underwent vitrectomy and intrascleral intraocular lens fixation using a standardized Yamane technique as the primary procedure during complicated phacoemulsification. Patients were evaluated preoperatively and 6 months postoperatively for best-corrected distance visual acuity, correspondence to the preoperative refractive target in the spherical equivalent, endothelial cell count, and complications. RESULTS: Mean preoperative best-corrected visual acuity was 1.16 ± 0.3 logarithm of the minimum angle of resolution (logMAR), the endothelial cell count was 1910.5 ± 297.64, and target refraction at baseline was -0.197 ± 0.087. Postoperatively, best-corrected visual acuity was significantly improved; the mean value was 0.05 logMAR ± 0.06. Mean baseline target refraction in the spherical equivalent was -0.20 ± -0.09 (range: -0.08 to -0.37), and mean final refraction was -0.44 ± -0.14 (range: -0.25 to -0.75) with no significant difference (p=0.87). No complication was registered intra- and postoperatively. CONCLUSION: Standardization of the Yamane technique seemed a valuable option for patients who had complicated phacoemulsification to achieve a predictable refractive outcome. Synopsis. The predictable refractive outcome could be achieved with the immediate standardized Yamane technique in patients with intraoperative cataract luxation in the vitreous chamber during phacoemulsification.

Detection of serum uric acid in primary open angle glaucoma: A pilot study.

PURPOSE: To assess the association between the serum levels of uric acid (UA) and primary open-angle glaucoma (POAG). METHODS: In this pilot study, 46 eyes of 23 patients with a clinical history of POAG and 30 eyes of 15 healthy subjects were included. All patients underwent a complete ophthalmological examination, including best corrected visual acuity (BCVA), intraocular pressure (IOP), and gonioscopy. Visual field parameters, such as mean deviation (MD) and pattern standard deviation (PSD), and optical coherence tomography (OCT) values of the optic nerve head, including retinal nerve fiber layer (RNFL) thickness and vertical cup/disc ratio (VCDR), were noted. A blood sample was collected from each subject for serum UA measurement. RESULTS: IOP, MD, PSD, RNFL thickness, and VCDR resulted significantly different in POAG patients, when compared with controls (p < 0.05). POAG patients showed significantly lower levels of mean serum UA than healthy controls (4.00 ± 0.66 mg/dL vs 4.95 ± 0.86 mg/dL, respectively, p < 0.0001). Furthermore, severe POAG patients showed mean serum levels of UA lower than mild POAG patients (3.36 ± 0.70 mg/dL vs 4.22 ± 0.51 mg/dL, respectively, p = 0.01). Visual field and OCT parameters were statistically correlated with the mean serum levels of UA in POAG eyes (p < 0.05). CONCLUSION: Results suggest that in POAG patients, serum UA levels may be decreased and correlated with visual field and OCT parameters worsening. Further larger multi-center prospective studies are necessary to confirm our findings and establish the role of UA in glaucoma.

Intravitreal dexamethasone implant one month before versus concomitant with cataract surgery in patients with diabetic macular oedema: the dexcat study.

PURPOSE: To report clinical outcomes of two different timings of intravitreal dexamethasone (DEX) implant administration for prevention of diabetic macular oedema (DME) worsening following cataract surgery. METHODS: This multicentre, retrospective study included patients with DME who received an intravitreal DEX implant 1 month before cataract surgery, 'precataract DEX' group, or at the time of cataract surgery, 'concomitant treatments' group. Inclusion criteria were a follow-up ≥3 months and ophthalmological examination with optical coherence tomography (OCT) imaging at baseline (cataract surgery) and throughout follow-up. Anatomical improvement was considered to be a decrease in OCT central subfield (CSF) thickness ≥20% compared to baseline. The primary outcomes were anatomical and functional results at 3 months. RESULTS: Two hundred twenty-one patients were included: 136 in the 'precataract DEX' group and 85 in the 'concomitant treatments' group. At 3 months, a reduction of CSF thickness ≥ 20% was found in 7.3% of eyes in the 'precataract DEX group' and in 83.7% of eyes in the 'concomitant treatments' group (p < 0.001), with mean CSF thickness lower in the latter group (371 ± 52 µm versus 325 ± 57 µm, p < 0.001). At 3 months, mean best-corrected visual acuity had improved from baseline in both groups (p < 0.001), with no difference between groups (p = 0. 20). No serious systemic adverse events were reported. CONCLUSION: Both approaches prevented a worsening of DME, showing a comparable visual outcome. Dexamethasone (DEX) implant given at the same time as cataract surgery provided a better anatomical outcome.

Anterior Acute Uveitis Report in a SARS-CoV-2 Patient Managed with Adjunctive Topical Antiseptic Prophylaxis Preventing 2019-nCoV Spread Through the Ocular Surface Route.

PURPOSE: To report the clinical-epidemiological association between acute anterior uveitis and acute bilateral follicular conjunctivitis in a 30-year-old female patient who had tested positive for the SARS-CoV-2 RT-PCR. METHODS: A 30-year-old female visited emergency ophthalmology care at the Siena Crosslinking Centre, Italy, for a bilateral eye redness lasting two weeks, associated with unilateral photophobia and blurred vision in her right eye. She visited on the 23rd of March 2020 in the full pandemic period and presented chills and fever with a temperature of 39.0°C, associated with complete loss of taste. Since eye examination findings, systemic symptoms and epidemiological criteria correlated with SARS-CoV-2 infection, she was referred to Siena University Hospital, Italy, for the SARS-CoV-2 nasopharyngeal buffer and haematological examinations for uveitis. RESULTS: Eye examination revealed bilateral conjunctival hyperaemia with acute follicular conjunctivitis associated with right eye acute anterior uveitis characterized by diffuse pigmentary and whitish immune precipitates over the anterior capsule of the crystalline lens and initial anterior lens opacity explaining the blurred vision. Adjunctive prophylactic eye topical treatment, included in the acronym SHYPIO (0.02% sodium hypochlorite solution, 0.6% povidone iodine eye-drops and 10.50% ozonized oil eye-drops), was associated with conventional uveitis therapy to prevent the virus spread through the ocular surface route. CONCLUSION: Our report demonstrates that complicated acute anterior uveitis (iridocyclitis) with blurred vision could be associated with SARS-CoV-2 infection, being potentially sight-threatening for early complicated lens opacity. Ophthalmologists examining suspected or asymptomatic patients should be aware of the risk of 2019-nCoV infection.

A pilot study to evaluate the levels of aqueous humor trace elements in open-angle glaucoma.

BACKGROUND: Primary open angle glaucoma (POAG) is the most common form of chronic, progressive optic neuropathies characterized by slow degeneration of the retinal ganglion cells and their axons, resulting in visual field loss. Risk factors for this disease are elevated intraocular pressure (IOP), increased age, European and African ethnicity, family history, myopia and decreased corneal thickness. In addition, studies indicated that levels of trace elements are also significantly related to the POAG. METHOD: The association between toxic and essential elements and POAG was explored in a population-based case-control study in the Sardinia Island (Italy). The aqueous humor levels of Al, Cd, Cu, Fe, Hg, Mn, Ni, Pb and Zn were measured in 25 POAG patients compared to 20 age- and gender-matched healthy controls by sector field inductively coupled mass spectrometry. Risk factors as gender, age and increased IOP were also explored. RESULTS: The concentrations of Fe, Hg and Zn were significantly higher in POAG patients than in control subjects, showing these elements as possible determinants in POAG development or degeneration. Other findings were the increased Cu and Fe levels in glaucomatous patients with age less than 70 years. Levels of Ni were found elevated in POAG females. Mercury accumulated more in POAG females, in patients over 70 years and in those with higher levels of IOP in the left eye. Moreover, the positive associations CuFe and Mn-Zn may indicate synergistic effects of elements. CONCLUSIONS: Altogether, these findings suggested a multifactorial role in the risk for POAG disease. The present study documented the levels of trace elements in aqueous humor of Sardinian POAG patients for the first time.

Giant Cell Arteritis: The Experience of Two Collaborative Referral Centers and an Overview of Disease Pathogenesis and Therapeutic Advancements.

PURPOSE: Giant cell arteritis (GCA), a chronic vasculitis of the large and medium-sized arteries, affects people >50 years of age. This study assessed the prevalence of visual manifestations and other clinical features at presentation in an Italian cohort of GCA patients. Recent advances in the pathophysiology, diagnosis, and therapy of GCA are also reviewed. METHODS: This retrospective, single-center study conducted by the ophthalmology and internal medicine clinics of one university recruited 56 patients from 2005 to 2016 and followed them for 11-54 months. RESULTS: Ocular involvement was diagnosed in 19 patients (33.9%), with permanent vision loss in 19.6% (7.1% of the cohort with bilateral vision loss). Arteritic anterior and posterior ischemic optic neuropathy were diagnosed in 11 patients (57.9%) and 1 patient (5.3%), respectively, cotton wool spots in 3 patients (15.8%), central retinal artery occlusion in 2 patients (10.5%), and anterior segment ischemia and multifocal choroidal ischemia in 1 patient each (5.3%). Polymyalgia rheumatica was associated with GCA in 44.6% of the patients. The most common extra-ocular manifestation was constitutional symptoms (82.1% of the patients). Large-vessel involvement, including of the ascending aorta, aortic arch, and left axillary artery, was diagnosed by magnetic resonance or computed tomography (CT) angiography and 18FDG positron emission/CT. Glucocorticoids (GCs) remain the standard-of-care worldwide, but methotrexate, provided as a steroid-sparing drug in 41% of the patients, resulted in earlier tapering, a lower cumulative dose of GCs, and a lower rate of relapse. Among the combinations of GCs and immunosuppressive drugs proposed to treat GCA, only tocilizumab has effectively induced and maintained disease remission. CONCLUSION: According to our data and literature reports: a) GCA is a systemic disease; b) its diagnosis is expedited by the adjunct use of imaging techniques; c) insights into the pathogenesis of GCA may allow an improved, differentiated therapeutic approach.

Baseline predictors for visual acuity loss during observation in diabetic macular oedema with good baseline visual acuity.

PURPOSE: To investigate clinical baseline characteristics and optical coherence tomography biomarkers predicting visual loss during observation in eyes with diabetic macular oedema (DMO) and good baseline visual acuity (VA). METHODS: A sub-analysis of a 12-month, retrospective study, including patients with baseline VA ≤0.1 logMAR (≥20/25 Snellen) and centre-involving DMO. The primary outcome measure was the correlation between baseline characteristics and VA loss ≥10 letters during follow-up. RESULTS: A total of 249 eyes were included in the initial study, of which 147 eyes were observed and 80 eyes received anti-vascular endothelial growth factor (VEGF) treatment at baseline. Visual acuity (VA) loss ≥10 letters occurred in 21.8% (observed cohort) and in 24.3% (treated cohort), respectively. Within observed eyes, presence of hyperreflective foci [HRF; odds ratio (OR): 3.18, p = 0.046], and disorganization of inner retina layers (DRIL; OR: 2.71, p = 0.026) were associated with a higher risk of VA loss ≥10 letters. In observed eyes with a combined presence of HRF, DRIL and ellipsoid zone (EZ) disruption, the risk of VA loss was further increased (OR: 3.86, p = 0.034). In eyes with combined presence of DRIL, HRF and EZ disruption, risk of VA loss was 46.7% (7/15 eyes) in the observed cohort, and 26.3% (5/19 eyes) in the treated cohort (p = 0.26). CONCLUSION: Patients with DMO and good baseline VA, managed by observation, are of increased risk for VA loss if DRIL, HRF and EZ disruption are present at baseline. Earlier treatment with anti-VEGF in these patients may potentially decrease the risk of VA loss at 12 months.

Microperimetric Biofeedback Training after Successful Inverted Flap Technique for Large Macular Hole.

Background: Despite the high closure rate of large macular hole (LMH) after surgery, visual recovery is often worse than expected. Microperimetric biofeedback can improve visual function in macular pathologies. We evaluated the efficacy of biofeedback on macular function after successful inverted flap technique for LMH. Methods: In this prospective comparative study, 26 patients after LMH surgical closure were enrolled. The whole sample was equally divided into two groups. In Group 1 (trained), patients underwent a double cycle of microperimetric biofeedback, using structured light stimulus plus acoustic tone; in Group 2 (control), patients underwent scheduled visits. We analyzed visual acuity, retinal sensitivity at central 12° (macular sensitivity, MS) and 4° (central macular sensitivity, CMS), and fixation stability over twelve months. Results: Visual acuity improved mainly in the trained group, without any significant differences between the groups (p > 0.05). Only after training did MS significantly improve (p = 0.01). CMS more significantly improved in the trained (p < 0.001) than the control group (p < 0.01) (Group 1 vs. 2, p = 0.004). Only in the trained group did fixation significantly improve (3 months, p ≤ 0.03; 12 months, p ≤ 0.01). An equality test on matched data confirmed a greater significant improvement of CMS (p ≤ 0.02) at all follow-up and fixation (p ≤ 0.02) at last follow-up after training. Conclusion: Microperimetric biofeedback consolidates and increases the improvement of retinal sensitivity and fixation gained after successful inverted flap technique.

Amyloidosis and Ocular Involvement: an Overview.

Purpose: To describe the ophthalmic manifestations of amyloidosis and the corresponding therapeutic measures.Methods: The 178 patients included in the study had different types of amyloidosis, diagnosed at a single internal medicine institution (Bari, Italy). To provide a comprehensive review of the types of amyloidosis that can be associated with ocular involvement, the images and clinical descriptions of patients with amyloidosis structurally related to gelsolin, keratoepithelin and lactoferrin were obtained in collaborations with the ophthalmology departments of hospitals in Mainz (Germany) and Helsinki (Finland).Results: Overall, ocular morbidity was detected in 41 of the 178 patients with amyloidosis (23%). AL amyloidosis was diagnosed in 18 patients with systemic disease, 3 with multiple myeloma, and 11 with localized amyloidosis. AA amyloidosis was detected in 2 patients with rheumatoid arthritis and 3 with Behçet syndrome, and transthyretin amyloidosis in 4 patients. The treatment of AL amyloidosis is based on chemotherapy to suppress the production of amyloidogenic L-chains and on surgical excision of orbital or conjunctival masses. AA amyloidosis is managed by targeting the underlying condition. Vitreous opacities and additional findings of ocular involvement in patients with transthyretin amyloidosis indicate the need for pars plana vitrectomy. Gelsolin amyloidosis, characterized by lattice corneal amyloidosis and polyneuropathy, results in recurrent keratitis and corneal scarring, such that keratoplasty is inevitable. In patients with lattice corneal dystrophies associated with amyloid deposits of keratoepithelin fragments, corneal transparency is compromised by deposits of congophilic material in the subepithelial layer and deep corneal stroma. Patients with established corneal opacities are treated by corneal transplantation, but the prognosis is poor because recurrent corneal deposits are possible after surgery. In patients with gelatinous drop-like dystrophy, the amyloid fibrils that accumulate beneath the corneal epithelium consist of lactoferrin and can severely impair visual acuity. Keratoplasty and its variants are performed for visual rehabilitation.Conclusion: A routine ophthalmic follow-up is recommended for all patients with established or suspected amyloidosis, independent of the biochemical type of the amyloid. Close collaboration between the ophthalmologist and the internist will facilitate a more precise diagnosis of ocular involvement in amyloidosis and allow the multidisciplinary management of these patients.Abbreviations: CD: corneal dystrophy; CLA: corneal lattice amyloidosis; CNS: central nervous system; CT: computed tomography; FAP: familial amyloidotic polyneuropathy; GDLCD: gelatinous drop-like corneal dystrophy; GLN: gelsolin; LCD: lattice corneal dystrophy; MRI: magnetic resonance imaging; OLT: orthotopic liver transplantation; TEM: transmission electron microscopy; TGFBI: transforming growth factor ß induced; TTR: transthyretin.

Inverted internal limiting membrane-flap technique for large macular hole: a microperimetric study.

BACKGROUND: Inverted Internal Limiting Membrane (ILM)-flap technique would seem to lead to higher closure rate and better visual acuity than traditional procedure with ILM peeling for the treatment of large macular hole (LMH). Visual acuity recovery does not reveal many other functional changes related to surgical approach. Our purpose was to evaluate macular function and morphology over a 1-year follow-up after inverted ILM-flap technique for LMH by using microperimetry in order to predict visual prognosis. METHODS: This study was a prospective unrandomized single-center study. 23 eyes of 22 patients with idiopathic LMH, with a minimum diameter ranging from 400 to 1000 µm, were included. All patients underwent vitrectomy with inverted ILM-flap technique and gas tamponade. We analyzed macular hole closure rate and functional outcomes including best-corrected visual acuity (BCVA), macular sensitivity (MS) at central 12° and central macular sensitivity (CMS) at central 4°, and fixation behavior as bivariate contour ellipse area (BCEA, degrees2) at 68%, 95%, and 99% of fixation points measured by microperimeter, over a follow-up of 12 months. RESULTS: The macular hole closure rate was 98%. The BCVA improved from 20/230 (Logmar, 1.06 ± 0.34) to 20/59 (logMar, 0.47 ± 0.45) at last follow-up (p < 0.001). Retinal sensitivity and BCEA significantly improved (MS, p = 0.001; CMS, p < 0.0001; BCEA: 68%, p < 0.01; 95%, p < 0.01; 99%, p = 0.001). Multiple stepwise regression analysis showed the final BCVA was significantly associated with macular hole size (ß = 0.002, p = 0.03), preoperative MS (ß = - 0.06, p = 0.001) and BCEA at 95% and 99% of fixation points (ß = - 0.12, p = 0.01; ß = 0.06, p = 0.01). CONCLUSIONS: Inverted ILM-flap technique for LMH results in good morphologic and functional outcomes. Macular hole size and microperimetric parameters as preoperative MS and BCEA have a predictive role on post-surgical visual acuity.

Real-world outcomes of non-responding diabetic macular edema treated with continued anti-VEGF therapy versus early switch to dexamethasone implant: 2-year results.

AIMS: To provide 2-year follow-up data on eyes with diabetic macular edema (DME) that were non-responsive after three initial anti-vascular endothelial growth factor (VEGF) injections, comparing functional and anatomical outcomes under continued anti-VEGF therapy versus dexamethasone (DEX) implant. METHODS: Multicenter, retrospective chart review comparing eyes with treatment-naïve DME and a suboptimal response to a loading phase of anti-VEGF therapy (3 injections given monthly) which were then treated with (a) further anti-VEGF (n = 72) or (b) initially switched to DEX implant (n = 38). Main outcome measures were change in visual acuity (VA) and central subfield thickness (CST) from the end of the loading phase to 24 months. RESULTS: In 79% of the 12-month study population (87/110 eyes), 24-month data were available. One quarter of eyes in each group switched treatments during the second year. Eyes that were switched early to DEX implant maintained the functional and anatomical improvements at 24 months which were seen in the first year (from month 3: + 8.9 letters, - 214 µm). Eyes that were switched from anti-VEGF therapy to steroids in the second year improved VA and reduced CST at 24 months (from month 12: + 6.8 letters, p = 0.023; - 226 µm, p = 0.004). In eyes continued on anti-VEGF therapy, VA and CST were stable at 24 months (from month 3: + 2.8 letters, p = 0.254; - 24 µm, p = 0.243). Eyes that were non-responsive to anti-VEGF therapy for 12 months had similar chances to experience a VA gain from further therapy as eyes that were non-responsive for 3 months only (23.8 vs. 31.0%, p = 0.344). CONCLUSIONS: The beneficial effect of an early switch to DEX implant in DME non-responders seen at month 12 was maintained during the second year. A later switch from anti-VEGF to steroids still provided significant improvement. Eyes continued on anti-VEGF over a period of 24 months maintained vision. A quarter of eyes, which had not improved vision at 12 months, exhibited a delayed response to treatment.

Morphologic and functional outcomes of different optical coherence tomography patterns of myopic foveoschisis after vitrectomy and inner limiting membrane peeling.

OBJECTIVE: To evaluate the morphologic and functional outcomes of different optical coherence tomography (OCT) patterns of myopic foveoschisis after vitrectomy with Inner Limiting Membrane (ILM) peeling. METHODS: In this prospective non-randomised study, 62 consecutive eyes with Myopic Foveoschisis were categorised into three groups according to OCT pattern: retinoschisis type (Rt) Group (23/62), foveal detachment type (FDt) Group (20/62) and macular hole type (MHt) Group (19/62). All patients underwent 25-Gauge vitrectomy and ILM peeling. Air or gas tamponade was used. All patients were observed at month 1, 2, 4 and 6 after surgery. MAIN OUTCOMES MEASURES: surgical success as resolution of myopic foveoschisis, central retinal thickness (CRT), IS/OS junction recovery and best-corrected visual acuity (BCVA) measurement. Any complication was reported. RESULTS: In all eyes OCT showed a resolution of the retinoschisis, foveal detachment and macular hole pattern, respectively. CRT significantly decreased in all Groups (p < .001), mainly in MHt. IS/OS junction recovery was mainly observed in MHt. BCVA significantly increased in all Groups (p < .01). A functional gain ≥2 Snellen lines occurred in 70, 85 and 68% in the Rt, FDt and MHt Group, respectively. Final BCVA was correlated with preoperative BCVA (R 0.74, p < 0.0001), postoperative CRT (R -0.49, p < 0.0001), and the recovery of IS/OS junction at 6 months (R 0.76, p < 0.0001). Few postoperative complications occurred. CONCLUSIONS: Vitrectomy with ILM peeling results in favourable anatomic and functional outcomes for different patterns of myopic foveoschisis.

Glucose-6-Phosphate Dehydrogenase (G6PD) Deficiency and Late-stage Age-Related Macular Degeneration.

Purpose: Age-related macular degeneration (AMD) is the leading cause of blindness in the elderly in Western Countries. Evidence indicates that Glucose-6-Phosphate Dehydrogenase (G6PD) deficiency, a common genetic abnormality, may protect against ischemic heart and cerebrovascular disease, ocular vascular disorders, and colorectal cancer. This study was undertaken to ascertain whether G6PD deficiency may protect against AMD. Materials and Methods: 79 men with late-stage AMD and 79 male, age-matched cataract controls without AMD were recruited in March-December 2016. Smoking status, clinical history, and drug use were recorded. A blood sample was taken from each participant. Complete blood count, hemoglobin, glucose, creatinine, cholesterol, triglycerides, transaminases, bilirubin, and erythrocyte G6PD activity were measured. Stepwise logistic regression was used to investigate the association between G6PD deficiency and AMD. Results: G6PD deficiency was found in 7 (8.9%) AMD patients and 8 (10.1%) controls, a not statistically significant difference. Stepwise logistic regression disclosed that AMD was significantly associated with increased diastolic blood pressure (OR=1.09, 95% CI=1.03-1.15, P=0.02) and LDL-cholesterol (OR=1.02, 95% CI=1.0001-1.03, P=0.049) and lower values of white blood cell (WBC) count (OR=0.71, 95% CI=0.56-0.88, P=0.02) and aspartate aminotransferase (AST) (OR=0.92, 95% CI=0.85-0.99, P=0.044). Conclusion: Results suggest that G6PD deficiency has no protective effect on nor is a risk factor for AMD. Larger studies are necessary to confirm whether increased diastolic blood pressure and LDL-cholesterol and lower values of WBC count and AST are risk factors for AMD.

Real-world outcomes of observation and treatment in diabetic macular edema with very good visual acuity: the OBTAIN study.

AIMS: To describe and compare the functional and anatomical outcomes of untreated and treated diabetic macular edema (DME) in eyes with very good baseline visual acuity (VA) in a real-world setting. METHODS: A 12-month, retrospective, multicenter, observational cohort study, including DME patients with baseline visual acuity (VA) ≤ 0.1 logMAR (≥ 20/25 Snellen) and central subfield thickness (CST) > 250 µm with intra- and/or subretinal fluid seen on optical coherence tomography. RESULTS: A total of 249 eyes were included, of which 155 were treated and 94 were non-treated during follow-up. Most eyes maintained vision (VA gain or VA loss < 5 letters) at 12 months (treated: 58.1%; non-treated: 73.4%). In non-treated eyes with stable VA within the first 6 months, VA was maintained throughout the follow-up in most cases (86.3%). In non-treated eyes with VA loss ≥ 5 letters within 6 months (36.7%), further observation led to worse visual outcome than treatment (- 4.2 vs. - 7.8 letters, p = 0.013). In eyes in which treatment was initiated at baseline (n = 102), treatment with 8-12 anti-VEGF injections led to better visual outcome compared to treatment with less injections (- 0.3 ± 3.6 letters vs. - 3.8 ± 6.2 letters, p = 0.003). CONCLUSION: In a real-world setting, the majority of DME patients with very good VA maintained vision at 12 months, regardless of whether the DME was treated or not. This study supports close observation of eyes with DME and very good VA with consideration of treatment when a one line drop in vision is observed.