Intravitreal DEX Implant for the Treatment of Diabetic Macular Edema: A Review of National Consensus.

Diabetic macular edema (DME)'s therapeutic approach can frequently be challenging. The purpose of the review is to propose evidence-based recommendations on the employment of intravitreal dexamethasone implants (DEX) when approaching patients suffering from DME. Seven national consensuses redacted by different groups of retina specialists from Europe and Asia were examined and confronted. Each consensus was redacted utilizing a Delphi approach, in person meetings, or by reviewing the literature. DEX can be studied as a first-line strategy in individuals suffering from DME with inflammatory OCT biomarkers, in vitrectomized eyes, in patients with recent cardiovascular events, in pregnant women, in patients scheduled to undergo cataract surgery or with poor compliance. The other parameters considered were the indications to the DME treatment, when to switch to DEX, the definition of non-responder to anti-VEGFs agents and to the DEX implant, whether to combine DEX with laser photocoagulation, the association between glaucoma and DEX, and the management of DEX and the cataract. Although several years have passed since the introduction of DEX implants in the DME treatment, there is still not a unified agreement among retina specialists. This paper compares the approach in the DME treatment between countries from different continents and provides a broader and worldwide perspective of the topic.

COVID-19 pandemic and ophthalmological emergencies: a case-control analysis of the impact of lockdowns in a University Hospital in Lombardy region, Italy.

PURPOSE: To evaluate the incidence of ocular pathologies seen at the ophthalmological emergency department (OED) during the national lockdown in 2020 due to the COVID-19 pandemic and compare it to the corresponding period in 2019. METHODS: Electronic records of patients who presented at the OED of our University Hospital in Varese, Italy during the COVID-19 lockdown were compared with that from the corresponding period in 2019. Records from the spring (2020A) and winter (2020B) lockdowns were compared with each other and with the same periods in 2019 (2019A and 2019B). Statistical analyses were performed by unpaired Student's t-tests, Poisson's regression and Chi-square test. RESULTS: The number of consultations at the OED significantly decreased during the COVID-19 lockdown (p value <.0001). The largest decreases were observed in the youngest (age <15 years: -77.3%) and oldest (age >61 years, -68.5%) age groups. The proportion of men who consulted increased significantly from 61.76% in 2019A to 67.63% in 2020A, and from 54.56% in 2019B to 62.79% in 2020B. A significant reduction in deferrable consultations was also reported (from 943 in 2019 to 335 in 2020; p value <.0001). A statistically significant decrease in the number of consultations involving ocular trauma was also reported despite an increase in its proportion among all consultations for ocular pathologies in 2020. CONCLUSIONS: Our evaluation showed a significant reduction in the number of OED consultations in all deferrable pathologies. Although the incidence of conditions that affect visual function was lower, these were more frequent in the lockdown period. The significant reduction in the number of deferrable consultations highlights the misuse of the OED.

Role of Vitrectomy in Nontractional Refractory Diabetic Macular Edema.

BACKGROUND: Currently, the gold standard of diabetic macular edema (DME) treatment is anti-vascular endothelial growth factor (VEGF) injections, although a percentage of patients do not respond optimally. Vitrectomy with or without internal limiting membrane (ILM) peeling is a well-established treatment for DME cases with a tractional component while its role for nontractional cases is unclear. The aim of this study is to evaluate the role of vitrectomy with or without ILM peeling in nontractional refractory DME. METHODS: We performed a retrospective review of twenty-eight eyes with nontractional refractory DME treated with vitrectomy at San Giuseppe Hospital, Milan, between 2016 and 2018. All surgeries were performed by a single experienced vitreoretinal surgeon. In 43.4% of cases, the ILM was peeled. Best corrected visual acuity and optical coherence tomography (OCT) scans were assessed preoperatively and at 6, 12, and 24 months post-vitrectomy. RESULTS: The mean central macular thickness improved from 413.1 ± 84.4 to 291.3 ± 57.6 µm at two years (p < 0.0001). The mean logarithm of the minimum angle of resolution logMAR best-corrected visual acuity (BCVA) improved after two years, from 0.6 ± 0.2 to 0.2 ± 0.1 (p < 0.0001). We found no difference between ILM peeling vs. no ILM peeling group in terms of anatomical (p = 0.8) and visual outcome (p = 0.3). Eyes with DME and subfoveal serous retinal detachment (SRD) at baseline had better visual outcomes at the final visit (p = 0.001). CONCLUSIONS: We demonstrated anatomical and visual improvement of patients who underwent vitrectomy for nontractional refractory DME with and without ILM peeling. Improvement was greater in patients presenting subretinal fluid preoperatively.

Macular Holes: Main Clinical Presentations, Diagnosis, and Therapies.

Macular holes are a spectrum of retinal diseases that comprehends full-thickness macular holes (FTMHs), refractory/recurrent macular holes, lamellar macular holes (LMHs), myopic macular holes (MMHs), traumatic macular holes, and macular holes secondary to other retinal pathologies or injuries. There are various classifications of the subtypes of macular hole, and only in recent times researchers defined a common nomenclature, especially thanks to the evolution in retinal imaging, offered by new instruments like the swept-source OCT. The proposed therapies for macular holes are different and range from a "wait-and-see" approach to the vitrectomy, with different results in each subtype of macular hole. This narrative review has the purpose to investigate the available evidence in literature to give a summary of the knowledge about these retinal pathologies.

OCT Biomarkers in Neovascular Age-Related Macular Degeneration: A Narrative Review.

Age-related macular degeneration (AMD) is the leading cause of legal blindness in elderly people. Neovascular AMD (nAMD) is responsible for the majority of cases of severe visual loss in eyes with AMD. Optical coherence tomography (OCT) is the most widely used technology for the diagnosis and follow-up of nAMD patients, which is widely used to study and guide the clinical approach, as well as to predict and evaluate treatment response. The aim of this review is to describe and analyze various structural OCT-based biomarkers, which have practical value during both initial assessment and treatment follow-up of nAMD patients. While central retinal thickness has been the most common and one of the first OCT identified biomarkers, today, other qualitative and quantitative biomarkers provide novel insight into disease activity and offer superior prognostic value and better guidance for tailored therapeutic management. The key importance of retinal fluid compartmentalization (intraretinal fluid, subretinal fluid, and subretinal pigment epithelium (RPE) fluid) will be discussed firstly. In the second part, the structural alterations of different retinal layers in various stages of the disease (photoreceptors layer integrity, hyperreflective dots, outer retinal tubulations, subretinal hyperreflective material, and retinal pigment epithelial tears) will be analyzed in detail. The last part of the review will focus on how alterations of the vitreoretinal interface (vitreomacular adhesion and traction) and of the choroid (sub-RPE hyperreflective columns, prechoroidal clefts, choroidal caverns, choroidal thickness and choroidal volume, and choroidal vascular index) interact with nAMD progression. OCT technology is evolving very quickly, and new retinal biomarkers are continuously described. This up-to-date review article provides a comprehensive description on how structural OCT-based biomarkers provide a valuable tool to monitor the progression of the disease and the treatment response in nAMD patients. Thus, in this perspective, clinicians will be able to allocate hospital resources in the best possible way and tailor treatment to the individual patient's needs.

Myopic Simple Hemorrhage Presenting as Radial Hemorrhage in Henle's Fiber Layer.

This case report describes a simple hemorrhage (SH) presenting as radial hemorrhage in Henle's fiber layer (HFL) in a patient with high myopia. A 26-year-old girl with high myopia was referred to our center for sudden onset of decreased vision and a central scotoma in the right eye (OD). Best corrected visual acuity (BCVA) was 20/100 OD. Fundus examination showed a stellate intraretinal hemorrhage in the fovea of the OD. The hemorrhage was organized in a peculiar petaloid pattern with feathery distal edges, suggesting localization within the radially oriented HFL. The presence of both choroidal neovascularization and microvascular abnormalities consistent with macular telangiectasia type 2 (MacTel 2) were excluded. Based on these findings, a diagnosis of myopic SH was made. At 4-month follow-up BCVA OD spontaneously improved to 20/40, without any treatment been ever administered to the patient. Spectral-domain optical coherence tomography OD showed reabsorption of the hemorrhage and almost complete restoration of the foveal architecture. The intraretinal location and spread of the hemorrhage into the HFL in our patient are an unusual presentation of SH, which vividly highlights the anatomy of the fovea. Since fibers in HFL are quite delicate and loosely arranged, this layer is very susceptible to deposition of transudates, exudates, hemorrhage, and other products. Radial hemorrhage in HFL has been originally reported in 4 patients as complication of MacTel 2. It has been previously postulated that it may represent a characteristic finding in MacTel 2 that may develop as a result of microvascular abnormalities of the deep retinal capillary plexus. On the contrary, our data suggest that radial hemorrhage in the HFL does not represent a characteristic finding of MacTel 2, but must rather be considered a non-specific sign with multiple possible etiologies.

The morphology of choroidal neovascularization in chronic central serous chorioretinopathy presenting with flat, irregular pigment epithelium detachment.

PURPOSE: To evaluate morphological characteristics of choroidal neovascularization in chronic central serous chorioretinopathy (CSC) presenting with flat and irregular pigment epithelium detachment (FIPED) by means of innovative multimodal imaging. METHODS: In this observational cross-sectional study, we examined 10 consecutive patients affected by chronic CSC and FIPED using fluorescein angiography (FA), indocyanine-green angiography (ICGA) and optical coherence tomography angiography (OCTA). A qualitative analysis of the nature and characteristics of neovascular membrane was performed, combining available multimodal imaging and literature data. RESULTS: Multiple areas of retinal pigment epithelium alterations, macular hypo- and hyperpigmentation and atrophic areas were identified. Spectral domain OCT (SD-OCT) showed subretinal fluid in 80% of eyes and the 'double layer sign' in all patients. Late FA phases showed staining areas without leakage in all eyes; ICGA showed a hyperfluorescent plaque with surrounding hypofluorescence in 80% of patients. OCTA detected characteristic neovascular networks in the outer retina within the FIPEDs, classified as filamentous vessels with a pruned tree-like pattern in five eyes and a tangled pattern in three eyes. The choriocapillaris network showed dark areas in 80% of eyes and diffuse dark spots in all eyes. CONCLUSION: Multimodal imaging completes clinical characterization of FIPEDs in chronic CSC. This study using OCTA technology describes the phenotype of hidden neovascular lesions in shape and morphology.

Effect of basic fibroblast growth factor and cytochrome c peroxidase combination in transgenic mice corneal epithelial healing process after excimer laser photoablation.

PURPOSE: To evaluate the role of prepared basic fibroblast growth factor (bFGF) and cytochrome c peroxidase (CCP) combination eyedrops in corneal epithelial healing of transgenic mice (B6(A)-Rpe(rd12)/J) after excimer laser photoablation. MATERIALS AND METHODS: In this prospective study, 216 eyes of 108 mice underwent bilateral photorefractive keratectomy. We considered 4 groups: A, B, C, and D. Group A received standard topical postoperative therapy with tobramycin, diclofenac, and dexamethasone eyedrops plus CCP at 3 drops per day for a week or until corneal re-epithelialization was achieved. Group B received standard topical postoperative therapy plus bFGF eyedrops and phosphate-buffered saline (PBS) 3 drops per day for a week or until corneal re-epithelialization was complete. In group C, 1 eye received standard topical postoperative therapy plus CCP eyedrops, bFGF eyedrops, and PBS 3 drops per day for a week or until corneal re-epithelialization was complete. Control eyes (group D) received a standard topical postoperative therapy plus placebo eyedrops. Mice were followed-up for a week from the day after the surgery to evaluate the rate of corneal re-epithelialization. RESULTS: Data were analyzed by ANOVA using the XLSTAT 2010 software. Eyes in group A, B, and C healed completely before the fifth postoperative day, achieving, respectively, a re-epithelialization time of 92 hours ± 10 SD, 90 hours ± 12 SD, and 86 hours ± 12 SD. Group D had a re-epithelialization time of 121 hours ± 8 SD (P < 0.05). No side effects or toxic effects were documented. CONCLUSIONS: Results suggest that re-epithelialization after phototherapeutic keratectomy can benefit from topical therapy with CCP/bFGF combination eyedrops. Further clinical studies are needed to evaluate the long-term effectiveness of these eyedrops to prevent corneal haze.