Clinical Characteristics of Unilateral Macular Neovascularization Patients with Pachydrusen in the Fellow Eye.

Background/Objectives: To approach the clinical properties of pachydrusen that differ from conventional drusen, we investigated the incidence of macular neovascularization (MNV) in fellow eyes and the treatment outcomes of intravitreal aflibercept (IVA) in MNV eyes of unilateral MNV patients with pachydrusen in the fellow eye. Methods: We retrospectively studied 261 consecutive patients with treatment-naïve unilateral MNV. Patients were classified into four groups according to the type of drusen in the fellow eye: the pachydrusen group (n = 49), the soft drusen group (n = 63), the subretinal drusenoid deposit (SDD) group (n = 24), and the no drusen group (n = 125). The development of the MNV in the fellow eye was evaluated for five years, and the retreatment proportion after three monthly aflibercept injections was evaluated for one year. Results: The choroidal thickness in the fellow eyes and MNV eyes was the greatest in the pachydrusen group (all p < 0.001). The 5-year incidence of MNV in the pachydrusen group was similar to that in the soft drusen group and no drusen group. The pachydrusen group had a lower retreatment rate than the other groups did (pachydrusen group: 46.4%; soft drusen group: 78.1%; SDDs: 87.5%; no drusen group: 83.3%). Conclusions: Unilateral MNV patients with pachydrusen in the fellow eye had a lower retreatment rate (46.4%/1 year); therefore, aflibercept monotherapy using the PRN regimen is one of the preferred treatment methods for MNV patients with pachydrusen in the fellow eye.

The Effect of a Loading Dose Regimen in the Switch to Brolucizumab for Patients with Aflibercept-Resistant nAMD.

Purpose: To evaluate the one-year outcomes of switching to brolucizumab with and without a loading dose regimen (three monthly injections) in eyes with aflibercept-resistant neovascular age-related macular degeneration (nAMD). Methods: We retrospectively studied nAMD patients who had retinal exudate under bimonthly injections of aflibercept and were switched to brolucizumab from aflibercept. Patients were grouped into intravitreal brolucizumab injection (IVBr) with a loading dose regimen (loading group) and without a loading dose regimen (nonloading group). We assessed the best-corrected visual acuity (BCVA), central retinal thickness (CRT) at the fovea, subfoveal choroidal thickness (SFCT), IVBr status (number of injections and last injection interval), and retinal exudate status on optical coherence tomography. Results: Overall, 52 eyes received ≥1 IVBr; 26 eyes received ≥3 IVBr with 12-month follow-up. A total of 13 eyes in the loading group and 13 eyes in the nonloading group were reviewed. One year after switching, BCVA changed from 0.28 ± 0.25 to 0.19 ± 0.28 in the loading group (P=0.28) and from 0.25 ± 0.20 to 0.23 ± 0.25 in the nonloading group (P=0.92). The mean CRT decreased from 263.6 ± 40.7 µm to 221.7 ± 54.6 µm in the loading group (P=0.03), while it only changed from 244.9 ± 77.2 µm to 221.0 ± 78.7 µm in the nonloading group (P=0.26). Both the loading and nonloading groups achieved 69% dry macula. The number of injections received was significantly higher in the loading group (7.6 ± 0.6 vs. 6.8 ± 0.4, P < 0.001). Two patients (4.2%) developed intraocular inflammation. Conclusion: Switching to brolucizumab from aflibercept for eyes with nAMD with resistance to bimonthly injections of aflibercept is a valuable treatment option with and without the loading regimen. This trial is registered with UMIN000023676.

Clinical Characteristics of Neovascular Age-Related Macular Degeneration without Typical Drusen.

PURPOSE: To evaluate the clinical characteristics of neovascular age-related macular degeneration (nAMD) patients without typical drusen. METHODS: We retrospectively studied 165 eyes in 165 patients with treatment-naïve nAMD, including typical AMD and polypoidal choroidal vasculopathy (PCV). According to the fellow eye condition, the patients were divided into nAMD with and without typical drusen groups. Eyes with soft drusen or subretinal drusenoid deposits were classified into the nAMD with the typical drusen group. Smoking status and diagnoses of hypertension and diabetes were identified from hospital records and patient recall. We assessed best-corrected visual acuity (BCVA), central retinal thickness (CRT) at the fovea, subfoveal choroidal thickness (SFCT), and the number of injections received. RESULTS: The nAMD without typical drusen group was significantly younger (77.9 ± 7.6 vs. 71.8 ± 8.3, P < 0.001) and had thicker SFCT at baseline (207.9 ± 99.5 vs. 260.1 ± 113.2 µm, P=0.007) and a higher proportion of PCV (30.6 vs. 63.1%, P < 0.001). The proportion of ever-smokers was significantly higher in the nAMD without typical drusen group (54.8 vs. 70.9%, P=0.036). There were no statistically significant differences in the proportion of patients with hypertension or diabetes; BCVA, CRT, or SFCT changes; or the number of injections between the nAMD with and without typical drusen groups. CONCLUSION: The clinical features of patients in the nAMD without typical drusen group were almost identical to those of pachychoroid-driven choroidal neovascularization (CNV) patients. The nAMD without typical drusen group had a significantly higher proportion of ever-smokers than the nAMD with typical drusen group. Smoking could be a risk factor for the development of pachychoroid-driven CNV.

Quantitative Analysis of Macular Inner Retinal Layer Using Swept-Source Optical Coherence Tomography in Patients with Optic Tract Syndrome.

OBJECTIVE: To evaluate macular inner retinal layers using swept-source optical coherence tomography (SS-OCT) in patients with homonymous hemianopia due to optic tract syndrome (OTS). METHODS: Sixteen eyes of 8 patients with OTS were studied. The macular retinal nerve fiber layer (mRNFL), ganglion cell layer and inner plexiform layer (GCL + IPL), and mRNFL and GCL + IPL (GCC) were measured by SS-OCT (DRI OCT-1 Atlantis®).The scanned area was divided into eight regions and two hemiretinae. Each retinal thickness of the OTS group was compared with that of the 25 control subjects. RESULTS: The GCC thickness in the ipsilateral eyes was significantly reduced in all regions, although predominant thinning of the GCC in the contralateral eyes was found in the nasal region. The GCC + IPL thickness was preferentially reduced at the temporal regions in the ipsilateral eyes and at the nasal regions in the contralateral eyes. The reduction rate of the GCL + IPL thickness was 29.6% at the temporal hemiretina in the ipsilateral eyes and 35.2% at the nasal hemiretina in the contralateral eyes. CONCLUSION: We found preferential loss of the GCC + IPL thickness corresponding to the hemifield defects in each eye. Quantitative analysis by SS-OCT is capable of detecting the characteristic RGC loss due to OTS.

MR dacryocystography: comparison with dacryoendoscopy in positional diagnosis of nasolacrimal duct obstruction.

PURPOSE: To compare the findings of MR dacryocystography with those of dacryoendoscopy and subsequent surgery in patients with nasolacrimal duct obstruction, and to determine the efficacy of MR dacryocystography in the positional diagnosis of nasolacrimal duct obstruction. MATERIALS AND METHODS: Thirty-one patients with clinically suspected nasolacrimal duct obstruction who underwent MR dacryocystography and dacryoendoscopy with subsequent surgical procedure were included. MR dacryocystography was performed by using heavily T2-weighted fast spin echo sequence in the coronal and axial planes after the topical administration of normal saline drops into the conjunctival sacs. RESULTS: In MR dacryocystography, stenosis/obstruction at the canalicular level was correctly diagnosed in nine patients (100 %). Stenosis/obstruction at the lacrimal sac level was correctly diagnosed in 14 of 16 patients (87.5 %) in MR dacryocystography. Three patients with coexistent stenosis/obstruction at both the canalicular and the lacrimal sac level were misinterpreted as stenosis/obstruction at the canalicular level on MR dacryocystography. The overall accuracy of MR dacryocystography in depicting stenosis/obstruction was 84 %. CONCLUSIONS: MR dacryocystography after the topical administration of normal saline drops into the conjunctival sacs is a well-tolerated, minimally invasive imaging technique to identify the level of stenosis/obstruction in patients with nasolacrimal duct obstruction before dacryoendoscopy and subsequent surgery.

Time Course of Macular and Peripapillary Inner Retinal Thickness in Non-arteritic Anterior Ischaemic Optic Neuropathy Using Spectral-Domain Optical Coherence Tomography.

To report a time course of the ganglion cell complex (GCC) and circumpapillary retinal nerve fibre layer (cpRNFL) thicknesses using spectral-domain optical coherence tomography in patients with non-arteritic anterior ischaemic optic neuropathy (NAION), five patients with unilateral NAION were studied (the average age of 66.8 ± 7.8 years old). Forty-one age-matched normal controls were also enrolled. The GCC and cpRNFL thicknesses were measured at the initial visit and at 1, 3, 6, and 12 months using RTVue-100. The GCC thickness and the cpRNFL thickness of the patients were compared with those of the normal controls. The GCC thickness in the NAION patients was 96.49 µm at the initial visit, 84.28 µm at 1 month, 74.26 µm at 3 months, 71.23 µm at 6 months, and 69.51 µm at 12 months. The values at 1, 3, 6, and 12 months were significantly reduced (p < 0.01). The cpRNFL thickness at the initial visit was significantly increased, whereas the values at 6 and 12 months were significantly reduced (p < 0.01). The GCC thickness is more useful for the detection of retinal ganglion cell loss at an early stage than the cpRNFL thickness, because the GCC thickness is unaffected by optic disc swelling at the initial visit, unlike the cpRNFL thickness.

[Two cases of optic neuritis in children with rapid thinning of the ganglion cell complex].

BACKGROUND: There are many reports regarding the circumpapillary retinal nerve fiber layer (cpRNFL) in optic neuritis (ON). However, few studies of changes over time in the ganglion cell complex (GCC) have been reported. As far as we know, no studies of such changes in children have been reported. In the present study, we report two patients with pediatric ON in which the time course of GCC and cpRNFL were observed using optical coherence tomography. CASES: Two cases, one 9-year-old boy and one 11-year-old boy. The two patients showed acute visual impairment, relative afferent pupillary defect, and swelling of the optic disc, leading to the diagnosis of ON. Regardless of whether visual function was improved after steroid pulse therapy, thinning of the GCC and cpRNFL progressed rapidly over time. CONCLUSION: Atrophy of the retinal inner layer in the macula occurred soon after the onset of ON. Although the inflammation was reduced after treatment, atrophy of the ganglion cells continuted to progress. GCC thickness measurement in pediatric ON is useful for pathological assessment and followup, because we can detect atrophy of the ganglion cells and retinal nerve fibers soon after onset.

Factors associated with visual recovery after sub-Tenon injection of triamcinolone acetonide in diabetic macular edema.

BACKGROUND: The purpose of this retrospective chart review was to evaluate factors associated with improvement of visual acuity after a single sub-Tenon injection of triamcinolone acetonide in patients with diabetic macular edema. METHODS: We reviewed the medical records for 63 consecutive eyes with diabetic macular edema treated by sub-Tenon injection of triamcinolone acetonide and assessed at 2 months postoperatively. We evaluated changes in morphology, foveal photoreceptor status, and parafoveal cystic change, and also measured the central retinal thickness and macular volume. The association of these factors with improvement of vision (logarithm of the minimum angle of resolution, logMAR) was investigated. RESULTS: Eyes were classified as having cystoid macular edema (CME, n = 52), serous retinal detachment (n = 24), or diffuse diabetic macular edema (n = 4). In eyes with CME, the mean logMAR of visual acuity improved significantly (P = 0.003) from 0.35 ± 0.31 at baseline to 0.29 ± 0.29 after 2 months. However, there was no significant improvement of visual acuity in the eyes with serous retinal detachment or diffuse diabetic macular edema after sub-Tenon injection of triamcinolone acetonide (P = 0.549 and P = 0.545, respectively). The central retinal thickness and macular volume were both reduced significantly after sub-Tenon injection of triamcinolone acetonide in eyes with CME and serous retinal detachment. However, improvement of visual acuity in the eyes with CME was not correlated with the reduction of central retinal thickness or macular volume. Parafoveal cystic changes showed significant improvement after sub-Tenon injection of triamcinolone acetonide in eyes with CME. Photoreceptor status was significantly associated with the visual prognosis in eyes with CME, but not in eyes with serous retinal detachment. CONCLUSION: Visual acuity improved significantly after sub-Tenon injection of triamcinolone acetonide without photoreceptor recovery in eyes with CME. Improvement of parafoveal cystic changes in the eyes with CME suggests that bipolar cells or their accessory cells might have displayed functional recovery.

Factors affecting imaging of spectral-domain optical coherence tomography in gas-filled eyes after macular-hole surgery.

PURPOSE: We investigated factors affecting imaging of spectral-domain optical coherence tomography (SD-OCT) in gas-filled eyes after macular-hole (MH) surgery. METHODS: The study comprised 25 eyes in 23 patients, eight men and 15 women, with a mean age of 66.9 (48-77) years, all of whom had undergone vitrectomy for MH. Sulfur hexafluoride (SF(6)) gas was used as a tamponade, and the patients were maintained in a prone position after surgery. The SD-OCT imaging was performed on postoperative days 1 and 2. RESULTS: The success rate of imaging was 88.0% (22/25 eyes) on postoperative day 1 and 95.8% (23/24 eyes) on postoperative day 2. The rate of MH closure in successful imaging cases was 81.8% (18 eyes) on postoperative day 1 and 95.7% (22 eyes) on postoperative day 2. The imaging accuracy in gas-filled eyes increased by setting the focus value of the OCT to a myopic refractive shift. CONCLUSION: The imaging of many gas-filled eyes following MH surgery is possible, even at the early postoperative stage, by setting the focus value of the OCT to a myopic refractive shift.

[Evaluation of recovery process of photoreceptor outer segment after retinal detachment repair].

PURPOSE: To evaluate the relations in the recovery process between the photoreceptor outer segment and visual acuity of repaired macula-off rhegmatogenous retinal detachment (RRD), using spectral-domain optical coherence tomography (SD-OCT). SUBJECTS AND METHODS: Twenty-three eyes with repaired macula-off RRD were examined to assess the photoreceptor inner and outer segment junctions (IS/OS), the external limiting membranes (ELM) and the thickness of the outer nuclear layer (ONL). The correlation between this recovery process and log MAR visual acuity was assessed at three months and six months after surgery. RESULTS: The mean logMAR visual acuity of the group with IS/OS disruptions at three months and without IS/OS disruptions at six months was 0.34 +/-0.09 (mean +/- SE, n=7) at three months and significantly improved to 0.06 +/- 0.08 at six months. In the group with IS/OS disruptions and without ELM disruptions at three months, the mean logMAR visual acuity was 0.36 +/- 0.27 (n=6) at three months and improved significantly to 0.07 +/- 0.24 at six months. CONCLUSIONS: There was a correlation between the reduction of visual acuity with repaired macula-off RRD and the disruption of IS/OS, and a correlation was also found between the improvement in visual acuity after repaired macula-off rhegmatogenous retinal detachment and reduction of IS/OS disruptions. The results suggest that absence of ELM disruptions is a requirement for improvement of IS/ OS disruptions.

Classification of Duane's retraction syndrome: two additional electromyogram types.

BACKGROUND: Huber's clinical and electromyographical classifications of Duane's retraction syndrome have been considered to correspond to each other. However, cases that do not correspond to these classifications have been reported recently. CASES: Retrospectively, we tried to classify the clinical types and electromyogram types of 17 eyes (15 cases) with Duane's retraction syndrome according to Huber's classification. OBSERVATIONS. Eleven eyes could not be classified into any of Huber's electromyogram types. Among these eyes, two major additional electromyogram patterns were newly classified: a center-peak type, in which the lateral rectus or medial rectus muscle showed maximum activity in the primary position; and a type with continuous lateral rectus muscle discharge. Some minor electromyogram patterns were also recorded. CONCLUSION: The wide variation in these electromyogram patterns may be due to the diversity of the lesions in Duane's retraction syndrome, which can be the result of muscular, nuclear, internuclear, or supranuclear failure.