Predictive Factors Influencing the Evolution of Acquired Vitelliform Lesions in Intermediate Age-Related Macular Degeneration Eyes.

PURPOSE: In this study, we identify risk factors that predict the progression of acquired vitelliform lesions (AVLs) over time. DESIGN: Retrospective cohort study. SUBJECTS: One hundred sixty-three eyes of 132 patients with a diagnosis of intermediate age-related macular degeneration (iAMD) with AVL. METHODS: This retrospective study evaluated consecutive eyes with AMD from a retina clinic population and included 1181 patients and 2362 eyes. After excluding cases with associated geographic atrophy, macular neovascularization (MNV), vitreomacular traction, and those with <2 years of follow-up data, the final analysis cohort consisted of 163 eyes (132 patients) with ≥1 AVL. The first available visit in which an AVL was evident was considered the baseline visit, and follow-up data were collected from a visit 2 years (± 3 months) later. Progression outcomes at the follow-up visit were classified into 6 categories: resorbed, collapsed, MNV, stable, increasing, and decreasing. Subsequently, we analyzed the baseline characteristics for each category and calculated odds ratios (ORs) to predict these various outcomes. MAIN OUTCOME MEASURES: The study focused on identifying predictive factors influencing the evolution of AVL in iAMD eyes. RESULTS: In total, 163 eyes with AVL had follow-up data at 2 years. The collapsed group demonstrated a significantly greater baseline AVL height and width compared with other groups (P < 0.001). With regard to qualitative parameters, subretinal drusenoid deposits (SDDs) and intraretinal hyperreflective foci (IHRF) at the eye level, AVL located over drusen, and IHRF and external limiting membrane disruption over AVL were significantly more prevalent in the collapsed group compared with other groups (P < 0.05 for all comparisons). Odds ratios for progressing to atrophy after 2 years of follow-up, compared with the resorbed group, were significant for SDD (OR, 2.82; P = 0.048) and AVL height (OR, 1.016; P = 0.006). CONCLUSIONS: The presence of SDDs and greater AVL height significantly increases the risk of developing atrophy at the location of AVL after 2 years of follow-up. These findings may be of value in risk prognostication and defining patient populations for inclusion in future early intervention trials aimed at preventing progression to atrophy. FINANCIAL DISCLOSURES: Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Acquired Vitelliform Lesions in Intermediate Age-Related Macular Degeneration: A Cross Sectional Study.

PURPOSE: This study aims to define the characteristics of acquired vitelliform lesions (AVLs) in patients with intermediate age-related macular degeneration (iAMD). DESIGN: Retrospective, observational, cross sectional study. SUBJECTS: This study included 217 eyes with AVLs associated with iAMD, and an equivalent number of control patients. METHODS: OCT scans were evaluated for qualitative and quantitative parameters at both the eye and lesion level. Eye-level parameters included the presence of: hyporeflective core drusen, intraretinal hyperreflective foci (IHRF), subretinal drusenoid deposits, macular pachyvessels, central retinal thickness, and central choroidal thickness. Lesion-level qualitative parameters included the presence of ellipsoid zone (EZ) and external limiting membrane disruption overlying the AVL, IHRF overlying the AVL, AVL overlying drusen, pachyvessels under the AVL, a solid core within AVL, and AVL location. Lesion-level quantitative characteristics included AVL height and width, AVL distance from the fovea, and sub-AVL choroidal thickness. MAIN OUTCOME MEASURES: The primary outcomes assessed included the frequency of IHRF, the presence of macular pachyvessels, central choroidal thickness, and the dimensions (both height and width) of AVLs. RESULTS: Comparing the AVL and control groups, the frequency of IHRF (AVL: 49.3% vs. control: 26.3%) and macular pachyvessels (37.3% vs. 6.9%) was significantly higher in the AVL case group, and the central choroidal thickness (256.8 ± 88 µm vs. 207.1± 45 µm) was thicker in the AVL group. Acquired vitelliform lesions located over drusen, with overlying IHRF, or situated subfoveally, and AVL lesions with EZ disruption were found to have a greater lesion height and width compared with AVL lesions lacking these characteristics (P value < 0.001 for all). Additionally, a significant negative correlation was observed between the distance from the fovea and AVL height (Spearman rho: -0.19, P = 0.002) and width (Spearman rho: -0.30, P = 0.001). CONCLUSIONS: This study represents the largest reported cohort of AVL lesions associated with iAMD. Novel findings include the higher frequency of pachyvessels in addition to the presence of a thicker choroid in these eyes, as well as the greater height and width of AVL closer to the foveal center. These findings may offer insights into pathophysiologic mechanisms underlying the development of AVL. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Current Management of Subretinal Hemorrhage in Neovascular Age-Related Macular Degeneration.

Age-related macular degeneration (AMD) is the leading cause of irreversible vision loss among individuals aged 65 years and older in the USA. For individuals diagnosed with AMD, approximately 12% experience varying levels of subretinal hemorrhage (SRH), which can be further classified by size into small, medium, and massive measured in disc diameters. SRH is an acute and rare sight-threatening complication characterized by an accumulation of blood under the retina arising from the choroidal or retinal circulation. Released iron toxins, reduced nutrient supply, fibrin meshwork contraction, and outer retinal shear forces created by SRH contribute to visual loss, macular scarring, and photoreceptor damage. SRH treatment strategies aim to displace hemorrhage from the foveal region and prevent further bleeding. Although there are no standardized treatment protocols for SRH, several surgical and nonsurgical therapeutical approaches may be employed. The most common surgical approaches that have been utilized are pars plana vitrectomy (PPV) combined with multiple maneuvers such as the removal of choroidal neovascularization lesions, macular translocation, retinal pigment epithelium patch repair, SRH drainage, intravitreal injection of recombinant-tissue plasminogen activator (tPA), expansile gas and air displacement, and anti-vascular endothelial growth factor (anti-VEGF) injections. Nonsurgical therapeutical approaches include intravitreal anti-VEGF monotherapy, intravitreal tPA administration without PPV, and photodynamic therapy. This review article aims to explore the current treatment strategies and supporting literature regarding both surgical and nonsurgical, of SRH in patients with AMD. Moreover, this article also aims to highlight the distinct treatment modalities corresponding to different sizes of SRH.

Analysis of Publication Productivity and Academic Rank of Ophthalmology Residency Program Directors in the United States.

PURPOSE: Female ophthalmologists are underrepresented in the field of ophthalmology. This study aimed to analyze the gender differences among ophthalmology residency program directors (PDs) in the United States with respect to academic rank, number of publications, and h-index. METHODS: This cross-sectional study evaluated 120 ophthalmology residency PDs from 120 ophthalmology residency programs during the 2022 San Francisco Match. The gender information was collected from institutional websites. The information regarding the state of each institute, academic rank, degree (MD or DO), age, and publication productivity was also recorded. RESULTS: From the 120 residency programs, 120 ophthalmology residency PDs were identified. Most PDs had an MD degree (118 out of 120, 98.3%), while only a few had a DO degree (2 out of 120, 1.7%). Only 31 (25.8%) out of 120 residency PDs were female. There was a statistically significant difference between female residency PDs and male residency PDs (p<0.0001). Male PDs had a higher h-index (15.2 ± 1.2) compared to their female counterparts (11.9 ± 0.97) (p=0.003). Regarding academic rank, male PD number was higher in each category, including assistant professor, associate professor, and full professor. CONCLUSIONS: United States ophthalmology residency programs have a smaller portion of females compared to male PDs. Furthermore, full professors are more likely to be male, and males have higher publication productivity in terms of h-index. To promote equality among ophthalmologists, future initiatives should focus on addressing the gender disparities in ophthalmology residency programs and the selection of residency PDs.

Gender Disparities Among Academic Vitreoretinal Specialists in the United States With Regard to Scholarly Impact and Academic Rank.

Background and objective While men outnumber women in the specialty of ophthalmology in general, the subspecialty of vitreoretinal surgery in particular has the highest percentage of men across all ophthalmic subspecialties. This study aimed to analyze the gender disparities regarding the publication productivity and academic rank of academic vitreoretinal specialists in the United States (US). Methods This cross-sectional study evaluated 116 ophthalmology residency programs in the US participating in the 2022 San Francisco Match. The academic vitreoretinal faculty from each ophthalmology residency program was included. The information on gender, academic rank, and publication activity in terms of the h-index were collected from institutional websites, the Scopus database, and the National Library of Medicine PubMed website. Results A total of 467 academic vitreoretinal specialists were identified. Among them, 345 (73.9%) were men, and 122 (26.1%) were women (p<0.001). When the academic ranks were analyzed, a higher number of men (43.8%) were found to hold the rank of full professor as compared to women. Furthermore, a higher number of women (47.5%) were found to hold the rank of assistant professor as compared to their male colleagues. Regarding the number of publications, in all academic rank categories, women had a significantly lower number of publications compared to men (p<0.001). Men also had a higher publication productivity or scholarly impact [h-index=15.2 ± 0.82 standard error of the mean (SEM)] compared to women (h-index=12.8 ± 0.99 SEM) (p=0.0004). Higher h-index correlated with higher academic rank, from assistant professor through full professor (p<0.001). Conclusion The field of vitreoretinal surgery has significantly fewer women compared to men, with women producing fewer publications and having less scholarly impact. H-index and total number of publications are also associated with a higher academic rank. Furthermore, full professors are more likely to be men, while assistant professors are more likely to be women. Future efforts should be aimed at reducing the gender disparity in vitreoretinal surgery.

Use of Informational Brochures on Knowledge of Cataracts in Rural Ecuador.

Background Cataracts are the leading global cause of preventable blindness. Despite the high prevalence of cataracts in rural Ecuadorian communities, no community-wide educational efforts on the impact of cataract-related blindness have been attempted. This study used an educational brochure to assess individual knowledge of cataract blindness before and after the distribution of the brochure. Methods We conducted electronic surveys with 100 patients over the age of 18 who visited the Fundacion Internacional Buen Samaritano Paul Martel (FIBUSPAM) clinic serving the Chimborazo region of Ecuador. Participation in the study included an introduction and written consent followed by a pre-survey. Every patient was given a brochure. After reviewing the brochure, patients were then asked to complete the same survey again. Each survey question received one mark. Knowledge was considered "good" if the subject correctly answered four out of seven questions and "poor" if they scored ≤3. Results Of the 100 patients, 21 had poor knowledge surrounding cataracts. Cataract awareness was lowest in the group without formal education (50%). In addition, 17 participants demonstrated poor knowledge before the informational brochure was distributed, and all improved to "good" knowledge after. Following brochure distribution, there was an improved knowledge of cataract anatomy (correct answer: 32.9% to 94.6%), treatment of cataracts (80% to 95.9%), cataract symptoms (36.7% to 95.9%), age at risk (88.8% to 97.3%), and relationship to blindness (93.5% to 98.6%). In contrast, overall knowledge of the risk factors for cataracts (46.8% to 37%) and prevention of the onset of the cataract (81.3% to 77%) slightly decreased after the brochure was given. Overall, the increase in the number of correct answers after the brochure was not significant (p = 0.25). Conclusions To our knowledge, this is a rare study to assess the effect of informational brochures on cataract knowledge in rural Ecuador. This study was limited by selection bias and did not look at the long-term recall of knowledge. The results of this study suggest that brochures can improve health awareness; however, brochures alone may not be enough. Additional assessments on the use of oral and visual aids are needed. Health education efforts should go beyond simple brochures and focus on innovative strategies to improve health education and communication efforts.

Single versus double Perclose techniques for vascular closure during transfemoral transcatheter aortic valve replacement.

INTRODUCTION: The preferred approach for transcatheter aortic valve replacement (TAVR) is transfemoral. There has been widespread adoption of the Perclose ProglideTM device for vascular closure. Typically, two devices are deployed before upsizing the access sheath in the "preclose technique." Prior investigations have compared the use of a single device versus double device technique, but none have shown significant clinical benefit to either approach. METHODS: Five hundred and six patients underwent transfemoral TAVR (TF-TAVR) with single or double Perclose devices for vascular closure from July 2015 to February 2020. A retrospective review was conducted, and propensity-matched analyses were used to account for differences in baseline characteristics. RESULTS: In the matched analysis, there were 251 patients in the single Perclose group and 238 in the double. There was a statistically significant improvement in overall procedural success using the single closure device (94.6% vs. 88.5%, p = 0.009) This was defined as intraprocedural hemostatic control, lack of contrast extravasation, arterial dissection, occlusion, or stenosis >50% in the final crossover angiogram, as well as unimpaired limb perfusion without claudication throughout the index hospitalization. There was also a significant improvement in arterial dissection rates (0.6% vs. 4.6%, p = 0.004), stenosis >50% (1.3% vs. 4.4%, p = 0.028), and Valve Academic Research Consortium major vascular complications (1.8% vs. 4.9%, p = 0.038). CONCLUSION: A single Perclose device is a safe means of vascular closure during TF-TAVR and may have important clinical benefits compared to the commonly used two-device technique.

Clinical management of uveal melanoma: a comprehensive review with a treatment algorithm.

Uveal melanoma (UM), the most frequently occurring non-cutaneous melanoma and most common primary intraocular malignancy in adults, arises from the melanocytes of the choroid in approximately 95% of cases. Prompt diagnosis and treatment is vital as primary tumor size is one of the key factors associated with survival. Despite recent advances in management, more than half of the patients develop metastatic disease which portends poor survival. Currently, treatment options for UM include local resection, enucleation, plaque brachytherapy, and/or particle beam radiotherapy (RT). Enucleation was initially the standard of care in the management of UM, but a shift towards eye-preserving therapeutic choices such as RT and local resection has been noted in recent decades. Plaque brachytherapy, a form of localized RT, is the most popular option and is now the preferred treatment modality for UM. In this review we discuss the etiopathogenesis, clinical presentation and diagnosis of UM and place a special emphasis on therapeutic options. Furthermore, we review the current literature on UM management and propose a functional treatment algorithm for non-metastatic disease.

Heme Oxygenase-1 dictates innate - adaptive immune phenotype in human liver transplantation.

Liver transplantation (LT) has become the standard of care for patients with end-stage liver disease and those with hepatic malignancies, while adaptive immune-dominated graft rejection remains a major challenge. Despite potent anti-inflammatory and cytoprotective functions of heme oxygenase-1 (HO-1) overexpression upon innate immune-driven hepatic ischemia reperfusion injury, its role in adaptive immune cell-driven responses remains to be elucidated. We analyzed human biopsies from LT recipients (n = 55) to determine putative association between HO-1 levels and adaptive/co-stimulatory gene expression programs in LT. HO-1 expression negatively correlated with innate (CD68, Cathepsin G, TLR4, CXCL10), adaptive (CD4, CD8, IL17) and co-stimulatory (CD28, CD80, CD86) molecules at the graft site. LT recipients with high HO-1 expression showed a trend towards improved overall survival. By demonstrating the association between graft HO-1 levels and adaptive/co-stimulatory gene programs, our study provides important insights to the role of HO-1 signaling in LT patients.

Recipient HO-1 inducibility is essential for posttransplant hepatic HO-1 expression and graft protection: From bench-to-bedside.

By documenting potent antioxidative and anti-inflammatory functions, preclinical studies encourage heme oxygenase-1 (HO-1)-inducing regimens in clinical orthotopic liver transplantation (OLT). We aimed to determine the importance of recipient-derived HO-1 in murine and human OLTs. Hepatic biopsies from 51 OLT patients were screened for HO-1 expression (Western blots) prior to put-in (basal) and post reperfusion (stressed) and correlated with the hepatocellular function. In parallel, livers from HO-1 proficient mice (WT; C57/BL6), subjected to ex vivo cold storage (18 hour), were transplanted to syngeneic myeloid HO-1 deficient (mHO-1 KO) or FLOX (control) hosts, and sampled postreperfusion (6 hour). In human OLT, posttransplant but not pretransplant HO-1 expression correlated negatively with ALT levels (P = .0178). High posttransplant but not pretransplant HO-1 expression trended with improved OLT survival. Compared with controls, livers transplanted into mHO-1 KO recipient mice had decreased HO-1 levels, exacerbated hepatic damage/frequency of TUNEL+ cells, increased mRNA levels coding for TNFα/CXCL1/CXCL2/CXCL10, higher frequency of Ly6G+/4HN+ neutrophils; and enhanced MPO activity. Peritoneal neutrophils from mHO-1 KO mice exhibited higher CellRox+ ratio and increased TNFα/CXCL1/CXCL2/CXCL10 expression. By demonstrating the importance of posttransplant recipient HO-1 phenotype in hepatic macrophage/neutrophil regulation and function, this translational study identifies recipient HO-1 inducibility as a novel biomarker of ischemic stress resistance in OLT.