Risk Factors for Meeting Criteria for Switching from Bevacizumab to Aflibercept When Treating Eyes with Diabetic Macular Edema and Visual Acuity of < 20/40.

PURPOSE: To identify factors for meeting prespecified criteria for switching from bevacizumab to aflibercept in eyes with center-involved diabetic macular edema (CI-DME) and moderate vision loss initially treated with bevacizumab in DRCR Retina Network protocol AC. DESIGN: Post hoc analysis of data from a randomized clinical trial. PARTICIPANTS: Two hundred seventy participants with one or both eyes harboring CI-DME with visual acuity (VA) letter score of 69 to 24 (Snellen equivalent, 20/50-20/320). METHODS: Eligible eyes were assigned to receive intravitreal aflibercept monotherapy (n = 158) or bevacizumab followed by aflibercept if prespecified criteria for switching were met between 12 weeks and 2 years (n = 154). MAIN OUTCOME MEASURES: Meeting switching criteria: (1) at any time, (2) at 12 weeks, and (3) after 12 weeks. Associations between meeting the criteria for switching and factors measured at baseline and 12 weeks were evaluated in univariable analyses. Stepwise procedures were used to select variables for multivariable models. RESULTS: In the group receiving bevacizumab first, older participants showed a higher risk of meeting the switching criteria at any time, with a hazard ratio (HR) for a 10-year increase in age of 1.32 (95% confidence interval [CI], 1.11-1.58). Male participants or eyes with worse baseline VA were more likely to switch at 12 weeks (for male vs. female: odds ratio [OR], 4.84 [95% CI, 1.32-17.81]; 5-letter lower baseline VA: OR, 1.30 [95% CI, 1.03-1.63]). Worse 12-week central subfield thickness (CST; 10-µm greater: HR, 1.06 [95% CI, 1.04-1.07]) was associated with increased risk of switching after 12 weeks. The mean ± standard deviation improvement in visual acuity after completing the switch to aflibercept was 3.7 ± 4.9 letters compared with the day of switching. CONCLUSIONS: The identified factors can be used to refine expectations regarding the likelihood that an eye will meet protocol criteria to switch to aflibercept when treatment is initiated with bevacizumab. Older patients are more likely to be switched. At 12 weeks, thicker CST was predictive of eyes most likely to be switched in the future. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

The 0.19-mg Fluocinolone Acetonide Intravitreal Implant Reduces Treatment Burden in Diabetic Macular Edema.

PURPOSE: To assess treatment burden in patients with diabetic macular edema (DME) after the 0.19-mg fluocinolone acetonide (FAc) intravitreal implant (ILUVIEN). DESIGN: Prospective and retrospective analyses of a 36-month, phase 4, open-label, observational study. METHODS: Setting: Multicenter. PATIENT POPULATION: Included patients had DME and previously received corticosteroid treatment without a clinically significant rise in intraocular pressure (IOP) (N = 202 eyes in 159 patients). Patients were not randomized. OBSERVATION PROCEDURES: Prospective, observational treatment burden data were analyzed for their relationship to safety and functional efficacy outcomes across 36 months. MAIN OUTCOME MEASURES: Outcomes included the mean number of yearly treatments, supplemental-free probability over time, best-corrected visual acuity, and monitoring of IOP-related events. RESULTS: Over 36 months, the mean number of yearly treatments decreased from 3.5 before FAc to 1.7 after FAc; at 36 months, 68.3% of patients required 0 to 2 treatments per year. After FAc, the percentage of eyes requiring supplemental therapy decreased vs before FAc (P < .0001 for each). Through 36 months, 25% of FAc-treated eyes did not require supplemental treatment. At 36 months, mean best-corrected visual acuity increased by 4.5 letters vs a decline of 6.4 letters in the 36 months before FAc. IOP elevations >25 mm Hg occurred in 18.2% of eyes that did not receive supplemental treatment after FAc vs 27.2% of eyes that received supplemental treatments, which included additional intraocular steroids. CONCLUSIONS: Over 36 months, the FAc implant is associated with improved visual outcomes and better disease control as measured by a significant reduction in yearly treatment burden in patients with DME.

Bilateral Lupus Chorioretinopathy in a Patient With Active Systemic Lupus Erythematosus.

Ocular involvement is commonly seen in systemic lupus erythematosus (SLE). However, chorioretinopathy is an easily missed ocular manifestation of SLE. Early recognition and a multidisciplinary treatment approach can play a key role in reducing the ocular and systemic morbidity seen with this condition. This case report describes a patient with active SLE who presented with bilateral lupus chorioretinopathy. The patient demonstrated a significant improvement in ocular symptoms once the systemic disease was controlled.

360° retinectomy for the treatment of complex retinal detachment.

PURPOSE: To review the anatomical and functional outcomes of eyes that underwent 360° retinectomy for a variety of indications and compare them with previously published results. METHODS: Retrospective case series. We reviewed the data of 40 patients (41 eyes) who underwent pars plana vitrectomy and 360° retinectomy. The principal indication for surgery in this series was retinal detachment after penetrating trauma (26 of 41 eyes [63%]). Anatomical success was defined as complete retinal reattachment or attachment posterior to the scleral buckle, if present. RESULTS: Thirty of the 41 eyes (73%) had follow-up of at least 6 months after 360° retinectomy, and of these, 11 eyes (37%) had recurrent retinal detachment. Seven of the latter eyes underwent repeat pars plana vitrectomy with anatomical success in 6 eyes (86%). Overall, anatomical success was achieved in 25 of 30 eyes (83%) with follow-up of ≥ 6 months after ≥ 1 operations (including 360° retinectomy). Visual results were limited with only 4 of 35 eyes (11%) in which visual acuity could be tested achieving ambulatory vision, which may reflect the preponderance of posttraumatic retinal detachments in this series. CONCLUSION: The anatomical results of this series are comparable with those in the reported literature and indicate that vitrectomy with 360° retinectomy can be beneficial in the management of complex retinal detachments in otherwise unsalvageable eyes.

Diabetic macular edema: pathogenesis and treatment.

Diabetic macular edema is a major cause of visual impairment. The pathogenesis of macular edema appears to be multifactorial. Laser photocoagulation is the standard of care for macular edema. However, there are cases that are not responsive to laser therapy. Several therapeutic options have been proposed for the treatment of this condition. In this review we discuss several factors and mechanisms implicated in the etiology of macular edema (vasoactive factors, biochemical pathways, anatomical abnormalities). It seems that combined pharmacologic and surgical therapy may be the best approach for the management of macular edema in diabetic patients.

Penetrating trauma associated with findings of multiple evanescent white dot syndrome in the second eye: coincidence or an atypical case of sympathetic ophthalmia?

PURPOSE: To report a case of sympathetic ophthalmia (SO) resembling multiple evanescent white dot syndrome (MEWDS). METHODS: Retrospective chart review. RESULTS: A 17-year-old girl with a ruptured globe in the right eye underwent prompt primary repair and vitrectomy, scleral buckling, and silicone oil infusion 3 weeks later. Eight weeks after injury, she presented with visual loss in the left eye. Fundus examination in the left eye disclosed optic disk swelling and well-circumscribed, 100 to 500 microm diameter gray-white lesions at the level of the retinal pigment epithelium (RPE) posterior to the equator, sparing the fovea. On fluorescein angiography, the lesions appeared as areas of blocked choroidal fluorescence in the arterial phase and were associated with dye leakage in a wreathlike pattern during venous filling. Dye leakage occurred at the optic disk. Visual field testing showed depressed central sensitivity and an enlarged blind spot in the left eye. The patient was treated with prednisone and underwent diagnostic enucleation of the right eye. Histopathology showed rare choroidal granulomata and pigment phagocytosis. Vision improved to 20/20 in the left eye, and the window defects persisted. Visual field testing 6 months later was normal. One month after discontinuing prednisone, new areas of RPE hypopigmentation developed. Two weeks later, choroidal inflammation recurred and periphlebitis developed. CONCLUSION: This case indicates that SO can mimic MEWDS.

A new technique for suture fixation of posterior chamber intraocular lenses that eliminates intraocular knots.

PURPOSE: The aim of this study was to describe a new technique for transscleral suturing of posterior chamber intraocular lenses (PCIOLs) without intraocular knots. DESIGN: Retrospective noncomparative case series. PARTICIPANTS: Twenty-four eyes underwent implantation of PCIOLs with this new technique. METHODS: Suture fixation of PCIOLs was performed in eyes without capsular support. MAIN OUTCOME MEASURES: The anatomic and functional outcome of surgery was determined during a follow-up of 2 to 40 months. RESULTS: The PCIOL remained well centered without tilt in 22 of 24 (92%) eyes. The PCIOL was well centered in 16 of 17 (94%) eyes followed for > or =6 months. Complications related to lens suturing were minimal and resolved spontaneously. Final visual outcome depended almost entirely on the underlying health of the retina and optic nerve. CONCLUSION: This technique eliminates intraocular knots, minimizes operating time with an open globe, and provides excellent lens centration in the absence of capsular support.

Pars plana vitrectomy for refractory diabetic macular edema.

OBJECTIVE: The aim of this study is to describe the results of pars plana vitrectomy (PPV) for refractory diabetic macular edema (DME). METHODS: Review of the relevant peer-reviewed scientific literature identified using Medline. MAIN OUTCOME MEASURES: The anatomical and functional outcome of surgery. RESULTS: Vitrectomy with or without internal limiting membrane (ILM) peeling can be beneficial for the treatment of DME that is resistant to laser photocoagulation or sub-Tenon's steroid injection. Visual improvement has been reported in approximately 40-90% of patients, with approximately 85-100% experiencing either improvement or stabilization of vision. Retinal edema decreases or resolves in approximately 70-100% of patients. Complications range in severity with approximately 5-20% of patients developing peripheral retinal breaks, approximately 1-2% developing retinal detachment, approximately 2% developing macular hole, and approximately 10-60% developing cataract. Severe complications such as rubeosis iridis and the fibrinoid syndrome have also been reported. CONCLUSION: Pars plana vitrectomy can be an effective treatment for diabetic macular edema refractory to laser therapy and/or sub-Tenon's capsule steroid injection.

Management of traumatic hyphema.

Hyphema (blood in the anterior chamber) can occur after blunt or lacerating trauma, after intraocular surgery, spontaneously (e.g., in conditions such as rubeosis iridis, juvenile xanthogranuloma, iris melanoma, myotonic dystrophy, keratouveitis (e.g., herpes zoster), leukemia, hemophilia, von Willebrand disease, and in association with the use of substances that alter platelet or thrombin function (e.g., ethanol, aspirin, warfarin). The purpose of this review is to consider the management of hyphemas that occur after closed globe trauma. Complications of traumatic hyphema include increased intraocular pressure, peripheral anterior synechiae, optic atrophy, corneal bloodstaining, secondary hemorrhage, and accommodative impairment. The reported incidence of secondary anterior chamber hemorrhage, that is, rebleeding, in the setting of traumatic hyphema ranges from 0% to 38%. The risk of secondary hemorrhage may be higher in African-Americans than in whites. Secondary hemorrhage is generally thought to convey a worse visual prognosis, although the outcome may depend more directly on the size of the hyphema and the severity of associated ocular injuries. Some issues involved in managing a patient with hyphema are: use of various medications (e.g., cycloplegics, systemic or topical steroids, antifibrinolytic agents, analgesics, and antiglaucoma medications); the patient's activity level; use of a patch and shield; outpatient vs. inpatient management; and medical vs. surgical management. Special considerations obtain in managing children, patients with hemoglobin S, and patients with hemophilia. It is important to identify and treat associated ocular injuries, which often accompany traumatic hyphema. We consider each of these management issues and refer to the pertinent literature in formulating the following recommendations. We advise routine use of topical cycloplegics and corticosteroids, systemic antifibrinolytic agents or corticosteroids, and a rigid shield. We recommend activity restriction (quiet ambulation) and interdiction of non-steroidal anti-inflammatory agents. If there is no concern regarding compliance (with medication use or activity restrictions), follow-up, or increased risk for complications (e.g., history of sickle cell disease, hemophilia), outpatient management can be offered. Indications for surgical intervention include the presence of corneal blood staining or dangerously increased intraocular pressure despite maximum tolerated medical therapy, among others.