An artificial intelligence system for the whole process from diagnosis to treatment suggestion of ischemic retinal diseases.

Ischemic retinal diseases (IRDs) are a series of common blinding diseases that depend on accurate fundus fluorescein angiography (FFA) image interpretation for diagnosis and treatment. An artificial intelligence system (Ai-Doctor) was developed to interpret FFA images. Ai-Doctor performed well in image phase identification (area under the curve [AUC], 0.991-0.999, range), diabetic retinopathy (DR) and branch retinal vein occlusion (BRVO) diagnosis (AUC, 0.979-0.992), and non-perfusion area segmentation (Dice similarity coefficient [DSC], 89.7%-90.1%) and quantification. The segmentation model was expanded to unencountered IRDs (central RVO and retinal vasculitis), with DSCs of 89.2% and 83.6%, respectively. A clinically applicable ischemia index (CAII) was proposed to evaluate ischemic degree; patients with CAII values exceeding 0.17 in BRVO and 0.08 in DR may be associated with increased possibility for laser therapy. Ai-Doctor is expected to achieve accurate FFA image interpretation for IRDs, potentially reducing the reliance on retinal specialists.

Distribution of leakage index using ultra-widefield fluorescein angiography in patients with non-ischemic branch retinal vein occlusion and its association with macular edema.

BACKGROUND: To investigate the distribution of leakage index in patients with non-ischemic branch retinal vein occlusion (BRVO) and its correlation with the severity of macular edema. METHODS: Retrospective observational study. Forty-five eyes of 45 patients with BRVO were included. Late ultra-widefield fluorescein angiography images of the affected eyes were processed and analyzed for their leakage index using Fiji software. The visible panretinal area was further divided into the peri­macular area (PMA), near-peripheral area (NPA), midperipheral area (MPA), and far-peripheral area (FPA). The relationship between the leakage index and central retinal thickness (CMT) was analyzed for the panretina and each subregion. RESULTS: The median (interquartile range) leakage indexes of the panretina, PMA, NPA, MPA, and FPA were 5.532% (7.667%), 23.127% (26.073%), 8.303% (16.807%), 1.588% (6.204%), and 0.408% (2.215%), respectively, with a mean CMT of 552.800 ± 183.335 µm. The CMT was positively correlated with the leakage index in the panretina, PMA, NPA, MPA and FPA (r = 0.468, 0.426, 0.463, 0.447, 0.320, respectively; all p < 0.05). CONCLUSIONS: The leakage index in non-ischemic BRVO patients is associated with macular edema severity. The leakage index has the potential to be a useful indicator for monitoring and guiding treatment of macular edema in BRVO patients.

Retinal Vascular Occlusion and Underlying Generalized Vascular Diseases. / Retinale Gefäßverschlüsse als Ausdruck eines generalisierten Gefäßleidens.

Retinal vascular occlusion not only threatens vision loss but is also associated with other systemic risk factors and vascular diseases. Interdisciplinary cooperation is of great importance in these patients. The risk factors hardly differ between arterial and venous retinal occlusions, which is due to the special anatomy of retinal vessels. Major underlying conditions associated with retinal vascular occlusion include arterial hypertension, diabetes mellitus, dyslipidemia, cardiac disease, particularly atrial fibrillation, or vasculitis of large- and middle-sized arteries. Every new diagnosed retinal vascular occlusion should therefore be taken as an occasion to search for risk factors and possibly adjust an already existing therapy in order to prevent further vascular events.

Update on Retinal Vein Occlusion.

Retinal vein occlusion represents the second leading cause of retinal vascular disorders, with a uniform sex distribution worldwide. A thorough evaluation of cardiovascular risk factors is required to correct possible comorbidities. The diagnosis and management of retinal vein occlusion have changed tremendously in the last 30 years, but the assessment of retinal ischemia at baseline and during follow-up examinations remains crucial. New imaging techniques have shed light on the pathophysiology of the disease and laser treatment, once the only therapeutic option, is now only one of the possible approaches with antivascular endothelial growth factors and steroid injections being preferred in most cases. Nowadays long-term outcomes are better than those achievable 20 years ago and yet, many new therapeutic options are under development, including new intravitreal drugs and gene therapy. Despite this, some cases still develop sight-threatening complications deserving a more aggressive (sometimes surgical) approach. The purpose of this comprehensive review is to reappraise some old but still valid concepts and to integrate them with new research and clinical data. The work will provide an overview of the disease's pathophysiology, natural history, and clinical features along with a detailed discussion on the advantages of multimodal imaging and of the different treatment strategies with the aim of providing retina specialists with the most updated knowledge in the field.

Neovascular Glaucoma: An Update.

Neovascular glaucoma (NVG) is a severe type of secondary glaucoma with devastating complications and generally poor visual prognosis. NVG is defined by the development of pathological neovessels over the iris and the iridocorneal angle that can block the outflow of aqueous humor, causing elevation of intraocular pressure (IOP). The pathogenesis of NVG is, in most cases, associated with ischemia of the posterior segment, which is most frequently associated with proliferative diabetic retinopathy or central retinal vein occlusion. The advanced stages of NVG are by iris and angle neovascularization, angle, and extremely high IOP, accompanied by ocular pain and poor vision. The therapeutic approach of NVG is based on the reduction of retinal ischemia by panretinal photocoagulation. Intravitreal anti-VEGF administration can contribute to the regression of neovascularization, and topical and systemic medications may be necessary for IOP control. However, if medical treatment with these agents is not enough, surgical procedures may be required to lower IOP and prevent glaucomatous optic neuropathy. Early and prompt diagnosis, with identification of the underlying etiology, can improve IOP control and final visual outcome. The aim of this study is to review current knowledge of the pathogenesis and management of NVG.

Ranibizumab intravítreo para el tratamiento de oclusiones vasculares retinianas: análisis mediante tomografía de coherencia óptica / Intravitreal Ranibizumab for the Treatment of Retinal Vascular Occlusions: Analysis Using Optical Coherence Tomography

Introducción: El uso del medicamento ranibizumab intravítreo favorece la reducción del edema macular generador de las oclusiones vasculares retinianas causantes de la pérdida visual. Objetivo: Evaluar la eficacia y seguridad de la administración intravítreo de ranibizumab en el cambio de espesor macular central en las oclusiones vasculares retinianas analizado mediante tomografía de coherencia óptica. Material y métodos: Se desarrolló un estudio de tipo retrospectivo, analítico, correlacional y observacional de campo con diseño no experimental en 125 pacientes mayores de 30 años con oclusión vascular retiniana diagnosticados en la consulta de oftalmología del Hospital "Teodoro Maldonado Carbó" durante enero de 2017 a junio de 2018. La técnica ANOVA compara las medias para determinar mediante el proceso de contraste de hipótesis si existen diferencias estadísticamente significativas entre estas. Resultados: El análisis de la agudeza visual con escala logMAR demostró diferencias estadísticamente significativas entre los promedios obtenidos 3 meses antes y después de la aplicación del tratamiento (p=0,0001). Se encontró 28,8 por ciento de efectos adversos. Con frecuencia en aumento de presión intraocular (4 por ciento), sequedad ocular (16 por ciento) y hemorragia conjuntival (11,2 por ciento). Conclusiones: El ranibizumab en oclusiones vasculares retinianas proporciona una mejor agudeza visual corregida en relación con el grosor macular, favorece el desarrollo de nuevos vasos sanguíneos a partir de vasos preexistentes desde migración de células endoteliales(AU)

Introduction: The use of the intravitreal ranibizumab favors the reduction of the macular edema that generates retinal vascular occlusions that cause visual loss. Objective: To evaluate the efficacy and safety of the intravitreal administration of ranibizumab in the change in central macular thickness in retinal vascular occlusions analyzed by optical coherence tomography. Material and methods: A retrospective, analytical, correlational and observational field study with a non-experimental design was carried out on 125 patients over 30 years of age diagnosed with retinal vascular occlusion in the Ophthalmology Service of "Teodoro Maldonado Carbó" Hospital during the period between January 2017 and June 2018. The ANOVA technique was used to compare means in order to determine, through the hypothesis contrast process, if there are statistically significant differences between them. Results: Visual acuity analysis using the logMAR scale showed statistically significant differences between the averages obtained 3 months before and after the application of the treatment (p =0.0001). In addition, 28,8 percent of adverse effects were found. The most frequent ones included increased intraocular pressure (4 percent), dry eyes (16 percent), and conjunctival hemorrhage (11,2 percent). Conclusions: In retinal vascular occlusions, Ranibizumab provides a better corrected visual acuity in relation to macular thickness, favors the development of new blood vessels from pre-existing vessels from endothelial cell migration(AU)

Six Cases of Retinal Vascular Anomalies after Coronavirus Disease 2019: A Case Series.

BACKGROUND: The novel coronavirus disease 2019 (COVID-19) and its rapid spread has resulted in unexplored clinical ophthalmological manifestations. This report aims to describe a series of retinal vascular anomalies diagnosed with the use of fluorescein angiography, following contraction of COVID-19. HISTORY AND SIGNS: Symptoms reported by patients were central scotoma (one case), inferior scotoma (one case), and a sensation of mild loss of vision during the COVID-19 follow-up (four cases). Best-corrected visual acuity was preserved in all patients, apart from one, who had a visual acuity of 0.4, decimal scale (6/15, Snellen) in the left eye. THERAPY AND OUTCOME: Clinical manifestations included bilateral retinal vasculitis (two cases), branch retinal vein occlusion (one case), branch retinal artery occlusion (one case), hemi-central retinal vein occlusion (one case), and optic disc edema due to central retinal vein occlusion (one case) occurring 0 - 8 months after COVID-19 contraction. Serological testing was performed in every patient to exclude any other recognized cause of retinal vascular occlusion and inflammation and to confirm immunity against the novel coronavirus. None of the patients required any ocular treatment. CONCLUSIONS: Arterial and venous occlusive as well as inflammatory retinal vascular pathologies can occur both during and after the acute phase of COVID-19 as manifestations of ocular long-term effects of COVID-19 and should be included in the differential diagnosis of retinal occlusive pathologies. This case series suggests that careful investigations, including fundoscopy and fluorescein angiography, should be required in patients with visual complaints, both in the acute and long-term follow-up of COVID-19.

Central retinal thickness changes and risk of neovascular glaucoma after intravitreal bevacizumab injection in patients with central retinal vein occlusion.

This retrospective study evaluated changes in the central retinal thickness (CRT) and the risk factors for neovascular glaucoma (NVG) after intravitreal bevacizumab injection under a pro re nata (PRN) regimen for macular oedema in 57 eyes with central retinal vein occlusion (CRVO). The clinical characteristics at the time of NVG diagnosis were assessed, and baseline and final clinical characteristics and mean CRT values at 1-, 3-, and 6-month follow-up evaluations were recorded. The incidence of NVG was 21.1%, with the neovascular group (12 eyes) showing poor baseline and final visual acuity, a higher incidence of baseline ischaemic-type CRVO and subretinal fluid, a higher mean CRT at the 1-month follow-up, and a higher number of intravitreal bevacizumab injections during the 6-month follow-up. Nine eyes with NVG (75%) showed a mean CRT < 300 µm at the time of diagnosis. An ischaemic CRVO and higher CRT at the 1-month follow-up were related to the development of NVG in the multivariate analysis. Thus, NVG development in CRVO patients treated with intravitreal bevacizumab injections was associated with an ischaemic CRVO and elevated CRT at the 1-month follow-up; PRN bevacizumab regimens based on CRT or control of macular oedema did not completely prevent NVG development.

Combination intravitreal anti-vascular endothelial growth factor inhibitors and macular laser photocoagulation relative to intravitreal injection monotherapy in macular oedema secondary to retinal vein occlusion: a meta-analysis of randomized controlled trials.

BACKGROUND/OBJECTIVES: This meta-analysis investigates the efficacy and safety of intravitreal anti-VEGF injections (IVI) compared to combination laser photocoagulation and IVI (LPC-IVI) in treating macular oedema secondary to retinal vein occlusion (RVO). SUBJECTS/METHODS: A literature search of MEDLINE, EMBASE and Cochrane CENTRAL was conducted from inception until March 2021. Randomized controlled trials that reported relevant efficacy and/or safety parameters following LPC-IVI relative to IVI were included. Meta-analysis was conducted with a random effects model. The primary outcome was best-corrected visual acuity (BCVA), while secondary outcomes were central macular thickness (CMT), central retinal thickness (CRT), central subfield thickness (CST), number of IVIs received, and incidence of adverse events. RESULTS: A total of 10 studies were included, for which 362 eyes were randomized to LPC-IVI and 365 to IVI. In comparing macular laser photocoagulation with IVI (MLP-IVI) in BRVO patients, no significant differences were seen in final BCVA (p = 0.78) or change in BCVA (p = 0.09) after treatment. Similarly, no significant differences were seen in final CMT (p = 0.54), change in CMT (p = 0.33), final CRT (p = 0.90), change in CRT (p = 0.97), or number of injections required (p = 0.78). The same results were seen in subgroup analyses for macular laser without peripheral laser in BRVO and CRVO patients. Consistent results were observed when considering peripheral LPC-IVI to IVI in BRVO and CRVO. CONCLUSIONS: No significant differences were seen between combination MLP-IVI or peripheral LPC-IVI relative to IVI monotherapy for final BCVA or OCT parameters in macular oedema secondary to RVO.

Significant vision improvement and successful prevention of recurrence by electroacupuncture in hemiretinal vein occlusion combined with macular edema: A case report.

RATIONALE: Retinal vein occlusion (RVO) is the second commonest retinal vascular pathology, with macular edema (ME) as one of its major complications, which could finally cause vision loss. Anti-vascular endothelial growth factor (anti-VEGF therapy), as the standard therapy, has an unsustainable effect and needs repeated injections, which associates with frequent adverse events and significant economic burden. We reported a patient who had developed RVO and ME, and finally recovered after electroacupuncture treatment. PATIENT CONCERNS: A 56-year-old woman complained a decrease of visual acuity in the right eye for 1 year. She received injection of 0.5 mg Conbercept, one of the anti-VEGF therapies, in the vitreous cavity 6 times in 1 year, and finally turned to acupuncture for help out of short-term effectiveness after each injection and high expenditure (CNY 40,800). No other severe medical history was reported. DIAGNOSIS: Under comprehensive consideration of clinical manifestations and the results of fluorescein fundus angiography and optical coherence tomography, the patient was diagnosed with hemi-RVO and ME. INTERVENTIONS: The patient received electroacupuncture 3 sessions per week throughout 8 months (93 sessions in total). OUTCOMES: The visual acuity of the patient was improved from 0.6 to 0.9 after the 8-month electroacupuncture treatment and remained stable during the 24-month follow-up; the central retinal thickness remained stable between 350 and 414 throughout the treatment and follow-up periods. Patients regarded the vision-related quality of life as satisfactory. The total expenditure of electroacupuncture treatment was CNY 6045. The patient did not receive any Conbercept injection over the whole period of 32 months. No relevant adverse events occurred. LESSONS: Electroacupuncture might be effective in alleviating the symptoms of hemi-RVO-associated ME, with a potential of long-lasting effect. The frequency of anti-VEGF therapy could be reduced to the most extent, and the possibility of recurrence could be reduced as well, resulting good economic benefits.

Anatomic-Functional Correlates in Lesions of Retinal Vein Occlusion.

Purpose: To evaluate anatomic-functional associations at sites of retinal lesions in retinal vein occlusion (RVO). Methods: This pilot, prospective, observational study was conducted at the Northern Ireland Clinical Research Facility (NICRF) of Queen's University and the Belfast Health and Social Care Trust, Northern Ireland, between August 1, 2018, and September 30, 2019. The study included 10 treatment-naïve patients with RVO (10 RVO eyes and 10 fellow eyes). There were 81 points/sites assessed for each eye at baseline; six patients were re-assessed 6 months after anti-vascular endothelial growth factor therapy at the same locations. We investigated associations between retinal sensitivity and presence of structural RVO lesions, including retinal ischemia, hemorrhages, intraretinal fluid (IRF) and subretinal fluid outside the foveal/parafoveal regions. Comparisons were made between RVO eyes and fellow eyes at baseline, and between RVO eyes at baseline and at 6 months after treatment. Regression models were used to investigate anatomic-functional associations. Results: At baseline, strong associations were found between reduced retinal sensitivity and presence of ischemia (estimate = -2.08 dB; P < 0.001), intraretinal fluid (estimate = -7.82 dB; P < 0.001), and subretinal fluid (estimate = -8.66 dB; P < 0.001). Resolution of subretinal fluid but not intraretinal fluid was associated with improved function (estimate = 2.40 dB [P = 0.022]; estimate = 1.16 dB [P = 0.228], respectively). However, reperfusion of ischemic retina, observed in 31 of 486 points (6%) 6 months after anti-vascular endothelial growth factor therapy, was associated with a further decrease in retinal sensitivity (estimate = -2.34 dB; P = 0.035). Conclusions: Retinal sensitivity was decreased at sites of RVO lesions. Decreased function at sites of retinal ischemia did not recover after treatment, even when reperfusion occurred.

Diabetic and Retinal Vascular Eye Disease.

The retinal vasculature is the only neurovascular system directly visible to the human eye, easily evaluated by fundoscopy and many imaging modalities. This window allows physicians to diagnose and treat retinal pathologies and detect systemic diseases including diabetes, hypertension, hypercoagulable/hyperviscosity syndromes, and vasculitis. Diabetic retinopathy is the most common retinal vascular disease, followed by retinal vein and artery occlusion. Patients with these conditions require medical optimization to prevent further damage to the eyes and to the other organs. Both the internists and medical subspecialists play a crucial role in the prevention, detection, evaluation, and management of vision-threatening retinal vascular diseases.

Rapid reduction of macular edema due to retinal vein occlusion with low-dose normobaric hyperoxia.

PURPOSE: We investigated the effects of a relatively inexpensive, non-invasive, short-term treatment with low-dose normobaric hyperoxia (NBH) on macular edema in patients with retinal vein occlusion (RVO). METHODS: Participants with macular edema associated with RVO were treated with 5 LPM of NBH via facemask (40% fraction of inspired oxygen, FIO2) for 3 h. Patients with non-fovea involving edema who elected to be observed returned for a second treatment 1 month later to test reproducibility. RESULTS: A 3-h session of NBH (n = 45) resulted in decreased maximum macular thickness (MMT) (mean 7.10%, t34=9.63 P<.001) and central macular thickness (CMT) (mean 4.64%, t34=6.90, P<.001) when compared to untreated eyes with RVO measured over the same period of time (n = 12) or their healthy fellow eye (n = 34; MMT:t34=-9.60, P<.001;CMT: t34=-6.72, P<.001). Patients who had a second NBH treatment 1 month later experienced a recurrence of their edema, but demonstrated a similar significant reduction in MMT and CMT after the second NBH treatment. CONCLUSIONS: Three-hour treatment with 40% FIO2 NBH results in a significant reduction in MMT and CMT. This study supports an ischemic mechanism for macular edema associated with retinal vein occlusion. TRANSLATIONAL RELEVANCE: Short-term low-dose normobaric hyperoxia is a simple, inexpensive, and ubiquitous treatment that may provide an alternate or adjunctive approach to treating macular edema in patients who are resistant to or cannot afford anti-VEGF medications.

The laser combined with intravitreal injection of ranibizumab for treatment of macular edema secondary to branch retinal vein occlusion: A protocol for systematic review and meta-analysis.

BACKGROUND: At present, laser is regarded as an effective treatment for macular edema secondary to branch retinal vein occlusion. With the breakthrough of anti-vascular endothelial growth factor drugs in ophthalmology clinical research, the intravitreal injection of ranibizumab is widely applied, but both methods have their limitations, so some clinical studies have combined and applied them together. However, the clinical results are inconsistent and controversial, and there is no relevant system evaluation for the laser combined with intravitreal injection of ranibizumab for treatment of macular edema secondary to branch retinal vein occlusion now. OBJECTIVE: Meta analysis is used to analyze and evaluate the effectiveness and safety of the laser combined with intravitreal injection of ranibizumab for treatment of macular edema secondary to branch retinal vein occlusion. METHOD: CNKI, VIP, WANFANG, China Biology Medicine disc, Web of Science, PubMed, Embase, Cochrane Library have used random controlled clinical trial of laser combined with intravitreal injection of ranibizumab for treatment of macular edema secondary to branch retinal vein occlusion from the establishment of the database to October 2020. Two researchers conducted independent screening, quality assessment and data extraction for the literatures, and used RevMan5.3 to conduct Meta analysis for the included literatures. RESULT: The research has evaluated the effectiveness and safety of the laser combined with intravitreal injection of ranibizumab for treatment of macular edema secondary to branch retinal vein occlusion through the aspects of the best corrected visual acuity 6 months after operation, macular center thickness and the incidence of adverse reactions such as elevated intraocular pressure, endophthalmitis, vitreous hemorrhage and cataract. CONCLUSION: Laser combined with intravitreal injection of ranibizumab for treatment of macular edema secondary to branch retinal vein occlusion has good effect, and the research has provided reliable evidence for the use of clinical treatment of the laser combined with intravitreal injection of ranibizumab for treatment of macular edema secondary to branch retinal vein occlusion.