BETTER BASELINE VISION LEADS TO BETTER OUTCOMES AFTER THE 0.19-mg FLUOCINOLONE ACETONIDE INTRAVITREAL IMPLANT IN DIABETIC MACULAR EDEMA.

PURPOSE: Analysis of a 3-year, Phase 4, open-label, observational study evaluating the association of baseline best-corrected visual acuity (BCVA) with visual, treatment burden, and retinal thickness variability (RTV) outcomes and intraocular pressure (IOP)-related events after the 0.19-mg fluocinolone acetonide (FAc) intravitreal implant. METHODS: Data from patients with diabetic macular edema (DME) who did not have a clinically significant rise in IOP after previous corticosteroid treatment (N = 202 eyes from 159 patients) were segregated by baseline BCVA of ≥20/40 or <20/40 and analyzed for BCVA, number of yearly supplemental DME treatments, RTV, and incidence of IOP-related events. RESULTS: At 36 months post-FAc, eyes with better baseline BCVA (≥20/40) maintained baseline BCVA, whereas vision in eyes with worse baseline BCVA (<20/40) increased by approximately 7 letters to 61.34 letters (Snellen equivalent approximately 20/60; P < 0.05). Treatment burden and RTV decreased post-FAc regardless of baseline BCVA. Eyes with better baseline BCVA (≥20/40) had numerically fewer IOP-related events post-FAc versus eyes with worse baseline BCVA (<20/40), including a lower incidence of incisional IOP-lowering surgery. CONCLUSION: The 0.19-mg FAc implant improved RTV and treatment burden regardless of baseline BCVA. Better baseline BCVA (≥20/40) was associated with long-term BCVA maintenance. Although eyes with worse baseline BCVA (<20/40) experienced significantly improved BCVA, it never rose to the level of those with better baseline BCVA. These data indicate that early, effective intervention in DME, before significant vision loss occurs, is key to maintaining visual outcomes.

PREDICTIVE FACTORS FOR PROLIFERATIVE VITREORETINOPATHY FORMATION AFTER UNCOMPLICATED PRIMARY RETINAL DETACHMENT REPAIR.

PURPOSE: To determine predictive factors of proliferative vitreoretinopathy (PVR) formation after uncomplicated primary retinal detachment repair. METHODS: Retrospective, single-center, case-control study of 74 consecutive patients with (37 eyes) and without (37 eyes) PVR formation after undergoing uncomplicated primary surgery for retinal detachment repair. Logistic regression was used to assess factors associated with PVR formation. RESULTS: Retinal detachment involving the macula was 4.2 times (adjusted odds ratio; 95% confidence interval, 1.4-12.9; P = 0.0119) more likely to have PVR formation compared with those without. Patients who were current or former smokers were 3.6 times (adjusted odds ratio; 95% confidence interval, 1.1-11.7; P = 0.0352) more likely to have PVR formation compared with nonsmokers. Compared with 25-gauge (g) vitrectomy, larger gauge vitrectomy (20 g or 23 g) was 3.6 times (adjusted odds ratio; 95% confidence interval, 1.2-11.3; P = 0.0276) more likely to have PVR formation. Duration of retinal detachment symptoms, high myopia, lens status, lattice degeneration, location of retinal break, number of retinal breaks, and surgical technique (e.g., scleral buckle with or without vitrectomy versus vitrectomy alone) were not found to be predictive of PVR formation. CONCLUSION: Cigarette smoking and macular involvement are significant risk factors predictive of PVR formation after uncomplicated primary retinal detachment repair.

Endophthalmitis after Intravitreal Injection of Vascular Endothelial Growth Factor Inhibitors: Management and Visual Outcomes.

PURPOSE: We describe the presentation of patients developing endophthalmitis after intravitreal injection with vascular endothelial growth factor (VEGF) inhibitors. Moreover, we evaluate the management by comparing the outcomes of immediate tap and injection of intravitreal antibiotics (TAI) versus initial surgical pars plana vitrectomy (PPV). Finally, we analyze the predictive factors of visual outcomes at 6-month follow-up. DESIGN: Retrospective, single-center, nonrandomized interventional study. PARTICIPANTS: Patients developing endophthalmitis after receiving an intravitreal injection of anti-VEGF agent between 2006 and 2016. METHODS: All patients received a vitreous biopsy sent for cultures before the initiation of treatment: TAI group versus PPV with intravitreal antibiotics (PPV group). MAIN OUTCOME MEASURES: Best-corrected visual acuity (BCVA) at 6-month follow-up after treatment for endophthalmitis. RESULTS: A total of 258 357 intravitreal injections occurred over the course of the 10-year period, of which 40 patients (0.016%) had endophthalmitis within 3 weeks after injection. In total, 34 patients (85.0%) had pain and 25 patients (62.5%) had hypopyon on initial examination. Among 24 culture-positive cases, 66.7% of the causative organisms were coagulase-negative Staphylococcus, followed by Streptococcus species (10.0%). The best-corrected visual acuity (BCVA) (logarithm of the minimum angle of resolution [logMAR]) at 6-month follow-up was significantly worse for patients who had a positive culture for Streptococcus species (4.0; standard deviation [SD], 0.8) (approximately light perception) compared with those who had a positive culture for coagulase-negative Staphylococcus (0.4; SD, 0.3) (∼20/50) (P < 0.0001). Compared with the TAI group, a higher proportion of samples were culture-positive in the PPV group (90.9% vs. 48.3%, P = 0.03). There was no statistically significant difference in BCVA at 6-month follow-up between the TAI and PPV groups. Younger age (<85 years) and lower intraocular pressure (IOP) (≤25 mmHg) at presentation were predictive of achieving a BCVA of 20/400 or better at 6-month follow-up after treatment. Initial management (TAI vs. PPV), duration of symptoms, presence of pain, presence of hypopyon, presenting BCVA, and culture status (positive vs. negative) were not found to be predictive of visual outcomes at 6-month follow-up. CONCLUSIONS: No significant difference in BCVA at 6-month follow-up was detected between the TAI and PPV groups. Younger age and lower IOP at presentation were associated with better visual outcomes at 6-month follow-up.

DYSFUNCTIONAL AUTONOMIC REGULATION OF THE CHOROID IN CENTRAL SEROUS CHORIORETINOPATHY.

PURPOSE: To study the effect of changing perfusion pressures on retinal and choroidal structure in central serous chorioretinopathy (CSC). METHODS: This prospective observational case series included seven healthy volunteers (14 eyes) and seven patients (14 eyes) with CSC. Each patient underwent spectral domain optical coherence tomography with enhanced depth imaging in the upright (sitting) and supine positions. Image segmentation focused on central macular thickness, subretinal fluid, total macular volume, choroidal thickness, and choriocapillaris thickness. Blood pressure and heart rate were measured in the upright and supine positions. RESULTS: Choriocapillaris thickness was thicker in CSC participants (34.23 µm; range, 30.9-36.5 µm) compared with healthy controls (13.96 µm; range, 7.15-23.87 µm) (P ≤ 0.001). The choroid was similarly thicker in CSC participants (371.4 µm; range, 200.2-459.4 µm) compared with healthy controls (231.4 µm; range 161.8-287.5 µm) (P ≤ 0.001). Choroidal thickness increased in patients with CSC when transitioning from upright (371.4 µm) to supine (377.8 µm) (P ≤ 0.01). By contrast, there was an 11.97% decrease in choroid thickness in normal controls when transitioning from upright (231.4 µm) to supine (203.9 µm). There were no significant hemodynamic changes. CONCLUSION: We demonstrated that choroidal thickness increased in response to increased perfusion pressures in patients with CSC and not in normal controls. These findings likely represent an autonomic dysregulation of choroidal blood flow in patients with CSC.

OCULAR HYPERTENSION AFTER INTRAVITREAL DEXAMETHASONE (OZURDEX) SUSTAINED-RELEASE IMPLANT.

PURPOSE: To evaluate ocular hypertension (OHT) after Ozurdex injection to determine the incidence of OHT, therapy for OHT, and any associative factors such as diagnosis, underlying glaucoma and therapy, or sequential Ozurdex injection(s). METHODS: Retrospective consecutive case series with patients receiving one or more intravitreal Ozurdex implantations at a tertiary care academic center. Ocular hypertension was defined as a single measurement of ≥30 mmHg or an increase of ≥10 mmHg from baseline. RESULTS: Ninety-four injections in 52 patients (59 eyes) were reviewed. Forty eyes received a single injection, and 19 eyes received multiple injections. Ocular hypertension developed in 14 patients (26.9%). Thirteen patients (25%) had preexisting glaucoma or suspicion of glaucoma, and 6 of these developed OHT. Glaucoma eye drops were initiated after 13 injections (13.8%). Invasive surgery for glaucoma was required in 3 patients (3.2%): all had glaucoma or suspicion of glaucoma (one case was related to neovascular glaucoma and unlikely related to steroid response after Ozurdex). There was no difference in relative intraocular pressure increase (i.e., difference between final follow-up or subsequent intravitreal injection vs. baseline) between single versus multiple Ozurdex injections (P = 0.883). CONCLUSION: Patients (26.9%) who received Ozurdex developed OHT. Glaucoma or glaucoma-suspicion factors were present in all patients who required invasive surgery for glaucoma. A greater proportion of patients who received multiple injections had an intraocular pressure elevation, but the relative intraocular pressure increase was not significant.

Depression and burden among the caregivers of visually impaired patients: a systematic review.

Caregiving has evolved as an important issue not only for those receiving care, but for those providing it as well. While caregiving allows those with disabilities to better adapt, it has been shown to take a toll on the caregiver on various levels, such as invoking depression and burden. The purpose of this study was to perform a systematic review of the literature pertaining to depression and burden among caregivers of patients with visual impairment. A comprehensive literature search using multiple databases was conducted to include all articles on burden of care or depression among the caregivers of the visually impaired. Nine studies were included in this review. There was demonstrable association of depression and burden with the caregivers of the visually impaired. Communication theory, emotional contagion, and care burden were cited as factors associated with depression in these studies. A number of other elements were also identified to play a role in depression and burden, such as providing greater hours of supervision to the patient, multiple chronic conditions in the patient or caregiver, patient not completing vision rehabilitation, and female gender of the caregiver. By identifying those at risk for decreased quality of life outcomes, health care providers may be able to alter the management of the visually impaired, such as advocating the use of vision rehabilitation clinics in order to minimize the caregiver burden and depression.

COMBINED VITRECTOMY AND INTRAVITREAL DEXAMETHASONE (OZURDEX) SUSTAINED-RELEASE IMPLANT.

PURPOSE: To evaluate the safety and efficacy of combining intravitreal dexamethasone implantation (Ozurdex) with pars plana vitrectomy (PPV). METHODS: A retrospective review was conducted on cases where Ozurdex injection was performed in the operating room in conjunction with pars plana vitrectomy. Our primary outcome measure was the presence of surgical complications in the perioperative and 3-month postoperative window. We also measured visual acuity, intraocular pressure (IOP), and macular edema at baseline, one, and 3 months after surgery. RESULTS: Fifteen eyes in 14 cases were reviewed. There were no complications intraoperatively or at 1-month postoperatively. Two patients (2 eyes) with prior retinal detachment developed proliferative vitreoretinopathy and redetachment at 3 months. Visual acuity improved in 7 of 15 eyes, and an average improvement of 2 lines was achieved for the entire cohort. There was no overall change in intraocular pressure although 1 patient developed an increase in intraocular pressure >5 mmHg. Five of 9 patients with baseline macular edema experienced improvement or resolution at 3 months. CONCLUSION: Intraoperative Ozurdex in combination with PPV may be safe and effective in treating macular edema caused by many different underlying diseases.

Factors associated with spontaneous release of vitreomacular traction.

PURPOSE: To analyze the factors that may predict the release of vitreomacular traction (VMT) and vitreomacular adhesion. METHODS: Retrospective case-control study of sixty-one patients with VMT imaged by optical coherence tomography over at least 3 months. Records from all patients seen at the University of Iowa from January 2012 to September 2013 were screened for the ICD9 code for VMT, vitreomacular adhesion, and epiretinal membrane (379.27 and 362.56). Release of VMT (R-VMT) was defined by resolution of patients' symptoms or traction by optical coherence tomography without surgical intervention or ocriplasmin injection. Individual factors or characteristics were evaluated by chi-square test. Using a binary logistic regression model, the potentially prognostic factors were evaluated for contribution to R-VMT. RESULTS: Of the 61 patients that met entry criteria, 21 (35%) developed R-VMT during optical coherence tomography follow-up, and 40 (65%) did not. Isolated inner retinal distortion without outer retinal involvement was significantly associated with R-VMT (P = 0.01). Vitreous injections were also associated with R-VMT (P = 0.02). CONCLUSION: Eyes with VMT and isolated inner retinal distortion and those receiving vitreous injections are more likely to develop VMT release without the need for surgical intervention or ocriplasmin treatment.

Peripapillary choroidal neovascular membrane in a teenage boy: presenting feature of idiopathic intracranial hypertension and resolution with intravitreal bevacizumab.

Peripapillary choroidal neovascular membrane (ppCNVM) is an infrequent finding in patients with idiopathic intracranial hypertension (IIH). In the pediatric subgroup there is only a single previously reported case. We describe the use of intravitreal bevacizumab for ppCNVM in a teenage boy with IIH.

The real-world efficacy and safety of faricimab in neovascular age-related macular degeneration: the TRUCKEE study - 6 month results.

BACKGROUND/OBJECTIVE: Investigate real-world patients receiving faricimab for the treatment of neovascular age-related macular degeneration (nAMD). SUBJECTS/METHODS: Multicenter, retrospective chart review was conducted on patients treated with faricimab for nAMD from February 2022 to September 2022. Collected data includes background demographics, treatment history, best-corrected visual acuity (BCVA), anatomic changes, and adverse events as safety markers. The main outcome measures are changes in BCVA, changes in central subfield thickness (CST) and adverse events. Secondary outcome measures included treatment intervals and presence of retinal fluid. RESULTS: After one injection of faricimab, all eyes (n = 376), previously-treated (n = 337) and treatment-naïve (n = 39) eyes demonstrated a + 1.1 letter (p = 0.035), a + 0.7 letter (p = 0.196) and a + 4.9 letter (p = 0.076) improvement in BCVA, respectively, and a - 31.3 µM (p < 0.001), a - 25.3 µM (p < 0.001) and a - 84.5 µM (p < 0.001) reduction in CST, respectively. After three injections of faricimab, all eyes (n = 94), previously-treated (n = 81) and treatment-naïve (n = 13) eyes demonstrated a + 3.4 letter (p = 0.03), a + 2.7 letter (p = 0.045) and a + 8.1 letter (p = 0.437) improvement in BCVA, and a - 43.4 µM (p < 0.001), a - 38.1 µM (p < 0.001) and a - 80.1 µM (p < 0.204) reduction in CST, respectively. One case of intraocular inflammation was observed after four injections of faricimab and resolved with topical steroids. One case of infectious endophthalmitis was treated with intravitreal antibiotics and resolved. CONCLUSIONS: Faricimab has demonstrated improvement or maintenance of visual acuity for patients with nAMD, along with rapid improvement of anatomical parameters. It has been well-tolerated with low incidence of treatable intraocular inflammation. Future data will continue to investigate faricimab for real-world patients with nAMD.

Anatomical and visual outcomes of macular hole surgery with short-duration 3-day face-down positioning.

PURPOSE: The role of face-down posturing after macular hole (MH) surgery remains unclear and controversial. We evaluated the anatomical and visual outcomes of MH repair using a short duration (3 days) of prone positioning. METHODS: Prospective series of 50 consecutive eyes in 50 patients with Stage 2 or Stage 3 idiopathic MHs. All eyes underwent vitrectomy MH surgery with internal limiting membrane peeling and 20% sulfur hexafluoride (SF6) gas tamponade. The procedure was combined with phacoemulsification cataract surgery in phakic eyes. Surgical outcomes, MH closure rates, complications, and postoperative visual acuity were investigated. RESULTS: Anatomical closure of MHs was achieved in 49 (98%) of 50 eyes by 1 surgery. Postoperative logarithm of the minimum angle of resolution visual acuity decreased (i.e., improved) by 0.271 (95% confidence interval, 0.101-0.441 [P = 0.0024]). One complication of intraocular lens pupillary capture and one case of chronic cystoid macular edema were observed. There were no complications attributed to intraocular pressure fluctuations. CONCLUSION: Vitrectomy with internal limiting membrane peeling and gas tamponade with SF6 followed by short-duration 3-day face-down positioning is a successful surgical intervention for Stage 2 and Stage 3 idiopathic MHs. This method possessed minimal complications and offered significant improvement in visual acuity.

Retrolenticular Vitreous Opacities as a Diagnostic Indicator of Systemic Amyloidosis.

Purpose: Systemic amyloidosis is a group of rare, life-threatening disorders characterized by the deposition of amyloid plaques in numerous tissues. Vitreous involvement can occur in amyloidosis and here we describe critical diagnostic findings. Methods: Case report of vitreous amyloidosis diagnosis confounded by non-specific presentation. Results: Despite false-negative vitreous biopsies, in the setting of previous vitreoretinal surgery, the case reveals vitreous opacities, decreased visual acuity, and retinal neovascularization as critical signs in ocular amyloidosis. Conclusions: Here we present the signs and symptoms that raise suspicion for vitreous amyloidosis and how to approach diagnosis early in the disease presentation.

Trocar-Based Surgical Approach to Suprachoroidal Hemorrhage Drainage.

Purpose: Suprachoroidal hemorrhage is an uncommon but serious ocular condition that typically occurs in the setting of intraocular surgery and trauma. We present an external trans-conjunctival vitreoretinal trocar-cannula-based drainage of suprachoroidal hemorrhage as a viable surgical approach. Methods: Case report. Results: Trans-conjunctival trocar-cannula-based drainage of suprachoroidal hemorrhage is a safe and efficacious surgical approach to drainage of large choroidal hemorrhages. Conclusions: Although discrepancies persist regarding the optimal surgical approach to suprachoroidal hemorrhage management; herein, we describe the successful execution of an external trans-conjunctival vitreoretinal trocar-cannula-based drainage of suprachoroidal hemorrhage.

Vitrectomy with Silicone Oil Tamponade and Single-Dose Intravitreal Methotrexate for Recurrent Retinal Detachment with Proliferative Vitreoretinopathy.

Our case emphasizes the approach of a single-dose of intraoperative methotrexate (MTX) - applied directly into silicone oil - to arrest the anomalous progression of proliferative vitreoretinopathy (PVR). A 78-year-old male presented with severe vision loss secondary to a pseudophakic macula-off rhegmatogenous retinal detachment oculus sinister (OS). He was initially treated with primary pars plana vitrectomy and intraocular gas; however, the patient developed recurrent macula-off retinal detachment complicated by proliferative vitreoretinopathy OS. Subsequent management involved vitrectomy with membrane removal, silicone oil tamponade, and adjuvant intravitreal MTX. The patient had an uneventful postoperative recovery with a dramatic vision improvement after silicone oil removal OS. Here, we highlight the use of silicone oil tamponade with single-dose adjuvant MTX for the management of complex retinal detachment associated with proliferative vitreoretinopathy.

Long-Acting Fluocinolone Acetonide Intravitreal Implant for Recurrent Bilateral Non-Infectious Posterior Uveitis.

Purpose: Our case emphasizes the utility of long-acting intravitreal fluocinolone implants (YUTIQ) for managing recalcitrant forms of non-infectious posterior uveitis, NIPU. Patient: We present a case of bilateral NIPU refractory to topical corticosteroids and intravitreal triamcinolone and dexamethasone. Results: Management with bilateral YUTIQ improved local ocular inflammatory control with improved vision and anatomical outcomes. Conclusion: NIPU can develop into recurrent forms resistant to short-acting therapeutics. Long-acting efficacy with YUTIQ emphasizes the need to recognize such refractory NIPU cases.

Vision Recovery Velocity, Momentum and Acceleration: Advanced Vitreoretinal Analytics as Measure of Treatment Efficacy for Neovascular Age-Related Macular Degeneration.

PURPOSE: Currently, varying treatment paradigms and different clinical trial constructs preclude cross-trial comparison between different available vascular endothelial growth factor (VEGF) inhibitors. This study aimed to review the evidence and compare the efficacy of anti-VEGF therapies for neovascular age-related macular degeneration (nAMD), and to develop metrics as a means of facilitating standardized comparison between different anti-VEGF agents within the Advanced VitreoRetinal Analytics (AVRA) model. METHODS: The study analyzed key outcomes in clinical trials of bevacizumab, ranibizumab, aflibercept, and brolucizumab, including best corrected visual acuity (BCVA), number of injections, and duration of follow-up (minimum follow-up of 48 weeks). RESULTS: The AVRA model includes 1) vision recovery velocity (VRV; letters per unit time), which provides a metric of letters gained or lost over time (or the speed of improvement); 2) injection momentum (InjMom; number of injections multiplied by letters per unit time; units of injections•(letters/time)), which is defined as the number of injections multiplied by VRV and describes the quantity of treatment needed to achieve a vision outcome; and 3) vision recovery acceleration (VRA; letters per unit time squared; units of letters/time2), which denotes final VRV minus initial VRV, per unit time, and describes the rate of change in letters gained or lost over time. CONCLUSION: AVRA stipulates that the ideal VEGF inhibitor to treat nAMD would have a higher positive VRV (more letters gained per unit time), low InjMom (lower treatment burden requiring fewer interventions for a given visual acuity outcome), and VRA approximating zero (indicating stable vision over time). AVRA allows comparisons across different trials to determine the optimal anti-VEGF agent for the treatment of nAMD.