Dual pathway inhibition with faricimab for previously treated neovascular age-related macular degeneration and diabetic macular oedema: guidance from a UK panel of retina specialists.

BACKGROUND/OBJECTIVES: Some eyes with neovascular age-related macular degeneration (nAMD) and centre-involving diabetic macular oedema (DMO) fail to respond sufficiently or lose response over time to standard of care intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy. This paper explores clinical scenarios for switching to dual action angiopoietin-2 (Ang-2)/VEGF-A inhibitor faricimab (Vabysmo, Roche Products Limited) in previously anti-VEGF-treated patients. METHODS: A national steering group meeting of UK retina specialists was held in London on 27 October 2023. Clinician practice and experience were reviewed together with pivotal clinical trial data and early findings from real-world settings. Roche Products Limited facilitated and funded the meeting. RESULTS: While there is no standardised protocol for identifying suboptimal response, the authors review relevant clinical biomarkers of disease activity used in routine clinical practice to determine patient response and guide treatment decisions. Common reasons identified for considering a change of treatment were lack of efficacy demonstrated by suboptimal anatomic or visual improvement and insufficient durability of response. The panel outline strategies for switching to faricimab among eligible patients with a prior anti-VEGF treatment history, with initial monthly loading doses or maintaining the previous treatment interval before attempting to extend, that may be integrated into current treat-and-extend (T&E) clinical pathways for treating patients with nAMD and DMO. General considerations for switching between treatments are also reviewed. CONCLUSION: Clinicians may consider a treatment switch to faricimab in nAMD and DMO patients who have suboptimal disease control or insufficient durability of response on initial anti-VEGF therapy.

Bariatric surgery-what the ophthalmologist needs to know.

The incidence of bariatric surgery is increasing due to obesity being one of our top public health challenges. As such, bariatric-related ophthalmic changes are a potentially new clinical area of knowledge, with increasing published evidence on post-bariatric complications experienced by patients and identified by clinicians. We reviewed the available literature and summarised the different complications and potential recommendations. A search strategy was conducted with PubMed, Cochrane, Medline, Embase, Allied and Complementary Medicine and DH-DATA databases to look for papers answering our research question: "What are the ophthalmological complications for patients after bariatric surgery?". Our search gave a total of 59 relevant papers. Bariatric surgery, particularly subtypes that cause direct bypass of nutrients from the stomach, lead to nutritional deficiencies. Vitamin A, crucial for proper functioning of body systems and specialised cells, manifests ophthalmologically as corneal ulceration, nyctalopia, conjunctival xerosis and more. Thiamine levels are also depleted, leading to Wernicke's Encephalopathy. Pre-existing diabetic retinopathy is also noted to worsen sub acutely, although evidence is conflicting. Patients undergoing surgery to treat idiopathic intracranial hypertension would have reduced IOP and resolving papilloedema. Other comorbidities of obesity like HBA1C levels, obstructive sleep apnoea, and metabolic syndrome also resolve post-surgery. History taking remains the cornerstone of medical practice. From the evidence, we suggest consideration of pre-surgery screening for ophthalmic pathology and post-operative monitoring of disease progression. Real-world data needs to continuously be analysed to create definitive management pathways that can help clinicians recognise ophthalmic complications early, improving patient outcomes.

Three-dimensional printing in ophthalmology and eye care: current applications and future developments.

Three-dimensional (3D) printing uses a process of adding material in a layer-by-layer fashion to form the end product. This technology is advancing rapidly and is being increasingly utilized in the medical field as it becomes more accessible and cost-effective. It has an increasingly important role in ophthalmology and eyecare as its current and potential applications are extensive and slowly evolving. Three-dimensional printing represents an important method of manufacturing customized products such as orbital implants, ocular prostheses, ophthalmic models, surgical instruments, spectacles and other gadgets. Surgical planning, simulation, training and teaching have all benefitted from this technology. Advances in bioprinting seem to be the future direction of 3D printing with possibilities of printing out viable ocular tissues such as corneas and retinas in the future. It is expected that more ophthalmologists and other clinicians will use this technology in the near future.

The role of optical coherence tomography in therapeutics and conditions, which primarily have systemic manifestations: a narrative review.

Optical coherence tomography is designed to evaluate in vivo qualitative and quantitative changes of the anterior segment, optic nerve and the retina. Initial applications of this technology were confined mainly to ophthalmic diseases. However recently, numerous studies have evaluated its use in systemic conditions and in therapeutics where, optic nerve and retinal architecture can be assessed to monitor progression of systemic conditions and its response to treatment. This is a narrative review aimed at evaluating the debate surrounding the role of spectral domain optical coherence tomography, in systemic conditions where optic nerve affection can be measured and be used in the diagnosis, monitoring and assessment of treatment effect as a non-invasive, quick, novel technique.

Central serous chorioretinopathy with angioid streaks: a rare combination.

Purpose: This rare case shows the presence of both angioid streaks (AS) and central serous chorioretinopathy (CSC) in the same eye. Methods: A 41-year-old Caucasian male who also has a positive family history of AS was diagnosed with angioid streaks. He was followed for few years, later developed CSC in his good eye. Results: Fundus fluorescein led to the diagnosis of CSC and indocyanine green angiography ruled out the possibility of idiopathic polypoidal choroidal vasculopathy (IPCV). The CSC followed a chronic course of non-resolution and finally half fluence photodynamic therapy was performed. Unfortunately, there was still some deterioration of vision with poor response. Conclusion: There is no known correlation between the two disorders and their presence in one eye has not been reported to our knowledge.

Nonarteritic anterior ischemic optic neuropathy associated with interferon and ribavirin in a patient with hepatitis C.

PURPOSE: To report a case of a temporal artery biopsy negative anterior ischemic optic neuropathy associated with a recently completed course of pegylated interferon 2 α with ribavirin for chronic hepatitis C. OBSERVATIONS: Despite the early presentation with symptoms and prompt treatment with systemic intravenous steroids the patient experienced deterioration of their optic neuropathy over the following few days. Although nonarteritic anterior ischemic optic neuropathy is a common disorder with known risk factors, the timing of onset of symptoms in our patient was suggestive of a possible etiology related to treatment with ribavirin and interferon 2 α, as found in the previously reported cases. CONCLUSIONS AND IMPORTANCE: There have been a few reported cases of the association between the use of interferon/ribavirin for treatment of chronic hepatitis with nonarteritic anterior ischemic optic neuropathy. In these cases stopping the drug caused some improvement of symptoms or halting the progression of optic neuropathy. Having reviewed the literature on previous cases, we postulate that there may be a dose related reaction to explain the delay and deterioration of vision in some cases despite stopping the drugs. We also advise that any person who is started on this treatment for chronic hepatitis are appropriately counselled as to the potential optic nerve side effect of the drug, based on the evidence reported in the literature.

Reversible visual loss in a patient with rheumatoid arthritis and the role of vascular imaging.

Spontaneous vertebral artery dissection is a condition that can have lethal consequences. The condition should be considered in young male patients who present with a stroke. At presentation, headaches, cerebral ischaemic episodes and oculosympathetic paresis are the most commonly encountered manifestations. The diagnosis is confirmed with angiography. Here, we present a middle-aged male gardener with rheumatoid arthritis and signs of vertebral artery dissection to highlight the importance of diagnosis and discuss the controversies in management.

Macular Hole Formation After Intravitreal Ranibizumab Injection in Wet Age-Related Macular Degeneration.

Ranibizumab is a monoclonal antibody fragment that inhibits angiogenesis by inhibiting vascular endothelial growth factor A, used as a treatment for patients with wet aged-related macular degeneration (ARMD). Adverse effects from intravitreal Ranibizumab injections are well recognised. Macular hole formation following Ranibizumab injection is a complication that has been recently reported in few case reports. We present a larger case series of five patients, who developed full thickness macular holes (FTMH) after intravitreal Ranibizumab injections for treatment of wet ARMD that we were aware of between 2009 and 2013.

One-year outcome of bevacizumab therapy for chronic macular edema in central and branch retinal vein occlusions in real-world clinical practice in the UK.

BACKGROUND: The purpose of this study was to investigate the 12-month outcome of macular edema secondary to both chronic and new central and branch retinal vein occlusions treated with intravitreal bevacizumab in the real-life clinical setting in the UK. METHODS: Retrospective case notes analysis of consecutive patients with retinal vein occlusions treated with bevacizumab in 2010 to 2012. Outcome measures were visual acuity (measured with Snellen, converted into logMAR [logarithm of the minimum angle of resolution] for statistical calculation) and central retinal thickness at baseline, 4 weeks post-loading phase, and at 1 year. RESULTS: There were 56 and 100 patients with central and branch retinal vein occlusions, respectively, of whom 62% had chronic edema and received prior therapies and another 32% required additional laser treatments post-baseline bevacizumab. Baseline median visual acuity was 0.78 (interquartile range [IQR] 0.48-1.22) in the central group and 0.6 (IQR 0.3-0.78) in the branch group. In both groups, visual improvement was statistically significant from baseline compared to post-loading (P<0.001 and P=0.03, respectively), but was not significant by month 12 (P=0.058 and P=0.166, respectively); 30% improved by at least three lines and 44% improved by at least one line by month 12. Baseline median central retinal thickness was 449 µm (IQR 388-553) in the central group and 441 µm (IQR 357-501) in the branch group. However, the mean reduction in thickness was statistically significant at post-loading (P<0.001) and at the 12-month time point (P<0.001) for both groups. The average number of injections in 1 year was 4.2 in the central group and 3.3 in the branch group. CONCLUSION: Our large real-world cohort results indicate that bevacizumab introduced to patients with either new or chronic edema due to retinal vein occlusion can result in resolution of edema and stabilization of vision in the first year.

Dome-shaped macula: a compensatory mechanism in myopic anisometropia?

The purpose of this article was to describe a patient with dome-shaped macula in the setting of mild myopic anisometropia and to speculate regarding the role of this feature as a compensatory mechanism in ocular development. The clinical records of a 49-year-old woman with this condition were reviewed. Spectral-domain optical coherence tomographic images revealed evidence of a dome-shaped macula. B-scan ultrasonography measured axial lengths of 23.8 mm in the right eye and 22.8 mm in the left eye. Spherical equivalents were -1.375 and +0.375 in the right and left eyes, respectively. Examination of the left eye was unremarkable. Dome-shaped macula has previously only been described in patients with high myopia. These findings support the hypothesis that myopic anisometropia, rather than absolute refractive status, is central to the development of dome-shaped macula and that this feature represents a protective mechanism aimed at reducing the effects of anisometropia.

Spectral domain optical coherence tomography can detect visible and subthreshold laser burns using 532-nm laser.

Retinal burns of subthreshold intensity created using micropulsed diode laser, which remain clinically invisible, have been shown to be successful in treating macular edema while minimizing the risk of collateral damage to the retina. A study was conducted to determine whether spectral domain optical coherence tomography (SD-OCT) could be used to detect subthreshold retinal burns created using the 532-nm green wavelength laser. A series of retinal burns of gradually decreasing intensity were created in 10 eyes. Retinal burns produced with duration of laser exposure of 0.03 second or less, although clinically invisible, were detectable on the SD-OCT scan as increased retinal reflectivity confined to the outer retinal layers. This series demonstrates the potential of using SD-OCT imaging to verify delivery of subthreshold laser burns.

Late onset of subfoveal choroidal neovascularisation following cerebral radiotherapy.

A report of choroidal neovascularisation (CNV) associated with radiation retinopathy. A 43-year-old Caucasian man presented with a 4-week history of sudden loss of central vision in the left eye, 8.5 years following radical radiotherapy for left tempero-parietal anaplastic astrocytoma. His visual acuity was 6/6 in the right eye and 6/60 in the left eye. Ophthalmoscopy of the left eye showed central macular pigmented area surrounded by subretinal fluid, haemorrhage and exudates. Fundus fluorescein angiography revealed left subfoveal CNV with surrounding macular oedema and peripheral retinal ischaemia. Radiation retinopathy associated CNV is a late ocular complication of cerebral radiotherapy. It should be investigated as a possible aetiology of severe visual loss in long-term survivors of cerebral tumours who have previously received radiotherapy.

Spectral domain optical coherence tomography can detect visible and subthreshold laser burns using 532-nm laser.

Retinal burns of subthreshold intensity created using micropulsed diode laser, which remain clinically invisible, have been shown to be successful in treating macular edema while minimizing the risk of collateral damage to the retina. A study was conducted to determine whether spectral domain optical coherence tomography (SD-OCT) could be used to detect subthreshold retinal burns created using the 532-nm green wavelength laser. A series of retinal burns of gradually decreasing intensity were created in 10 eyes. Retinal burns produced with duration of laser exposure of 0.03 second or less, although clinically invisible, were detectable on the SD-OCT scan as increased retinal reflectivity confined to the outer retinal layers. This series demonstrates the potential of using SD-OCT imaging to verify delivery of subthreshold laser burns.

Ocular syphilis unmasked following intravitreal triamcinolone injection.

PURPOSE: To report intravitreal triamcinolone (IVTA)-induced unmasking of ocular syphilis. DESIGN: Two case reports. METHODS: A homosexual, diabetic male with macular edema treated with bilateral IVTA and a male with bilateral panuveitis and macular edema who underwent vitrectomy and IVTA. Both developed occlusive retinal vasculitis and panuveitis postinjection. Syphilis serology was positive although both denied previous symptoms. RESULTS: Intramuscular penicillin lead to resolution of inflammation but both sustained severe loss of vision. Cause-and-effect relationship demonstrated between IVTA and reactivation of syphilis. CONCLUSIONS: Intravitreal corticosteroid can modulate the immune response to intraocular syphilis; vigilance is required, particularly in high-risk patients.

Giant cell arteritis complicated by acute pancreatitis: a case report.

INTRODUCTION: We describe a case of giant cell arteritis in a woman who was treated with high-dose systemic corticosteroids and subsequently developed acute pancreatitis. CASE PRESENTATION: A 78-year-old Caucasian woman presented with four weeks of progressive headache and scalp tenderness. One day before ophthalmology assessment, she had experienced visual obscurations in both eyes. Her visual acuity was 6/9 in both eyes, with a right afferent pupillary defect and right swollen optic nerve. She was diagnosed as having temporal arteritis and was urgently treated with high-dose pulsed intravenous and oral corticosteroids. Her previous diet-controlled diabetes needed insulin and oral hyperglycaemic therapy to control erratic blood sugars. On day 8 of treatment with steroids, she became unwell with epigastric pain and vomiting. She was diagnosed with acute pancreatitis and was treated conservatively. CONCLUSION: Acute pancreatitis, a potentially life-threatening condition, is a rare but important side effect of systemic corticosteroids.