PHOTODYNAMIC THERAPY-INDUCED ACUTE EXUDATIVE MACULOPATHY IN A CASE SERIES OF CIRCUMSCRIBED CHOROIDAL HEMANGIOMA.

PURPOSE: To describe the incidence, features, and clinical outcomes of photodynamic therapy-induced acute exudative maculopathy (PAEM) in circumscribed choroidal hemangioma. METHODS: Prospective series of 10 patients who underwent standard-fluence photodynamic therapy for circumscribed choroidal hemangioma. Best-corrected visual acuity in the Early Treatment Diabetic Retinopathy Score and swept-source optical coherence tomography were performed before PDT and 3 days and 1 month after PDT. Central retinal thickness, circumscribed choroidal hemangioma retinal thickness, and subretinal fluid were measured. Photodynamic therapy-induced acute exudative maculopathy was considered as an increase ≥50 µ m in subretinal fluid or intraretinal fluid or the appearance of fibrin 3 days after photodynamic therapy. RESULTS: Six men and four women were included; median age was 55 years (19-69 years). The incidence rate of PAEM was 7 of 10. Five PAEM patients showed an increase in intraretinal fluid, two in subretinal fluid, and one developed abundant fibrin. Median best-corrected visual acuity at baseline was 57.5 letters (5-76 letters) being stable at 1 month (64 letters; 5-80) ( P = 0.03). Median central retinal thickness increased from 516 µ m (262-1,265 µ m) to 664.5 µ m after 3 days and diminished to 245 µ m after 1 month (156-1,363) ( P ≤ 0.022). In 6 of 7 of PAEM, a complete resolution of the fluid was obtained. CONCLUSION: Photodynamic therapy-induced acute exudative maculopathy was frequent in circumscribed choroidal hemangioma, although a favorable prognosis was observed in most cases.

ACUTE EXUDATIVE MACULOPATHY AND BACILLARY LAYER DETACHMENT IN PATIENTS WITH CENTRAL SEROUS CHORIORETINOPATHY AFTER PHOTODYNAMIC THERAPY.

PURPOSE: To describe the incidence and characteristics of photodynamic therapy-induced acute exudative maculopathy (PAEM) and bacillary layer detachment in patients with chronic central serous chorioretinopathy. METHODS: This was a prospective observational case series including 92 eyes of 75 patients who underwent photodynamic therapy. Best-corrected visual acuity, optical coherence tomography, and optical coherence tomography angiography were performed before, 3 days, 1 month, and 3 months after half-fluence photodynamic therapy. Two groups were established depending on the presence or absence (N = 28 and N = 64, respectively) of PAEM. Choriocapillaris flow voids increase, subfoveal choroidal thickness, and the presence of choroidal neovascularization were collected. RESULTS: The incidence of PAEM was 28/92 (30.4%). There was no difference in the age, sex, baseline subretinal fluid, subfoveal choroidal thickness, or the presence of choroidal neovascularization between groups (P ≥ 0.094). No differences emerged in the subretinal fluid at 1 and 3 months after photodynamic therapy between groups (P ≥ 0.524), nor in the mean best-corrected visual acuity gain at 3 months (4.1 ± 7.6 vs. 3.6 ± 6.4 letters; P = 0.773). A bacillary layer detachment was observed in 13 patients with PAEM (46.4%). CONCLUSION: Photodynamic therapy-induced acute exudative maculopathy is frequent in patients with chronic central serous chorioretinopathy but has a favorable prognosis. There was no association between PAEM and age, sex, subfoveal choroidal thickness, or choroidal neovascularization; however, it was related to choriocapillaris flow voids increase.

Minimal detectable change of the disc-fovea angle for ocular torsion assessment.

PURPOSE: The disc-fovea angle (DFA) is used as a relevant indicator of ocular torsion change in cyclovertical strabismus. However, interpretation of the variation in time must differentiate whether a real change has occurred or if the disparity is due to random measurement error. The aim of the study was to obtain the minimal detectable change (MDC) of the DFA. It represents the minimal variation between two measurements that may be considered a real ocular torsion change. METHODS: A prospective cross-sectional study was conducted in San Carlos Clinical Hospital of Madrid, Spain. Sixty healthy right eyes from 60 patients (31 men and 29 women) were recruited. Three digital fundus photographs were obtained, and between measurements, the patient moved their head away from the head support and then returned. Two observers quantified the DFA with software designed with MATLAB. Test-retest and interrater reliability were calculated. RESULTS: Mean participant age was 56.1 years (SD 16.6, range 25-85). Mean DFA was 8.1° (SD 3.5, range 1.3-18.5). Test-retest reliability for Observer 1 (Ob1), Observer 2 (Ob2) and interrater reliability were excellent (ICC 0.80, 0.83 and 0.95, respectively). Precision was 2.9° (Ob1) and 3.0° (Ob2), and the MDC95 was 4.1° (Ob1) and 4.2° (Ob2). Bland-Altman analysis revealed an absence of bias and a homoscedastic distribution of the differences. CONCLUSIONS: The MDC of the DFA in fundus photography was 4°, which represents the minimal change that may be considered a real change in ocular torsion. This result may improve the interpretation of ocular torsion changes in surgery and clinical scenarios.

Long-term effect of intravitreal ranibizumab therapy on retinal nerve fiber layer in eyes with exudative age-related macular degeneration.

PURPOSE: To investigate long-term effect (96 months) of intravitreal ranibizumab administered for exudative age-related macular degeneration (AMD) on retinal nerve fiber layer (RNFL) thickness when used following a pro re nata regimen. METHODS: In this prospective study, 20 eyes of 20 patients diagnosed with exudative AMD were included. Contralateral non-exudative AMD eyes of nine of these patients were included as controls. Data on intraocular pressure (IOP) and number of injections were recorded. Spectralis optic coherence tomography (OCT) of the circumpapillary RNFL was performed under dilation when diagnosis was made and before the three loading injections. "Follow-up" software was selected to accurately compare baseline with subsequent images through the 8 years of the study. RESULTS: Baseline IOP was 14.1 mmHg both in study (standard deviation, SD: 0.8) and control eyes (SD: 0.9) and remained unchanged during the study. Mean number of injections was 21 (SD: 2.8) at the end of the study. Mean average thickness of RNFL in the study eye group at the end of the study was 96.5 µm (SD: 2.1). Mean loss for the study period was 5.3 µm (SD: 0.7; p < 0.0001). Corresponding RNFL values for controls were 92.9 (SD: 3.2) and 5.8 µm (SD: 1.2; p < 0.001). Superior temporal sector had the greatest loss in both groups, followed by inferior and nasal sectors. No statistically significant differences were found when comparing losses in injected eyes versus control eyes. CONCLUSIONS: RNFL thickness decreased both equally in injected eyes and control eyes. Thus, no long-term effects of intravitreal ranibizumab were observed on the retinal nerve fiber layer thickness.

ARMS2 A69S polymorphism is associated with the number of ranibizumab injections needed for exudative age-related macular degeneration in a pro re nata regimen during 4 years of follow-up.

PURPOSE: To investigate whether single-nucleotide polymorphisms (SNPs) known to be strongly associated with the development of age-related macular degeneration (AMD) have an influence on recurrence rate of choroidal neovascularization (CNV) activity during 4-year ranibizumab treatment for exudative AMD. METHODS: This prospective study included 103 treatment-naïve patients (103 eyes) that received initially a loading dose of 3 monthly ranibizumab injections and thereafter, were treated according to an as-needed regimen for a 4-year follow-up period. Baseline values, visual outcome, and recurrence rate were examined. CFH Y402H and ARMS2 A69S polymorphisms were determined and their association with lesion recurrence and visual outcome was analyzed using a one-way analysis of variance (ANOVA) with post hoc comparison tested by Fisher's LSD method. Multivariate linear regression analysis was then used to identify factors associated with recurrence rate. RESULTS: The cumulative total mean number of ranibizumab injections at the end of each year of the follow-up was 5.3 ± 1.8, 9.2 ± 2.9, 12.6 ± 4.6, and 15.7 ± 6.1. There was great inter-patient variability. Nineteen eyes (18.5%) did not experience recurrence during the first year, and five (4.8%) still displayed inactive CNV after 4 years of follow-up. No significant association was found between the number of injections and mean best corrected visual acuity (BCVA) change or final BCVA at the end of the study period. Genotypes had no influence on baseline characteristics or visual outcome but a significant association was found between the A69S polymorphism and the number of injections needed by the patients. Homozygous for the T risk allele required more retreatments over the 48-month follow-up. CONCLUSIONS: The ARMS2 A69S polymorphism was associated with CNV recurrence rate in our patient cohort. Prediction of a greater risk of recurrence could help to design more appropriate follow-up treatment strategies for patients with neovascular AMD.

DIFFERENTIAL MACULAR FEATURES ON OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY IN EYES WITH CHOROIDAL NEVUS AND MELANOMA.

PURPOSE: To evaluate optical coherence tomography angiography (OCTA) characteristics of macular vascular details in eyes with choroidal nevus and melanoma, compared with unaffected contralateral eye. METHODS: Retrospective comparative analysis comprising 70 patients with choroidal nevus and 36 patients with choroidal melanoma examined with optical coherence tomography angiography. Measurements included central macular thickness (CMT), superficial (sFAZ) and deep (dFAZ) foveal avascular zone (FAZ) area, and superficial (sCVD) and deep (dCVD) capillary vascular density (CVD). RESULTS: In patients with nevus, CMT (affected vs. unaffected eye) was similar (267 vs. 265 µm, P = 0.67), whereas in patients with melanoma, CMT demonstrated greater thickness in affected eye (322 vs. 259 µm, P < 0.0001). In eyes with nevus, the FAZ (affected vs. unaffected eye) showed similar values in sFAZ (0.238 vs. 0.232 mm, P = 0.72) and dFAZ (0.284 vs. 0.271 mm, P = 0.48). In eyes with melanoma, similar values for sFAZ (0.249 vs. 0.260 mm, P = 0.73) were noted, whereas dFAZ was larger in the affected eye with macular melanoma (0.530 vs. 0.252 mm, P = 0.012) and similar in eyes with extramacular melanoma (0.300 vs. 0.285, P = 0.75). Regarding CVD (affected vs. unaffected eye), eyes with nevus showed similar sCVD (54 vs. 53.9%, P = 0.81) and dCVD (60 vs. 59.4%, P = 0.19). Reduced dCVD was found in four eyes with nevus, all with three or more risk factors for growth (P < 0.01). In eyes with melanoma, significant reduction was found in both sCVD (50.5 vs. 53.1%, P = 0.006) and dCVD (56.6% vs. 59.8%, P = 0.0003). Reduction in sCVD was related to presence of subretinal fluid (P = 0.03). Reduction in dCVD was found with subretinal fluid presence (P = 0.003) or absence (P = 0.03), with both macular (P < 0.001) and extramacular (P < 0.001) melanoma, and with increasing tumor thickness (P = 0.005). Reduced dCVD was found in 11% of eyes with nevus versus 58% of eyes with melanoma (Chi-square test: 26.31; P < 0.0001). CONCLUSION: Compared with contralateral eye, eyes with choroidal nevus demonstrate similar CMT, FAZ, and CVD. In contrast, eyes with melanoma show increased CMT, enlarged FAZ, and reduced CVD, particularly related to increasing tumor thickness. Optical coherence tomography angiography could be a useful tool in differentiating choroidal nevus from melanoma.

Multiple Evanescent White Dot Syndrome (MEWDS) Secondary to Acute Retinal Pigment Epitheliitis: Possible Atypical Presentation of MEWDS?

PURPOSE: To report a case of possible multiple evanescent white dot syndrome secondary (MEWDS) to acute retinal pigment epitheliitis (ARPE). METHODS: Case report. RESULTS: A 16-year-old female presented to the ophthalmology emergency department with a 5-day history of blurred vision in the left eye (OS). Initial examination revealed a visual acuity (VA) of 89 letters on the Early Treatment Diabetic Retinopathy Study (ETDRS)(-0.08 logMAR) chart in the right eye (OD) and 53 letters(0.64 logMAR) in the OS. Anterior segment biomicroscopy was normal, with no evidence of inflammation in the anterior chamber. Evaluation of the posterior pole revealed an alteration in the retinal pigment epithelium (RPE) in the OS. Optical coherence tomography (OCT) at the macular level showed disruption at the external limiting membrane (ELM), ellipsoid zone (EZ), interdigitation zone (IZ), and the RPE-Bruch's membrane (RPE-Bm) complex. Fundus autofluorescence (FAF) demonstrated hypofluorescent areas in the peripapillary region. No treatment was indicated. After two weeks, there was an improvement in VA, with 90 ETDRS letters(-0.1 logMAR) in the OD and 85 letters(0.0 logMAR) in the OS, as well as improvement in the OCT at the level of the ELM and EZ. However, a marked increase in white spots was observed throughout the posterior pole. By 5-months post-onset, a complete resolution of retinal alterations was observed in both OCT and FAF. CONCLUSION: ARPE and MEWDS exhibit overlapping clinical features, which can sometimes complicate differentiation. This case is consistent with MEWDS secondary to ARPE, although an atypical presentation of MEWDS cannot be ruled out.

Validity and Reliability of 2 Cirrus Optical Coherence Tomography Procedures for Measuring Objective Ocular Torsion.

PURPOSE: Torsional eye position by the disc-fovea angle (DFA) is a relevant objective parameter in vertical strabismus. DFA measurement with optical coherence tomography (OCT) has proven to be a good alternative to the gold standard measurement in fundus photography. Our study aims to analyze the validity and reliability of 2 undescribed Cirrus high-definition OCT (HD-OCT; Carl Zeiss Meditec) methods that offer clinical advantages for measuring objective cycloposition in normal patients compared with Spectralis spectral-domain OCT (Heidelberg Engineering) and the reference method. DESIGN: Prospective validity and reliability analysis. METHODS: Objective cycloposition by means of the DFA was measured in the right eyes of 59 binocularly normal individuals attending the ophthalmology service of a medical institution. DFA was obtained by fundus photography (gold standard), FoDi software of Spectralis spectral-domain OCT, HD 1 line scan of Cirrus HD-OCT, and macular cube of Cirrus HD-OCT (fundus, FoDi, line, and cube methods, respectively). Measurements were performed 3 times for each method and the patient was repositioned and realigned between captures. Posterior manual quantification was made by 2 observers with external protractor software for the fundus and cube methods. RESULTS: The 3 OCT methods showed and excellent agreement with fundus photography (ICC 0.83-0.84) with no significant differences comparing mean values (P = .36 for fundus-FoDi, P = .09 for fundus-line, and P = .09 for fundus-cube). Absolute differences between methods were 1.5°. All methods showed excellent reliability (ICC 0.92 for FoDi, 0.91 for line, 0.92 for cube, and 0.91 for fundus). The minimal detectable change was lower than 3° and the absolute difference between repeated measurements was 1° for all methods. Interrater reliability was excellent for methods requiring manual quantification (ICC 0.98 for cube, ICC 0.94 for fundus). CONCLUSIONS: Measurement of the DFA by Cirrus HD-OCT methods in normal patients was a valid and reliable alternative for the cycloposition assessment. Among the methods, the Cirrus OCT HD 1 line improved clinical performance due to the simplicity and speed of measurement, with no need to export the image for quantification.

Sudden Consecutive Bilateral Amaurosis Secondary to Central Retinal Artery Occlusion After Kidney Transplantation.

Central retinal artery occlusion (CRAO) is a medical emergency, considered a stroke equivalent by the American Heart Association. There are a few reported cases of bilateral CRAO, most of them occurring in the context of a systemic predisposing condition. We present a case of bilateral CRAO following kidney transplantation. This 58-year-old man suffered CRAO in the right eye 24 hours after having kidney transplantation surgery. Treatment with an intravenous bolus of high-dose corticosteroids and full-dose anticoagulation therapy was initiated. However, 48 hours later, the patient suffered contralateral CRAO, resulting in irreversible bilateral amaurosis. CRAO is a rare but devastating complication of non-ophthalmological surgery and must be considered in postoperative patients with visual complaints. CRAO may have different causal mechanisms, but due to the similarity of their clinical manifestations, accurate etiology is not always easy to establish. Given the importance of an early diagnosis, all physicians should know about its risk factors and be aware of how patients with suspected CRAO must be rapidly referred for general and ophthalmological evaluation.

Intervortex Venous Anastomosis in the Macula in Central Serous Chorioretinopathy Imaged by En Face Optical Coherence Tomography.

PURPOSE: To assess the presence of macular intervortex venous anastomosis in central serous chorioretinopathy (CSCR) patients using en face optical coherence tomography (EF-OCT). METHODS: A cross-sectional study where EF-OCT 6 × 6 and 12 × 12 mm macular scans of patients with unilateral chronic CSCR were evaluated for anastomosis between vortex vein systems in the central macula. The presence of prominent anastomoses was defined as a connection with a diameter ≥150 µm between the inferotemporal and superotemporal vortex vein systems which crossed the temporal raphe. Three groups were studied: CSCR eyes (with an active disease with the presence of neurosensorial detachment; n = 135), fellow unaffected eyes (n = 135), and healthy eyes as controls (n = 110). Asymmetries, abrupt termination, sausaging, bulbosities and corkscrew appearance were also assessed. RESULTS: In 79.2% of the CSCR eyes there were prominent anastomoses in the central macula between the inferotemporal and superotemporal vortex vein systems, being more frequent than in fellow eyes and controls (51.8% and 58.2% respectively). The number of anastomotic connections was higher in the affected eye group (2.9 ± 1.8) than in the unaffected fellow eye group (2.1 ± 1.7) and the controls (1.5 ± 1.6) (p < 0.001). Asymmetry, abrupt terminations and the corkscrew appearance of the choroidal vessels were more frequent in the affected eyes, although no differences in sausaging or bulbosities were observed. CONCLUSIONS: Intervortex venous anastomoses in the macula were common in CSCR, being more frequently observed in affected eyes than in fellow unaffected eyes and healthy controls. This anatomical variation could have important implications concerning the pathogenesis and classification of the disease.

ABCA4 c.6480-35A>G, a novel branchpoint variant associated with Stargardt disease.

Introduction: Inherited retinal dystrophies (IRDs) can be caused by variants in more than 280 genes. The ATP-binding cassette transporter type A4 (ABCA4) gene is one of these genes and has been linked to Stargardt disease type 1 (STGD1), fundus flavimaculatus, cone-rod dystrophy (CRD), and pan-retinal CRD. Approximately 25% of the reported ABCA4 variants affect RNA splicing. In most cases, it is necessary to perform a functional assay to determine the effect of these variants. Methods: Whole genome sequencing (WGS) was performed in one Spanish proband with Stargardt disease. The putative pathogenicity of c.6480-35A>G on splicing was investigated both in silico and in vitro. The in silico approach was based on the deep-learning tool SpliceAI. For the in vitro approach we used a midigene splice assay in HEK293T cells, based on a previously established wild-type midigene (BA29) containing ABCA4 exons 46 to 48. Results: Through the analysis of WGS data, we identified two candidate variants in ABCA4 in one proband: a previously described deletion, c.699_768+342del (p.(Gln234Phefs*5)), and a novel branchpoint variant, c.6480-35A>G. Segregation analysis confirmed that the variants were in trans. For the branchpoint variant, SpliceAI predicted an acceptor gain with a high score (0.47) at position c.6480-47. A midigene splice assay in HEK293T cells revealed the inclusion of the last 47 nucleotides of intron 47 creating a premature stop codon and allowed to categorize the variant as moderately severe. Subsequent analysis revealed the presence of this variant as a second allele besides c.1958G>A p.(Arg653His) in an additional Spanish proband in a large cohort of IRD cases. Conclusion: A splice-altering effect of the branchpoint variant, confirmed by the midigene splice assay, along with the identification of this variant in a second unrelated individual affected with STGD, provides sufficient evidence to classify the variant as likely pathogenic. In addition, this research highlights the importance of studying non-coding regions and performing functional assays to provide a conclusive molecular diagnosis.

Impact of ocular dominance on circumpapillary and macular retinal nerve fibre layer thickness and ganglion cell layer thickness in a healthy pediatric population.

OBJECTIVE: This study was designed to evaluate potential differences in circumpapillary retinal nerve fibre layer (cpRNFL) thickness and segmented macular retinal layers between dominant and nondominant eyes on spectral-domain optical coherence tomography in a pediatric population. DESIGN: Cross-sectional study. PARTICIPANTS: 89 healthy children attending a general pediatric clinic. METHODS: Participants underwent sighting dominant testing and macular and cpRNFL spectral-domain optical coherence tomography. Segmented macular layer thicknesses and cpRNFL thickness were compared for individual patients based on their ocular dominance. RESULTS: Ocular dominance occurred particularly in the right eye (64.7%). Dominant and nondominant eyes did not differ significantly in axial length or spherical equivalent refraction; axial length: 22.99 ± 1.17 mm versus 22.98 ± 1.19 mm; p = 0.51 and spherical equivalent refraction: -0.09 ± 2.68 D versus 0.32 ± 2.93 D; p = 0.41. In the comparison of the macular ganglion layer the average thickness in the 1 mm central Early Treatment Diabetic Retinopathy Study area was significantly different between the dominant and nondominant eye (16.56 ± 6.02 µm vs 17.58 ± 8.32 µm; p = 0.02). However, when compensating with Bonferroni, this difference was no longer statistically significant. There were no differences in the analyses of average global and sectorial cpRNFL thickness in dominant and nondominant eyes. CONCLUSION: Dominant eyes demonstrated no significantly thicker average macular retinal nerve fiber layer (mRNFL), Ganglion cell layer (GCL) thickness or cpRNFL thickness. No ocular characteristic was found to be associated with the relative dominance of an eye in eyes with low anisometropia.

Long-Term Consequences of COVID-19 Lockdown in Neovascular AMD Patients in Spain: Structural and Functional Outcomes after 1 Year of Standard Follow-Up and Treatment.

Consequences of the COVID-19 pandemic on medical care have been extensively analyzed. Specifically, in ophthalmology practice, patients suffering age-related macular degeneration (AMD) represent one of the most affected subgroups. After reporting the acute consequences of treatment suspension in neovascular AMD, we have now evaluated these same 242 patients (270 eyes) to assess if prior functional and anatomical situations can be restored after twelve months of regular follow-up and treatment. We compared data from visits before COVID-19 outbreak and the first visit after lockdown with data obtained in subsequent visits, until one year of follow-up was achieved. For each patient, rate of visual loss per year before COVID-19 pandemic, considered "natural history of treated AMD", was calculated. This rate of visual loss significantly increased during the lockdown period and now, after twelve months of regular follow-up, is still higher than before COVID outbreak (3.1 vs. 1.6 ETDRS letters/year, p < 0.01). Percentage of OCT images showing active disease is now lower than before the lockdown period (51% vs. 65.3%, p = 0.0017). Although anatomic deterioration, regarding signs of active disease, can be apparently fully restored, our results suggest that functional consequences of temporary anti-VEGF treatment suspension are not entirely reversible after 12 months of treatment, as BCVA remains lower and visual loss rate is still higher than before the COVID-19 pandemic.

Validity and Reliability of Semiautomatic Ocular Cycloposition Measurement With Spectralis Optical Coherence Tomography.

PURPOSE: Disc-fovea angle determined by fundus photography (P-DFA) is considered the gold standard for cycloposition assessment. Fovea-to-disc alignment (FoDi) software of the spectral-domain optical coherence tomography (SD-OCT) (Spectralis) also measures the DFA (O-DFA) based on subject fixation and offers important clinical advantages. This study aimed to analyze the validity and reliability of measuring cycloposition using OCT and to determine its performance in eyes with poor foveal definition. DESIGN: Validity and reliability analysis. METHODS: In 60 eyes with normal foveal definition and 32 eyes with poorly defined fovea, ocular cycloposition was assessed by 2 observers using 5 fundus photographs and 5 FoDi analyses each. Patients were repositioned after every capture. RESULTS: Cycloposition assessed by O-DFA was 7.6 ± 3.5-degrees, and P-DFA was 7.9 ± 3.8-degrees. The concordance between methods was good (intraclass correlation coefficient [ICC], 0.71), with absolute differences ranging from zero to 4-degrees in 85% of the subjects. The precision was 1.4-degrees for O-DFA and 3.0-degrees for P-DFA. Repeatability and reproducibility were excellent in both techniques. In the group of patients with poor foveal definition, the precision of P-DFA changed from 3.0-degrees to 4.8-degrees, whereas the O-DFA remained stable. CONCLUSIONS: OCT had a good agreement with the fundus photography method. O-DFA showed better precision than P-DFA. O-DFA repeatability and reproducibility were excellent and unconditioned by foveal status.

Effect of COVID-19 Lockdown in Spain on Structural and Functional Outcomes of Neovascular AMD Patients.

This is a retrospective single-center study of patients with neovascular age-related macular degeneration whose follow-up was delayed due to COVID-19 pandemic with at least three months between visits in Madrid, Spain. The purpose of the study was to evaluate best corrected visual acuity (BCVA) changes and try to identify features in optical coherence tomography (OCT) that could be related to more profound visual loss. It included 270 eyes. The two last visits before lockdown were used for comparison with the visit after lockdown. BCVA changed from 60.2 ± 18.2 to 55.9 ± 20.5 ETDRS letters. 29% of the eyes lost more than 5 letters. OCT was active in 67% of eyes before lockdown and in 80.4% after lockdown. Multiple lineal analysis showed that patients whose OCT before lockdown presented with a combination of intra and subretinal fluid were more likely to suffer a greater visual loss (p = 0.002). These patients should be encouraged to not miss any visits in case a new lockdown is imposed.

Systemic Effects of Repeated Intraocular Dexamethasone Intravitreal Implant in Diabetic Patients: A Retrospective Study.

INTRODUCTION: The objective of this study is to evaluate the influence of repeated intraocular dexamethasone implant (Ozurdex) injections on metabolic control in type 2 diabetic patients. METHODS: Retrospective study of 165 type 2 diabetic patients starting Ozurdex treatment who received no less than three consecutive injections. Glycated hemoglobin (HbA1c), serum creatinine, total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, and triglycerides (TGs) were evaluated during 15 months of follow-up after Ozurdex treatment onset. RESULTS: Fifty-seven patients met inclusion criteria. Mean baseline values for HbA1c, creatinine, total cholesterol, HDL cholesterol, and TGs before treatment (7.1%, 1.3, 176.7, 51.1, and 125.6 mg/dl, respectively) were similar to mean values after Ozurdex onset (Wilcoxon test p values were 0.68, 0.41, 0.06, 0.87, and 0.33, respectively) and remained stable during the follow-up period. Mean LDL cholesterol levels increased slightly after Ozurdex treatment onset (90.1 vs 88.2 mg/dl, p = 0.04) but after 15 months of follow-up they had returned to baseline values. Transient increase in LDL cholesterol was remarkable in the group of 24 bilaterally treated patients (96.8 vs 88.4 mg/dl, p = 0.03). A third of these patients increased their baseline LDL values by more than 20%. Even with continuous injections of Ozurdex, LDL cholesterol levels also declined back to baseline by month 15. CONCLUSION: Ozurdex injections had no influence on HbA1c or renal function. Lipid profile changes were mild and transient. However, a significant temporary increase has been found in LDL cholesterol levels in patients receiving simultaneous bilateral injections. Lipid levels should be monitored in patients starting with bilateral Ozurdex injections especially in those with recent history of acute myocardial infarction.

Rotation of retinal vascular arcades and comparison with disc-fovea angle in the assessment of cycloposition.

BACKGROUND/AIMS: To assess the agreement between disc-fovea angle (DFA) and the retinal vascular arcades rotation to measure cycloposition. Device repeatability and reproducibility between observers were also evaluated. METHODS: Cycloplegic retinography was taken in 321 eyes of 165 normal patients and repeated in 18 eyes at least 24 h later. Two independent observers used software to determine DFA, vein-related angle (VRA) and artery-related angle (ARA) in every retinography. Mean value of related angle (MRA) (mean value of VRA and ARA) was calculated. RESULTS: Camera repeatability was good (Intra-class Correlation Coefficient, ICC 0.89). In Bland-Altman analysis, mean VRA, ARA and MRA were 4° to 5° different from DFA (p<0.01). There was poor correlation between DFA and other methods (ICC): DFA versus VRA 0.3, versus ARA 0.4, versus MRA 0.5. Reliability between observers was good in all methods. The multivariate analysis showed no interaction between each method and eye side, sex or observer (p>0.05). CONCLUSIONS: The rotation of retinal vascular arcades using a first-order approximation technique is no substitute to DFA when assessing torsion in fundus photographs. Of the methods tested, MRA correlated most closely, but DFA remains the gold standard for cycloposition. The rotation of vascular arcades provides a qualitative assessment, particularly in uncertain macular location.

Clinical relevance of foveal location on retinal nerve fiber layer thickness using the new FoDi software in spectralis optical coherence tomography.

PURPOSE: To evaluate the effect of improper foveal location on retinal nerve fiber layer (RNFL) thickness measurements by using the new FoDi software in spectral-domain optical coherence tomography (Spectralis SDOCT). METHODS: Cross-sectional study with 126 subjects: 66 healthy, 30 early, and 30 moderate glaucomatous eyes. Fast RNFL scans were performed by using the new FoDi technology. The position of the fovea was manually displaced inferiorly after acquisition (producing clockwise torsion of scan circle) and then superiorly (counterclockwise) to generate study sets of images. Differences in RNFL thickness between foveal-guided and alternative scans were analyzed and color changes in sector charts were evaluated. RESULTS: In healthy eyes, placing the fovea inferiorly led to significant RNFL thickness changes in all sectors. Locating the fovea superiorly seemed to have less impact. Early glaucomatous eyes were more susceptible to quantitative changes, but moderate glaucomatous eyes were more susceptible to qualitative changes. CONCLUSIONS: Improper fovea disc alignment when using the FoDi software in Spectralis OCT significantly affected sectoral RNFL thickness measurements and color chart representation. As final report of FoDi analysis does not show the foveal position used, careful acquisition is encouraged, so that results are reliable. Otherwise, this technique can easily be misinterpreted and patients could be misdiagnosed.