Short-Term Effects of Brolucizumab in the Treatment of Wet Age-Related Macular Degeneration or Polypoidal Choroidopathy Refractory to Previous Anti-Vascular Endothelial Growth Factor Therapy.

Background and objectives: To report the initial response to a single intravitreal brolucizumab (IVI-B) injection in wet age-related macular degeneration (wAMD) or polypoidal choroidopathy (PCV) complicated with either persistent subretinal fluid (SRF) or pigment epithelial detachment refractory to previous anti-vascular endothelial growth factor (anti-VEGF) therapy. Material and methods: In this retrospective study, all eyes received a single IVI-B (6 mg/0.05 mL) for wAMD or PCV with treatment-resistant SRF or PED. Outcome measures included assessment in central retinal thickness (CRT), visual acuity, and evaluation for changes in the SRF or PED on OCT. Follow-up was prior to the first brolucizumab injection, then at 1 week and 5 weeks afterwards. Results: In total, 10 eyes of 10 patients (6 women [60%]) were enrolled. Five patients had wAMD and five patients had PCV. Average age of participants was 67.6 years. All patients received one IVI-B. All patients were not treatment-naïve to anti-VEGF agents. At the first week and fifth week following the first IVI-B, seven out of seven patients (100%) had resolved SRF. However, seven out of nine patients (78%) had no improvement of their PED at 5 weeks follow-up. Mean PED height and width before the first IVI-B was 339.77 µm and 2233.44 µm, respectively. Mean PED height and width at the fifthweek following the first IVI-B was 328.125 µm and 2129.5 µm, respectively. Overall mean visual acuity before the first IVI-B was 0.224; and 5 weeks following the first IVI-B was 0.38. Conclusions: Treatment with brolucizumab resulted in anatomical improvement for all patients with persistent SRF. Limited efficacy was seen for persistent PED. Brolucizumab appears to be a safe and effective option for treatment-resistant SRF. Future multicenter collaborative studies are warranted.

Changes of Estimated Glomerular Filtration Rate and Glycated Hemoglobin A1c in Diabetic Macular Edema Patients Treated by Ranibizumab and Aflibercept in the Tertiary Referral Hospital.

Background and Objectives: Intravitreal injections (IVI) of vascular endothelial growth factor (VEGF) inhibitors are guideline-indicated treatments for diabetic macular edema (DME). However, some recent data have suggested that IVI VEGF inhibitors might, through systemic absorption, lead to a reduction in renal function. Our study aims to compare changes in glycated hemoglobin A1c (HbA1c) and estimated glomerular filtration rate (eGFR) between patients who received IVI ranibizumab and aflibercept treatment and patients who have not received IVI treatments. Materials and Methods: There were 17,165 DME patients with documented ophthalmology visits in the China Medical University Hospital-Clinical Research Data Repository. Those with a history of ESRD or bevacizumab treatment history, and those with missing information on HbA1c or eGFR, were excluded. After matching by age (±2 years), gender, and the year of clinical visit, 154 patients with medical treatment (including ranibizumab and aflibercept) and 154 patients without medical treatment were included in the study. The difference between HbA1c and eGFR at baseline and 3 and 12 months after the index date between the two groups was assessed. Results: Mean HbA1c and eGFR decreased between baseline and 12 months after the index date in both groups (p < 0.05). Compared with the non-treatment group, the treatment group had significantly lower HbA1c 3 and 12 months after the index date. There was no significant difference in eGFR between the two groups. In the generalized estimating equations (GEE) model, HbA1c in the treatment group was lower than the non-treatment group (−0.44%, 95% CI = −0.75, −0.14), but eGFR was similar after adjusting for age, gender, and index-year. HbA1c and eGFR decreased with the time in the adjusted GEE model (p < 0.0001) in both groups. Conclusions: This study showed that eGFR decreased with age and time and was not related to IVI anti-VEGF treatments in our tertiary referral hospital. IVI anti-VEGF therapy was also associated with better HbA1c control. It is suggested that DME patients can receive intravitreal VEGF inhibitors without inducing more renal impairment.

Endoscopy-assisted extraction of orbital and nasal foreign body.

Penetrating orbital injury with a foreign body is a complex problem that requires an interdisciplinary therapeutic approach. Conventionally, an external approach using either transconjuntival or transseptal entry is used by an ophthalmologist. However, there is a risk of damage to the optic nerve and orbital tissue using only the traditional approach. This study concerns a 36-year-old male who has an intra-orbital foreign body (OrbFB). Timely three-dimensional reconstruction computed tomography scan demonstrated an 8-cm-long intra-OrbFB adjacent to the optic nerve penetrating to the contralateral nasal cavity. Endoscopic inspection confirmed a chopstick fragment. Assisted by transnasal endoscopy, the chopstick penetrating from the orbit to the nasal cavity was smoothly removed. Nasal endoscopy is useful for an ophthalmologist in removing foreign body in the orbit.

Navigation-assisted endoscopic surgery of lacrimal sac tumor.

Tumor of lacrimal sac invading into orbit has to be removed carefully to avoid injuring the eyeball, optic nerve, and extraocular muscles. Transnasal endoscopic-assisted tumor excision is a method to remove the tumor from the nasal cavity through the lacrimal sac to the orbit in one procedure. A 55-year-old female patient with thyroid carcinoma removed more than 10 years ago. She recently had a swollen submandibular lymph node enlargement, which was pathologically diagnosed as metastatic carcinoma. Follow-up investigation showed a tumor in the ipsilateral lacrimal sac with invasion into adjacent orbit and nasal cavity. The tumor was removed through image-guided surgery (IGS), navigation-assisted transnasal endoscopic-assisted excision. The tumor was removed as much as possible. The eyeball, extraocular muscles, and optic nerve were not injured in the surgery. Postoperative swelling was minimal with mild nasal hemorrhage. No ecchymosis and conjunctiva chemosis and eyelid swelling was noticed. Ocular motility was full without diplopia. Although exenteration and partial maxillectomy were suggested after pathological result showed a carcinoma of lacrimal sac, patient did not want these extensive surgery immediately. On patient request to reserve the eyeball function, navigation-assisted transnasal endoscopic excision is a safe and efficient method for the preliminary surgery. This case of orbital tumor excision using endoscope and IGS navigation system is the first case by Taiwan ophthalmologists.

The rescue effect of adalimumab in the treatment of refractory pediatric panuveitis complicated with steroid-induced glaucoma.

We report the rescue effects of adalimumab (HUMIRA®) therapy in a case of refractory pediatric panuveitis complicated with steroid-induced glaucoma. A 13-year-old girl had suffered from blurred vision since January 2013. Bilateral idiopathic panuveitis with macular edema (ME) was diagnosed. She had previously been treated with systemic steroids, methotrexate, cyclosporine, and mycophenolate. All treatments had failed to suppress the ocular inflammation and ME persisted. Intravitreal dexamethasone implant injections were given to both eyes and ME subsided; however, complications with steroid-induced glaucoma and cataract occurred. ME also recurred following absorbance of the dexamethasone implant. After administration of subcutaneous adalimumab injections every 2 weeks, inflammatory activity was well controlled and ME subsided. Phacoemulsification and posterior intraocular lens implantation were performed in both eyes. Menorrhagia and anemia were noted 9 months after adalimumab treatment. Thereafter, adalimumab was reduced and her anemia improved. Her vision had remained 20/20 for 33 months. Refractory pediatric uveitis usually requires more aggressive treatment. Intraocular glucocorticoid releasing implant could be used to lessen the possible systemic side effects in children. Intravitreal dexamethasone implant was effective in treating the inflammatory ME but could be complicated with steroid glaucoma and cataract. Tumor necrosis factor-blocking agents have been used to treat chronic, refractory uveitis in adults as well as children. Adalimumab was a favorable biological agent in steroid-responding pediatric patient of refractory noninfectious uveitis but could be complicated with menorrhagia. Long-term follow-up and more cases are mandatory.