Remodelling intravitreal therapy pathways for macular disease during the COVID-19 pandemic and an Austrian national lockdown.

OBJECTIVE: To analyse the remodelling and recovery of a relocated intravitreal injection (IVI) service with an adapted treatment regimen in a tertiary referral centre during a nationwide lockdown with initial cancellation of all non-emergency treatments caused by the COVID-19 pandemic. METHODS AND ANALYSIS: For this retrospective observational study at Hanusch Hospital, Vienna, between 16 March 2020 and 5 May 2020, we conducted an analysis of an appointment booking system based on prioritisation incorporating disease class, severity and fellow eye status by evidence-based impact on irreversible structural impairment and survey data from telephone interviews. Recapture time was defined as the time-to-discard the backlog of patients in need for treatment. Non-attendance was stratified as treatment refusal for personal reasons and non-attendance due to lockdown-related restrictions. RESULTS: Of the 1109 patients, 241 (21.7%) were considered as highly urgent, 269 (24.3%) as urgent, 402 (36.2%) as semiurgent and 197 (17.8%) as non-urgent. Recapture time was 15 days for highly urgent patients, 22 days for urgent patients, 43 days for semiurgent patients and 46 days for non-urgent patients. The proportion of patients who refused treatment due to personal reasons was 5.2%, with a mean age of 82.4 years; 29 patients (2.6%) could not attend due to lockdown-related restrictions. CONCLUSION: By streamlining treatment based on urgency as well as increasing the number of bilateral IVI, recapture time was fast. We could provide a safe treatment environment for healthcare professionals and patients after resetting the injection service outside of the hospital with increased levels of protection.

Effect of Subfoveal and Extrafoveal Hyporeflective Zones due to Iatrogenic Traction during Membrane Peeling for Epiretinal Membranes on Postoperative Outcomes.

PURPOSE: The aim of our study using an intraoperative optical coherence tomography (iOCT) device was to assess the rate of neurosensory elevation with resulting subfoveal and extrafoveal hyporeflective zones during membrane peeling and to evaluate a possible influence on postoperative outcomes. PROCEDURES: This study included patients scheduled for pars plana vitrectomy with membrane peeling due to idiopathic epiretinal membrane. All patients underwent 23-G pars plana vitrectomy with iOCT-guided membrane peeling and were scheduled for follow-up examinations at 1 day, 5 days, and 3 months after surgery. RESULTS: Among the 171 patients included, subfoveal and extrafoveal hyporeflective zones could be detected in 12 patients (7%). Follow-up at 3 months after surgery was available for 149 patients with a median improvement in best corrected visual acuity of +2 lines (IQR: +1 to +4 lines). There were no significant differences in outcomes between patients with and those without subfoveal/extrafoveal hyporeflective zones concerning visual acuity, macular thickness, occurrence of intraretinal cystoid changes, and postoperative hyporeflective zones. CONCLUSIONS: No significant differences in postoperative outcomes were observed between patients with and those without subfoveal/extrafoveal hyporeflective zones.

Risk factors for postoperative intraretinal cystoid changes after peeling of idiopathic epiretinal membranes among patients randomized for balanced salt solution and air-tamponade.

PURPOSE: Epiretinal membranes (ERM) are macular disorders leading to loss of vision and metamorphopsia. Vitrectomy with membrane peeling displays the gold standard of care. Aim of this study was to assess risk factors for postoperative intraretinal cystoid changes in a study population randomized for balanced salt solution and air-tamponade at the end of surgery. METHODS: A prospective randomized study, including 69 eyes with idiopathic ERM. Standard 23-gauge three-port pars plana vitrectomy with membrane peeling, using intraoperative optical coherence tomography (OCT), was performed. Randomization for BSS and air-tamponade was performed prior to surgery. RESULTS: Best-corrected visual acuity improved from 32.9 letters to 45.1 letters 3 months after surgery. Presence of preoperative intraretinal cystoid changes was found to be the only risk factor for presence of postoperative intraretinal cystoid changes 3 months after surgery (p = 0.01; odds ratio: 8.0). Other possible risk factors such as combined phacoemulsification with 23G-ppv and membrane peeling (p = 0.16; odds ratio: 2.4), intraoperative subfoveal hyporeflective zones (p = 0.23; odds ratio: 2.6), age over 70 years (p = 0.29; odds ratio: 0.5) and air-tamponade (p = 0.59; odds ratio: 1.5) were not found to be significant. CONCLUSION: There is strong evidence that preoperative intraretinal cystoid changes lead to smaller benefit from surgery.

Diagnostic precision of a microscope-integrated intraoperative OCT device in patients with epiretinal membranes.

PURPOSE: Preoperative and postoperative optical coherence tomography (OCT) of macular pathologies can be regarded as the gold standard diagnostic technique, providing detailed information on the microstructures of the macula for planning the surgical procedure and comparing improvements after surgery in the follow-up period. Intraoperative use of OCT is a novel application to support surgeons during macular surgery. The aim of this study was to examine the diagnostic precision of a microscope-integrated intraoperative spectral-domain OCT (i-OCT) device and compare imaging results to a stand-alone spectral-domain OCT (SD-OCT) device. METHODS: This prospective study included 41 eyes of 41 patients scheduled for pars plana vitrectomy with membrane peeling due to an idiopathic epiretinal membrane (ERM). Intraoperative imaging with the i-OCT device was performed at the beginning of the surgery and compared to preoperative SD-OCT images. RESULTS: Preoperative and intraoperative SD-OCT evaluations showed high intraobserver and interobserver reproducibility for the presence of ERM, lamellar macular hole, and vitreomacular traction. For intraretinal cystoid changes, intraobserver and interobserver reproducibility for both OCTs was rather poor, mainly due to microcystic changes. CONCLUSIONS: Intraoperative spectral-domain OCT offers high reproducibility regarding the visibility of ERM, lamellar macular holes, and vitreomacular traction. Microcystic changes cause discrepancies in interpretation, often simply diagnosed as retinal thickening.

Visualizing Macular Structures During Membrane Peeling Surgery With an Intraoperative Spectral-Domain Optical Coherence Tomography Device.

BACKGROUND AND OBJECTIVE: The aim of this study was to examine the quality of intraoperative visualization of the posterior hyaloid, epiretinal membrane (ERM), inner limiting membrane (ILM), and hyporeflective subfoveal zone with a commercially available, microscope-integrated spectral-domain OCT setup (mi-SD-OCT) (Rescan 700; Carl Zeiss Meditec AG, Germany). PATIENTS AND METHODS: Twenty patients prospectively scheduled for pars plana vitrectomy with membrane peeling due to an idiopathic ERM were included. Standard 23-gauge, three-port pars plana vitrectomy with membrane peeling and staining of the ERM with a trypan blue-based chromovitrectomy dye was performed in all cases. Intraoperative SD-OCT was performed before and after peeling and visualization of the posterior hyaloid, ERM, ILM, and presence of subfoveal hyporeflective zones were examined. OCT follow-ups were performed 2 days and 3 months after surgery. The study was approved by the local ethics committee of the city of Vienna. RESULTS: Successful intraoperative visualization of ERM by mi-SD-OCT was possible in all cases. The posterior hyaloid and ILM could not be seen in the mi-SD-OCT scans, whereas an intraoperative subfoveal hyporeflective zone presented in 35% of cases. In 12.5% an independent subfoveal hyporeflective zone presented postoperatively. Visual acuity improved in 93.8% of patients after surgery. CONCLUSION: mi-SD-OCT appears to be a valuable tool for intraoperative visualization of the ERM and offers immediate visualization of retinal anatomy during peeling. Therefore, it adds to the understanding of intraoperative traumatic changes due to the peeling procedure.

Eplerenone in patients with chronic recurring central serous chorioretinopathy.

PURPOSE: To evaluate the effect of eplerenone on patients with long-term recurring central serous chorioretinopathy (CSC). METHODS: In this retrospective case series, 11 patients with chronic recurring CSC were included. The main focus was to include patients who had undergone photodynamic therapy (4 patients), had undergone anti-vascular endothelial growth factor treatment (3 patients), or had several episodes of CSC in the past (4 patients) (mean age 60 years; SD 9.7, range 47-76). RESULTS: Four patients (36.4%) had full resorption of neurosensory detachment under therapy of eplerenone with improvement of vision, while 4 more patients had improvement of vision despite residual edema. Eight patients (73%) had improved visual acuity (VA) at the end of eplerenone therapy, 2 patients had no change in VA, and 1 patient decreased VA. Mean time of treatment was 10.6 ± 9.9 weeks (range 3-38 weeks). All patients showed subretinal deposits, with 6 of them having hyperautofluorescent subretinal deposits. CONCLUSIONS: Eplerenone represents a new treatment option for patients with CSC. Our data indicate a good response in those patients, leading to improvement of VA in 73% of patients.

Predicting Lens Diameter: Ocular Biometry With High-Resolution MRI.

PURPOSE: The aim of this study was to correlate different biometric dimensions of the eye as measured from ocular magnetic resonance imaging (MRI) scans to predict the lens diameter. METHODS: High-resolution ocular MRI scans of 100 eyes of 100 patients were reviewed. Various anatomical variables of the eye such as the axial length, the globe diameter, and the lens dimensions were measured. Also, the distances between the ciliary sulcus and angle-to-angle were measured. A partial least square (PLS) regression model was built to analyze which variables influence the model regarding the lens dimensions. RESULTS: Sixty-two eyes of 62 patients were included in the final analysis. The lens diameter ratio (horizontal to vertical) was 0.93 (SD: 0.04; 0.83-1.00). The partial least square regression showed a significant connection (P < 0.001) between the horizontal and vertical diameter. The partial least square regression model that included the globe diameter and the axis length resulted in the best prediction for the horizontal lens diameter. Similar to the horizontal lens diameter, globe diameter was the best predictor for the vertical lens diameter followed by the distance of the ciliary sulcus. White-to-white distance, distance of the ciliary sulcus, and axial eye length were found to have a high influence on the angle-to-angle distance. CONCLUSIONS: The introduced models may serve as tools to predict the capsular bag biometry in a preoperative setting for cataract surgery or lens refilling procedures.

Proton beam radiotherapy of diffuse iris melanoma in 54 patients.

BACKGROUND: Treatment modalities in iris melanoma include excision, plaque radiotherapy, photon or proton beam therapy and enucleation. In extensive tumours and diffuse seeding, radiotherapy remains as an alternative to enucleation. METHODS: This study is a retrospective, consecutive, interventional, single-institutional case series. 54 patients with a diffuse and non-resectable iris melanoma diagnosed from September 1998 to June 2012 were included. A 68-megaelectron volt proton beam was used to treat the anterior segment with a total dose of 4×12.5 cobalt grey equivalent. The cases were evaluated for local tumour control, eye retention, functional outcome and local complications after treatment. RESULTS: During a mean follow-up of 62.7 months (median 54.8 months, range 5.5-159.6 months), local tumour control was achieved in 96.3% of the patients. Cataract and glaucoma were the main complications developing after irradiation in 42.6% and 55.6%, respectively. In 34 of 44 patients (77.3%) who underwent cataract removal, a visual acuity of 20/40 or better following surgery was preserved. Enucleation was performed in three patients. The reason was suspected tumour recurrence in one and glaucoma in two. Hepatic metastasis occurred in one patient. CONCLUSIONS: As an alternative to enucleation, whole anterior segment fractionated proton beam radiotherapy offered excellent local tumour control in diffuse iris melanoma. Given the limited alternatives, the rate of complications appears acceptable and visual function could be preserved in the majority of the patients during follow-up.

Comments on "Backpropagation algorithms for a broad class of dynamic networks".

In a recent paper, De Jesús proposed a general framework for describing dynamic neural networks. Gradient and Jacobian calculations were discussed based on backpropagation-through-time (BPTT) algorithm and real-time recurrent learning (RTRL). Some errors in the paper of De Jesús bring difficulties for other researchers who want to implement the algorithms. This comments paper shows the critical parts of the publication and gives errata to facilitate understanding and implementation.