Sensitivity and specificity of MultiColor imaging in detecting proliferative diabetic retinopathy.

PURPOSE: To evaluate the accuracy of MultiColor imaging (MC) compared to fluorescein angiography (FA) in detecting proliferative diabetic retinopathy (PDR) and associated diabetic retinopathy features. METHODS: Fifty-nine eyes from 38 PDR patients were included. MC images were reviewed by 2 independent masked graders. A qualitative analysis based on the following features was performed: neovascular complexes (NVC), disc neovascularization (NVD), neovascularization elsewhere (NVE), microaneurysm (MA), intraretinal hemorrhage (IRH), vitreous hemorrhage (VH), preretinal hemorrhage (PRH), fibrosis, hard exudates (HE), epiretinal membrane (ERM), diabetic macular edema (DME), ischemia and laser spots (LS). Measures of diagnostic accuracy compared to FA were determined. RESULTS: The sensitivity for the detection of NVC using MC was 95.1%, with a specificity of 40.0%, positive predictive value (PPV) of 92.9% and negative predictive value (NPV) of 50.0%. Sensitivity and specificity were higher in detecting NVD (88.9% and 76.9%) while NVE registered higher PPV (88.9%). MC was highly sensitive in detecting IRH, HE, ERM and LS (100%), MA (98.0%) and fibrosis (95.5%). Highest specificity was found for VH (100.0%), DME (100.0%), PRH (98.1%) and LS (89.5%). The area under the receiver-operating characteristic analysis of MC was excellent in NVD (0.83, 95% confidence interval (CI), 0.71-0.95, p < 0.001), IRH (0.89, 95% CI 0.74-1.00, p < 0.001), VH (0.81, 95% CI 0.60-1.00, p = 0.005) and PRH (0.89, 95% CI 0.68-1.00, p = 0.004) and outstanding in LS detection (0.95, 95% CI 0.87-1.00, p < 0.001). These results are likely due to the contrast and quality of the MC since better discrimination is enabled by the green wavelength. CONCLUSION: MC is useful in evaluation of PDR patients and can complement noninvasive imaging. MC detected some PDR features more accurately than FA such as NVD, IRH, VH, PRH, and LS.

Ultrasonic circular cyclocoagulation prospective safety and effectiveness study.

PURPOSE: To evaluate the efficacy and safety of ultrasound cycloplasty procedures (UCP) in patients with uncontrolled glaucoma. METHODS: Prospective longitudinal study with UCP was performed by EyeOP1© probe with 8 s duration on 6 or 8 sectors, according to baseline intraocular pressure (IOP). Complete ophthalmic examination was performed pre- and post-operatively at 1st day, 1st week, 1st, 3rd, 6th, 9th and 12th months. UCP was repeated beyond 3rd month if IOP was > 21 mmHg, under maximum therapy, without major complications. Primary outcomes were complete (IOP reduction ≥ 20% or reduction in number of antiglaucomatous drugs and IOP ≥ 5 mmHg without occurrence of major complications) and qualified (IOP reduction ≥ 20% or reduction in number of antiglaucomatous drugs and IOP ≥ 5 mmHg) surgical success rates at 12 months. Secondary outcomes were mean IOP reduction, mean number of drugs reduction, rates of failure, number of repeated procedures, mean time to failure and occurrence of complications. RESULTS: Fourteen eyes of 13 patients (11 male) with advanced glaucoma (Hoddap classification) were included. Six were surgically naïve. Mean age was 68.29 ± 10.66 years. Four eyes were treated in 8 sectors (28.5%). Patients were followed for 12 months after first UCP procedure. Overall surgical success was achieved in 92.9% at 6 months and in 100% of cases at 12 months. Mean IOP significantly reduced from 28.50 ± 7.61 mmHg to 13.79 ± 6.97 at 1 month, 17.36 ± 8.58 at 3 months, 17.79 ± 6.29 at 6 months, 16.3 ± 4.6 at 9 months and to 15.23 ± 5.09 at 12 months (p < 0.01). Mean number of drugs reduced from 3.71 ± 0.61 to 2.43 ± 1.51 at 3 months, 2.86 ± 1.1 at 6 months, 2.64 ± 0.93 at 9 months and to 2.92 ± 0.86 at 12 months (p < 0.05). Major reversible complications included choroidal detachment in 2 (14.29%) and corneal edema in 1 eye (7.14%), without permanent visual acuity reduction. Minor reversible complications included anterior chamber reaction (92.25%), conjunctival hyperemia (71.43%) and superficial keratitis (57.4%). Four eyes (28.57%) had indication for repeating UCP, with mean period to failure of 8.1 ± 3.95 months. CONCLUSION: UCP procedures are effective in reducing IOP in severe glaucoma. Its application and repetition seem to be a medium-long term acceptable alternative to cyclodestructive surgery. However, long-term efficacy and safety require yet further investigation.

Bull's Eye Maculopathy in Near-Infrared Reflectance as An Early Sign of Hydroxychloroquine Toxicity.

Hydroxychloroquine (HCQ) ocular toxicity is rare but severe, and progression can occur even after termination of therapy. Case reports have suggested that a bull's eye maculopathy detected by near-infrared reflectance (NIR) may indicate early HCQ toxicity. This retrospective cross-sectional study evaluated patients treated with HCQ who underwent routine screening with optical coherence tomography (OCT), fundus autofluorescence (FAF) and 10-2 perimetry. NIR images captured alongside OCT were subsequently graded independently by 2 masked graders for the presence of bull's eye maculopathy, and the result was compared to the outcome of the screening. A total of 123 participants (246 eyes) were included, and 101 (90%) were female. The patients' mean age was 55.2 ± 13.8 years. The mean time of HCQ usage was 84.0 ± 72.3 months, and the mean weekly dose was 2327 ± 650 mg. Two eyes showed toxicity in all 3 routine screening exams, with one patient suspending HCQ. The prevalence of bull´s eye lesions in NIR was 13% (33 eyes) with substantial intergrader agreement, a 71.3% specificity and 88.0% negative predictive value for HCQ toxicity. We suggest that NIR changes may be a sign of early HCQ toxicity. The detection of NIR bull´s eye lesions may warrant an increased screening frequency.

Update on Optical Coherence Tomography and Optical Coherence Tomography Angiography Imaging in Proliferative Diabetic Retinopathy.

Proliferative diabetic retinopathy (PDR) is a major cause of blindness in diabetic individuals. Optical coherence tomography (OCT) and OCT-angiography (OCTA) are noninvasive imaging techniques useful for the diagnosis and assessment of PDR. We aim to review several recent developments using OCT and discuss their present and potential future applications in the clinical setting. An electronic database search was performed so as to include all studies assessing OCT and/or OCTA findings in PDR patients published from 1 January 2020 to 31 May 2021. Thirty studies were included, and the most recently published data essentially focused on the higher detection rate of neovascularization obtained with widefield-OCT and/or OCTA (WF-OCT/OCTA) and on the increasing quality of retinal imaging with quality levels non-inferior to widefield-fluorescein angiography (WF-FA). There were also significant developments in the study of retinal nonperfusion areas (NPAs) using these techniques and research on the impact of PDR treatment on NPAs and on vascular density. It is becoming increasingly clear that it is critical to use adequate imaging protocols focused on optimized segmentation and maximized imaged retinal area, with ongoing technological development through artificial intelligence and deep learning. These latest findings emphasize the growing applicability and role of noninvasive imaging in managing PDR with the added benefit of avoiding the repetition of invasive conventional FA.

Optical coherence tomography features of neovascularization in proliferative diabetic retinopathy: a systematic review.

BACKGROUND: Diabetic retinopathy (DR) is a leading cause of blindness due to diabetic macular edema (DME) or complications of proliferative diabetic retinopathy (PDR). Optical coherence tomography (OCT) is a noninvasive imaging technique well established for DME but less used to assess neovascularization in PDR. Developments in OCT imaging and the introduction of OCT angiography (OCTA) have shown significant potential in PDR. OBJECTIVES: To describe the tomographic features of PDR, namely of neovascularization, both of the optic disc (NVD) and elsewhere (NVE), intraretinal microvascular abnormalities (IRMA), retinal nonperfusion areas (NPA), status of the posterior vitreous, vitreoschisis and vitreous and subhyaloid/sub-ILM hemorrhages. DATA SOURCES: Electronic database search on PubMed and EMBASE, last run on December 19th 2019. STUDY ELIGIBILITY CRITERIA PARTICIPANTS AND INTERVENTIONS: Publications assessing OCT and/or OCTA findings in PDR patients. All study designs were allowed except for case-reports, conference proceedings and letters. STUDY APPRAISAL: Newcastle-Ottawa Scale for observational studies was used for purposes of risk of bias assessment. RESULTS: From the 1300 studies identified, 283 proceeded to full-text assessment and 60 were included in this comprehensive review. OCT was useful in detecting NVD and NVE, such as in characterizing disease activity and response to laser and/or anti-VEGF therapies. The absence of posterior vitreous detachment seemed determinant for neovascular growth, with the posterior hyaloid acting as a scaffold. OCTA allowed a more detailed characterization of the neovascular complexes, associated NPA and disease activity, allowing the quantification of neovessel area and flow index. However, changes in OCTA blood flow signal following local therapies did not necessarily correlate with structural regression. Widefield and ultra-widefield OCTA were highly sensitive in the detection of PDR, adding value to disease staging and monitoring. Compared to fluorescein angiography, OCTA was more sensitive in detecting microvascular changes indicating disease progression. LIMITATIONS: Publication languages were restricted. Most included studies were observational and non-comparative. Risk of bias regarding case representativeness. CONCLUSIONS: OCT-based retinal imaging technologies are advancing rapidly and the trend is to be noninvasive and wide-field. OCT has proven invaluable in diagnosing, staging and management of proliferative diabetic disease with daily application in clinical and surgical practices.

Transient choroidal detachment after ultrasonic circular cyclocoagulation.

Two patients with refractory glaucoma followed in our ophthalmology department registered progression on left eyes (OS) despite best practice. Best corrected visual acuity (BCVA) was 9/10 and 8/10 and intraocular pressure (IOP) was above 20 mm Hg while under maximal hypotensive therapy. The procedure was performed under retrobulbar anaesthesia with second-generation EyeOp1probes. In follow-up, OS were hypotonic with registered IOP ≤5 mm Hg and revealed a 3/10 BCVA. The funduscopy showed one temporal and superior and another nasal and temporal choroidal detachments. The patients started oral steroids and interrupted all ocular hypotensive medication. After therapy, patients returned with normal rising OS IOPs and with totally reapplied choroids, accompanied by normalised BCVA. These two cases are proof of the possibility of transient choroidal detachment after a ultrasonic circular cyclocoagulation. While a very rare major vision-threatening complication, every ophthalmologist should remind it when sudden BCVA reductions occur after this procedure.

Pigmented paravenous retinochoroidal atrophy associated with unilateral cystoid macular oedema.

A 65-year-old man was referred to our department with complaints of blurred vision in the left eye. Funduscopic examination revealed areas of retinochoroidal atrophy along the retinal veins bilaterally and bone spicule pigmentation along the nasal and superior temporal venous branches, as well as macular oedema in the left eye. Fluorescein angiography, visual field test, optical coherence tomography and electrophysiological examination were performed, and results were compatible with the diagnosis of pigmented paravenous retinochoroidal atrophy (PPRCA). Treatment with topical dorzolamide and intravitreal bevacizumab in the left eye resulted in poor anatomical and visual response. There is scarce documentation of macular involvement with non-inflammatory unilateral cystoid macular oedema in PPRCA in the literature. Further investigation is required to elucidate the pathogenesis of PPRCA and to properly manage these patients.