INTRAVITREAL DEXAMETHASONE IMPLANT AS ADJUVANT TREATMENT FOR BEVACIZUMAB- AND RANIBIZUMAB-RESISTANT NEOVASCULAR AGE-RELATED MACULAR DEGENERATION: A Prospective Pilot Study.

PURPOSE: To study the benefit of intravitreal dexamethasone implant in the management of neovascular age-related macular degeneration resistant to bevacizumab and ranibizumab. METHODS: Patients with persistent macular fluid on optical coherence tomography despite monthly treatment with at least three consecutive bevacizumab injections followed by at least three ranibizumab injections were prospectively enrolled. A single dexamethasone implant was administered followed by intravitreal ranibizumab 1 week later. Ranibizumab was continued afterward on an as-needed basis. Main outcomes were improvement in central retinal thickness and best-corrected visual acuity. RESULTS: Nineteen patients (19 eyes) were enrolled. There was no significant change in best-corrected visual acuity over 6 months. Greatest reduction in mean central retinal thickness, from 295.2 µm to 236.2 µm, occurred 1 month after dexamethasone implant (P < 0.0001). By Month 6, mean central retinal thickness was 287.3 µm (P = 0.16). Eyes with only intraretinal fluid (13 eyes) achieved a fluid-free macula. Eyes with predominantly subretinal fluid (6 eyes) did not improve central retinal thickness and continued monthly ranibizumab. Mean baseline intraocular pressure was 13.2 mmHg, which peaked at 15.6 mmHg by Month 2 (P = 0.004). CONCLUSION: Intravitreal dexamethasone implant improved only macular intraretinal fluid in eyes with neovascular age-related macular degeneration resistant to bevacizumab and ranibizumab. However, this treatment had a limited duration.

Spectral domain optical coherence tomography in children: normative data and biometric correlations.

BACKGROUND: The aim was to report normative values of retinal nerve fiber layer (RNFL) and macular parameters in children using spectral domain optical coherence tomography (OCT) and to perform correlations with age, refractive error and axial length. METHODS: This was an observational cross-sectional study recruiting 113 healthy children aged 6 to 17 years with no ocular abnormality except refractive error. After a comprehensive eye examination and axial length measurement, RNFL and macular thickness measurements were performed using the Cirrus OCT machine. Main outcome measures were macular volume, macular thickness and RNFL thickness values as well as their correlations with age, refractive error and axial length. Right eyes of all subjects were selected for analysis. RESULTS: One hundred and eight children were included in the study, 65 females and 43 males. Mean age was 10.7+/-3.1 years, average spherical equivalent refraction (SE) was -0.02+/-1.77(-4.25 to +5.00) diopters and average axial length was 23.5+/-1.0 (21.5 to 25.8)mm. Mean RNFL thickness was 95.6+/-8.7 µm, average macular thickness was 279.6+/-12.5 µm, central macular thickness was 249.1+/-20.2 µm, and mean macular volume was 10.1+/-0.5 mm(3). Central macular thickness values were significantly higher in males (p < 0.001). RNFL measurements did not correlate with age but did show a positive correlation with SE. All macular parameters were consistently positively correlated with age and most of them were positively correlated with SE. When controlling for axial length, only the macular inner circle thickness was positively correlated with age. CONCLUSIONS: Using Cirrus OCT, normative RNFL and macular parameters in healthy children below 18 years of age were established; measurements varied by age and gender.

Success of Endoscopic Laser Cyclophotocoagulation vs Repeat Transscleral Treatment after Prior Transscleral Cycloablation.

Aim: To compare the efficacy of endoscopic cyclophotocoagulation (ECP) vs repeat transscleral cyclophotocoagulation (TCP) in eyes with persistent glaucoma despite prior treatment with TCP. Materials and methods: This was a retrospective chart review of glaucoma patients at the American University of Beirut Medical Center over 10 years who underwent ECP or repeat TCP. We reported qualified and complete success; success was defined as postoperative intraocular pressure (IOP) ≤21 mm Hg, with (qualified) or without medications (complete) and without procedure-related complications. Results: This study included 23 eyes of 21 patients with various forms of uncontrolled glaucoma who had failed TCP. A total of 13 eyes of 12 patients underwent ECP with a mean age of 39.9 ± 23.2 years, and 10 eyes of nine patients underwent repeat TCP with a mean age of 27.2 ± 22.6 years. A significant decrease in IOP was observed from 38.5 ± 7.9 mm Hg preoperatively to 25.2 ± 8.8 mm Hg postrepeat TCP (p = 0.006) and from 33.0 ± 9.5 to 12.8 ± 3.9 mm Hg post-ECP (p < 0.001), noted at a mean follow-up time of 39.2 ± 44.4 and 41.5 ± 37.4 months, respectively. The mean number of antiglaucoma medications decreased in the two groups (from 3.8 ± 1.0 preoperatively to 1.8 ± 0.9 postoperatively for ECP and from 3.5 ± 1.3 to 3.1 ± 0.9 postoperatively for TCP); however, the drop was only statistically significant post-ECP. Qualified success was significantly higher after ECP vs repeat TCP (91.7 vs 40%, respectively). Complete success was achieved only in 1/12 (8.3%) eyes in the ECP group. Conclusion: Endoscopic cyclophotocoagulation (ECP) performed in glaucomatous eyes previously treated with transscleral cycloablation provided more IOP control as compared to repeat TCP by directly treating viable tissue in previously skipped ciliary processes and in between processes. Clinical significance: In glaucomatous eyes previously treated with transscleral cycloablation, ECP attained better IOP control than repeat transscleral cycloablation. How to cite this article: Al-Haddad C, Barikian A, Moussawi ZE, et al. Success of Endoscopic Laser Cyclophotocoagulation vs Repeat Transscleral Treatment after Prior Transscleral Cycloablation. J Curr Glaucoma Pract 2023;17(4):191-196.

Numerous recurrent trichilemmal cysts of the scalp: differential diagnosis and surgical management.

Trichilemmal cysts are common benign soft tissue tumors that occur in hairy areas, especially the scalp, where they present themselves as solitary masses that could be easily treated by surgical excision followed by pathologic identification. It is unusual to find these benign masses in very large numbers in 1 scalp. In the current article, we describe a 43-year-old woman who presented with 51 scalp masses, some of which recurred after repetitive excisions somewhere else by different surgeons under local anesthesia. These masses involved only the scalp and spared all the face. The patient presented to our clinic for a radical solution to clear her scalp from the unaesthetic look and appearance that forbid her from exposing her head and for hygienic reasons relating to the foul smell of repeated previous recurrences and infections. Her clinical presentation is described, and the suggested differential diagnosis and management for such a patient is discussed.

Dose-Response Relationship between Intravitreal Injections and Retinal Nerve Fiber Layer Thinning in Age-Related Macular Degeneration.

PURPOSE: To determine if multiple intravitreal injections of vascular endothelial growth factor (VEGF) inhibitors for unilateral exudative age-related macular degeneration (eAMD) are associated with thinning of the retinal nerve fiber layer (RNFL), we compared RNFL thickness measurements from the injected eye with that of the fellow eye with nonexudative age-related macular degeneration (neAMD). DESIGN: Retrospective, cross-sectional study. PARTICIPANTS: Patients undergoing anti-VEGF therapy for unilateral eAMD. METHODS: Patients receiving anti-VEGF therapy secondary to eAMD in 1 eye with neAMD in their fellow eye were identified. Patients with a known diagnosis of glaucoma were excluded. Spectral domain OCT measurements of the peripapillary RNFL thickness from both eyes were performed and compared. The differences in the RNFL thickness measurements between eyes were correlated with the number of injections and the duration of therapy. MAIN OUTCOME MEASURES: Correlation between the number of anti-VEGF injections and peripapillary RNFL thinning. RESULTS: A total of 108 eyes of 54 patients were evaluated in this study. The average peripapillary RNFL thickness measurements of the injected eye and fellow eye were 87.3 ± 9.6 µm and 89.0 ± 7.5 µm, respectively (P = 0.055). The RNFL thickness difference (fellow eye minus injected eye) was significantly correlated with the number of injections (r = 0.40, P = 0.002) and months of injections (r = 0.38, P = 0.005). The relationship between the difference in the RNFL thickness and the number of injections had a nonlinear dose-response relationship that became apparent after approximately 30 injections and 50 months of injections. CONCLUSIONS: The difference in RNFL thickness measurements between injected eyes and uninjected fellow eyes was largely within the reported normal limits for interocular differences between healthy eyes. Nevertheless, there was a dose-response relationship between RNFL thinning and number of injections among patients receiving a greater number of injections, suggesting that anti-VEGF injections may have a modest effect on the RNFL thickness after several years of therapy in eyes requiring more anti-VEGF injections; however, we cannot exclude that the RNFL thinning may be secondary to active age-related macular degeneration (AMD) disease progression in both eyes.

Comparison Between Graders in Detection of Diabetic Neovascularization With Swept Source Optical Coherence Tomography Angiography and Fluorescein Angiography.

PURPOSE: We compared the ability of ophthalmologists to identify neovascularization (NV) in patients with proliferative diabetic retinopathy using swept-source optical coherence tomography angiography (SS-OCTA) and fluorescein angiography (FA). DESIGN: Retrospective study comparing diagnostic instruments. METHODS: Eyes with proliferative diabetic retinopathy or severe nonproliferative diabetic retinopathy and a high suspicion of NV based on clinical examination were imaged using SS-OCTA and FA at the same visit. Two separate grading sets consisting of scrambled, anonymized SS-OCTA and FA images were created. The ground truth for presence of NV was established by consensus of 2 graders with OCTA experience who did not participate in the subsequent assessment of NV in this study. The 2 anonymized image sets were graded for presence or absence of NV by 12 other graders that included 2 residents, 6 vitreoretinal fellows, and 4 vitreoretinal attending physicians. The percentage of correct grading of NV using SS-OCTA and FA was assessed for each grader and across grader training levels. RESULTS: Forty-seven eyes from 24 patients were included in this study. Overall, the mean percentage of correct NV grading was 87.8% using SS-OCTA with B-scans and 86.2% using FA (P = .92). Assessing each grader individually, there was no statistically significant asymmetry in correct grading using SS-OCTA and FA. CONCLUSIONS: Ophthalmologists across training levels were able to identify diabetic NV with equal accuracy using SS-OCTA and FA. Based on these results, SS-OCTA may be an appropriate standalone modality for diagnosing diabetic NV.

Wide field swept source OCT angiography in acute syphilitic placoid chorioretinitis.

PURPOSE: To describe the clinical and swept source OCT angiographic features of a patient with acute syphilitic posterior placoid chorioretinitis (ASPPC). OBSERVATIONS: A 67-year-old man presented with acute loss of vision in the left eye. On exam, we noted a yellowish placoid lesion in the macula. Optical coherence tomography (OCT) imaging showed RPE nodularity and disruption of the inner segment-outer segment region in the left eye. Fluorescein angiography showed early hyperfluorescent and late staining within the placoid lesions. Wide field swept source OCT angiography (SS-OCTA) showed macular choriocapillaris perfusion flow deficits. Laboratory tests revealed positive 1:128 rapid plasma reagin titer and fluorescent treponemal antibody absorption (FTA-ABS) tests. OCT imaging revealed complete restoration of the IS-OS boundary layer with near complete resolution of the RPE granularity after adequate penicillin therapy. SS-OCTA showed resolution of choriocapillaris flow deficit in the left eye. Improvement in BCVA correlated with improvement in choriocapillaris perfusion. CONCLUSIONS AND IMPORTANCE: This is the first case that describes long-term SS-OCTA findings in ASPPC. SS-OCTA is a fast, safe, and easily repeatable imaging modality that offers valuable insights in our understanding of the pathophysiology and the response to treatment of ASPPC.

The Extent of Retinal Involvement of Canthaxanthin Crystalline Retinopathy Demonstrated by Multimodal Imaging.

Limited information is known about the extent of canthaxanthin crystalline retinopathy on the retinal layers. The authors describe a 51-year-old woman who was taking canthaxanthin for tanning purposes for 7 years. Three years after cessation of this agent, she presented with asymmetric crystalline retinopathy affecting both eyes. She was lost to follow-up, and upon returning 4 years later, the crystalline retinopathy persisted but the number of crystals had decreased. Using swept-source optical coherence tomography, the authors showed that the crystalline retinopathy affected all retinal layers. In addition, retinal pigmented epithelial detachments were present suggesting persistent damage caused by the canthaxanthin. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:727-731.].

Changing Trends in Eye-Related Complaints Presenting to the Emergency Department in Beirut, Lebanon, over 15 Years.

OBJECTIVE: To report the 15-year trend in ophthalmic presentations to the emergency department (ED) at the only medical center in Lebanon that provides 24-hour ophthalmologic care. METHODS: Retrospective review of 1967 patients presenting to the ED with eye-related complaints between September 1997 and August 1998 and between September 2012 and August 2013. Diagnoses were classified into 4 categories according to the International Society of Ocular Trauma and include penetrating eye injuries, nonpenetrating eye trauma, nontraumatic ophthalmic emergencies, and nontraumatic, nonurgent ophthalmic conditions. RESULTS: One thousand sixty eye-related presentations out of 39,158 total ED visits (2.71%) presented in 1997 compared to 907 out of 46,363 in 2012 (1.96%). Penetrating and nonpenetrating eye emergencies decreased between 1997 and 2012 (7.17% to 4.19%, p = 0.003 and 52.64% to 29.00%, p < 0.001, resp.) while nonurgent cases increased from 30.19% to 53.47% (p < 0.001). 57% of patients were covered by third-party guarantors in 1997 versus 73% in 2012. CONCLUSION: Our results demonstrate a significant increase in nonurgent cases in parallel with the proportion of third-party payers, an issue to be addressed by public health policies and proper resource allocation. A detailed nationwide review is needed to make solid recommendations for the management of ophthalmologic presentations in the ED.

Genotype/Phenotype Correlation in Primary Congenital Glaucoma Patients in the Lebanese Population: A Pilot Study.

BACKGROUND: The incidence of primary congenital glaucoma (PCG) varies among geographic regions and ethnic groups. The frequency of PCG in Lebanon and identification of disease-causing mutations have not been studied previously. PURPOSE: To investigate the role of Cytochrome P1B1 (CYP1B1) gene and Myocillin (MYOC) gene mutations in PCG in the Lebanese population and study possible genotype/phenotype correlations. METHODS: Patients with unilateral or bilateral PCG diagnosed at the American University of Beirut Medical Center and their first-degree relatives (parents and siblings) were screened for CYP1B1 and MYOC mutations. Demographic and phenotypic characteristics were recorded. Phenotypic characteristics pertaining to disease severity and outcomes were compared. RESULTS: Eighteen Lebanese families (66 subjects) with at least one member affected with PCG were included in this study. Mutations in the CYP1B1 gene were detected in 6 families (33%). Five previously described mutations (p.R444Q; p.E229K; p.R469W; p.G61E; p.M1T) and one new single nucleotide deletion were identified (1793delC). Patients in whom CYP1B1 mutations were detected tended to have a more severe phenotype as evidenced by earlier age at diagnosis, higher rate of bilateral disease, and higher number of glaucoma surgeries than those in whom no CYP1B1 mutations were present. MYOC gene mutations were not detected in any patients. CONCLUSION: The rate of CYP1B1 mutations in Lebanese patients with PCG is lower than that reported in other Arab and Middle Eastern populations and suggests other genes are responsible for PCG in the remainder.

Intravitreal Adalimumab in Active Noninfectious Uveitis: A Pilot Study.

PURPOSE: To evaluate the short-term efficacy of intravitreal adalimumab (IVA) for the treatment of eyes with active noninfectious uveitis. METHODS: Consecutive eyes with active noninfectious uveitis were injected with IVA at 0, 2, then every 4 weeks for total of 26 weeks. RESULTS: Six out of 7 patients (12 of 13 eyes) completed 26 weeks of treatment. One patient (1 eye) failed treatment. Seven out of 12 eyes had improvement of ≥2 ETDRS lines. Three out of three eyes had resolution of anterior chamber cells. And 9 of 10 eyes with vitreous haze had zero haze at 26 weeks. Five out of 8 eyes with macular edema had complete resolution. Median fluorescein angiography score improved from 14 to 4 on last follow-up. CONCLUSIONS: IVA was effective in controlling the inflammation, decreasing the macular edema, and improving the best corrected visual acuity in the majority of eyes in this series.

Etiology and Clinical Features of Ocular Inflammatory Diseases in a Tertiary Center in Lebanon.

PURPOSE: To identify the pattern of uveitis in patients presenting to the American University of Beirut Medical Center (AUBMC) uveitis service in Lebanon. METHODS: The charts of patients seen between January 2009 and September 2011 were retrospectively reviewed. Data pertaining to patient demographics, eye examination on presentation, workup, and final diagnoses were collected. RESULTS: The total number of charts reviewed was 209. The most common noninfectious etiologies were Behçet disease, sarcoidosis, and HLA-B27-associated uveitis, while toxoplasmosis, herpes, and tuberculosis were the most common infectious etiologies. The mean duration of the disease before presentation to our center was 38 ± 56 months (range 0-284 months), with cataract formation in 90/234 (38%) and visual impairment in 134/291 (46%) eyes on presentation. CONCLUSIONS: This case series reveals a significant delay in referring uveitis cases to a specialized center, which may contribute to the high percentage of patients presenting with ocular complications.

Induction with intravitreal bevacizumab every two weeks in the management of neovascular age-related macular degeneration.

PURPOSE: To explore the benefit of rapid induction with intravitreal bevacizumab for neovascular age-related macular degeneration (AMD). DESIGN: Single-institution prospective randomized pilot study. METHODS: Patients with treatment-naïve neovascular AMD were randomized 1:1:1 into 1 of 3 groups based on the induction sequence: (1) every 2 weeks for 3 consecutive injections; (2) every 4 weeks for 3 consecutive injections; and (3) immediate pro re nata (prn) after the first injection. Retinal angiomatous proliferation and polypoidal choroidal vasculopathy were excluded. Best-corrected visual acuity (BCVA) and central retinal thickness using optical coherence tomography (OCT) were measured at baseline and at each follow-up. After induction, bevacizumab was administered as needed based mainly on OCT. Main outcome measure was mean initial fluid-free interval after induction. Secondary outcomes were mean improvement in BCVA and central retinal thickness. RESULTS: Each group included 30 patients (30 eyes). Mean initial fluid-free interval was 2.4, 3.4, and 3.5 months for biweekly induction, monthly induction, and immediate prn groups, respectively (P = .03). Significance was lost when corrected for age and sex (P = .073). Mean improvement in BCVA, central retinal thickness, and total number of injections were similar among the groups at 12 months. Six eyes in the biweekly induction group developed subretinal fibrosis vs no eyes in the other 2 groups (P = .003). CONCLUSION: Biweekly induction with intravitreal bevacizumab for treatment-naïve neovascular AMD does not increase initial fluid-free interval or cause significant anatomic and functional benefit compared to monthly induction or immediate prn. There is also the potential development of subretinal fibrosis with biweekly induction.