Microvasculature Changes of Myopic Choroidal Neovascularization and the Predictive Value of Feeder Vessel Disappearance after Ranibizumab Treatment Revealed Using Optical Coherence Tomography Angiography.

AIM: To investigate vascular changes of myopic choroidal neovascularization (mCNV) after ranibizumab treatment using optical coherence tomography-angiography (OCTA). METHODS: Consecutive subjects with a diagnosis of mCNV were included. Patients underwent intravitreal injection of ranibizumab treatment with a 6-month follow-up. All patients underwent a complete ophthalmological examination and OCTA evaluation. The 3 × 3 OCTA en face images were analyzed for the absence/presence of mCNV, CNV area, and CNV network morphology. In particular, the morphology of the mCNV was analyzed in order to detect the presence/absence of feeder vessels. RESULTS: Eleven subjects were evaluated. At baseline, the mCNV was identified in all cases on OCTA. At 6 months, the mean mCNV area was not statically significantly reduced in comparison with baseline values (p > 0.05), while the morphologic analysis revealed a complete disappearance of the feeder vessel in 6 eyes. The subgroup analysis of these latter showed that the CNV area was significantly reduced, visual acuity had improved, and only one intravitreal injection was administrated over the entire follow-up period. CONCLUSIONS: OCTA allowed the detection of qualitative and quantitative vascular changes in mCNV. The disappearance of the feeder vessel was associated with better anatomical as well as functional outcomes at the last follow-up visit.

CHRONIC CENTRAL SEROUS CHORIORETINOPATHY: Early and Late Morphological and Functional Changes After Verteporfin Photodynamic Therapy.

PURPOSE: To describe early and late morphological and functional changes in subjects receiving photodynamic therapy (PDT) for chronic central serous chorioretinopathy. METHODS: Patients with chronic central serous chorioretinopathy were prospectively enrolled and received standard PDT. At the baseline examination, each subject underwent complete ophthalmological examination, including best-corrected visual acuity (BCVA) assessment, fluorescein angiography and indocyanine green angiography, spectral domain optical coherence tomography, and microperimetry. Spectral domain optical coherence tomography, microperimetry, and BCVA assessment were repeated in multiple sections over 7 days after PDT and at 1-, 3-, and 12-month intervals. Main outcome measures were: identification of early changes (1-week examination) in BCVA, retinal sensitivity, and spectral domain optical coherence tomography parameters and their influence on outcomes at the 1-year follow-up. RESULTS: Three main patterns of early response to PDT were identified during the 1-week examination. The neurosensory retinal detachment most frequently decreased rapidly (12/19 pts), with complete resolution in 50% of cases. An increase in neurosensory retinal detachment height was registered in 16% (3/19) of cases, whereas in 21% (4/19), a large fluctuation in neurosensory retinal detachment was encountered. Best-corrected visual acuity declined significantly in 5/12 patients in the first group and was stable or improved in the remaining cases. Overall, retinal sensitivity diminished in 16/19 subjects, with a mean worsening of 2.56 dB (P = 0.0002). At the 12-month examination, final mean BCVA improved by 14.4 letters (P = 0.001) and a similar progressive recovery in the retinal sensitivity was observed (+2.69 dB, P = 0.0039). The neurosensory retinal detachment completely resolved in 18/19 (95%) cases, with a parallel significant reduction in central foveal choroidal thickness (P < 0.0001). CONCLUSION: Three patterns of early response to standard PDT can be identified. Although an early and abrupt reduction in BCVA and retinal sensitivity after treatment is possible, this does not compromise a final improvement in visual functions.

SUBTHRESHOLD LASER TREATMENT FOR SEROUS RETINAL DETACHMENT IN DOME-SHAPED MACULA ASSOCIATED WITH PATHOLOGIC MYOPIA.

PURPOSE: To evaluate the effects of the subthreshold laser treatment as a therapeutic option in the treatment of serous retinal detachment secondary to dome-shaped macula. METHODS: Prospective pilot study with 12-month follow-up. Each patient underwent a complete ophthalmologic examination, including best-corrected visual acuity, fluorescein angiography, indocyanine green angiography, and spectral domain optical coherence tomography. Eyes with persistent serous retinal detachment lasting for a minimum of 12 months and absence of best-corrected visual acuity improvement underwent subthreshold laser treatment in a single session. The laser spots were delivered in a contiguous mode, covering the area of hyperfluorescence recognized on indocyanine green angiography. The primary outcome measure was the best-corrected visual acuity changes at the 12-month examination. Secondary outcomes included changes in central foveal thickness (CFT) and number of eyes achieving a complete serous retinal detachment resolution. RESULTS: Twelve eyes (8 patients) were included in the study. Best-corrected visual acuity changed from a baseline value of 0.8 ± 0.2 (±SD, logarithm of the minimum angle of resolution [Snellen equivalent: 20/125]) to 0.48 ± 0.1 (Snellen equivalent: 20/60, P = 0.001). Central foveal thickness decreased from 320 ± 52 µm to a final value of 266 ± 41 µm (P = 0.001). Serous retinal detachment reduced in all cases; however, just one eye (8.3%) showed a complete resolution at the 12-month examination. Fluorescein angiography and indocyanine green angiography showed that the hyperfluorescence had disappeared after subthreshold laser treatment. No adverse event was registered, including enlargement of atrophic alterations and choroidal neovascularization. CONCLUSION: Subthreshold laser treatment can lead to improvements in visual acuity and central foveal thickness in myopic eyes with serous retinal detachment secondary to dome-shaped macula. Further studies are required to confirm our preliminary results.

SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHY FEATURES IN DIFFERENT STAGES OF BEST VITELLIFORM MACULAR DYSTROPHY.

PURPOSE: To provide a systematic classification of findings regarding the different stages of vitelliform macular dystrophy on spectral domain optical coherence tomography (SD-OCT). METHODS: Ninety-four eyes of 47 patients were recruited in a prospective cross-sectional study. All patients underwent a complete ophthalmologic examination, including best-corrected visual acuity using Early Treatment Diabetic Retinopathy Study (ETDRS) charts, biomicroscopy, and SD-OCT. The findings assessed included vitelliform material, neurosensory detachment, status of external limiting membrane, ellipsoid zone and retinal pigment epithelium, choroidal excavation, foveal cavitation, choroidal neovascularization, vitreomacular traction, and macular hole. The primary outcome measure was the identification of SD-OCT findings in each vitelliform macular dystrophy stage. Secondary outcomes included the correlations between SD-OCT features and visual acuity changes. RESULTS: The outer retinal layers (external limiting membrane, ellipsoid zone, and retinal pigment epithelium) were found to be more commonly disrupted in Stages 2 to 4 (range: 86%-100%), whereas their absence was more typical of Stage 5 (71%-86%). Vitelliform material was found in 100% of Stages 2 and 3, 93% of Stage 4, and interestingly in 43% of Stage 5. Eyes characterized by vitelliform material showed a greater correlation with higher best-corrected visual acuity than eyes without it (0.35 logarithm of the minimum angle of resolution vs. 0.80 ± 0.36 logarithm of the minimum angle of resolution, approximately 20/45 and 20/125 Snellen equivalent, respectively) (t = 3.726, P < 0.05). Moreover, its absence was associated with a best-corrected visual acuity of 0.5 logarithm of the minimum angle of resolution or worse (approximately 20/63 Snellen equivalent; P < 0.05). Subretinal fluid was more common in Stages 3 and 4 (72.7% and 75%, respectively) than Stages 2 and 5 (P = 0.004). Eyes with subretinal fluid were significantly associated with a visual acuity of 0.2 logarithm of the minimum angle of resolution or worse (approximately 20/32 Snellen equivalent; P = 0.04). CONCLUSION: Spectral domain optical coherence tomography assessment primarily indicates an outer retinal layer disruption in Stages 2 to 4, along with the presence of vitelliform material extending into the more advanced clinical stages too. Eyes characterized by the persistence of vitelliform material show better best-corrected visual acuity. Future investigations based on a longitudinal follow-up are warranted to correlate SD-OCT modifications with functional responses to identify SD-OCT indicators for prognostic and therapeutic purposes.

HOW VITREOMACULAR INTERFACE MODIFIES THE EFFICACY OF ANTI-VEGF THERAPY FOR MYOPIC CHOROIDAL NEOVASCULARIZATION.

PURPOSE: To evaluate the efficacy of intravitreal ranibizumab in the treatment of myopic choroidal neovascularization (mCNV) complicated by vitreoretinal interface alterations. METHODS: Thirty-two patients affected by mCNV and concurrent vitreoretinal interface disorders, including macular epiretinal membrane (18 patients), lamellar macular hole (4 patients), full-thickness macular hole (1 patient), broad/focal vitreomacular traction (3 patients), broad/focal vitreomacular adhesion (4 patients), and myopic foveoschisis (2 patients), were enrolled in a prospective study. After a comprehensive ophthalmologic examination, including best-corrected visual acuity (BCVA), fluorescein angiography, and spectral-domain optical coherence tomography, each patient received a first intravitreal ranibizumab. Further re-treatments were performed in the presence of choroidal neovascularization activity (new hemorrhages, leakage on fluorescein angiography, intraretinal/subretinal fluid on spectral-domain optical coherence tomography, visual acuity loss of five letters). Main outcome measure was the change in the BCVA and in the central foveal thickness. Data were compared with the historical control group with uncomplicated mCNV. RESULTS: The median BCVA in the epiretinal membrane-myopic choroidal neovascularization subgroup showed a stabilization from the baseline value of 0.30 logarithm of minimal angle resolution (20/40) to 0.40 (20/50, P: 0.49) at the last visit (30 ± 13 months). Median BCVA significantly improved from 0.30 (20/40) to 0.10 (20/25, P: 0.0005) in the mCNV group and was better than the epiretinal membrane-myopic choroidal neovascularization subgroup (0.008). Central foveal thickness reduced significantly within both groups, with no difference between the groups at the final examination. Considering the vitreoretinal alterations with lower prevalence, BCVA stabilization was registered after a follow-up of 28.9 ± 13 months, with a median BCVA of 0.3 logarithm of minimal angle resolution (20/40) at the baseline and at the final examination. A nonstatistically significant reduction in the median central foveal thickness was registered at the final examination (P: 0.12). CONCLUSION: The data show that ranibizumab is effective in controlling mCNV activity when associated with vitreoretinal interface alterations. However, a visual recovery was observed only in patients with uncomplicated mCNV.

THE EXPANDING CLINICAL SPECTRUM OF CHOROIDAL EXCAVATION IN MACULAR DYSTROPHIES.

PURPOSE: To assess the prevalence and the clinical course of focal choroidal excavation (FCE) in patients affected by macular dystrophies. METHODS: Prospective case series. All the patients underwent a complete ophthalmologic examination, including best-corrected visual acuity and spectral domain optical coherence tomography. The presence of choroidal neovascularization (CNV) was assessed on the basis of the leakage detected on fluorescein angiography. RESULTS: A total of 162 eyes from 81 patients with macular dystrophy were included in the study. FCE was diagnosed in seven eyes (4.3% of the eyes), including four eyes with Best vitelliform dystrophy, two eyes with pattern dystrophy associated with pseudoxanthoma elasticum, and one case of Stargardt disease. In eyes with FCE and macular dystrophy, the mean best-corrected visual acuity was 0.4 ± 0.1 logarithm of the minimum angle of resolution (approximately corresponding to 20/50 Snellen equivalent) at baseline and was stable to 0.41 ± 0.1 logarithm of the minimum angle of resolution (approximately corresponding to 20/50 Snellen equivalent) at the final visit. In four of these seven eyes, FCE was associated with a subfoveal CNV. The CNV was managed with one intravitreal anti-vascular endothelial growth factor injection, achieving the complete anatomical stabilization of the CNV and recovery of the best-corrected visual acuity. CONCLUSION: Focal choroidal excavation can be infrequently encountered in patients with macular dystrophies. The presence of CNV may complicate FCE in these patients, and anti-vascular endothelial growth factor seems to be an effective treatment with no progression of FCE over time.

QUANTITATIVE ANALYSIS OF OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY IN ADULT-ONSET FOVEOMACULAR VITELLIFORM DYSTROPHY.

PURPOSE: To quantify the foveal avascular zone area at superficial capillary plexus (SCP) and deep capillary plexus (DCP) and the global, parafoveal, and perifoveal vessel densities at SCP, DCP, and choriocapillaris using optical coherence tomography angiography in patients affected by adult-onset foveomacular vitelliform dystrophy (AOFVD). METHODS: Twenty eyes of 20 consecutive patients (10 females, 50%) with AOFVD and 20 eyes of 20 healthy controls presenting at the Department of Ophthalmology of San Raffaele Hospital, Milan, Italy were enrolled. All patients underwent a complete ophthalmic examination, including 3-mm × 3-mm optical coherence tomography angiography centered on the macula. The vessel density was calculated in the three plexuses (i.e., SCP, DCP, and choriocapillaris) by mean of image binarization, and foveal avascular zone area was manually outlined at SCP and DCP with ImageJ software. RESULTS: In the SCP, patients with AOFVD disclosed a significant reduction of global (P < 0.001), parafoveal (P = 0.0017), and perifoveal (P = 0.0019) vessel density. In the DCP, parafoveal vessel density was higher in patients with AOFVD (P = 0.0026), whereas no significant difference was appreciated for both the global image (P = 0.5) and the perifoveal area (P = 0.5). Patients with AOFVD showed less dense choriocapillaris (P = 0.012) and perifoveal circle (P = 0.0152), whereas no difference was observed in the perifoveal zone (P = 0.07). Foveal avascular zone area was significantly enlarged at the DCP (P = 0.0184), but not at the SCP. CONCLUSION: Patients with AOFVD have quantitative vascular alterations in all vascular layers.

MICROPERIMETRY IN BEST VITELLIFORM MACULAR DYSTROPHY.

PURPOSE: To investigate retinal sensitivity in eyes with all the clinical stages of Best vitelliform macular dystrophy (VMD). METHODS: Thirty-two patients affected by VMD in subclinical, vitelliform, pseudohypopyon, vitelliruptive, and atrophic stages were enrolled in this prospective cross-sectional study. Patients underwent a complete ophthalmologic examination, including determination of best-corrected visual acuity (BCVA), staging of the disease (Gass's classification), and microperimetry by means of the macular integrity assessment microperimeter. The primary outcome measure was to describe the alterations in the retinal sensitivity of eyes affected by VMD in different stages. Secondary outcome measures included correlations between retinal sensitivity and best-corrected visual acuity and the correlation between the VMD stage and the specific microperimetry pattern. RESULTS: Mean retinal sensitivity was reduced in all the VMD stages. Nevertheless, vitelliform, pseudohypopyon, and vitelliruptive stages turned out to be very similar, especially within 10°. Fixation was classified as stable in 27 eyes (44.2%), relatively unstable in 16 eyes (26.2%), and unstable in 18 eyes (29.5%). Fixation stability correlated both with the disease stage and best-corrected visual acuity. CONCLUSION: VMD is characterized by complex microperimetric abnormalities, involving the whole macular area. Microperimetry may contribute to the global clinical assessment of patients affected by VMD and could be used in future therapeutic approaches.

INTRARETINAL HYPERREFLECTIVE FOCI IN BEST VITELLIFORM MACULAR DYSTROPHY.

PURPOSE: To report on the presence of hyperreflective foci (HF) on spectral domain optical coherence tomography in patients with Best vitelliform macular dystrophy (BVMD), and to describe the relationship between HF and stages of the disease. METHODS: Consecutive patients diagnosed with BVMD were enrolled in a prospective cross-sectional study. All patients and control subjects underwent a complete ophthalmologic examination, including best-corrected visual acuity and spectral domain optical coherence tomography. MAIN OUTCOME MEASURE: identification of HF in BVMD. Secondary outcome: assessment of the HF in each stage and correlation with best-corrected visual acuity. RESULTS: Overall, 75 eyes of 39 patients were included in the study (Stage 1: 13%, Stage 2: 43%, Stage 3: 15%, Stage 4: 21%, and Stage 5: 8%). On spectral domain optical coherence tomography assessment, intraretinal HF were present in 83% of all eyes, in 91% of eyes affected by clinical BVMD (Stages 2-5) and in 100% of patients in Stages 4 and 5. In 46% of clinically diseased eyes, HF were localized in the fovea and in correspondence with the BVMD lesions at the level of the outer nuclear layer and outer plexiform layer. Hyperreflective foci were present in 16% of control eyes. Mean number of HF in eyes affected by clinical BVMD stood at 7.67 ± 7.35. These were predominantly small HF (6.23 ± 6.14, P < 0.001) localized in the outer nuclear layer (5.19 ± 5.38, P = 0.001) and presented largely in the extrafoveal, rather than the foveal area (5.21 ± 5.57 vs 2.46 ± 2.73, P = 0.001). Analysis of HF distribution revealed that the control group and Stage 1 eyes had the fewest HF; Stage 4 displayed a significant increase in the number of HF compared with Stages 2 and 3; Stage 5 also showed an increased number of HF, although this difference was statistically significant only with Stage 3 eyes. The best-corrected visual acuity was negatively related to the number of HF, with best-corrected visual acuity deteriorating as the number of HF increased in Stages 2 to 5 (P < 0.001). CONCLUSION: This study describes the presence of HF in BVMD using spectral domain optical coherence tomography. Our data suggest that HF identification is correlated with the progression of the disease and could represent a useful biomarker of BVMD.

A Pathogenetic Classification of Diabetic Macular Edema.

PURPOSE: The aim of this study was to define a new pathogenetic classification of diabetic macular edema (DME) and to present the results of its application in common clinical practice. METHODS: One hundred and seventy-seven consecutive patients with center-involving DME, central retinal thickness (CRT) ≥250 µm, were prospectively enrolled. A complete ophthalmological examination included best-corrected visual acuity (BCVA) assessment, fundus photography, and spectral-domain optical coherence tomography (OCT). The DME classification was broken down into 4 categories, combining the presence of retinal thickening with the presence/absence of visible vascular dilations and OCT-detectable macular traction. The OCT parameters included were as follows: CRT, subretinal fluid, intraretinal cysts, and hyper- reflective foci (HF). RESULTS: Four subtypes of DME were identified: vasogenic (131 eyes, DME with vascular dilation), nonvasogenic (46 eyes, DME without vascular dilation), tractional (11 eyes), and mixed DME (13 eyes). Vasogenic DME was the pattern mainly represented in each subclass of CRT (< 300, 300-400, and > 400 µm), with tractional DME observed especially with CRT > 400 µm. Internal and external cysts and a greater presence of hard exudates were predominantly found in vasogenic DME, whereas HF was equally distributed in the 4 DME subgroups. CONCLUSION: The study offers a new pathogenetic classification able to detect significant differences among DME subtypes. A tailored therapeutic approach could take into consideration specific changes associated with the different DME subtypes.

Multimodal imaging of foveal cavitation in retinal dystrophies.

PURPOSE: Inherited retinal dystrophies and cone dysfunction syndromes may show a sharp hyporeflective interruption in the outermost retinal layers on optical coherence tomography (OCT), known as foveal cavitation (FC). The aim of the study was to describe the morpho-functional features of FC in patients affected by retinal dystrophies by means of multimodal imaging. METHODS: A consecutive series of patients affected by FC were prospectively recruited for the study. Patients underwent short-wavelength (SW) and near-infraRed (NIR) fundus autofluorescence (FAF), spectral domain OCT (SD-OCT), microperimetry (MP), and multifocal electroretinogram (mfERG). Mean size of FC on OCT was correlated with best-corrected visual acuity (BCVA). RESULTS: Overall, 15 patients (30 eyes) were enrolled. Mean age was 38.2 ± 14.5 years (range: 10-60), with nine females (60 %). Mean BCVA was 0.5 ± 0.4 LogMAR. SD-OCT revealed focal loss of outer retinal layers and disruption of inner segment ellipsoid zone. Vertical height of FC (mean 27.77 ± 18.77 µm) was indirectly related to BCVA; complete forms of FC, with total loss of outer OCT bands, showed a poorer visual outcome. The FC size on NIR-FAF turned out to be larger with respect to SD-OCT and SW-FAF. CONCLUSION: Our data indicate that the presence of FC worsens functional outcome in patients affected by retinal disorders; complete and higher lesions are associated with a worse morpho-functional prognosis in these eyes.

OUTER RETINAL LAYER CHANGES AFTER DEXAMETHASONE IMPLANT FOR CENTRAL RETINAL VEIN OCCLUSION.

PURPOSE: To analyze the outer retinal layer changes on spectral-domain optical coherence tomography after dexamethasone implant for the treatment of macular edema secondary to central retinal vein occlusions (CRVO). METHODS: Thirty patients affected by macular edema related to CRVO (8 patients less than 50 years of age with nonischemic CRVO [<50-niCRVO], 12 patients more than 50 years with niCRVO [>50-niCRVO], and 10 patients with ischemic CRVO [iCRVO]) were included in a prospective study. After a comprehensive ophthalmologic examination, including best-corrected visual acuity, fluorescein angiography, and spectral-domain optical coherence tomography, each patient received a first implant. Further retreatments were performed on the basis of macular edema detection from the fourth month. Main outcome measure was the change in outer retinal layers at the 12-month examination. RESULTS: The retinal layers of interest (external limiting membrane; ellipsoid zone; and retinal pigment epithelium) were classified as absent, disrupted, or present. The best baseline optical coherence tomography profile was found in <50-niCRVO group (absent external limiting membrane, ellipsoid zone, and retinal pigment epithelium layers in no patients; present and disrupted external limiting membrane in 25% and 75% of cases, respectively; disrupted ellipsoid zone and retinal pigment epithelium in 100% of cases), whereas the worst was detected in the iCRVO group (absent external limiting membrane, ellipsoid zone, and retinal pigment epithelium in 40%, 40%, and 10% of cases, respectively). A significant recovery of the retinal layers was observed in all CRVO subgroups; the greatest improvement was found in <50-niCRVO group. Median best-corrected visual acuity in the whole group improved from 0.85 to 0.45 (P = 0.0001). It is noteworthy that a significant best-corrected visual acuity gain was achieved only in eyes showing present or disrupted layers at baseline regardless of the CRVO subgroup examined, whereas eyes with absent layers at baseline were unable to attain any improvement. CONCLUSION: Dexamethasone implant can promote the resolution of macular edema in patients affected by any CRVO subform, but a beneficial functional outcome could be achieved by eyes showing no absence of outer retinal layers on spectral-domain optical coherence tomography at baseline.

DYNAMIC AND STATIC VESSEL ANALYSIS IN PATIENTS WITH RETINITIS PIGMENTOSA: A Pilot Study of Vascular Diameters and Functionality.

PURPOSE: To evaluate in vivo the vascular anatomy and functionality of early manifestation retinitis pigmentosa (RP) by means of a dynamic and static vessel analyzer. METHODS: Fourteen patients with early RP and 14 normal subjects were consecutively enrolled in this observational, prospective study. Each patient underwent a complete ophthalmologic examination, including dynamic and static retinal vessel analysis using the Dynamic Vessel Analyzer. RESULTS: The patients with RP and the control group were well matched in age and sex. Patients with RP had a mean best-corrected visual acuity of 20/25 (range: 20/40-20/20). Dynamic vessel analysis performed in patients with RP showed an arterial and venous dilation during flicker stimulation of 5.28 ± 1.7% and 4.07 ± 1.78%, respectively. Only arterial dilation was statistically different compared with control subjects (3.33 ± 0.99%, P = 0.0062). Static retinal vessel analysis in patients with RP showed a decreased mean central retinal artery equivalent (P < 0.001) and central retinal vein equivalent (P < 0.001) compared with control subjects. By contrast, the arterial-to-venous ratio was similar in both groups (RP: 0.79 ± 0.11, control group 0.86 ± 0.04, P = 0.072). CONCLUSION: Our data confirm that retinal arterial and venous narrowing is present at an early stage in patients affected by RP. However, dynamic vessel analysis shows how the retina of patients with RP with no best-corrected visual acuity loss presents an augmented artery dilation response compared with normal subjects and retained neurovascular coupling.

FACTORS INFLUENCING VISUAL ACUITY IN PATIENTS RECEIVING ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR FOR MYOPIC CHOROIDAL NEOVASCULARIZATION.

PURPOSE: To identify the prognostic variables relative to myopic choroidal neovascularization (CNV) treated with intravitreal ranibizumab/bevacizumab. METHODS: Forty-eight patients with myopic CNV were enrolled in a prospective, interventional, non-randomized 12-month study. Intravitreal ranibizumab/bevacizumab was administered in a pro-re-nata regimen and re-treatment was performed in the presence of angiographic leakage, intraretinal/subretinal fluid on optical coherence tomography, new hemorrhages, five-letter decrease and increased metamorphosia. The primary outcome measures were the identification of the predictive value of symptom duration, patient's age, refractive error, best-corrected visual acuity (BCVA), central macular thickness (CMT), CNV area, CNV location, retinal hemorrhages, atrophy, lacquer cracks, and CNV-fundus autofluorescence pattern (hyper-fundus autofluorescence/patchy pattern). The secondary outcomes were patients requiring either one or two injections to achieve CNV stabilization. RESULTS: The mean BCVA improved from 0.49 ± 0.30 (logarithm of minimal angle resolution, Snellen equivalent 20/63) to 0.39 ± 0.32 (20/49) at 1-year follow-up (P = 0.043). Univariate and multiple stepwise linear regression analysis identified baseline BCVA (P = 0.0003), symptom duration (P = 0.005), CMT (P = 0.02), and fundus autofluorescence pattern (P = 0.005) as the explanatory variables on the final BCVA and the change in the mean BCVA. Overall, patients with better baseline BCVA, early diagnosis, lower CMT, or disclosing a hyperfundus autofluorescence CNV pattern achieved better visual outcomes. Patients responding with just one to two intravitreal injections (45.8%) obtained better visual outcomes compared with patients receiving three or more injections, and this group consisted of younger patients with lesser CMT, smaller CNV area, and fewer baseline hemorrhages. CONCLUSION: Ranibizumab/bevacizumab therapy was effective in improving and maintaining visual acuity in myopic choroidal neovascularization. Early diagnosis, better baseline BCVA, and hyperfundus autofluorescence CNV pattern were strongly associated with better functional outcomes. Moreover, CNV distinguished by its small size and low CMT responded more favorably, achieving a better visual outcome.

Non-Responders to Intravitreal Ranibizumab in Subfoveal Choroidal Neovascularization Secondary to Age-Related Macular Degeneration.

AIM: Evaluation of the proportion of patients affected by subfoveal choroidal neovascularization secondary to age-related macular degeneration who are non-respondent to intravitreal ranibizumab injections (IVRI). METHODS: Patients received 3 monthly IVRI, with monthly retreatments, in accordance with a pro re nata scheme (fluid on optical coherence tomography, leakage on fluorescein angiography, new haemorrhages). Non-responders were classified as follows: functional non-responder (best-corrected visual acuity worsening by a minimum of 2 ETDRS lines); anatomical non-responder (central foveal thickness not decreasing by at least 10% compared with baseline value); complete non-responder (both anatomical and functional non-responder criteria apply). PRIMARY OUTCOME MEASURE: identification of the proportion of non-responders. RESULTS: Four patients (7%) were functional non-responders at the 1-month examination, and 5, 5 and 7% at the 2-, 3- and 6-month examinations, respectively. Two of 4 initial non-responders were reclassified as responders during the 6-month follow-up. Twenty-three eyes (43%) were anatomical non-responders at the 1-month visit, and 32, 28 and 21% at 2, 3 and 6 months, respectively. Sixteen of 23 (70%) initially non-respondent eyes became respondent over the follow-up. Two eyes (4%) were classified as complete non-responders after 1 month. Non-responders amounted to 4, 0 and 2% at the 2-, 3- and 6-month examinations, respectively. No initially complete non-responding eye remained so over the follow-up. CONCLUSION: Data indicate a low proportion of functional and anatomical non-responders to IVRI. Further studies are warranted providing a better definition of non-responder and a clearer picture of the magnitude of response, when present.

Functional assessment of the fundus autofluorescence pattern in Best vitelliform macular dystrophy.

PURPOSE: To identify the fundus autofluorescence (FAF) patterns in Best vitelliform macular dystrophy (VMD). METHODS: Patients affected by VMD in vitelliform, pseudohypopyon, and vitelliruptive stages underwent a complete ophthalmological examination, including best-corrected visual acuity (BCVA), short-wavelength FAF (SW-FAF), near-infrared FAF (NIR-FAF) and microperimetry. MAIN OUTCOME MEASURES: the identification of the correlation between SW-FAF and NIR-FAF patterns of the foveal region with BCVA, and central retinal sensitivity in eyes affected by VMD. The secondary outcomes included the definition of the frequency of foveal patterns on SW-FAF and NIR-FAF. RESULTS: Thirty-seven of 64 (58 %), 8 of 64 (12.5 %) and 19 of 64 (29.5 %) eyes showed vitelliform, pseudohypopyon, and vitelliruptive stages respectively. Three main FAF patterns were identified on both techniques: hyper-autofluorescent pattern, hypo-autofluorescent pattern, and patchy pattern. BCVA was significantly different in eyes with hypo-autofluorescent and patchy patterns with respect to eyes showing a hyper-autofluorescent pattern. Similar differences were registered in the FS according to SW-FAF classification. However, the FS differed in each subgroup in the NIR-FAF analysis. Subgroup analyses were performed on the patchy pattern, combining FAF and fundus abnormalities. Considering both FAF techniques, the BCVA differed between the vitelliform and pseudohypopyon stages, and between the vitelliform and vitelliruptive stages. In the NIR-FAF classification, there was a significant statistical difference in the FS between each subgroup; in the SW-FAF, there was a significant difference between the vitelliform and pseudohypopyon stages and the vitelliform and vitelliruptive stages. CONCLUSIONS: Three main FAF patterns can be identified in VMD. The patchy pattern is the most frequent, accounting for 70 % of eyes on SW-FAF and 80 % of eyes on NIR-FAF. A tighter correlation links the classification of NIR-FAF patterns and FS. Longitudinal investigations are warranted to evaluate the course of FAF patterns and their role in disease monitoring.

CORRESPONDENCE OF LEAKAGE ON FLUORESCEIN ANGIOGRAPHY AND OPTICAL COHERENCE TOMOGRAPHY PARAMETERS IN DIAGNOSIS AND MONITORING OF MYOPIC CHOROIDAL NEOVASCULARIZATION TREATED WITH BEVACIZUMAB.

PURPOSE: To describe the morphologic alterations on spectral domain optical coherence tomography in active myopic choroidal neovascularization (CNV) receiving intravitreal bevacizumab and to evaluate its diagnostic accuracy, taking fluorescein angiography as a reference examination. METHODS: Thirty patients (30 eyes) were prospectively enrolled. Each eye was imaged with fluorescein angiography and spectral domain optical coherence tomography at the baseline and at 1-, 2-, and 3-month examinations. Spectral domain optical coherence tomography parameters consisting of intraretinal/subretinal fluid and absence of external limiting membrane (ELM) visibility were considered signs of CNV activity and collated with the presence/absence of leakage on fluorescein angiography. Main outcome measures were frequencies of the retinal alterations associated with myopic CNV at the diagnosis and during monitoring of anti-vascular endothelial growth factor therapy. RESULTS: At the diagnosis, spectral domain optical coherence tomography identified subretinal fluid in 14 eyes (46%), intraretinal fluid associated with subretinal fluid in 12 eyes (40%), and absence of ELM visibility in 30 of the 30 eyes (100%). During the follow-up, fluorescein leakage was noted in 32 visits (18, 8, and 6 eyes at the 1-, 2- and 3-month examinations, respectively). Taking into consideration spectral domain optical coherence tomography features of active myopic CNVs on fluorescein angiography, subretinal fluid was identified in 24 examinations (75%), intraretinal cysts with subretinal fluid were noted in 5 visits (15.6%), and the absence of ELM visibility was visible in 32 examinations (100%). The alterations of the ELM corresponded to the location of the fluorescein leakage. CONCLUSION: This study provides evidence that the absence of ELM visibility is a more reliable parameter for evaluating CNV activity than intraretinal/subretinal fluid collection and may constitute a useful option in diagnosing and monitoring the myopic CNV during anti-vascular endothelial growth factor therapy.

CHOROIDAL THICKNESS IN BEST VITELLIFORM MACULAR DYSTROPHY.

PURPOSE: To assess the changes in choroidal thickness in different stages of Best vitelliform macular dystrophy (VMD). METHODS: Thirty-four patients affected by VMD were prospectively enrolled and underwent a complete ophthalmologic examination, including best-corrected visual acuity measurement, biomicroscopic examination, and spectral domain optical coherence tomography. The Gass classification was used in defining the stages of VMD. Twenty healthy subjects served as the control group. Main outcome measures were the identification of choroidal changes in different stages of VMD and detection of a correlation between choroidal thickness and best-corrected visual acuity. RESULTS: No significant difference was found in the subfoveal choroidal thickness (SFCT) between eyes displaying Stage 1 and the control group (P = 0.181). Stages 2 and 3 showed an increased SFCT (320.4 and 319.1 µm, respectively) compared with that of control patients (P < 0.001 and P = 0.004, respectively). Stage 4 had a significantly inferior SFCT compared with Stages 2 and 3 (P = 0.007 and P = 0.025, respectively) but no significant difference was found between Stage 4 and control patients (P = 0.733). The Stage 5 group displayed a significant decrease in SFCT compared with that of the control group (181.3 µm and 238.4 µm, respectively, P = 0.002). Analyzing the association between SFCT and best-corrected visual acuity in patients affected by clinical VMD (Stages 2-5), the authors found that the best-corrected visual acuity decreased as the choroid thinned (P = 0.004). CONCLUSION: Choroidal thickness varies according to the stage of VMD, being higher in the vitelliform stage and thinner in the atrophic/cicatricial stage. Long-term studies are warranted to provide a more precise evaluation of the morphofunctional alterations in the different stages of VMD.

Acute central serous chorioretinopathy: a correlation study between fundus autofluorescence and spectral-domain OCT.

PURPOSE: To evaluate the correlation between fundus autofluorescence (FAF) and spectral-domain OCT (SD-OCT) morphological analysis in eyes with acute central serous chorioretinopathy (CSCR). METHODS: Thirty-one patients with a first episode of CSCR and symptom duration of less than 6 weeks were prospectively enrolled. FAF and SD-OCT examination were performed at baseline and at 2-month intervals. Main outcome measure was the correlation between FAF and SD-OCT retinal morphology. RESULTS: At baseline, 30/31 and 29/31 eyes showed a macular hypo-AF, corresponding to the neurosensory retinal detachment (SRD), on shortwave-FAF (SW-FAF) and near-infrared-FAF (NIR-FAF), respectively. While the SRD resolved, both FAF techniques showed a granular hyper-AF in 31 eyes. At first examination, SD-OCT confirmed the SRD with a photoreceptor outer-segment (OS) elongation in all cases. During SRD resolution, the photoreceptor layer appeared thicker and fragmented. Multiple hyper-reflective precipitates were detected in the outer plexiform and nuclear layer and between the photoreceptors and appeared colocalized with the hyper-AF dots composing the granular hyper-AF. After SRD resolution, the hypo-AF area reverted to a normal pattern on SW-FAF in all eyes and in 25/31 on NIR-FAF. Examination at 12 months showed that the granular hyper-AF was still detectable in 54 % eyes, whereas 6/31 eyes showed hypo-AF dots on NIR-FAF. On SD-OCT, the junction IS/OS was identifiable in 11/31 eyes soon after the SRD resolution and appeared completely restored in all patients at the final visit. CONCLUSION: The simultaneous acquisition of FAF and SD-OCT provides detailed findings of retinal abnormalities of CSCR and may help to understand the evolving process linked to CSCR.

DEXAMETHASONE IMPLANT FOR MACULAR EDEMA SECONDARY TO CENTRAL RETINAL VEIN OCCLUSION IN PATIENTS YOUNGER THAN 50 YEARS.

PURPOSE: To evaluate the effects of dexamethasone implant for macular edema secondary to central retinal vein occlusion in patients younger than 50 years. METHODS: Patients with no previous treatment, macular edema with central foveal thickness >250 µm and best-corrected visual acuity between 1.30 LogMAR and 0.30 LogMAR were prospectively recruited for a 12-month follow-up study. After baseline dexamethasone implant, re-treatment was performed starting from the fourth month if a best-corrected visual acuity deterioration with central foveal thickness >250 µm occurred after an initial improvement. The primary outcome was the change in the best-corrected visual acuity. Secondary outcomes included the proportion of eyes gaining at least 3 Early Treatment Diabetic Retinopathy Study lines, the change in the central foveal thickness, and the number of treatments. RESULTS: Mean best-corrected visual acuity changed significantly from 0.60 ± 0.38 LogMAR at baseline to 0.43 ± 0.48 at the 12-month examination (P = 0.03). Eight of 16 eyes (50%) gained 3 Early Treatment Diabetic Retinopathy Study lines. Mean central foveal thickness improved significantly from 705 ± 202 µm at baseline to 408 ± 196 µm at 12-month visit (P < 0.001). The patients received a mean of 1.8 ± 0.9 implants with 8/16 eyes and 3/16 receiving 1 and 2 implants, respectively. CONCLUSION: This present investigation indicates that dexamethasone implant can provide a 3-line improvement in half of the patients younger than 50 years and affected by macular edema secondary to central retinal vein occlusion.