Pars plana vitrectomy and subretinal tissue plasminogen activator for large exudative submacular hemorrhage: a case series.

BACKGROUND: To evaluate anatomical and functional outcomes of patients with large submacular hemorrhage (SMH) who treated by pars plana vitrectomy (PPV) in combination with subretinal tissue plasminogen activator (TPA) injection, intraocular gas tamponade, and with additional post-operative interventions. METHODS: Medical records of 9 patients who presented with large SMH secondary to age-related macular degeneration (AMD) and underwent PPV, subretinal TPA injection, and gas tamponade at Chiang Mai university hospital between January 2012 and January 2020 were reviewed. Collected data included preoperative visual acuity (VA), SMH extent and duration, intraoperation and post-operation complications, post-operative anatomical and VA responses, and the need for administer post-operation additional treatments. RESULTS: Overall, five patients were male and four patients were female with a mean (SD) age of 66.9 (7.7) years and a mean (SD) follow-up of 21.1 (16.1) months. A mean (SD) duration of SMH was 15.1 (10.9) days with a mean (SD) extent of SMH was 6.2 (3.4) disc diameters. At 1-month post-operation, complete SMH displacement was noted in eight (88.9%) patients. The mean (SD) VA significantly improved from LogMAR 1.9 (0.4) to 1.1 (0.4), (P = 0.004). During follow-up, eight patients (88.9%) were given additional therapy (anti-vascular endothelial growth factor (anti-VEGF) monotherapy, photodynamic therapy, or in combination). At final follow-up, a mean (SD) LogMAR VA of 0.9 (0.4) was significantly improved compared to baseline (P = 0.004). For intra- and post-operation complications, none developed intraoperative retinal break and retinal detachment. CONCLUSIONS: Vitrectomy with subretinal TPA injection, intraocular gas tamponade, and additional post-operation treatments provide benefit for anatomical and visual outcomes for patients with large SMH. It may consider as one of effective treatment in this group of patients.

Twelve-Month Outcomes of the Wavefront-Optimized Photorefractive Keratectomy for High Myopic Correction Compared with Low-to-Moderate Myopia.

PURPOSE: To evaluate the 12-months outcomes of photorefractive keratectomy (PRK) in patients with high myopia (≥ 6.0 diopters, D) compared with low-to-moderate myopia (< 6.0 D). PATIENTS AND METHODS: Records of 46 patients (69 eyes) who underwent PRK for myopic and astigmatic correction between October 2015 and December 2018 were reviewed. High myopic eyes (29 eyes) were compared with low-to-moderate myopic eyes (40 eyes). All surgeries were adjunct with 0.02% mitomycin C intraoperatively. Measured outcomes included postoperative uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), manifest refraction spherical equivalent, corneal haze rate, and any complications. RESULTS: At 12 months post-PRK, 26 eyes (89.7%) in the high myopia and 39 eyes (97.5%) in the low-to-moderate myopia group had UDVA ≥ 20/20, (p=0.30). Average postoperative logMAR UDVA at 12 months was -0.04 (20/18) and -0.11 (20/15) for the high myopia and low-to-moderate myopia groups, respectively. No eyes in either group had residual refractive errors >1 D. No eyes in both groups developed significant corneal haze at month 12. No eyes had a loss of greater than two Snellen lines of CDVA at 12 months post-surgery. The efficacy and safety indices at 12 months post-surgery were not significantly different between groups (1.06±0.26 vs.1.14±0.27, p =0.25 and 1.14±0.27 vs 1.17±0.26, p=0.60 for low-to-moderate myopia vs high myopia groups, respectively). CONCLUSION: PRK with high myopic correction provides excellent refractive outcomes and is safe, compared to those of low-to-moderate myopic correction.

Factors associated with 1-year visual response following intravitreal bevacizumab treatment for diabetic macular edema: a retrospective single center study.

BACKGROUND: To explore the association of clinical characteristics and retinal microstructural features on optical coherence tomography in predicting 1-year visual response following intravitreal bevacizumab injections in eyes with visual impairment from center-involved diabetic macular edema (CI-DME). METHODS: Medical records of patients with visual impairment from CI-DME, who initiated intravitreal bevacizumab injections between Jan 2012 and Dec 2016 and were followed for a minimum of 12 months were retrospectively reviewed. RESULTS: The study included 226 eyes with a mean (SD) baseline visual acuity (VA) of 51.8 (19.1) letters. At week 12, following the three initial treatments, a mean (SD) VA improved to 61.7 (17.8) letters. Visual gain ≥ 10 letters was observed in 109 eyes (48.2%), while a limited early visual gain < 5 letters was noted in 80 eyes (35.4%). At one year, 110 eyes (48.7%) achieved a good VA gain ≥ 10 letters. In addition, eyes with poor baseline VA had a higher proportion of eyes that obtained limited early VA gained at week 12 (< 5 letters) and maintained in this visual response category at moth 12 compared to eyes with better baseline VA (74.1% versus 59.1%). In the multivariable logistic regression, the following factors reduced the probability of 1-year visual gain ≥ 10 letters: elderly (p = 0.040), better baseline vision (p = 0.001), and limited early visual gain < 5 letters at week 12 (p < 0.001). In multivariable linear regression, male (p = 0.010) and eyes with the presence of hyperreflective foci on baseline OCT (p = 0.010) were likely to have higher VA improvement. However, eyes with better baseline VA (p = 0.002), limited early VA gain at week 12 (p < 0.001), and a presence of EZ disruption at week 12 (p = 0.002) were likely to have less VA improvement. CONCLUSIONS: Although bevacizumab is considered as effective management for CI-DME, variability in treatment responses is expected. This study revealed that baseline characteristics and visual responses at week 12 might help predict the long-term treatment response. Eyes with characteristics at risk of limited long-term visual outcome may require attention in optimizing their individual treatment strategies.

Sensitivity and Specificity of Potential Diagnostic Features Detected Using Fundus Photography, Optical Coherence Tomography, and Fluorescein Angiography for Polypoidal Choroidal Vasculopathy.

Importance: The use of indocyanine green angiography (ICGA) is a criterion standard for diagnosing polypoidal choroidal vasculopathy (PCV), an endemic and common cause of vision loss in Asian and African individuals that also presents in white individuals. However, the use of ICGA is expensive, invasive, and not always available at clinical centers. Therefore, knowing the value of certain features detected using fundus photography (FP), optical coherence tomography (OCT), and fluorescein angiography (FA) to diagnose PCV without ICGA could assist ophthalmologists to identify PCV when ICGA is not readily available. Objective: To explore the sensitivity, specificity, and predictive accuracy of potential diagnostic features detected using FP, OCT, and FA in diagnosing PCV without ICGA. Design, Setting, and Participants: Deidentified images of FP alone, OCT alone, and FA alone were graded by 3 retina specialists masked to ICGA findings for potentially diagnostic features of PCV prespecified before grading compared with the criterion standard grading of 2 other retina specialists with access simultaneously to FP, OCT, FA and ICGA. Specialists graded images of 124 eyes of 120 patients presenting between January 1, 2013, and December 31, 2016, with newly identified serous or serosanguinous maculopathy who had undergone FP, OCT, FA, and ICGA before treatment at a large referral eye center in Thailand. Main Outcomes and Measures: Sensitivity, specificity, positive predictive value, negative predictive value, and predictive accuracy from the area under the receiver operating characteristic curve (AUC). Results: The mean (SD) age of the patients was 57.7 (12.6) years, 52 were women, 68 were men, and the diagnosis (from ICGA) was PCV for 65 eyes (52.4%), central serous chorioretinopathy for 45 eyes (36.3%), and typical neovascular age-related macular degeneration for 12 eyes (9.7%). With the use of FP, a potential diagnostic feature for PCV was notched or hemorrhagic pigment epithelial detachment (AUC, 0.77; 95% CI, 0.70-0.85). With the use of OCT, potential diagnostic features for PCV were pigment epithelial detachment notch (AUC, 0.90; 95% CI, 0.85-0.96), sharply peaked pigment epithelial detachment (AUC, 0.86; 95% CI, 0.80-0.92), and a hyperreflective ring (AUC, 0.86; 95% CI, 0.80-0.92). When at least 2 of these 4 signs were present, the AUC was 0.93 (95% CI, 0.89-0.98), with a sensitivity of 0.95 (95% CI, 0.87-0.99), a specificity of 0.95 (95% CI, 0.82-0.97), a positive predictive value of 0.92 (95% CI, 0.83-0.97), and a negative predictive value of 0.95 (95% CI, 0.86-0.99). Conclusions and Relevance: These data suggest that the potential diagnostic features detected using FP and OCT provide high sensitivity and specificity for a diagnosis of PCV, especially when at least 2 of 4 highly suggestive signs are present.

Color Fundus Photography, Optical Coherence Tomography, and Fluorescein Angiography in Diagnosing Polypoidal Choroidal Vasculopathy.

PURPOSE: To determine sensitivity and specificity of polypoidal choroidal vasculopathy (PCV) diagnosis using color fundus photography (CFP), optical coherence tomography (OCT), and fundus fluorescein angiography (FFA) without indocyanine green angiography (ICGA). DESIGN: Validity analysis. METHODS: Treatment-naïve eyes with serous/serosanguinous maculopathy undergoing CFP, OCT, FFA, and ICGA imaging before treatment at a university hospital in Thailand (January 1, 2013 to June 30, 2015) were identified. Images of each subject were categorized into 4 sets (set A: CFP; set B: CFP+OCT; set C: CFP+FFA; set D: CFP+OCT+FFA). Six graders, 3 from Thailand (PCV endemic area) and 3 from the United States (nonendemic area), individually reviewed each set (without ICGA), and determined if the presumed diagnosis was PCV. In parallel, 2 other graders confirmed if each case had PCV or not using EVEREST criteria (including ICGA). Sensitivity and specificity of a PCV diagnosis with each set (without ICGA) were analyzed compared with diagnoses including ICGA. RESULTS: Of 119 study eyes (113 subjects, 57% male, mean age ± SD 59.9 ± 13.8 years), definite PCV diagnosis was 40.3%. Sensitivity of sets A, B, C, D: 0.63 (95% confidence interval [CI]: 0.47-0.76), 0.83 (95% CI: 0.69-0.92), 0.54 (95% CI: 0.39-0.68), 0.67 (95% CI: 0.51-0.79); specificities: 0.93 (95% CI: 0.84-0.97), 0.83 (95% CI: 0.72-0.91), 0.97 (95% CI: 0.89-0.99), 0.92 (95% CI: 0.82-0.97); accuracies: 0.81 (95% CI: 0.73-0.88), 0.83 (95% CI: 0.76-0.90), 0.79 (95% CI: 0.73-0.87), 0.82 (95% CI: 0.74-0.88). Discrepancies between Thai and US graders existed through sets A, C, and D. CONCLUSIONS: These data suggest that without ICGA, fundus photography combined with OCT provides high sensitivity and high specificity to diagnose PCV; adding FFA does not improve accuracy.