Real-world experience with brolucizumab in neovascular age-related macular degeneration over 2 years: the REBA extension study.

BACKGROUND: To determine long-term efficacy and safety of intravitreal brolucizumab therapy for neovascular age-related macular degeneration (nAMD) in the real-world setting. METHODS: Retrospective, observational, multicentric study and an extension of the REBA study (Real-world Experience with Brolucizumab in nAMD) to 24 months. The study entailed follow-up of 91 consecutive eyes (67 patients) with nAMD who received brolucizumab therapy and completed 24 months of follow-up. Both treatment-naïve and switch therapy patients were included. All relevant data were collected. The primary outcome measure was changed in best-corrected visual acuity (BCVA) over time. Secondary outcome measures included change in central subfield thickness (CST) and complications. RESULTS: The mean (SD) baseline BCVA was 48.4 (3.5) letters and 36.2 (7.1) letters in treatment-naïve group and switch therapy group, respectively. BCVA gain was + 9.2 (3.7) letters (p = 0.01) and + 7.7 (3.4) letters (p = 0.011), respectively. The change in mean (SD) CST has shown a significant decrease in retinal thickness in treatment-naïve group (from 432.5 (68.4) to 283.0 (51.3) µm; p = 0.018) and in switch therapy group (from 452.5 (40.5) to 271.0 (43.4) µm; p = 0.011) group. One switch patient developed vascular occlusion and another a macular hole after the fifth brolucizumab injection as reported in the primary study. Both patients recovered uneventfully. Three patients demonstrated reversible intraocular inflammation between months 10 and 24. CONCLUSION: Patients showed a significant anatomical and functional response to brolucizumab therapy in the real world, regardless of prior treatment status, until the end of the follow-up period. Overall, 5 significant untoward events were noted.

SINGLE INJECTION RESPONSE TO ANTIVASCULAR ENDOTHELIAL GROWTH FACTOR AGENTS IN PATIENTS WITH WET AGE-RELATED MACULAR DEGENERATION: Incidence and Characteristics.

PURPOSE: To determine the incidence of complete resolution of choroidal neovascular membrane-associated exudation with a single antivascular endothelial growth factor injection in treatment-naive wet age-related macular degeneration patients and its associated characteristics. METHODS: Retrospective, observational study of naive wet age-related macular degeneration patients who received antivascular endothelial growth factor therapy with ranibizumab/aflibercept and demonstrated complete resolution of retinal exudation with a single injection. Complete resolution was defined as the total disappearance of the intraretinal fluid, cysts, and subretinal fluid and a return of retinal thickness to <250 µm on spectral-domain optical coherence tomography. All relevant data were collected. Follow-up was scheduled on Days 1, 7, and 30 postoperatively and then monthly, with at least 9 visits mandatory per year if the macula remained fluid free. Appropriate statistical analyses were performed. RESULTS: Sixty-three patients (29 men; mean age 67.25 ± 4.40 years) were identified. The mean baseline and final-corrected distance visual acuity was 20/160 and 20/45, respectively. Patients completed a mean of 10.9 follow-up visits per year. Smaller choroidal neovascular membranes (<200 µm), early presentation, better presenting corrected distance visual acuity, subfoveal choroidal neovascular membranes, absence of blood/fibrosis, and use of aflibercept (2 mg) favored resolution with one injection. CONCLUSION: A subset (13.76%; 63/458, 95% confidence intervals: 10.73-17.25) of patients with treatment-naive wet age-related macular degeneration demonstrates resolution of choroidal neovascular membrane-associated exudation with a single antivascular endothelial growth factor injection, sustained over 2 years or more. This can lower therapy costs, treatments, office visits, and the potential risk of geographic atrophy.

ENDOGENOUS ENDOPHTHALMITIS IN THE SETTING OF COVID-19 INFECTION: A Case Series.

PURPOSE: To describe endogenous endophthalmitis in the setting of COVID-19 pneumonia. METHODS: Patients recovering from COVID-19 pneumonia who presented to our department with any or all of the following complaints: pain, watering, redness, and decreased vision were identified. All relevant data were collected for analysis. RESULTS: Three patients with endogenous endophthalmitis were identified. All patients had been treated for COVID-19 pneumonia and therefore had received remdesivir and systemic steroids; 2 of the 3 patients received tocilizumab. All patients received vitreous biopsy, vitrectomy, and intraocular antibiotic injection. Patient 1 demonstrated Klebsiella pneumoniae in blood culture, K. pneumoniae and Escherichia coli in urine culture, and K. pneumoniae in vitreous fluid, whereas Patients 2 and 3 demonstrated Stenotrophomonas maltophilia and methicillin-resistant Staphylococcus aureus in the blood and nasopharyngeal culture, respectively. Correspondingly, the same organism was cultured from vitreous in Patients 2 and 3. The visual acuity at the last follow-up in Patients 1 to 3 was 20/100, 20/80, and 20/40, respectively. The probable source of infection was identified in each as renal calculi, dental caries, and the pharynx, respectively. Real-time polymerase chain reaction demonstrated the presence of Severe Acute Respiratory Syndrome Coronavirus 2 in the vitreous fluid of Patient 1. CONCLUSION: We report good outcomes of early intervention for endogenous endophthalmitis in the setting of COVID-19 infection. We also document the presence of SARS-CoV-2 in vitreous.

UVEITIS TREATED WITH DEXAMETHASONE IMPLANT.

PURPOSE: To evaluate the real-life efficacy and safety of the intravitreal dexamethasone implant in uveitis. METHODS: This retrospective observational multicentric study included 152 eyes treated exclusively by 358 dexamethasone implant injections. The main outcome measures included change in the best-corrected visual acuity, central macular thickness, and vitreous haze score. RESULTS: Patients were treated with dexamethasone implant for macular edema (51.3%), vitritis with macular edema (40.1%), vitritis (5.3%), and other causes (3.3%). The mean duration of follow-up was 19.0 months. The mean gain in best-corrected visual acuity during follow-up was +12.1 letters. An improvement in best-corrected visual acuity ≥5, 10, and 15 letters was found in 64.5, 50.7, and 35.5% of cases, respectively. 59.7% of eyes with macular edema at baseline were found to be anatomical responders. Vitritis resolution (vitreous haze = 0+) was obtained in 81.4% of cases. Ocular hypertension (intraocular pressure ≥25 mmHg and/or gain ≥10 mmHg from baseline) occurred in 28.3% of patients. No filtering surgery/laser therapy was required. A total of 40.2% of phakic subjects underwent cataract surgery on average 11.2 months after the first injection. CONCLUSION: This study confirms the efficacy and safety of the dexamethasone implant in noninfectious uveitis. Cataract and ocular hypertension were not uncommon but easily manageable.

Sub-optimal gain in vision in retinal vein occlusion due to under-treatment in the real world: results from an open-label prospective study of Intravitreal Ranibizumab.

BACKGROUND: Macular edema secondary to retinal vein occlusion (RVO) is an important cause of loss of vision. Intravitreal injections (IVI) of anti-vascular endothelial growth factor (VEGF) are the standard of care in this disease, as shown in numerous randomized controlled trials. The purpose of this study was to study the efficacy and safety of ranibizumab, an anti-VEGF agent, in the real-world setting. METHODS: This was 48 weeks, open-label, prospective, multicentre, observational study. Patients diagnosed with ME secondary to RVO were treated with IVI of Ranibizumab 0.5 mg in real-world conditions. Efficacy was measured by improvement seen in best-corrected visual acuity (BCVA) in terms of Early Treatment of Diabetic Retinopathy Study (ETDRS) Letter Scores and change in central retinal thickness (CRT) measured by optical coherence tomography. RESULTS: One hundred eyes of 100 patients (79 with branch retinal vein occlusion and 21 with central retinal vein occlusion) were recruited in the study. The mean (standard deviation, SD) BCVA was 52.8 (21.99) letters at baseline and 62.3 (24.40) letters at week 48. From baseline, there was a significant improvement in BCVA by 7.7 letters (p = 0.001) at 48 weeks. The mean (SD) of CRT was 479.9 (216.25) µm at baseline and it decreased significantly to 284.9 (171.35) µm at week 48 (p < 0.001). During the study period, the average number of intravitreal injections was 3.5 per patient. There was no report of endophthalmitis in any eye. CONCLUSIONS: Ranibizumab is well tolerated and effective in treating macular edema secondary to RVO in real-world clinical settings. However, there is under-treatment compared to controlled clinical trials, and the gain in vision is sub-optimal with under-treatment. TRIAL REGISTRATION: Clinical Trials Registry - India: CTRI/2015/07/005985 .

Postmarketing safety surveillance of dexamethasone intravitreal implant in the treatment of visual impairment due to diabetic macular edema in India.

BACKGROUND: Diabetic macular edema (DME) is the most common cause of vision loss in diabetic patients. As India has the second largest population of diabetic patients worldwide, availability of various treatment options for DME is essential. This postmarketing surveillance study was conducted to fulfill a commitment to the Regulatory Authority of India to examine the safety of dexamethasone intravitreal (DEX) implant over 1 year in Indian patients with DME receiving ≥1 DEX implant for DME-related visual impairment in clinical practice. METHODS: This observational, prospective, non-interventional study enrolled patients aged ≥18 years scheduled to receive DEX implant for DME-related visual impairment. Baseline demographics, medical history, date of last DEX implant injection, detailed information about adverse events (AEs), AEs of special interest (AESIs), serious AEs (SAEs), and adverse drug reactions (ADRs) reported during postinjection visits and investigator telephone calls were collected. Primary outcome measures were treatment-emergent AE (TEAE), AESI, SAE, and ADR occurrences. RESULTS: Of the enrolled patients (19 sites throughout India; n = 250), 84 had received DEX implant previously; mean (standard deviation; SD) duration between prior and study entry dose was 199.4 (156.0) days, and 91 (36.4%) had ≥1 prior ophthalmic condition. Over a mean of 182.6 (88.6) follow-up days (min-max: 0-364 days), 22 TEAEs were reported by 7 (2.8%) patients, 6 of whom had previously received DEX. AESIs of increased IOP (n = 3, 6 events) and glaucoma (n = 1, 1 event) were considered non-serious, of mild/moderate severity, and related to DEX treatment. Eyelid ptosis was reported in 1 patient (1 event). Nonocular AEs included cardiac AEs (n = 3, 4 events), pyrexia (n = 1, 2 events), and dyspnea (n = 1, 2 events). Three (1.2%) patients had 12 serious AEs; most were cardiac disorders; all were unrelated to DEX treatment. Two (0.8%) deaths were considered unrelated to treatment. CONCLUSIONS: Based on voluntary reporting of adverse events in this surveillance study, DEX implant for treatment of DME-related visual impairment in the Indian population demonstrated a favorable safety profile with few treatment-related TEAEs (none were considered serious) during the 1-year follow-up. These data supplement previous findings and confirm the safety of DEX implant in this population during usual clinical practice. TRIAL REGISTRATION: World Health Organization Clinical Trials Registry: CTRI/2017/04/008396 . Registered 24 April 2017.

INTRAOCULAR DEXAMETHASONE IMPLANT POSITION IN SITU AND OCULAR HYPERTENSION.

PURPOSE: To determine the association between the dexamethasone implant position in the vitreous cavity and ocular hypertension (OHT). METHODS: Retrospective review of patients with at least one intravitreal dexamethasone implant injection between 2012 and 2016. Patients who had a minimum follow-up for 6 months and documented evidence of the implant position were included in the study. Steroid responders, glaucoma patients, vitrectomized eyes, and eyes with liquefied vitreous were excluded. Relevant data were collected from patient charts. Three positions (P1, P2, and P3) were identified: P1 (in contact with the pars plana/ciliary body region), P2 (anterior to vortex veins), and P3 (posterior to vortex veins). Ocular hypertension was defined as absolute intraocular pressure > 25 mmHg and/or intraocular pressure rise > 10 mmHg. The relationship between implant position and intraocular pressure rise after factoring in other characteristics was the outcome measure. Appropriate statistical analysis was performed. RESULTS: A total of 377 patients (432 eyes; 257 males; 677 injections) were eligible for analysis. The median age was 57.24 (±6.32) years. Eighty-eight eyes had OHT. Of these, 54 eyes had the implant in P1. P1 was associated with high intraocular pressure response (>15 mmHg; P = 0.004) and early (<15 days) onset OHT (r = 0.84, P < 0.001). CONCLUSION: Anterior position of dexamethasone implant in situ increases the risk of OHT.

Intravitreal dexamethasone implant for recalcitrant cystoid macular edema secondary to retinitis pigmentosa: a pilot study.

BACKGROUND: To determine the utility of the intravitreal dexamethasone implant as therapy for cystoid macular edema (CME) secondary to retinitis pigmentosa (RP) recalcitrant to carbonic anhydrase inhibitor therapy over 2 years as a pilot study. METHODS: This was a prospective case series. Patients who showed either an incomplete or no response to topical dorzolamide for at least 1 month and oral acetazolamide therapy for at least 15 days were recruited for the study with informed consent. A complete anterior and posterior segment examination was performed including fundus fluorescein angiography (FFA), optical coherence tomography scan (OCT) and electroretinogram to confirm the diagnosis. The dexamethasone implant was injected using a standardized technique. Follow ups were scheduled on days 1, 7, and 30 and then monthly thereafter for 2 years. The primary outcome measure was the change in corrected distance visual acuity (CDVA) and central subfield thickness (CST) at months 1, 6, 12, 18, and 24. The secondary outcome measure was complications, if any. Appropriate statistical analysis was done. RESULTS: Five patients (two males; six eyes; median age 49 years) were recruited for the study. All patients required at least two injections over 2 years. All patients demonstrated significant improvement in CDVA (p = 0.004) as well as CST measurements (p = 0.0038) over 2 years. No complications were noted. CONCLUSION: The intravitreal dexamethasone implant provides significant improvement in CDVA and CST measurements in patients with recalcitrant CME secondary to RP.

ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY FOR NAIVE IDIOPATHIC CHOROIDAL NEOVASCULARIZATION: A Comparative Study.

PURPOSE: To determine the clinical characteristics of patients with idiopathic choroidal neovascularization and to compare outcomes between intravitreal bevacizumab (IVB) and ranibizumab as therapy. METHODS: Retrospective analysis included demographics, the corrected distance visual acuity, details of the ocular examination, imaging, treatment, outcomes, and adverse events. Patients with minimum of 1-year follow-up were included in the study. Primary outcome measure was change in corrected distance visual acuity at the final visit compared with baseline. Secondary outcome measures were change in central macular thickness and subretinal fluid (if present) with treatment and adverse events. RESULTS: This study included 47 eyes of 45 patients with 30 males. Intravitreal bevacizumab group included 29 eyes (27 patients; with a median age of 39.4 ± 7.3 years). Intravitreal ranibizumab group included 18 eyes (18 patients; median age: 36.8 ± 9.3 years). Median baseline corrected distance visual acuity (logMAR) improved from 0.59 ± 0.38 to 0.2 ± 0.18 (P = 0.03) in intravitreal ranibizumab group and from 0.62 ± 0.41 to 0.18 ± 0.15 logMAR (P = 0.023) in intravitreal bevacizumab group. Median central macular thickness (in micrometers) improved from 315.11 ± 75.24 to 228.24 ± 67 (P = 0.036) in intravitreal bevacizumab group and from 327.24 ± 61.56 to 208 ± 53.42 (P = 0.031) in intravitreal ranibizumab group. There was no significant difference between groups in final corrected distance visual acuity (P = 0.31) or central macular thickness (P = 0.51). No adverse events were noted. CONCLUSION: Both intravitreal ranibizumab and intravitreal bevacizumab seem equally effective in treating idiopathic choroidal neovascularization with a good safety profile without recurrence.

Mycobacterium W administration for steroid resistant optic neuritis with long-term follow-up.

BACKGROUND: We report the long-term safety and outcomes of off-label Mycobacterium W (Mw) administration in steroid resistant optic neuritis. METHODS: In a case series, six patients with documented idiopathic corticosteroid refractory unilateral optic neuritis were treated with immuvac (Mycobacterium W extract). The dose was repeated at three months. Outcomes measures included the best corrected visual acuity (BCVA), pupillary reaction, colour vision, visual field(VF) examination (when possible), fundus examination and photography, and visually evoked potential (VEP) testing. BCVA, pupillary reaction, and color vision were monitored immediately prior to steroid therapy on days 1 and 7 post-steroid therapy, pre-Mw administration (i.e., 30 days after the last dose of steroids had been completed) and post-Mw administration on days 1, 7, 30, 90, 120, and 180. VF, VEP, and fundus photography were performed immediately prior to steroid administration, 30 days after the last dose of steroids (i.e., immediately prior to Mw), and at days 30, 90,120 and, 180. The patients were assessed six-month intervals thereafter for visual acuity, colour vision, and visual fields. RESULTS: There were five females and three males in the age range of 30-54 years. Minimum follow-up was five years. All patients showed improvement in visual acuity, colour vision, and pupillary reaction. The patients showed stable improvement. There was no recurrence of the disease and no adverse events till the end of the follow-up period. CONCLUSIONS: Mw appears to be safe in the long term and to improve steroid resistant optic neuritis; future randomized clinical trials would help affirm this observation.

Pantoea agglomerans endophthalmitis: clinical features and outcomes.

PURPOSE: To determine the clinical profile and outcomes of patients with Pantoea agglomerans endophthalmitis as seen at a tertiary eye care center in India. METHODS: Retrospective observational case series. Data collected included demographics, history, the initial and final corrected distance visual acuity, details of the ocular and systemic examination, surgeries performed, and the final anatomical outcome. The final corrected distance visual acuity and the anatomical outcome were the outcome measures. RESULTS: Four patients had traumatic endophthalmitis; the fifth developed endophthalmitis after cataract surgery. All patients were men with a mean age of 34.24 ± 23.34 years. Three patients had corneal laceration and traumatic cataract. All patients underwent vitreous sampling with intraocular antibiotic injection with or without lensectomy and corneal wound repair. The visual acuity at presentation ranged from hand motion to perception of light. One patient ended up with phthisis in the affected eye. One patient developed postoperative retinal detachment and underwent successful surgery. The final visual acuity ranged from 20/25 to no light perception. CONCLUSION: P. agglomerans is a likely source of infection in traumatic and postoperative cases. Though variable, it appears sensitive to common antibiotics. The visual and anatomical prognosis seems fair in most cases. Special care needs to be taken to ensure the organism is not missed, given the rarity of the condition and the isolation techniques required.

Postoperative Aspergillus Infection: A Case Series.

PURPOSE: To report the clinical findings, therapy and outcomes of pauci-symptomatic Aspergillus infection in 11 eyes of 11 patients who had recently undergone uneventful cataract surgery and IOL implantation in a single operating room on the same day. METHODS: Retrospective, observational study that looks at 11 patients who demonstrated Aspergillus infection after cataract surgery. All data were collected and intracameral samples sent for microscopic evaluation and culture. Additional swabs were sent from the operating room and operative consumables. RESULTS: A total of 11 eyes of 11 patients were included in the analysis and were followed for at least 12 months. All patients responded completely to local and systemic voriconazole therapy. The source of infection was noted to be air-conditioning vents. Eyes with manual small incision cataract surgery (11/17) had a higher propensity for infection. CONCLUSION: Pauci-symptomatic aspergillosis infection has been reported here following cataract surgery.

Spontaneous closure of an idiopathic macular hole after epiretinal membrane development.

Purpose: To report non-operative closure of an idiopathic full thickness macular hole (FTMH) spontaneous secondary to the development of a macular epiretinal membrane (ERM). Observations: A 68-year-old woman, with no relevant medical history, and a 6-month history of decreased visual acuity in her right eye was diagnosed to have an idiopathic FTMH. The patient refused surgery and the FTMH was followed-up for seven years. The spectral domain optical coherent tomography follow-up showed the evolution of the FTMH and its spontaneous closure after development of an ERM. In the presence of an ERM with vitreo-papillary detachment, it is possible that the centripetal forces involved helped bring together the edges of the macular hole resulting in a possible spontaneous closure. Additionally and separately, the presence of an ERM may act as scaffolding for Muller cell migration and consequent macular hole closure. Conclusions and importance: Development of an ERM was followed by non-operative FTMH closure in this specific case. It is important to note, that this is an extraordinary situation in which the patient had a favorable anatomical evolution despite having rejected conventional surgical intervention. Studies aimed at determining the mechanisms and situations in which these cases occur could provide answers that help us make more appropriate decisions. To our knowledge, the present case is the first in the literature to report a spontaneous closure of a FTMH secondary to the appearance and progression of a previously non-existent ERM.

Relevance of Visual Acuity Measurement for Therapeutic Decisions in Diabetic Macular Edema.

This study aimed to determine the validity of basing retreatment decisions on anatomical criteria alone (captured using optical coherence tomography (OCT)-OCT-guided strategy) rather than the gold standard (combined visual acuity (VA) and OCT) in patients with diabetic macular edema (DME). This cross-sectional study included 81 eyes undergoing treatment for DME from September 2021 to December 2021. An initial therapeutic treatment decision based on OCT results was made on inclusion. Subsequently, in light of the patient's VA score, this initial decision was upheld or adjusted, and the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. In 67 out of the 81 eyes included in the study (82.7%), the OCT-guided strategy produced equivalent results to the gold standard. In this study, the OCT-guided retreatment decision strategy yielded sensitivity and specificity of 92.3% and 73.8%, respectively, and PPV and NPV of 76.6% and 91.2%, respectively. These findings differed according to the patient's treatment regimen: the sensitivity and specificity for eyes under a treat and extend regimen was higher, 100% and 88.9%, respectively, than eyes under a Pro Re Nata regimen, 90% and 69.7%, respectively. These findings show that VA testing could be omitted from the follow-up of certain patients with DME treated with intravitreal injections without impacting the quality of care.

Outcomes of toll-like receptors' antagonism in steroid-resistant optic neuritis; a pilot study.

BACKGROUND: To investigate the safety and outcomes of off-label immunomodulator Mycobacterium w. (Mw), a TLR 9 antagonist in steroid-resistant idiopathic unilateral optic neuritis. METHODS: Case series. Eight patients with documented idiopathic unilateral optic neuritis who did not improve with methyl prednisolone followed by oral steroids as per the Optic Neuritis Treatment Trial (ONTT) were administered Mw 5 ml in 500 ml normal saline, 30 days after the last of dose of steroids had been administered. The dose was repeated at 3 months. Outcome measures monitoring the change in the best-corrected visual acuity (BCVA), pupillary reaction, colour vision, visual field (VF) examination (when possible), fundus examination and photography, visually evoked potential (VEP) testing. BCVA, pupillary reaction, and color vision were monitored immediately prior to steroid therapy, on days 1 and 7 post steroid therapy, pre Mw administration (i.e., 30 days after the last dose of steroids had been completed) and post Mw administration on days 1, 7, 30, 90, 120 and 180. VF, VEP and fundus photography was performed immediately prior to steroid administration, 30 days after the last dose of steroids (i.e., immediately prior to Mw), and days 30, 90,120 and 180 post Mw administration. RESULTS: There were five females and three males in an age range of 30-54 years. Six patients were available for follow-up at 6 months. All patients showed improvement in visual acuity, colour vision & pupillary reaction. Visual field monitoring was possible in four patients; all four had a centrocecal scotoma that persisted post steroid therapy but resolved 1 month post Mw therapy. Three out of five patients who had disc edema were available for all follow-ups, and showed resolution of disc edema post Mw therapy. The disc edema had persisted post steroid therapy. No adverse events were seen. The 2nd dose did not improve any of the said parameters. There was no recurrence of the disease up to the end of the follow-up period. CONCLUSIONS: Mw appears to improve steroid resistant optic neuritis; future randomized clinical trials would help affirm this observation.

Minimal surgery for tractional retinal detachment secondary to branch retinal vein occlusion: a case report.

BACKGROUND: Tractional retinal detachment secondary to retinal vein occlusion is a complex entity that can be extremely difficult to manage due to an intricate association of the retinal tissue with the fibrovascular proliferation, making vitreous dissection an extraordinarily difficult procedure. Minimal surgery without endo-tamponade can reduce recovery time and avoid complications of surgery, which in some cases can lead to blindness and even phthisis. CASE PRESENTATION: A 64-year-old Indian woman presented with progressive worsening of vision (right eye) due to fovea involving tractional retinal detachment secondary to supero-temporal branch retinal vein occlusion. After anterior, core and peripheral vitrectomy, the epicenter of the fibrous bridge causing foveal split was identified and released. The corrected distance visual acuity improved from 6/60 pre-operatively to 6/12 post-operatively. At the 5-year follow-up, the patient remains stable both anatomically and visually. CONCLUSIONS: This case illustrates how careful identification of the epicenter of traction helps maximize visual gain in patients with minimal risk of iatrogenic retinal tears and eliminates the need for endo-tamponade with either gas or silicone oil. Minimal surgery for tractional detachment provides excellent visual gains with minimal risks in select cases.

Risk Factors for COVID-19 Associated Mucormycosis: The Ophthalmologist's Perspective.

The COVID-19 pandemic has led to a dramatic rise in the incidence of rhino-orbito-cerebral mucormycosis (ROCM) in India. The purpose of our report is to describe the prevalence of ROCM in the context of SARS-CoV-2 infection during the second Indian COVID-19 wave, as well as its diagnostics proceeding, and to discuss the challenges met in the time frame from the suspected diagnosis to the therapeutic decision in such patients. We conducted a retrospective multicentre case series study at six centres of Sudhalkar and Raghudeep group of hospitals in India. ROCM was confirmed in 38 (2.5%) of the 1546 patients admitted with SARS-CoV-2 infection. The average time to establish a diagnosis was 16 days. In total, 19 (50%) patients suffered from type 2 diabetes and were mostly treated with hypoglycaemic agents (in 90% of cases). The standard of care for SARS-CoV-2 management included systemic steroids therapy, intravenous remdesivir for 5 days, and concomitant prophylactic antibiotic therapy following admission. The median (IQR) blood glucose levels in all patients during the course of hospitalisation was 320 (250.5-375) mg/dl. A total of 16% of patients had an irreparable functional loss, and the mortality was 5%. We may hypothesise that excessive administration of antibiotics that profoundly affects human microbiota, coupled with poorly controlled glycaemia and unprotocolised haphazard steroid administration, contribute to a favourable setting for mucormycosis infections.

Comparison of intraocular lens calculation methods after myopic laser-assisted in situ keratomileusis and radial keratotomy without prior refractive data.

AIM: To compare intraocular lens (IOL) calculation methods not requiring refraction data prior to myopic laser-assisted in situ keratomileusis (LASIK) and radial keratotomy (RK). METHODS: In post-LASIK eyes, the methods not requiring prior refraction data were Hagis-L; Shammas; Barrett True-K no-history; Wang-Koch-Maloney; 'average', 'minimum' and 'maximum' IOL power on the American Society of Cataract and Refractive Surgeons (ASCRS) IOL calculator. Double-K method and Barrett True-K no-history, 'average', 'minimum' and 'maximum' IOL power on ASCRS IOL calculator were evaluated in post-RK eyes. The predicted IOL power was calculated with each method using the manifest postoperative refraction. Arithmetic and absolute IOL prediction errors (PE) (implanted-predicted IOL powers), variances in arithmetic IOL PE and percentage of eyes within ±0.50 and ±1.00 D of refractive PE were calculated. RESULTS: Arithmetic or absolute IOL PE were not significantly different between the methods in post-LASIK and post-RK eyes. In post-LASIK eyes, 'average' showed the highest and 'minimum' showed the least variance, whereas 'average' and 'minimum' had highest percentage of eyes within ±0.5 D and 'minimum' had the highest percentage of eyes within ±1.0 D. In the post-RK eyes, 'minimum' had highest variance, and 'average' had the least variance and highest percentage of eyes within ±0.5 D and ±1.0 D. CONCLUSION: In post-LASIK and post-RK eyes, there are no significant differences in IOL PE between the methods not requiring prior refraction data. 'Minimum' showed least variance in PEs and more chances of eyes to be within ±1.0 D postoperatively in post-LASIK eyes. 'Average' had least variance and more chance of eyes within ±1.0 D in post-RK eyes.

Efficacy and Safety of Intravitreal Fluocinolone Acetonide Implant for Chronic Diabetic Macular Edema Previously Treated in Real-Life Practice: The REALFAc Study.

Diabetic macular edema (DME) is the main cause of visual impairment in diabetic patients and a chronic disease requiring long-term treatments. The fluocinolone acetonide (FAc) implant has recently been approved to treat DME in patients considered insufficiently responsive to available therapies. This study evaluates the functional and anatomical efficacy of the FAc implant in real-life practice. A total of 62 eyes with chronic DME were included and followed for a mean of 13.9 (+7.5) months. Previous treatment included at least anti-vascular endothelial growth factor (VEGF) in 83.9% of eyes, dexamethasone implant (DEX-I) in 100% of eyes, vitrectomy in 29.0% of eyes, and laser photocoagulation (either panretinal or focal photocoagulation) in 75.8% of eyes. The mean baseline best corrected visual acuity (BCVA) was 64.0 (+/−17.2) letters (median: 67.5 letters) with a mean DME duration of 60.3 (+/−30.6) months. The maximum BCVA gain occurred at 21 months with a mean gain of 5.0 (+/−12.7) letters. A total of 50.0% of eyes gained ≥5 letters during follow-up. Patients with lower BCVA at baseline had the lowest final BCVA (p < 0.001) but the highest BCVA gain (p = 0.02). The best overall improvement in mean central macular thickness (CMT) occurred at 18 months (p < 0.0001). The improvement in BCVA was inversely associated with the decrease in CMT and showed a decrease when CMT increased (DME recurrence). According to the history of vitrectomy, we did not find any significant difference in mean final BCVA (p = 0.1) and mean BCVA gain (p = 0.2) between eyes previously vitrectomized or not. A total of 23 eyes (37.1%) required additional treatment for DME, and 17.7% required an IOP-lowering procedure during follow-up. In conclusion, this real-life observational study demonstrated the efficacy and safety of the FAc implant in patients with chronic DME already treated with other available therapies.

Fluocinolone acetonide implant in diabetic macular edema: International experts' panel consensus guidelines and treatment algorithm.

Center-involving diabetic macular edema (DME) is a leading cause of vision impairment in working-age adults. While its management is particularly challenging in a poorly compliant population, continuous innovation and the advent of new molecules have improved its outcome. The control of glycemia and of systemic aggravating factors remain essential to slow down progression of disease complications including DME. The indications for macular laser photocoagulation has progressively been phased out as a standard of care and replaced by local intraocular anti-VEGFs biologics and glucocorticoids (GCs). Intravitreal GCs in controlled-release drug delivery systems have allowed to reduce injection frequency and treatment burden. The non biodegradable Fluocinolone Acetonide (FAc) implant allows a long-lasting stabilization of both functional and anatomic improvements. However, adequate patient selection and monitoring through regular follow-up are essential for optimal results. Based on their experience and the latest literature, the aim of the present review is to provide international expert panel consensus on the place of the FAc implant in the treatment algorithm of DME, as well as its safety profile and how to manage it.