Current Perspectives on Type 3 Macular Neovascularization due to Age-Related Macular Degeneration.

BACKGROUND: The aim of this review was to systematically summarize the current knowledge on type 3 macular neovascularization (MNV3) in age-related macular degeneration (AMD). SUMMARY: Recent histopathologic and multimodal imaging findings led to the consensus definition of the new term "type 3 macular neovascularization" in AMD. MNV3 originates in the deep vascular plexus as a neovascular process without connection with the retinal pigment epithelium in the initial stages. This type has numerous clinical and pathomorphologic features that separate it from the other two types of MNV in AMD. Besides, its frequency appears to be higher than previously thought. In optical coherence tomography (OCT), MNV3 can be classified into stages 1-3. Hyperreflective foci in the outer retina possibly represent a precursor lesion. In addition, MNV3 is characterized by a strong association with reticular pseudodrusen, a high rate of bilaterality, close associations with advanced age and arterial hypertension, decreased choroidal thickness, and decreased choriocapillaris flow signals. Data from latest anti-vascular endothelial growth factor studies in MNV3 suggest that the OCT biomarkers in intraretinal and subretinal fluids should be interpreted differently than in the other types. Additionally, data from MNV3 eyes should be analyzed separately, allowing optimal type-specific treatment strategies in the future. KEY MESSAGES: This review highlights the need for accurate characterization of neovascular AMD lesions and an MNV type-specific approach, particularly for MNV3.

High User Acceptance of a Retina e-Learning App in Times of Increasing Digitalization of Medical Training for Ophthalmologists.

INTRODUCTION: The aim was to identify changes in continuing education and training in ophthalmology in the context of the COVID-19 pandemic and advancing digitalization and to analyse the acceptance of e-learning tools among German ophthalmologists using a novel Retina Case App as an example. METHODS: The participants' training behaviour before and during the COVID-19 pandemic was surveyed. Furthermore, the acceptance and usability of the Retina Case App were evaluated using the System Usability Scale (SUS). A possible influence of the app on everyday clinical practice was assessed. RESULTS: A total of 145 ophthalmologists participated in the survey. The frequency of continuing medical education did not decrease for 62.8% of ophthalmologists during the pandemic. A significant increase in at least monthly use of online courses or lectures has been observed (90.3% vs. 28.2%, p < 0.001). No significant difference was identified in terms of frequency of use of print and digital journals or printed textbooks. The majority of participants stated that online training platforms are well suited to replace the absence of face-to-face events (73.8%). The mean SUS score was 87.7 (SD 11.9), which categorizes the app's usability as excellent. The majority agreed that the newly developed app enables faster learning (82.1%) and leads to increased motivation (71.7%). Most ophthalmologists (80.7%) felt that regular use of the app would improve confidence in the treatment of retinal diseases. CONCLUSIONS: The COVID-19 pandemic has led to a significant change in training behaviour in ophthalmology towards e-learning and online courses, which has not been accompanied by a general decline in training activity. The exemplarily investigated application showed a high user acceptance among ophthalmologists.

Differential effects of high-intensity interval training (HIIT) on choriocapillaris perfusion in healthy adults and patients with type 1 diabetes mellitus (T1DM).

PURPOSE: To investigate the effects of a four-week high-intensity interval training (HIIT) on choriocapillaris (CC) perfusion in young healthy adults and type 1 diabetes mellitus (T1DM) patients. METHODS: Data of two HIIT studies with baseline to follow-up comparison were retrospectively analysed. Twenty healthy participants and twenty T1DM patients without clinical signs of diabetic retinopathy were included. All participants had performed a four-week all-out HIIT protocol with a total of 8 training sessions. Changes in physical fitness were assessed using power output at the individual aerobic lactate threshold (IANT). Optical coherence tomography angiography (OCTA) imaging was performed at baseline and follow-up. CC images were analysed for number, size and total area of flow deficits (FD), mean signal intensity, signal intensity standard deviation and kurtosis of signal intensity distribution. RESULTS: At baseline, CC OCTA revealed a lower and more heterogeneous intensity signal in T1DM eyes (mean intensity signal and standard deviation of signal intensity, p < 0.001). Percent of CC FD area was greater in T1DM eyes (p < 0.001). While T1DM patients showed greater improvement of exercise capacity at IANT than healthy controls (group×time p = 0.0403), CC FD area and standard deviation of intensity increased in healthy controls but not in T1DM patients (group×time p ≤ 0.029). Moreover, linear regression slopes of FD region distribution differed significantly at baseline and follow-up (p = 0.0002) in healthy individuals but not in T1DM patients. CONCLUSIONS: Effects of regular physical exercise performed as HIIT on CC perfusion were only seen in healthy participants, not in T1DM patients suggesting impaired CC adaptation in T1DM.

Effect of high-intensity interval training in patients with type 1 diabetes on physical fitness and retinal microvascular perfusion determined by optical coherence tomography angiography.

OBJECTIVE: Physical activity may protect from ocular complications of diabetic retinopathy (DR). We investigated exercise training effects on the retinal microvasculature using optical coherence tomography angiography (OCTA) in type 1 diabetes (T1D). METHODS: Twenty T1D patients without clinical signs of DR performed four weeks of high-intensity interval training (HIIT). Cycle ergometry was used for determination of physical fitness. OCTA of the macula and optic nerve head was applied to analyze effects on the foveal avascular zone area, vessel density, vessel diameter index and fractal dimension of the superficial plexus, deep plexus and radial peripapillary capillaries. RESULTS: Large effects for improvement of physical fitness in terms of power output at the individual lactate threshold (+10.7 ± 11.3%, p < .001, ES = 0.95) and maximal power output (+8.2 ± 6.4%, p < .001, ES = 1.4) were detected. Participants presented a reduced increase in heart rate (HR) and lactate (LA) at given exercise intensities at follow-up (p ≤ .0176). Baseline OCTA revealed that HbA1c levels were associated with vessel density in the radial peripapillary capillary and the parafoveal superficial region (p ≤ .014). None of the analyzed microvascular parameters changed in response to the intervention. CONCLUSION: Despite favorable effects of HIIT on physical fitness of T1D patients, disease-specific training protocols may be needed to overcome potentially impaired retinal microvascular adaptations.

[Physical Therapy of Non-Exudative Age-Related Macular Degeneration]. / Physikalische Therapie der nicht exsudativen altersabhängigen Makuladegeneration.

Despite the success of anti-VEGF therapy (VEGF: vascular endothelial growth factor) in neovascular age-related macular degeneration (AMD) in the last decade, many unmet needs in AMD management remain. In order to improve patient eye health and relieve the burden on health systems, the development of new intervention options appears to be of great importance if they can delay or even prevent the progression of an early form into a late form. In the field of physical treatment for non-exudative AMD, there is no recognised therapy procedure to date. It now appears appropriate to pursue further research efforts in the field of intraocular blue filter lenses and subthreshold laser treatment in prospective studies. The following article provides an overview of the current strategies of physical therapy for non-exudative AMD.

[Expression of Motion Artifacts in OCT-Angiography Imaging in Healthy Subjects Using Two Different Devices]. / Vergleich der Bildqualität zweier unterschiedlicher OCT-Angiografie-Systeme mit Fokus auf Bewegungsartefakten bei gesunden Probanden.

BACKGROUND: To compare the expression of motion artifacts in optical coherence tomography angiography (OCT-A) in healthy subjects using two different devices. METHODS: In this study, 25 eyes of 25 healthy volunteers with no history of any ocular disease or ocular surgery were included. OCT-A imaging was performed using the RTVue XR Avanti (Optovue Inc., Fremont, California, USA) and the Spectralis OCT-A (Heidelberg Engineering, Heidelberg, Deutschland). The macula was imaged twice in each proband with active eye tracking (ET) using a 3 × 3 mm2 or a 10 × 10° scan, respectively. The expression of motion artifact was analyzed by two independent readers in the superficial OCT-angiogram using the Motion Artifact Score (MAS). RESULTS: The signal strength index (SSI) was 73.0 ± 7.8 (Optovue) and 39.6 ± 3.6 (Heidelberg), which is equivalent to 73.0% (Optovue SSImax = 100 = 100%) and 79.2% (SSImax = 50 = 100%) of the maximum quality score. Both devices showed a very good image quality (mean MAS Optovue: 1.32 ± 0.551, mean MAS Heidelberg: 1.7 ± 0.789, p = 0.006). Of all measurements, quilting/banding was found in 20% of Optovue patients (10/50) and 6% of Heidelberg patients (3/50). Stretching was found in 4% of Optovue patients (2/50) and in 6% of Heidelberg patients (3/50). Vessel doubling was only seen in one Optovue angiogram (2%) as well as a displacement (2%). Blink lines only existed in three Heidelberg angiograms (6%). CONCLUSION: Despite different software and hardware approaches, both devices were able to take high-quality images with a very low prevalence of motion artifacts. Nevertheless, these artifacts still also occur in healthy subjects with good fixation. With regards to MAS, there was a high agreement between the two readers. However, the analysis of artifacts remains complex and requires experience as well as a precise assessment in evaluating OCT-A images.

Prevalences of segmentation errors and motion artifacts in OCT-angiography differ among retinal diseases.

PURPOSE: To assess the prevalences of segmentation errors and motion artifacts in optical coherence tomography angiography (OCT-A) in different retinal diseases METHODS: In a retrospective analysis, multimodal retinal imaging including OCT-A was performed in one eye of 57 healthy controls (50.96 ± 22.4 years) and 149 patients (66.42 ± 14.1 years) affected by different chorioretinal diseases: early/intermediate age-related macular degeneration (AMD; n = 26), neovascular AMD (nAMD; n = 22), geographic atrophy due to AMD (GA; n = 6), glaucoma (n = 28), central serous chorioretinopathy (CSC; n = 14), epiretinal membrane (EM; n = 26), retinal vein occlusion (RVO; n = 11), and retinitis pigmentosa (RP; n = 16). Central 3 × 3 mm2 OCT-A imaging was performed with active eye-tracking (AngioVue, Optovue). Best-corrected visual acuity (BCVA) and signal strength index (SSI) were recorded. Images were independently evaluated by two graders using the OCT-A motion artifact score (MAS; scores I-IV) as well as a newly introduced segmentation accuracy score (SAS; score I-IIB). RESULTS: Mean SSI was 63.67 ± 9.2 showing a negative correlation with increasing age (rSp = - 0.42, p < 0.001, n = 206). In the healthy cohort, mean MAS was 1.45 ± 0.8 and segmentation was accurate (SAS I) in all eyes. In eyes with retinal pathologies, mean MAS was 2.1 ± 0.9 (p < 0.001). Lowest MAS was observed in GA (2.67 ± 0.5) and RVO (2.45 ± 1.1). Compared to an accurate segmentation in 100% in healthy subjects, 34.2% (n = 51) of all patients showed highest segmentation quality (p < 0.001). 63.8% showed segmentation errors in more than 5% of all single b-scans in one (SAS IIA, n = 58) or at least two (SAS IIB, n = 40) segmentation boundaries. Highest percentages of inaccurate segmentation (SAS IIA or IIB) were observed in the nAMD group (90.1%). The inner plexiform layer was the segmentation boundary most prone to inaccurate segmentation in all pathologies compared to the inner limiting membrane (ILM) and retinal pigment epithelium (RPE) segmentation layer. Incorrect ILM segmentation was only seen in patients with EM. CONCLUSIONS: Prior to both qualitative and quantitative analysis, OCT-A images must be carefully reviewed as motion artifacts and segmentation errors in current OCT-A technology are frequent particularly in pathologically altered maculae.

Optical Coherence Tomography Angiography Offers New Insights into Choriocapillaris Perfusion.

The choriocapillaris (CC) represents a fundamentally important vascular layer that is subject to physiologic changes with increasing age and that is also associated with a wide range of chorioretinal diseases. So far, information on blood flow in this specific layer has remained limited. With the advent of optical coherence tomography angiography (OCTA), new perspectives and possibilities of CC imaging have begun to evolve. This article shall review the opportunities and challenges of applying OCTA technology to the CC layer and summarize the current clinical efforts in OCTA CC imaging exemplarily in dry age-related macular degeneration and central serous chorioretinopathy.

Comparison of Choriocapillaris Flow Measurements between Two Optical Coherence Tomography Angiography Devices.

PURPOSE: To evaluate choriocapillaris (CC) perfusion in healthy subjects using 2 different optical coherence tomography angiography (OCT-A) devices. PROCEDURES: Macular OCT-A imaging (36 eyes of 36 subjects) was performed using Optovue AngioVue and Zeiss AngioPlex devices. CC decorrelation signal index was assessed, and CC data were analyzed regarding intra-device variability, inter-device correlation, age, signal strength, and fields of view. RESULTS: The intra-device variability of CC measurements in the 3 × 3 mm2 field was 5.3 and 2.6% (Angiovue and Angioplex, coefficients of variation; 6 × 6 mm2: 8.0 and 2.8%, respectively). Mean CC decorrelation signal index in 3 × 3 mm2 was 104.3 ± 6.7 (Angiovue) and 81.3 ± 9.2 (Angioplex) (6 × 6 mm2: 95.6 ± 8.1, 81.1 ± 6.5) with high correlation between both devices (3 × 3 mm2: p = 0.0053; 6 × 6 mm2: p = 0.0139). CC decorrelation signal index in 3 × 3 mm2 was significantly higher in subjects aged ≤58 years compared to subjects aged ≥59 years (Angiovue: 107.3 ± 3.6, 101.3 ± 7.7, p = 0.0156; Angioplex: 84.6 ± 7.6, 78.0 ± 9.5, p = 0.0371). Signal strength was 64.6 ± 8.9 (Angiovue) and 9.5 ± 0.8 (Angioplex). CONCLUSION: Both devices showed low intra-device variability and a high inter-device correlation. CC decorrelation signal index was negatively correlated with advancing age.

Exploring choriocapillaris under reticular pseudodrusen using OCT-Angiography.

PURPOSE: To evaluate if choriocapillaris (CC) vessel density and CC decorrelation signal index are compromised in eyes with reticular pseudodrusen (RPD) using optical coherence tomography angiography (OCT-A). METHODS: Decorrelation values in OCT-A CC images of 20 RPD patients were measured in the outer superior and the outer inferior sector of the EDTRS grid and compared to age-matched healthy controls. CC vessel density and CC decorrelation signal index were measured within a 30 µm and a 10 µm OCT-A CC slab. CC data were correlated to number of RPD lesions, predominantly present RPD stage, predominantly present RPD type, retinal area affected by RPD and choroidal thickness (CT). RESULTS: CC vessel density and CC decorrelation signal index decreased in correlation to advancing age in healthy subjects particularly in subjects older than 60 years (CC vessel density: 30 µm: p=0.0019; 10 µm: p=0.0014; CC decorrelation signal index: 30 µm: p=0.0005; 10 µm: p=0.0003). In the RPD group, CC vessel density (outer superior sector, 10 µm: 98.299) and CC decorrelation signal index (89.07) were significantly reduced compared to controls (99.203, p=0.0002; 98.09, p=0.0010). The number of RPD lesions was correlated to a reduced CC vessel density (30 µm: p=0.0355) but not to changes in CC decorrelation signal index. No correlations were found between CC parameters and either RPD stage, RPD type, size of RPD affected area or CT. CONCLUSIONS: OCT-A reveals a distinct reduction in CC vessel density and CC decorrelation signal index in eyes affected by RPD, which emphasizes the relevance of the CC layer in RPD pathogenesis.

Temporal retinal nerve fibre layer thinning in cluster headache patients detected by optical coherence tomography.

BACKGROUND: The exact pathophysiology of cluster headache (CH) is still not fully clarified. Various studies confirmed changes in ocular blood flow during CH attacks. Furthermore, vasoconstricting medication influences blood supply to the eye. We investigated the retina of CH patients for structural retinal alterations with optical coherence tomography (OCT), and how these changes correlate to headache characteristics, oxygen use and impaired visual function. METHODS: Spectral domain OCT of 107 CH patients - 67 episodic, 35 chronic, five former chronic sufferers - were compared to OCT from 65 healthy individuals. Visual function tests with Sloan charts and a substantial ophthalmologic examination were engaged. RESULTS: Reduction of temporal and temporal-inferior retinal nerve fibre layer (RNFL) thickness was found in both eyes for CH patients with a predominant thinning on the headache side in the temporal-inferior area. Chronic CH patients revealed thinning of the macula compared to episodic suffers and healthy individuals. Bilateral thinning of temporal RNFL was also found in users of 100% oxygen compared to non-users and healthy controls. Visual function did not differ between patients and controls. DISCUSSION: Our OCT findings show a systemic effect causing temporal retinal thinning in both eyes of CH patients possibly due to attack-inherent or medication-induced frequent bilateral vessel diameter changes. The temporal retina with its thinly myelinated parvo-cellular axons and its more susceptible vessels for the vasoconstricting influence of oxygen inhalation seems to be predisposed for tissue damage-causing processes related to CH.

MORPHOLOGY SCORE AS A MARKER OF RETINAL FUNCTION IN DRUSENOID PIGMENT EPITHELIAL DETACHMENT.

PURPOSE: To evaluate a morphology score for drusenoid pigment epithelial detachment (dPED) regarding predictability of a decline in retinal function beyond best-corrected visual acuity. METHODS: Thirteen eyes of 10 patients with dPED due to age-related macular degeneration (AMD) were included (age 72.8 ± 4.2 years). All underwent volume spectral domain optical coherence tomography, fluorescence angiography, and confocal scanning laser ophthalmoscopy infrared imaging as well as multifocal electroretinography and microperimetry. The dPED morphology score suggested consists of five parameters: hyperreflective spots in infrared, lesion diameter, lesion height, presence of vitelliform-like material in the subretinal space or subretinal fluid, and integrity of the ellipsoid zone in spectral domain optical coherence tomography. Subsequently, a score value between 0 and 1 according to the extent of morphologic changes was correlated to foveal multifocal electroretinography and microperimetry measurements. RESULTS: The mean best-corrected visual acuity was 20/40. The mean height and mean diameter of dPED were 312.2 ± 111 µm and 2,535 ± 805 µm. Two dPED showed no hyperreflective spots in confocal scanning laser ophthalmoscopy infrared images, three displayed a moderate stage of hyperreflective spots, and eight had severe hyperreflective spots. Two eyes showed subretinal fluid, and five patients showed vitelliform-like material in the subretinal space. Eight eyes revealed a severe disruption of the ellipsoid zone. Although no correlation was found between dPED morphology score and best-corrected visual acuity, eyes with a dPED morphology score >0.5 revealed distinctly decreased values in functional measurements compared with those with a score ≤0.5. CONCLUSION: The dPED morphology score aggregates all currently known morphologic changes in dPED and represents a valuable tool for clinical lesion evaluation. Furthermore, it allows for assessing an estimate of functional decline beyond best-corrected visual acuity.

Intravitreal dexamethasone implant [Ozurdex] for the treatment of nonarteritic anterior ischaemic optic neuropathy.

PURPOSE: To evaluate structural and functional outcomes of intravitreal dexamethasone implant (IDI) in three patients presenting with nonarteritic anterior ischaemic optic neuropathy. METHODS: IDI was administered once in three patients. Best-corrected visual acuity (BCVA), perimetry, volume spectral-domain optical coherence tomography scan of the optic disc (ODV), retinal nerve fibre layer (RNFL) scan and visually evoked potential (VEP) measurements were assessed at baseline and after one and 3 months. RESULTS: Mean BCVA was 20/100 in patient 1 (patient 2: 20/100; patient 3: 20/50) at baseline, 20/60 (patient 2: 20/400) at 1 month and 20/80 (20/400; 20/60) at 3 months. Mean deviation in perimetry developed from -4.90 dB (-22.09 dB; -8.68 dB) to -7.60 dB (-30.75 dB) and -14.23 dB (-30.59 dB; -7.17 dB). ODV and RNFL decreased during follow-up. VEP measurements showed a reduction in amplitudes during the entire observation period. CONCLUSIONS: All patients showed a reduction in papilla oedema over time. A functional improvement was not observed.

Quantification of retinal pigment epithelium tear area in age-related macular degeneration.

PURPOSE: To compare different quantification tools based on confocal scanning laser ophthalmoscopy for assessment of retinal pigment epithelium (RPE) tear area size. METHODS: Confocal scanning laser ophthalmoscopy fundus autofluorescence (FAF) and near-infrared reflectance (IR) images were retrospectively evaluated in 23 patients with RPE tear after intravitreal injection for pigment epithelium detachment due to exudative age-related macular degeneration at baseline and additionally in 11 patients after 5.1 ± 1.8 months of follow-up. Retinal pigment epithelium tear area was measured by three independent readers using three methods: manually on confocal scanning laser ophthalmoscopy FAF images, manually on confocal scanning laser ophthalmoscopy IR images, and using an FAF-based semiautomated software. RESULTS: Confidence intervals were 0.08 and 0.12 for FAF, 0.11 and 0.09 for FAF-based semiautomated software, and 0.25 and 0.27 for IR for intraobserver (Reader 1) and interobserver agreements (Readers 1 and 2), respectively. The average values of the square errors of the quantification methods were 0.040 ± 0.033 mm (FAF), 0.035 ± 0.060 mm (software), and 0.187 ± 0.219 mm (IR). Mean area of RPE tears at baseline given as the average measurement of all 3 readers using FAF-based semiautomated software was 5.77 ± 4.62 mm (range, 0.13-14.74 mm). Follow-up measurements of unilobular RPE tears (8 patients) showed no change in lesion area size (0.14 ± 0.33 mm); in contrast, multilobular RPE tears (3 patients) showed a progression in lesion area size of 1.80 ± 0.74 mm. CONCLUSION: Manual FAF-based and semiautomated FAF-based quantifications of RPE tear area are accurate and reproducible and superior to manual IR-based measurement. Retinal pigment epithelium tear area quantification is clinically relevant regarding further intravitreal treatment, particularly in multilobular RPE tears.

[Lens injury as a complication of intravitreal medication injection]. / Linsenverletzungen als Komplikation bei intravitrealer Medikamenteneingabe.

BACKGROUND: Intravitreal medication injections are an efficient and low-risk delivery technique for treating various retinal diseases. Rare serious complications include increased intraocular pressure, vitreous hemorrhage, retinal tears and detachment, intraocular inflammation and endophthalmitis. In the case series presented here, we report iatrogenic lens injuries caused by inadequate performance of intravitreal injections. METHODS: A multicenter data collection of patients treated with intravitreal injections with visible iatrogenic lens defects from 2016 to 2023 was retrospectively performed. RESULTS: Lens trauma after intravitreal injections was identified in six cases (69.3±6.5 years). While five cases were observed after anti-VEGF therapy, we identified lens injury after dexamethasone implantation in one patient. CONCLUSION: Iatrogenic lens injury during intravitreal injection is preventable with the correct injection technique. Knowledge of individual axis length and lens status also helps to avoid this complication.

Imaging the Area of Internal Limiting Membrane Peeling after Macular Hole Surgery.

Background: The aim of this study was to compare en-face optical coherence tomography (OCT) imaging and confocal scanning laser ophthalmoscopy (cSLO) imaging at different wavelengths to identify the internal limiting membrane (ILM) peeling area after primary surgery with vitrectomy and ILM peeling for macular hole (MH). Methods: In total, 50 eyes of 50 consecutive patients who underwent primary surgery with vitrectomy and ILM peeling for MH were studied. The true ILM rhexis based on intraoperative color fundus photography was compared to the presumed ILM rhexis identified by a blinded examiner using en-face OCT imaging and cSLO images at various wavelengths. To calculate the fraction of overlap (FoO), the common intersecting area and the total of both areas were measured. Results: The FoO for the measured areas was 0.93 ± 0.03 for en-face OCT, 0.76 ± 0.06 for blue reflectance (BR; 488 nm), 0.71 ± 0.09 for green reflectance (GR; 514 nm), 0.56 ± 0.07 for infrared reflectance (IR; 815 nm) and 0.73 ± 0.06 for multispectral (MS). The FoO in the en-face OCT group was significantly higher than in all other groups, whereas the FoO in the IR group was significantly lower compared to all other groups. No significant differences were observed in FoO among the MS, BR, and GR groups. In en-face OCT, there was no significant change in the ILM peeled area measured intraoperatively and postoperatively (8.37 ± 3.01 vs. 8.24 ± 2.81 mm2; p = 0.8145). Nasal-inferior foveal displacement was observed in 38 eyes (76%). Conclusions: En-face OCT imaging demonstrates reliable postoperative visualization of the ILM peeled area. Although the size of the ILM peeling remains stable after one month, our findings indicate a notable inferior-nasal shift of the overall ILM peeling area towards the optic disc.

[Iatrogenic retinal defects after intravitreal operative drug injections]. / Iatrogene Netzhautdefekte nach intravitrealer operativer Medikamenteneingabe.

BACKGROUND: Intravitreal operative drug injections represent one of the most frequently performed medical interventions. The risk profile is low. In addition to intraocular pressure elevation, the most frequent complications include exogenous endophthalmitis, vitreous hemorrhage and rhegmatogenous retinal detachment. Furthermore, isolated cases of lens injuries, macular holes associated with vitreoretinal traction and peripheral retinal defects have been described. In the present case series sharp iatrogenic macular and retinal defects are described. METHODS: Retrospective multicenter case collection of patients with iatrogenic retinal defects after intravitreal injections from 2016 to 2023. RESULTS: Iatrogenic retinal trauma after intravitreal injections for treatment of neovascular age-related macular degeneration was identified in 9 cases (72 years ± 8.1, 3 eyes pseudophakic). While sharp injuries within the macula occurred in six cases, extramacular lesions were detected in the other cases. CONCLUSION: Iatrogenic retinal and macular injuries are rare complications of intravitreal injections and when correctly carried out are preventable, especially with respect to use of cannulas and the choice of the distance from the limbus.

Old Problem in a New Guise: Retinal Pigment Epithelium Tear after Intravitreal Faricimab (Vabysmo®) Injection.

This case report describes a 78-year-old patient who developed a tear of the retinal pigment epithelium (RPE) during faricimab (Vabysmo®) therapy. After three consecutive intravitreal aflibercept (Eylea®) injections with persistent disease activity, therapy was switched to faricimab. The patient experienced a tear in the RPE 4 weeks postinjection. We report the first published case of RPE tear development after intravitreal faricimab injection in neovascular age-related macular degeneration. Faricimab has a new target structure in the angiopoietin-2 receptor in addition to VEGF. Patients at risk for RPE rupture were excluded from pivotal studies. Further investigation is needed to understand the effect of faricimab not only on visual acuity and intraretinal and subretinal fluid but also on mechanical stress on the RPE monolayer.

Subretinal drusenoid deposits associated with pigment epithelium detachment in age-related macular degeneration.

PURPOSE: To characterize retrospectively subretinal drusenoid deposits (SDD) in patients with pigment epithelium detachment (PED) secondary to age-related macular degeneration. METHODS: Confocal scanning laser ophthalmoscopy near-infrared reflectance images (820 nm) were recorded in 208 eyes of 104 patients with serous, drusenoid, or vascularized PED because of age-related macular degeneration in at least 1 eye. The digital images were evaluated by two independent readers with subsequent senior reader arbitration for prevalence of SDD. RESULTS: Serous PED was present in only two patients and was therefore not included in the statistical analysis. Subretinal drusenoid deposits were detected in 55 of 102 (53.9%) patients in at least 1 eye. Forty-six of those 55 patients showed SDD bilaterally (83.6%). Subretinal drusenoid deposits were present in 51 (50%) right eyes and 50 (49.0%) left eyes. One hundred and forty-six of 204 eyes showed a PED secondary to age-related macular degeneration of which 111 (76%) were vascularized and 35 (24%) drusenoid. Prevalence of SDD was correlated with age (P < 0.0001) and female gender (P = 0.014), but not with the type of PED (P = 0.174). Cohen kappa statistics showed good interobserver agreement for infrared imaging (0.78 for right eyes, 0.74 for left eyes). CONCLUSION: Subretinal drusenoid deposits represent a common phenotypic characteristic in eyes with PED because of age-related macular degeneration . As described in previous studies, SDD are readily identified using confocal scanning laser ophthalmoscopy imaging technology. Future studies should pursue the pathophysiologic role and the predictive value of the presence of SDD in the development of PED and a subsequent rip of the retinal pigment epithelium.