Short-term results of switchback from aflibercept to ranibizumab in neovascular age-related macular degeneration in clinical practice.

PURPOSE: This work was undertaken to analyze the efficacy of switchback from aflibercept to ranibizumab in patients with neovascular age-related macular degeneration (nAMD) who had previously switched from ranibizumab to aflibercept. METHODS: This retrospective double-center study included 45 patients with nAMD who were previously treated with ranibizumab, then aflibercept, and then ranibizumab again, regardless of the number of intravitreal injections received. The primary outcome was change in best-corrected visual acuity (BCVA) measured on the Early Treatment Diabetic Retinopathy Study ETDRS chart before (T0) and after (T1) the switch, and 3 months after the switchback (T2). Secondary outcomes included changes in central foveal thickness (CFT) measured at T0, T1, and T2, as analyzed on spectral-domain optical coherence tomography (SD-OCT), and the percentage of patients gaining five letters or better. RESULTS: Forty-seven eyes of 45 patients were switched back from aflibercept to ranibizumab. The mean BCVA was 67.4 ± 13.4 at T0, 66.7 ± 14.4 at T1, and 68.2 ± 13.9 at T2. BCVA was significantly improved between T1 and T2 (p = 0.0230), but not between T0 and T1 (p = 0.5153) or between T0 and T2 (p = 0.4248). The mean CFT decreased from 317.8 µm ± 89.6 at T0 to 306.9 µm ±68.0 at T1, and to 291.2 µm ± 76.6 at T2. The decrease in CFT was not statistically significant between either T0 and T1 or T1 and T2, but was significant between T0 and T2, when compared before switch and after switchback (p = 0.0027). However, when considering eyes that received three or more consecutive intravitreal injections of aflibercept before switchback, the statistical significance between T1 and T2 was lost, although a trend towards significance remained (p = 0.06). Thirteen eyes (27.7 %) gained five letters or more (range, 5-15 letters) after switchback. CONCLUSIONS: A short-term benefit of switchback from one anti-VEGF agent to another was observed in patients with nAMD who had shown no benefit from the initial switch.

The Pattern of Recurrence in Diabetic Macular Edema Treated by Dexamethasone Implant: The PREDIAMEX Study.

PURPOSE: To assess the time to functional and anatomic recurrence of macular edema (ME) after a first intravitreal dexamethasone implant in eyes with diabetic macular edema (DME). DESIGN: A 6-month observational, prospective, uncontrolled, multicenter, national case series. PARTICIPANTS: Thirty-seven patients included between January 2015 and June 2016. METHODS: Patients were monitored at baseline and then monthly over 6 months after the first treatment. MAIN OUTCOME MEASURES: Different patterns of recurrence were defined: qualitative and quantitative anatomic recurrences and functional recurrence. RESULTS: Median ME duration before the first dexamethasone implant was 2.04 months. All patients received a dexamethasone implant for the first time, but 73% of patients had not undergone any form of treatment previously. The mean time from baseline to qualitative anatomic, quantitative anatomic, and functional recurrence was 4.22 months (95% confidence interval [CI], 3.80-4.65 months), 4.73 months (95% CI, 4.34-5.12 months), and 4.89 months (95% CI, 4.53-5.26 months), respectively. Almost all patients (7/8) who demonstrated a qualitative anatomic recurrence showed a subsequent quantitative anatomic and functional recurrence days later. Mean improvement in best-corrected visual acuity was 10.1 letters (95% CI, 6.7-13.4 letters) and 7.3 letters (95% CI, 4.1-10.6 letters) at months 2 and 6, respectively. The mean reduction in central subfield macular thickness was 206 µm (95% CI, 157-255 µm) and 146 µm (95% CI, 98-195 µm) at months 2 and 6, respectively. CONCLUSIONS: Dexamethasone implant is a functionally and anatomically effective treatment for DME in real-life practice. Qualitative anatomic recurrence seems to be an early sign of quantitative anatomic and functional recurrence. Further studies should demonstrate if early retreatment at the qualitative anatomic recurrence stage could better protect patient visual function.

EN FACE OPTICAL COHERENCE TOMOGRAPHY (OCT) AND OCT ANGIOGRAPHY FINDINGS IN RETINAL ASTROCYTIC HAMARTOMAS.

PURPOSE: To report spectral-domain optical coherence tomography, en face optical coherence tomography (OCT), and optical coherence tomography angiography findings in retinal astrocytic hamartomas. METHODS: Four cases of retinal astrocytic hamartomas, with small white or yellowish typical retinal mass, were imaged with fundus photography, intravenous fluorescein angiography, fundus autofluorescence, spectral-domain OCT, en face OCT, and OCT angiography. RESULTS: The tumor was solitary in all cases and involved the posterior pole. It was idiopathic in three cases and was related to tuberous sclerosis complex in one case. The OCT findings included intralesional lucencies in two cases with no exudation. The tumor was within the retinal nerve fiber layer or deeper, usually overlying the inner plexiform layer providing a protusion in the vitreous cavity. Vitreous changes were present in all cases, corresponding to thickening and adhesion of the vitreous facing the lesion (two cases), apparent interdigitation with vitreous (one case), and marked condensation of the vitreous with interdigitations (one case). En face OCT imaging at the level of the retinal pigment epithelial zone showed a hyporeflective, round, well-delineated mass. A peripheral poorly defined hyperreflectivity with a central hyporeflectivity was observed at the level of mid-retina, likely because of shadowing effect. The OCT-A reveals a dense vascular network within the tumor. CONCLUSION: Retinal astrocytic hamartomas may be well characterized by non-invasive imaging using spectral-domain OCT, en face OCT, and OCT angiography. The OCT angiography seemed to show tumor vascularity, which may represent dilated disorganized and anastomotic superficial and deep plexus capillaries. The tumor is often unique, peripapillary, small in diameter, and dome-shaped on spectral-domain OCT protruding into the vitreous cavity, responsible for vitreous changes facing the lesion.

Ocular Toxocariasis: Clinical Features and Long-term Visual Outcomes in Adult Patients.

PURPOSE: To investigate clinical characteristics and treatment outcomes of proven ocular toxocariasis (OT) in adult patients. DESIGN: Retrospective, consecutive, interventional case series. METHODS: setting: Institutional. STUDY POPULATION: Consecutive OT patients with positive serum serology and positive western blot (WB) on ocular sample. OBSERVATION PROCEDURES: Clinical features, optical coherence tomography (OCT), and treatment outcomes. MAIN OUTCOME MEASURES: Best-corrected visual acuity (BCVA) and OCT central foveal thickness (CFT). RESULTS: Fourteen patients were included between 2011 and 2013. Mean age at diagnosis was 45.6 years. Mean duration between the first symptoms and diagnosis was 15.1 months. Uveitis was unilateral in all cases and all patients displayed vitreous inflammation. The main baseline findings were presence of ≥1 peripheral granulomas (57.1%), vasculitis (57.1%), vitreoretinal traction (57.1%), and chronic macular edema (ME) (71.4%). Delayed diagnosis (>8 months) seemed to be associated with higher rate of ME. All patients received albendazole. Systemic (n = 5) and/or local corticosteroids (CS) (n = 7) were administered in case of ME and/or posterior segment inflammation. Vitrectomy was performed when vitreous inflammation was severe and persistent despite CS or in case of threatening traction or visually significant epimacular membrane (28.6%). Overall, this regimen allowed significant decrease of CFT (P = .01). In the vitrectomy subgroup, mean BCVA increased (P = .01) and CFT decreased (P = .017). CONCLUSION: While some features such as granuloma are typical signs of OT, atypical features can delay the diagnosis. In doubtful situations, WB on ocular samples seems to be more specific than serum antibodies alone. ME seems to be a common complication of longstanding OT in the adult.