The prognostic value of peripheral retinal nonperfusion in diabetic retinopathy using ultra-widefield fluorescein angiography.

PURPOSE: To investigate the prognostic value of peripheral retinal nonperfusion in patients with diabetic retinopathy using ultra-widefield fluorescein angiography (UWFA). METHODS: A cross-sectional study included 78 treatment-naïve eyes with nonproliferative and proliferative diabetic retinopathy (NPDR and PDR). Eyes were divided into three groups: mild/moderate NPDR (n = 31), severe NPDR (n = 31), and PDR (n = 16). Three nonperfusion variables were calculated reflecting the proportion of nonperfused to visible retina based on initial UWFA: central nonperfusion (CNP) index, peripheral nonperfusion (PNP) index, and PNP ratio. The relationships between these indices and central subfield thickness (CST) and spectacle-corrected visual acuity (SCVA) were evaluated. RESULTS: CNP and PNP indices were significantly higher in the PDR group vs. mild/moderate NPDR group (p = 0.007 and 0.008, respectively) but not in the PDR group vs. severe NPDR group (p = 0.149 and p = 0.535, respectively). A significant linear correlation was found between the CNP and PNP indices in both severe NPDR and PDR groups (R2 = 0.141, p = 0.041, and R2 = 0.311, p = 0.025, respectively). Nonperfusion predominance was not statistically correlated with the presence of macular edema (p = 0.058) or disorganization of retinal inner layers (p = 1). In the severe NPDR group, there was a moderately positive correlation between CNP index and CST (rs = 0.496, p = 0.019) and no correlation between CNP index and SCVA when controlling for CST (p = 0.160). In the PDR group, a strong negative correlation between PNP ratio and CST was found (rs = -0.659, p = 0.014), but no correlation was observed between CNP index, CST, and SCVA. In the PDR group, a positive correlation was found between PNP index, PNP ratio, and SCVA (rs = 0.549, p = 0.027, and rs = 0.626, p = 0.010, respectively), even after controlling for CST (rs = 0.599, p = 0.040). CONCLUSIONS: Higher amounts of retinal nonperfusion are seen in patients with more severe retinopathy. Increased CNP is associated with macular thickening and subsequent vision loss. Having predominantly PNP was independently associated with worse VA, regardless of macular thickness. Further studies are needed to investigate the role of PNP in vision loss in diabetic retinopathy.

Comparison of color fundus photographs and fundus autofluorescence images in measuring geographic atrophy area.

PURPOSE: To assess the agreement between color fundus photographs (CFP) and fundus autofluorescence (FAF) images when measuring geographic atrophy (GA) area and reproducibility of measurements between graders. Frequency and disagreement types were also determined. METHODS: Eyes with GA secondary to age-related macular degeneration had CFP and FAF imaging on the same day. Seventy-two eyes from 72 patients were included in the analysis. Three graders calculated GA area using digital imaging software. Main outcome measures included agreement between graders for GA area on both FAF and CFP and agreement between both imaging modalities. RESULTS: The intraclass correlation for the 3 graders for FAF images was 0.99 (95% confidence interval, 0.98-0.99). For CFP, it was 0.96 (95% confidence interval, 0.94-0.97). The intraclass correlation between imaging modalities for Graders 1, 2, and 3 were 0.93, 0.85, and 0.87, respectively. Sensitivities to detect involvement of fovea (CFP, 86-97%; FAF, 72-93%) and specificities to detect sparing of fovea (CFP, 74-76%; FAF, 59-88%) overlapped between imaging modalities. CONCLUSION: Both CFP and FAF imaging are reliable for measuring GA area. Interobserver agreement was slightly higher for FAF images. Although the high agreement between modalities suggests that either would be appropriate for measuring GA area, using both may be the best approach for following GA progression.

Use of fundus autofluorescence images to predict geographic atrophy progression.

PURPOSE: Fundus autofluorescence imaging has been shown to be helpful in predicting progression of geographic atrophy (GA) secondary to age-related macular degeneration. We assess the ability of fundus autofluorescence imaging to predict rate of GA progression using a simple categorical scheme. METHODS: Subjects with GA secondary to age-related macular degeneration with fundus autofluorescence imaging acquired at least 12 months apart were included. Rim area focal hyperautofluorescence was defined as percentage of the 500-µm-wide margin bordering the GA that contained increased autofluorescence. Rim area focal hyperautofluorescence on baseline fundus autofluorescence images was assessed and categorized depending on the extent of rim area focal hyperautofluorescence (Category 1: ≤33%; Category 2: between 33 and 67%; Category 3: ≥67%). Total GA areas at baseline and follow-up were measured to calculate change in GA progression. RESULTS: Forty-five eyes of 45 subjects were included; average duration of follow-up was 18.5 months. Median growth rates differed among categories of baseline rim area focal hyperautofluorescence (P = 0.01 among Categories 1, 2, and 3; P = 0.008 for Category 1 compared with Category 3, Jonckheere-Terpstra test). CONCLUSION: A simple categorical scheme that stratifies the amount of increased autofluorescence in the 500-µm margin bordering GA may be used to differentiate faster and slower progressors.

HLA-A29 negative Birdshot-like chorioretinopathy associated with common variable immunodeficiency.

PURPOSE: To report the longest ophthalmic follow-up and the associated ocular complications of HLA-A29 negative Birdshot-like chorioretinopathy (BLCR) associated with common variable immunodeficiency (CVID). OBSERVATIONS: A 22-year-old man known for CVID presented with a 3-month history of decreased visual acuity OS. Funduscopy revealed significant cystoid macular edema OS, as well as optic disk edema and chorioretinal infiltrates without signs of vitritis OU. No infectious, inflammatory or neoplastic etiologies were identified. He subsequently received one dose of intravitreal triamcinolone OS which completely resolved the macular edema. The optic nerve edema persisted despite the addition of intravenous immunoglobulin. His visual acuity was 20/20 OU at the 24th follow-up month. CONCLUSION: and importance: To our knowledge, this is the third case of HLA-A29 negative BLCR associated with CVID. It is the first case with long-term follow-up providing, in consequence, the best understanding of the natural history and possible complications of this rare disease. Aggressive systemic treatment, in collaboration with an immunologist, is generally needed to control the ophthalmic complications.

Anterior infectious necrotizing scleritis secondary to Pseudomonas aeruginosa infection following intravitreal ranibizumab injection.

PURPOSE: To report the occurrence and management of severe infectious scleritis in a 75 year-old woman following intravitreal ranibizumab injection. OBSERVATIONS: A 75 year-old monocular woman receiving monthly intravitreal ranibizumab injection for wet age related macular degeneration in the left eye presented with severe dull pain, decreased vision, and scleral melt with discharge 2 weeks after her last injection. The dilated fundus exam was devoid of vitritis. The patient was admitted to our hospital for both diagnostic and therapeutic purposes. She was initially started on aggressive oral and topical antibiotics, but showed no significant improvement. The scleral cultures were positive for Pseudomonas aeruginosa. In view of the aggressive nature of her infection, intravenous antibiotics were added to the treatment regimen. The patient recovered her baseline visual function after two weeks of intravenous, oral and, topical antibiotics. CONCLUSIONS AND IMPORTANCE: To our knowledge, this is the first case of anterior infectious necrotizing scleritis secondary to Pseudomonas aeruginosa infection following intravitreal ranibizumab injection. Clinicians performing intravitreal injections should have a high index of suspicion for iatrogenic infections including scleritis and endophthalmitis, as these infections require aggressive topical and systemic antibiotics as well as possible hospitalization.

Analysis of macular volume in normal and glaucomatous eyes using optical coherence tomography.

PURPOSE: To evaluate macular volume in normal and glaucomatous eyes using optical coherence tomography (OCT). DESIGN: Case control study. METHOD: The authors assessed 272 eyes of 164 subjects as part of an institutional study at New England Eye Center in Boston, Massachusetts; 202 eyes were in the study group and 70 eyes in the control group. Eyes were categorized as normal (70 eyes of 43 subjects), glaucoma suspect (70 eyes of 44 subjects), early glaucoma (70 eyes of 47 subjects), or advanced glaucoma (62 eyes of 43 subjects). Subjects underwent analysis with the commercially available OCT1 unit. Optical coherence tomography macular neurosensory retinal thickness maps were used to calculate macular volume for comparison to Humphrey visual field testing, intraocular pressure measurement, and stereo biomicroscopy of the optic nerve head and nerve fiber layer. RESULTS: Using repeated measures regression, macular volume in normal (2.37 +/- 0.11 mm(3)) glaucoma suspect (2.33 +/- 0.16 mm(3)), and early glaucoma eyes (2.27 +/- 0.13 mm(3)) was significantly greater than in eyes with advanced glaucoma (2.12 +/- 0.23 mm(3), P =.0001, P =.0001, and P =.0008, respectively). Macular volume in normal eyes was significantly greater than in early glaucoma eyes (P =.01). CONCLUSIONS: Optical coherence tomography retinal macular volume correlates with known structural defects of glaucoma, providing a potential objective and quantitative parameter for evaluation. Our data show a significant difference in macular volume between normal, glaucoma suspect, and early glaucoma eyes, compared with advanced glaucomatous eyes as well as between normal and early glaucomatous eyes. This correlates with a trend of decreasing macular volume in eyes with more advanced disease.

Choroidal melanoma: clinical presentation and differential diagnosis.

Choroidal melanoma represents a diagnostic challenge in ophthalmology owing to the varied presenting symptoms and signs coupled with a wide variety of masquerading lesions. In this article the authors review the clinical presentation and differential diagnosis of this malignant neoplasm.