Anti-Vascular Endothelial Growth Factor Treatment in Diabetic Macular Edema-Results from a Large Single Center Cohort with Bevacizumab As First-Line Therapy.

PURPOSE: To explore visual acuity (VA) outcomes of anti-vascular endothelial growth factor (VEGF) intravitreal injections in treatment-naive eyes with diabetic macular edema (DME), with bevacizumab as first-line treatment. METHODS: Retrospective single-center cohort study over a three-year follow-up. 1765 eyes from 1179 patients treated with intravitreal injections were evaluated. The cohort was divided according to the treatment given: (1) bevacizumab monotherapy, (2) eyes switched to 2nd line agent, and (3) eyes switched to a 3rd line agent. RESULTS: 644 eyes of 444 patients met inclusion criteria. Mean age at presentation was 64.0±11.1 years. Mean follow-up period was 24.6±12.4 months. 67.1% of eyes were treated with bevacizumab monotherapy, 25.45% switched to a 2nd line agent, and 7.45% were switched to a 3rd line agent. Mean number of injections decreased significantly during each treatment year in the total cohort and within each treatment group (P<0.001). Mean VA for the total cohort and within each treatment group improved significantly throughout follow-up (P<0.001). No significant difference in VA found between the groups (P=0.373). CONCLUSIONS: This real-world study demonstrates robust and consistent VA gains over long-term follow-up in eyes with DME treated with either bevacizumab monotherapy or switching to alternative anti-VEGF agents in cases of suboptimal response.

Future perspectives for treating patients with geographic atrophy.

PURPOSE: Geographic atrophy (GA) is a late-stage form of age-related macular degeneration (AMD) characterized by the expansion of atrophic lesions in the outer retina. There are currently no approved pharmacological treatments to prevent or slow the progression of GA. This review describes the progression and assessment of GA, predictive imaging features, and complement-targeting investigational drugs for GA. METHODS: A literature search on GA was conducted. RESULTS: Expansion of atrophic lesions in patients with GA is associated with a decline in several measures of visual function. GA lesion size has been moderately associated with measures obtained through microperimetry, whereas GA lesion size in the 1-mm diameter area centered on the fovea has been associated with visual acuity. Optical coherence tomography (OCT) can provide 3-dimensional quantitative assessment of atrophy and is useful for identifying early atrophy in GA. Features that have been found to predict the development of GA include certain drusen characteristics and pigmentary abnormalities. Specific OCT features, including hyper-reflective foci and OCT-reflective drusen substructures, have been associated with AMD disease progression. Lesion characteristics, including focality, regularity of shape, location, and perilesional fundus autofluorescence patterns, have been identified as predictors of faster GA lesion growth. Certain investigational complement-targeting drugs have shown efficacy in slowing the progression of GA. CONCLUSION: GA is a progressive disease associated with irreversible vision loss. Therefore, the lack of treatment options presents a significant unmet need. OCT and drugs under investigation for GA are promising future tools for disease management.

Postponed care due to COVID-19 lockdown impact on visual acuity of retinal vein occlusion patients: a large cohort.

PURPOSE: To evaluate the impact of postponed care attributed to coronavirus disease (COVID-19) pandemic lockdowns on visual acuity and the number of anti-VEGF injections in patients with retinal vein occlusion (RVO). METHODS: A multicenter, retrospective study of consecutive RVO patients previously treated with anti-VEGF injections, which compared data from pre- (2019) and during (2020) COVID-19 lockdown period. RESULTS: A total of 814 RVO patients with a mean age of 72.8 years met the inclusion criteria. Of them, 439 patients were assessed in 2019 and 375 in 2020. There was no significant difference between the COVID-19 and pre-COVID-19 period in terms of baseline and final BCVA (p = 0.7 and 0.9 respectively), but there was a significantly reduced mean number of anti-VEGF injections during the COVID-19 period (5.0 and. 5.9 respectively, p < 0.01), with a constant lower ratio of injections per patient. A noticeable decline was found during March-May (p < 0.01) in 2020. Baseline BCVA (0.69, p < 0.01) and the number of injections (- 0.01, p = 0.01) were predictors of final BCVA. CONCLUSIONS: In a large cohort of RVO patients, during 2020 lockdowns imposed due to the COVID-19 pandemic, a significant reduction in the annual number of anti-VEGF injections was noted. The postponed care did not result in a significant impact on the final BCVA. Baseline BCVA and the number of annual injections serve as predictors for final BCVA in RVO patients.

Functional and anatomical outcomes of fovea on, fovea off and fovea-splitting rhegmatogenous retinal detachment.

PURPOSE: To compare the anatomical and functional outcomes of fovea-on, fovea-off, and fovea-split rhegmatogenous retinal detachment (RRD). METHODS: Retrospective case series of consecutive patients diagnosed with RRD and treated with only pars plana vitrectomy (PPV). Preoperative and postoperative optical coherence tomography (OCT) and functional outcomes were obtained prior to and 6 months after surgery. RRD extending to the edge of the fovea on OCT was termed fovea-split RRD. RESULTS: A total of 152 eyes were included, out of which 89 eyes presented with a fovea-off, 36 with a fovea-on, and 27 with a fovea-split RRD. The mean visual acuity (VA) preoperatively was 1.32 ± 0.58 logMAR (20/400 equivalent on Snellen chart), 0.19 ± 0.20 (20/30), and 0.71 ± 0.56 (20/100) for the fovea-off, fovea-on, and fovea-split groups, respectively (p < 0.001). The mean VA at 6 months of follow-up significantly improved for the fovea-split and fovea-off groups to 0.54 ± 0.79 (20/70) (p < 0.001) and 0.45 ± 0.29 (20/50) (p = 0.01), respectively, and remained stable for the fovea-on group 0.24 ± 0.20 (20/30) (p = 0.25). Differences in alterations of the outer retinal layers (p < 0.001) and in the in-segment/outer-segment ratio (p < 0.001) were found between the groups. CONCLUSION: Eyes with fovea-split RRD had both a preoperative and a final postoperative VA between those of fovea-on and fovea-off eyes and different anatomical changes on OCT. This new entity warrants different patient expectations for postoperative outcomes.

COVID-19 Pandemic Lockdowns' Impact on Visual Acuity of Diabetic Macular Edema: A Large Cohort.

INTRODUCTION: The objective of this study was to evaluate the impact of unplanned treatment gap, secondary to COVID-19 pandemic lockdowns, on visual acuity in previously treated diabetic macular edema (DME) patients. METHODS: A multicenter, retrospective study of DME patients, previously treated with anti-VEGF injections, who were followed up during COVID-19 pandemic (2020) compared to pre-CO-VID-19 period (2019). RESULTS: A total of 634 DME patients with a mean age of 68.4 years met the inclusion criteria, 385 were assessed in 2019 (pre-COVID-19) and 239 patients assessed in 2020 (COVID-19). Baseline best corrected visual acuity (BCVA) among patients in 2019 and 2020 was 0.52 ± 0.44, 0.45 ± 0.43 (logarithm of the minimal angle of resolution, respectively). There was no significant difference between the years 2020 and 2019 in baseline BCVA (p = 0.07). Mean number of anti-VEGF injections was significantly lower (5 vs. 6, p < 0.01), with a major lower ratio of injections per patient in the COVID-19 first lockdown period (March-June 2020) in the COVID-19 group. Baseline BCVA (p < 0.01) was the only significant predictor of final BCVA. Number of injections, age, gender, and the year were not found as predictors of final BCVA. CONCLUSIONS: In a large cohort of DME patients, an unplanned delay in treatment with anti-VEGF injections for 2-3 months, due to COVID-19 pandemic lockdown, had no significance impact on visual acuity. For most patients, returning to routine treatment regimen was sufficient for maintaining BCVA.

ASSOCIATION OF CHOROIDAL THICKNESS WITH RHEGMATOGENOUS RETINAL DETACHMENT REPAIR.

PURPOSE: To compare the choroidal thickness before and after pars plana vitrectomy for rhegmatogenous retinal detachment repair. METHODS: A retrospective case series of rhegmatogenous retinal detachment patients presenting between January 2015 and September 2020. Subfoveal choroidal thickness (SFCT) and anatomical success were measured in operated eyes and fellow eyes at presentation, as well as 3 months and 6 months after pars plana vitrectomy for rhegmatogenous retinal detachment repair. RESULTS: A total of 93 patients (males 59%) with a mean age of 61.8 ± 15.2 years were included. Eighty-one patients were anatomically successful (Group 1) and 12 redetached (Group 2). The mean SFCT of the operated eye at presentation was 258.3 ± 82.0 µm in comparison with 257.5 ± 83.7 µm in the fellow eye (P = 0.96). Group 2 presented with thicker SFCT than Group 1 at baseline (309.2 ± 56.2 vs. 250.7 ± 82.8 µm; P = 0.01). Both groups demonstrated thinning trend throughout follow-up. At 6-month follow-up, the mean SFCT was 225.6 ± 75.5 µm (P = 0.05). Fellow-eye SFCT was stable throughout follow-up (257 ± 83.7 at baseline vs. 255 ± 80.2 µm at 6 months). CONCLUSION: Eyes with rhegmatogenous retinal detachment demonstrated thinning in the SFCT after vitrectomy surgery. Eyes with recurrent retinal detachment presented with a thicker choroid at baseline. Thicker SFCT at presentation may play a role in retinal redetachment.

IMPACT OF COVID-19 PANDEMIC LOCKDOWNS ON VISUAL ACUITY OF PATIENTS WITH NEOVASCULAR AMD: A Large Cohort.

PURPOSE: Evaluating the impact of delayed care, secondary to coronavirus disease 2019 (COVID-19) pandemic lockdowns, on visual acuity in previously treated neovascular age-related macular degeneration (nAMD) patients. METHODS: This was a multicenter, retrospective, study of patients with nAMD previously treated with anti-VEGF injections who were followed up during 2019 (pre-COVID-19) and compared with patients with nAMD during 2020 (COVID-19). RESULTS: A total of 1,192 patients with nAMD with a mean age of 81.5 years met the inclusion criteria. Of these, 850 patients were assessed in 2019 (pre-COVID-19) and 630 patients were assessed in 2020 (COVID-19). Three hundred eight patients were assessed through both 2019 and 2020 and thus were included in both cohorts. There was no significant difference between 2020 and 2019 in baseline and change in best-corrected visual acuity (BCVA; P = 0.342 and P = 0.911, respectively). The mean number of anti-VEGF injections was significantly lower (5.55 vs. 6.13, P < 0.01), with constant lower ratio of injections per patient in the COVID-19 period. Baseline BCVA (0.859, P < 0.01), number of injections (-0.006, P = 0.01), and age (0.003, P < 0.01) were predictors of final BCVA. CONCLUSION: In patients with nAMD, delayed care secondary to COVID-19 pandemic lockdowns has no statistically significant impact on BCVA. Best-corrected visual acuity, older age, and lower number of yearly anti-VEGF injections are predictors for decrease BCVA.

CHANGE IN CHORIOCAPILLARIS FLOW DEFICITS WITHIN TEARS OF THE RETINAL PIGMENT EPITHELIUM IMAGED WITH SWEPT-SOURCE OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY.

PURPOSE: Choriocapillaris (CC) flow deficits (FDs) were measured in the areas exposed by tears of the retinal pigment epithelium (RPE) before and after their onset to determine their change over time. METHODS: Patients enrolled in a prospective, swept-source optical coherence tomography angiography (SS-OCTA) study were retrospectively reviewed for RPE tears, and scans were evaluated before and after RPE tear formation. Choriocapillaris flow deficits were measured within the bed of the tear and within a symmetric control region. RESULTS: Three patients with RPE tears were imaged before tear formation and for at least 16 months afterward. When the baseline and first posttear visit were compared, CC FDs decreased by 1.0% in the tear region and 1.7% in the control region ( P = 0.84). When the 16-month follow-up visits were compared with the first post-RPE tear visits, CC FDs decreased by 1.9% in tear regions and increased by 1.3% in control regions ( P = 0.37). CONCLUSION: No significant changes in CC FDs were observed before and after RPE tear formation and for 16 months afterward, suggesting that CC FDs can be reliably detected in the presence of an intact RPE and the absence of the RPE did not affect CC perfusion for at least 16 months.

SWEPT-SOURCE OPTICAL COHERENCE TOMOGRAPHY DETECTION OF BRUCH MEMBRANE AND CHORIOCAPILLARIS ABNORMALITIES IN SORSBY MACULAR DYSTROPHY.

PURPOSE: Swept-source optical coherence tomography angiography (SS-OCTA) was used to analyze Bruch membrane (BM) and choriocapillaris (CC) abnormalities in undiagnosed family members with Sorsby macular dystrophy (SMD). METHODS: In a family with SMD ( TIMP3 Tyr191Cys), SS-OCTA imaging was performed using the 6 × 6 mm scan patter and previously validated algorithms to detect abnormalities in BM and the CC, as well as the presence of reticular pseudodrusen and macular neovascularization. Genetic analyses were performed for TIMP3 mutations. RESULTS: Of eight family members, two were previously diagnosed with SMD and six were asymptomatic. SS-OCTA imaging of the 33-year-old proband revealed type 1 macular neovascularization in the left eye and bilateral reticular pseudodrusen, thickening of BM, CC thinning, and increases in CC flow deficits. A TIMP3 mutation was confirmed. His niece, despite having no clinical evidence of SMD, showed BM thickening and CC thinning on SS-OCTA. A TIMP3 mutation was confirmed. The proband's younger nephew and niece also carried the TIMP3 mutation without clinical evidence of SMD. Two additional members had normal examinations, unremarkable SS-OCTA findings, and no TIMP3 mutation. CONCLUSION: Swept-source optical coherence tomography angiography imaging can detect BM and CC abnormalities in vivo in subjects unaware of their TIMP3 status in a family with SMD.

A NOVEL FINDING OF HYPERREFLECTIVE MATERIAL IN THE SILICONE-RETINA INTERFACE: An Optical Coherence Tomographic and Histopathological Study.

PURPOSE: To describe novel findings of hyperreflective material in the silicone-retina interphase on spectral domain optical coherence tomography (SD-OCT) imaging in eyes with silicone oil tamponade. METHODS: Retrospective observational clinical study of consecutive patients who underwent primary pars plana vitrectomy with silicone oil tamponade for rhegmatogenous retinal detachment. Repeat clinical examination and spectral domain optical coherence tomography macular imaging performed 3 months after surgery were evaluated to identify any macular pathologies, including formation of epiretinal membranes, intraretinal changes, subretinal fluid, and edema before scheduled secondary vitrectomy for silicone oil removal. RESULTS: Eighty-two patients (mean age 54 years, range 22-89) were included. Twelve eyes (14%) showed discrete preretinal hyperreflective organized coarse material in the silicone-retina interphase on spectral domain optical coherence tomography. The material was scattered in the posterior pole, with several foci showing additional hyperreflectivity of the inner retinal layers beneath. These findings did not resemble silicone oil emulsification in size, shape, or reflectivity. CONCLUSION: This is the first report on hyperreflective material detected by spectral domain optical coherence tomography in the silicone-retina interphase in eyes with silicone oil tamponade. These findings may represent an inflammatory response to silicone oil exposure that may be the initial manifestation of a future proliferative process, warranting a rigorous follow-up protocol for affected patients.

Noninfectious Inflammatory Response following Intravitreal Bevacizumab Injections: Description of a Cluster of Cases in Two Centers and a Review of the Literature.

PURPOSE: To report a cluster of high incidence of noninfectious inflammatory reaction shortly after bevacizumab injection. METHODS: Data were collected from medical records of consecutive patients who underwent bevacizumab injections and presented with acute uveitis within 1-4 days. RESULTS: All 7 patients were injected intravitreally with bevacizumab from different batches and presented with visual deterioration. One patient with anterior uveitis complained of pain. None had hypopyon. Three patients with vitritis underwent a vitreous tap with an intravitreal injection of vancomycin and ceftazidime for possible infectious endophthalmitis. All patients received intensive topical antibiotic drops and steroids, and the intraocular inflammation resolved completely within 1 month. Five patients continued to receive bevacizumab injections without recurrent episodes. CONCLUSIONS: Our series demonstrates an incidence of noninfectious inflammatory reaction shortly after bevacizumab injection that is higher than that reported in the literature. The cause is more likely the preparation process in the same compounding pharmacy.

Topical 0.03% tacrolimus for subepithelial infiltrates secondary to adenoviral keratoconjunctivitis.

OBJECTIVE: To determine the safety and efficacy of topical 0.03% tacrolimus ointment treatment for subepithelial corneal infiltrates (SEIs). METHODS: This prospective non-controlled interventional case series included patients with SEIs who had been previously treated with topical corticosteroids with either no improvement or the medication being withdrawn due to associated intraocular pressure (IOP) elevation. The patients were treated with 0.03% tacrolimus ointment twice daily for 22 weeks (including a 1-month washout). The objective data were best-corrected Snellen visual acuity (BCVA), IOP, and full ocular examination results, including SEI severity and the Schirmer test. The subjective data were the patients' responses to a questionnaire at all follow-up visits. RESULTS: The patients consisted of five males (45%) and six females (55%) (mean age 50 ± 11 years) who were followed up for an average of 22 weeks. The mean BCVA (logarithm of the minimum angle of resolution [logMAR]) before and after treatment was 0.34 ± 0.09 and 0.08 ± 0.04 respectively (p = 0.042). All the patients evidenced significant objective clinical improvement, and none had a severe degree of SEI at the end of the treatment. The patients reported considerable reduction in the severity of their symptoms (foreign body sensation, glare, etc.). Three patients were excluded due to side-effects (one had severe dizziness and discomfort), and their data were excluded from the study. CONCLUSION: Topical tacrolimus 0.03% is a safe and effective alternative treatment in patients with SEIs who do not respond to other treatment modalities or have untoward side-effects from topical steroids.

Treatment patterns and visual acuity change of AMD patients, before, during and after the COVID-19 pandemic lockdowns: A large cohort.

PURPOSE: To evaluate the impact of the changes in treatment patterns before, during and after the COVID-19 pandemic on best-corrected visual acuity (BCVA) in previously treated neovascular age-related macular degeneration (nAMD) patients. METHODS: A multi-centre, retrospective, observational study of consecutive nAMD patients during 2019-2021. Data collected included demographics, BCVA, dates of intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections and clinic visits. RESULTS: A total of 1652 eyes of 1652 nAMD patients were included, out of which 850 eyes were assessed in 2019 (pre-COVID-19), 630 eyes were assessed in 2020 (COVID-19) and 974 eyes were assessed in 2021 (post-COVID-19). During the COVID-19 period, the mean number of anti-VEGF injections was significantly lower than the corresponding pre-COVID-19 and post-COVID-19 periods (5.55 compared to 6.13 and 6.60, respectively p < 0.01). A constant lower ratio of injections per patient/month was observed during COVID-19 compared to previous and following years, with a notable decline during March-April, reaching a ratio of 0.4 in 2020 versus 0.65 in 2019 and 0.62 in 2021 (p < 0.01). Baseline BCVA (0.825, p < 0.001), number of injections (-0.007, p < 0.001), gender (-0.027, p = 0.037) and age (0.004, p < 0.001) were shown to be significant predictors of final BCVA. CONCLUSION: During the COVID-19 period, patients were treated with significantly less intravitreal anti-VEGF injection compared to the previous year with compensation in the following year. These changes in treatment patterns did not have a significant impact on BCVA outcomes. Age, gender, baseline BCVA and number of injections are predictors of final visual outcomes.

Branch retinal vein occlusion treated with anti-VEGF: to switch or not to switch?

OBJECTIVE: To evaluate visual outcomes after switching from bevacizumab to ranibizumab or aflibercept in patients with macular edema (ME) secondary to branch retinal vein occlusion (BRVO). DESIGN: A retrospective, multi-center, observational study. PARTICIPANTS: Patients diagnosed with BRVO and were treated with at least 3 bevacizumab injections, before anti VEGF switch. METHODS: The follow-up period was 36 months, and the primary study outcomes assessed changes in best corrected visual acuity (BCVA) after anti VEGF switch. RESULTS: A total of 263 eyes of 263 patients with a mean age of 71.5 ± 11.2 years of which 50% were of male gender met the inclusion criteria. Of them, 175 eyes did not undergo switch, whereas 88 eyes underwent anti-VEGF switch. There was not a significant difference in mean age (p = 0.634) and gender (p = 0.269) between the groups. Baseline BCVA of the no-switch group was 0.47 ± 0.43 logMAR (20/59 Snellen) versus 0.6 ± 0.49 logMAR (20/79 Snellen) (p = 0.031) in the switch group, and at 36-months it was 0.41 ± 0.39 (20/51 Snellen) logMAR versus 0.54 ± 0.49 logMAR (20/69 Snellen) (p = 0.035), respectively. The difference between the rate of change in BCVA per year was insignificant between groups (p = 0.414). In multivariate analysis, baseline BCVA was the single significant predictor for switch (beta 0.137, p = 0.035). Patients with more than one anti-VEGF switch suffer from decrease in BCVA. CONCLUSIONS: Worse baseline BCVA is a significant predictor for anti-VEGF switch execution, though the switch has no significant impact on the change in BCVA over time. Multiple anti-VEGF switch is not recommended.

The Effect of Blue-light Filtering Intraocular Lenses on the Development and Progression of Macular Atrophy in Eyes With Neovascular Age-related Macular Degeneration.

PURPOSE: To assess the effect of blue-light filtering (BLF) intraocular lenses (IOLs) on the development and progression of macular atrophy (MA) in eyes with neovascular age-related macular degeneration (nAMD). DESIGN: Retrospective, clinical cohort study. METHODS: The study included patients with nAMD with anti-vascular endothelial growth factor (VEGF) injections who underwent uneventful cataract surgery between 2007 and 2018 with follow-up until June 2023. Subsequent MA rates were compared between subjects who received a BLF IOL or a non-BLF IOL. All optical coherence tomography scans were manually reviewed in a masked manner regarding patient baseline variables and IOL status by an experienced research technician. By using Heidelberg software, the area of MA was manually evaluated and calculated (mm2) by the program. The overall risk of developing new-onset MA and the effect of IOL type on disease progression were assessed. Death was included as a censoring event. RESULTS: Included were 373 eyes of 373 patients (mean age, 78.6 ± 6.7 years at surgery; 67.4% were female). BLF IOLs were implanted in 206 eyes, and non-BLF IOLs were implanted in 167 eyes with comparable follow-up times (3164 ± 1420 days vs 3180 ± 1403 days, respectively, P = .908) and other baseline parameters (age, gender, corrected distance visual acuity, macular thickness, cumulative number of anti-VEGF injections). Nine preexisting and 77 new-onset MA cases were detected, with similar distribution between BLF and non-BLF eyes (P = .598 and P = .399, respectively). Both univariate Kaplan-Meier (P = .366) and multivariate Cox regression analyses adjusted for age and gender showed that BLF-IOLs were comparable to non-BLF IOLs regarding hazard for new-onset MA (hazard ratio [HR], 1.236; 95% CI, 0.784-1.949; P = .363). Final MA area at the last visit was 5.14 ± 4.71 mm2 for BLF IOLs and 8.56 ± 9.17 mm2 for non-BLF IOLs (P = .028), with the mean annual MA area increase of 0.78 ± 0.84 mm2 and 1.26 ± 1.32 mm2, respectively (P = .042). CONCLUSIONS: BLF IOLs did not show added benefit over non-BLF IOLs in terms of MA-free survival but were associated with less progression over time in a cohort of patients with nAMD.

Influence of Carotid Endarterectomy on Choroidal Perfusion: The INFLATE Study.

PURPOSE: Patients with clinically significant carotid artery stenosis (CAS) undergoing carotid artery endarterectomy (CEA) were imaged with swept-source OCT angiography (SS-OCTA) imaging protocol to determine if there were changes in choroidal blood flow after surgery. DESIGN: Prospective observational study. PARTICIPANTS: Patients with clinically significant CAS undergoing unilateral CEA. METHODS: All participants underwent SS-OCTA imaging using a 6 × 6-mm scan pattern on both eyes before CEA and within 1 week after CEA. Previously validated automated algorithms were used to measure the mean choroidal thickness (MCT) and choroidal vascular index (CVI) within 2.5-mm and 5-mm circles centered on the fovea. Multivariable regression analysis was conducted to evaluate the impact of various baseline factors including age, mean arterial blood pressure, and degree of stenosis, on both baseline of MCT and CVI, and the changes in MCT and CVI. MAIN OUTCOME MEASURES: Changes in MCT and CVI. RESULTS: One hundred sixteen eyes from 60 patients with a mean age of 71.57 ± 7.37 years were involved in the study. At baseline, MCT in both the 2.5-mm and 5-mm circles was significantly thinner on the surgical side compared with the nonsurgical side (P = 0.03), while no significant differences were seen in the CVI at baseline between the 2 sides (2.5-mm circle: P = 0.24; 5-mm circle: P = 0.09). Within 1 week after CEA, there were significant increases in the MCT on the surgical side, as compared with the nonsurgical side, in both the 2.5-mm (P < 0.001) and the 5-mm (P < 0.001) circles. No significant change in mean CVI was noted before and after CEA on the surgical side versus the nonsurgical side (2.5-mm circle: P = 0.30; 5-mm circle: P = 0.97). Multivariable regression analysis revealed that baseline MCT before CEA significantly decreased with age on both the surgical (P < 0.001) and nonsurgical sides (P = 0.003) while the changes in MCT and CVI after CEA were not associated with age, mean arterial blood pressure, or degree of stenosis. CONCLUSION: A rapid and significant increase in MCT was observed on the ipsilateral side of CEA, suggesting an improvement in choroidal perfusion within 1 week after surgery. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

The Total Macular Burden of Hyperreflective Foci and the Onset of Persistent Choroidal Hypertransmission Defects in Intermediate AMD.

PURPOSE: The association between the total macular burden of hyperreflective foci (HRF) in eyes with intermediate AMD (iAMD) and the onset of persistent choroidal hypertransmission defects (hyperTDs) was studied using swept-source optical coherence tomography (SS-OCT). DESIGN: Post hoc subgroup analysis of a prospective study. METHODS: A retrospective review of iAMD eyes from subjects enrolled in a prospective SS-OCT study was performed. All eyes underwent 6×6 mm SS-OCT angiography (SS-OCTA) imaging at baseline and follow-up visits. En face sub-retinal pigment epithelium (subRPE) slabs with segmentation boundaries positioned 64-400 µm beneath Bruch's membrane (BM) were used to identify persistent choroidal hyperTDs. None of the eyes had persistent hyperTDs at baseline. The same subRPE slab was used to identify choroidal hypotransmission defects (hypoTDs) attributable to HRF located either intraretinally (iHRF) or along the RPE (rpeHRF) based on corresponding B-scans. A semiautomated algorithm was used by two independent graders to validate and refine the HRF outlines. The HRF area and the drusen volume within a 5mm fovea-centered circle were measured at each visit. RESULTS: The median follow-up time for the 171 eyes from 121 patients included in this study was 59.1 months (95%CI: 52.0-67.8 months). Of these, 149 eyes (87%) had HRF, and 82 (48%) developed at least one persistent hyperTD during the follow-up. Although univariable Cox regression analyses showed that both drusen volume and total HRF area were associated with the onset of the first persistent hyperTD, multivariable analysis showed that the area of total HRF was the sole significant predictor for the onset of hyperTDs (P<0.001). ROC analysis identified an HRF area ≥ 0.07 mm² to predict the onset of persistent hyperTDs within one year with an area under the curve (AUC) of 0.661 (0.570-0.753), corresponding to a sensitivity of 55% and a specificity of 74% (P<0.001). CONCLUSIONS: The total macular burden of HRF, which includes both the HRF along the RPE and within the retina, is an important predictor of disease progression from iAMD to the onset of persistent hyperTDs and should serve as a key OCT biomarker to select iAMD patients at high-risk for disease progression in future clinical trials.

Rediscovering Age-Related Macular Degeneration with Swept-Source OCT Imaging: The 2022 Charles L. Schepens, MD, Lecture.

PURPOSE: Swept-source OCT angiography (SS-OCTA) scans of eyes with age-related macular degeneration (AMD) were used to replace color, autofluorescence, infrared reflectance, and dye-based fundus angiographic imaging for the diagnosis and staging of AMD. Through the use of different algorithms with the SS-OCTA scans, both structural and angiographic information can be viewed and assessed using both cross sectional and en face imaging strategies. DESIGN: Presented at the 2022 Charles L. Schepens, MD, Lecture at the American Academy of Ophthalmology Retina Subspecialty Day, Chicago, Illinois, on September 30, 2022. PARTICIPANTS: Patients with AMD. METHODS: Review of published literature and ongoing clinical research using SS-OCTA imaging in AMD. MAIN OUTCOME MEASURES: Swept-source OCT angiography imaging of AMD at different stages of disease progression. RESULTS: Volumetric SS-OCTA dense raster scans were used to diagnose and stage both exudative and nonexudative AMD. In eyes with nonexudative AMD, a single SS-OCTA scan was used to detect and measure structural features in the macula such as the area and volume of both typical soft drusen and calcified drusen, the presence and location of hyperreflective foci, the presence of reticular pseudodrusen, also known as subretinal drusenoid deposits, the thickness of the outer retinal layer, the presence and thickness of basal laminar deposits, the presence and area of persistent choroidal hypertransmission defects, and the presence of treatment-naïve nonexudative macular neovascularization. In eyes with exudative AMD, the same SS-OCTA scan pattern was used to detect and measure the presence of macular fluid, the presence and type of macular neovascularization, and the response of exudation to treatment with vascular endothelial growth factor inhibitors. In addition, the same scan pattern was used to quantitate choriocapillaris (CC) perfusion, CC thickness, choroidal thickness, and the vascularity of the choroid. CONCLUSIONS: Compared with using several different instruments to perform multimodal imaging, a single SS-OCTA scan provides a convenient, comfortable, and comprehensive approach for obtaining qualitative and quantitative anatomic and angiographic information to monitor the onset, progression, and response to therapies in both nonexudative and exudative AMD. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Monovision surgery in myopic presbyopes: visual function and satisfaction.

PURPOSE: To describe our experience with monovision excimer laser correction in individuals with myopic presbyopia. METHODS: This prospective interventional case series was conducted in a private refractive surgery center on 40 patients with presbyopia aged 40 years and older, who were treated with monovision refractive surgery between 2010 and 2011. The dominant eye was corrected for distance vision and the nondominant eye was corrected for near vision, with anisometropia of ≥1.00 diopters (D). All patients underwent comprehensive objective and subjective visual assessments, including a questionnaire that was filled out preoperatively and at 6 and 12 months postoperatively. The primary outcomes were preoperative and postoperative refraction, binocular visual acuity, stereopsis, contrast sensitivity, glare, and questionnaire results. RESULTS: The 1-year follow-up was completed by 38 patients (95%). Preoperative and 1-year postoperative refraction of the distance eye spherical equivalent (SE), anisometropia SE, and uncorrected visual acuity were -4.05 ± 1.94 and -0.01 ± 0.22 D, 0.45 ± 0.50 and 1.73 ± 0.56 D, and 0.87 ± 0.2 and 0.09 ± 0.11 logMAR, respectively. Best-corrected visual acuity was unchanged. Both mean distance and near stereopsis decreased, from 52 to 142 seconds of arc and from 54 to 57 seconds of arc, respectively. Contrast sensitivity and glare decreased significantly. Patient satisfaction improved from 41.5 ± 30.4% to 85.2 ± 5.0% (range, 40 to 100%) at the 1-year follow-up. CONCLUSIONS: Monovision excimer laser correction provides both effective and satisfactory results and should be considered as an option for individuals with myopic presbyopia suitable for, and interested in, refractive surgery.

The roadmap to geographic atrophy treatment: A journey of trials and promise.

This review covers advancements in geographic atrophy (GA) research. It discusses genetic contributions to AMD, explores treatment strategies, including complement inhibition, and highlights recent FDA approvals, safety concerns and promising future directions.