Systemic and vitreous biomarkers - new insights in diabetic retinopathy.

PURPOSE: Diabetic retinopathy (DR) is a microvascular inflammatory and neurodegenerative disease. The purpose of this study was to analyze the relationship between DR severity and the levels of potential biomarkers in the serum and/or vitreous. METHODS: A prospective, consecutive, controlled, observational study was performed between June 2018 and January 2020. Blood and vitreous samples were collected on the day of vitrectomy in patients without diabetes and in patients with diabetes with epiretinal membrane, macular edema, and indication for vitrectomy. RESULTS: Transthyretin (TTR) was the only blood biomarker with levels statistically higher in patients with diabetes (p = 0.037). However, no correlation with DR severity was observed. Erythropoietin (EPO) was the only blood biomarker whose levels were associated with DR severity (p = 0.036). In vitreous samples, levels of EPO (p = 0.011), interleukin (IL)-6 (p < 0.001), IL-8 (p < 0.001), IL-17 (p = 0.022), monokine induced by interferon-γ (MIG) (p < 0.001), and interferon gamma-induced protein 10 (IP-10) (p = 0.005) were significantly higher in patients with diabetes. Additionally, in vitreous, IL-6, IL-8, MIG, and IPL-10 levels were also higher in more severe DR cases (p < 0.05). CONCLUSIONS: Among the studied biomarkers, vitreous IL-6, IL-8, MIG, and IP-10 were the ones whose levels had the strongest coherent relationship with DR severity prediction and, thus, have the best potential post-vitrectomy prognostic value.

Globe Ruptures: Outcomes and Prognostic Analysis of Severe Ocular Trauma.

PURPOSE: Eye trauma is an important cause of monocular visual loss worldwide. This study aimed to describe the structural and functional characteristics and outcomes of 281 globe ruptures. METHODS: Medical records of all patients undergoing surgery for a ruptured globe at Centro Hospitalar Universitário do Porto in the last 17 years were retrospectively reviewed. RESULTS: 281 eyes of 277 patients were included. The majority of them were males (71%) with a mean age of 59.7 ± 20.5. In 38.8% of the cases, the cause was a fall. At the time of admission, 29.5% of the eyes had a visual acuity (VA) greater than 20/200 and 12.5% had no light perception. The median time between trauma and primary repair was less than 8 h (interquartile range 5-12 h). A primary reconstruction was always attempted. Primary evisceration was performed in 14 cases (5%). In multivariable analysis, independent predictors of vision survival were male gender, shorter wound size, and absence of vitreous hemorrhage. CONCLUSION: In this large, retrospective study on globe ruptures, we identified male gender, short wound length, and the absence of vitreous hemorrhage or retinal detachment as predictors of improved functional outcome. We found a correlation between the presenting and final VAs. The Ocular Trauma Score predicted the outcome well. Our determination to reconstruct the traumatized eyes as early and as completely as possible was justified by the functional results: despite the severity of the injuries, one out of four eyes reached a final VA greater than 20/200.

The Impact of COVID-19 Pandemic on Surgical Primary Retinal Detachments.

PURPOSE: This study aimed to describe the impact of COVID-19 pandemic on the presentation characteristics, timings, and surgical decisions for primary rhegmatogenous retinal detachment (RRD). METHODS: A historical cohort including all patients who presented to the Surgical Retina Section at Centro Hospitalar Universitário do Porto (CHUPorto), over a 2-year period, was recruited and divided into 2 groups: pre-COVID and COVID groups. The onset of the COVID-19 pandemic was recorded as starting on March 18, 2020, the same day the first pandemic-related lockdown came to effect in Portugal. RESULTS: This study enrolled 449 eyes of 443 patients: 272 in the pre-COVID group and 177 in the COVID one. Of the patients, 63.6% were male, and the mean ± SD age was 63.0 ± 13.2 years (range 13-92 years). Of the eyes, 55.5% (n = 151) presented with macular detachment in the pre-COVID group compared with 66.9% (n = 119) in the COVID group (odds ratio [OR] 1.62; 95% confidence interval [CI]: 1.09-3.86; p = 0.016). The time from symptom onset to hospital admission (p = 0.021) and from admission to surgery (p < 0.001) was longer in the COVID era. In the COVID period, silicone oil (OR 2.03, 95% CI: 1.09-3.79, p = 0.025) and C3F8 gas (OR 2.42, 95% CI: 1.57-3.71, p < 0.001) were used more often. No differences in anatomical success or final visual acuity were found. CONCLUSIONS: The lockdown due to COVID pandemic affected the epidemiology of RRD. The services must adapt to the novel reality and produce backup plans for similar events. Despite the contingencies, the final results were not different between groups.

Changes in Ganglion Cell Layer Thickness after Treatment with the 0.2 µg/day Fluocinolone Acetonide Implant in Vitrectomized and Nonvitrectomized Eyes with Diabetic Macular Edema.

INTRODUCTION: The objective of this study is to compare changes in ganglion cell layer (GCL) between vitrectomized and nonvitrectomized eyes with diabetic macular edema (DME) over a 2-year period following treatment with 0.2 µg/day fluocinolone acetonide (FAc) implant. METHODS: Eighteen vitrectomized (group 1) and 8 nonvitrectomized (group 2) eyes were included in this cohort study. Changes in central macula GCL thickness were measured using the Spectralis spectral domain-optical coherence tomography at baseline and 6, 12, and 24 months of follow-up. Other parameters analyzed included best-corrected visual acuity (BCVA), central foveal thickness (CFT), and intraocular pressure (IOP). RESULTS: Treatment with the FAc implant led to small reductions in mean global GCL thickness versus baseline and contrasts with the control group that was stable or slightly increased versus baseline. FAc therapy also led to improvements in mean BCVA and CFT that were observed at Month 6 and maintained to Month 24. For vitrectomized and nonvitrectomized eyes, no differences were observed between mean global GCL, BCVA, and CFT values during follow-up. Linear correlations revealed that in all groups mean BCVA at Month 24 positively correlated with mean GCL thickness at baseline and at Month 24. IOP remained stable throughout the 24 months. CONCLUSION: There was no evident retinal neurodegeneration in the 2-year period following treatment with FAc in both groups. GCL thickness may be a useful biomarker for assessing safety and effectiveness in patients with DME.

Efficacy and Safety of Intravitreal Aflibercept Treat and Extend for Polypoidal Choroidal Vasculopathy in the ATLANTIC Study: A Randomized Clinical Trial.

IMPORTANCE: Polypoidal choroidal vasculopathy (PCV) is far less common and studied in a Caucasian population than in an Asian population, and the optimal treatment approach remains to be confirmed. METHODS: A 52-week, double-masked, sham-controlled, phase 4, investigator-initiated randomized clinical trial (RCT) in naive symptomatic Caucasian patients with PCV treated with aflibercept in a treat-and-extend regimen (T&E) (intravitreal aflibercept injection [IVAI] T&E). Patients were randomized at week 16 to receive IVAI T&E plus either sham photodynamic therapy (PDT) or standard fluence PDT with verteporfin. The main outcome measures were changes in best-corrected visual acuity (BCVA) from baseline to 52 weeks and polyp occlusion at week 52. Data are presented as median (interquartile range [IQR]) for BCVA, number of IVAI, and change in central retinal thickness (CRT). RESULTS: Of the 50 patients included in the study, 48 patients completed the 52 weeks of follow-up. During this period, a significant median (IQR) BCVA gain of 6 [2-12] Early Treatment Diabetic Retinopathy Study letters was observed for all patients (p < 0.001), after 8 (7-9) injections, with a significant reduction of -93.0 [-154.0, -44.0] µm in central macular thickness (p < 0.001). Using indocyanine green angiography, a complete occlusion of polypoidal lesions was documented in 72% of the cases. Still, no significant difference was detected between the sham PDT and the aflibercept PDT arms, at week 52, for BCVA change (6.5 [2-11] vs. 5 [2-13] letters (p = 0.98)), number of IVAIs (8.5 [7-9] vs. 8 [7-9] (p = 0.21)), change in CRT (-143 [-184; -47] vs. -89 [-123; -41.5] µm [p = 0.23]), and rates of complete polyp occlusion: 77 versus 68% (p = 0.53) or presence of fluid: 68 versus 57% (p = 0.56). No serious ocular adverse events were registered in the 2 arms. CONCLUSIONS AND RELEVANCE: To our knowledge, this is the first RCT to compare aflibercept T&E monotherapy with aflibercept T&E plus verteporfin PDT in a Caucasian population with PCV. Aflibercept monotherapy in a T&E showed to be effective and safe with a significant median BCVA improvement of 6 letters and a complete occlusion of polypoidal lesions in near 3 quarters of the eyes, at 1 year. As only 22% of the eyes underwent PDT treatment, the benefit of combined treatment for PCV in Caucasian patients could not be definitively elucidated from this study. TRIAL REGISTRATION: The clinical trial was registered in ClinicalTrials.gov Identifier NCT02495181 and the European Union Drug Regulating Authorities Clinical Trials Database EudraCT No. 2015-001368-20.

A Delphi study on the clinical management of age-related macular degeneration.

PURPOSE: Age-related macular degeneration (AMD) is one of the main causes of blindness and visual impairment worldwide. As achieving a dry macula is one of the main objectives in AMD management, the purpose of this work was to reach a consensus on the relevance of retinal fluid in function, disease activity control and treatment patterns. METHODS: Forty-seven Portuguese ophthalmologists specialized in AMD participated in a DELPHI panel. Two rounds of presential meetings were conducted and a cut-off of 80% or more of votes was defined to consider answers consensual. RESULTS: Consensus was reached for 11 out of 18 questions. These questions focused on the impact of anatomical results on visual acuity, standards exams and parameters to assess disease activity, frequency and factors which influence disease activity assessment, criteria to use non-fixed treatment regimens, usefulness of individualized regimens and conditions for treatment interruption. No consensus was obtained for relevance of the different fluid types in AMD prognosis, frequency of fluid presence assessment, factors commonly associated with progression to geographic atrophy, ideal conditions for a fixed treatment regimen, date of first disease activity assessment and parameters to monitor disease activity. CONCLUSIONS: Consensus was achieved for over half of the questions assessed through this Delphi study. The questions for which no consensus was reached concerned either subjects that need further investigation or monitoring times which are influenced by resource availability. Raising awareness for these issues will allow the improvement of AMD management and treatment.

Epiretinal membrane vitrectomy: outcomes with or without cataract surgery and a novel prognostic factor for cystoid macular edema.

PURPOSE: To assess the outcomes of vitrectomy with or without cataract surgery for the treatment of idiopathic ERM in phakic eyes and evaluate predictors of functional and anatomical outcomes. METHODS: Retrospective cohort of consecutive phakic ERM eyes distributed in three groups: a) combined (phacovitrectomy) group, b) PPV-only group, and c) consecutive group (PPV followed by cataract surgery). Main outcomes were final visual acuity (VA) and cystoid macular edema (CME) occurrence. Potential predictors of VA or CME included clinical variables and SD-OCT parameters. RESULTS: A total of 108 eyes were included in this study. There were no differences in the final VA between consecutive and combined groups (0.22 vs 0.10 logMAR, p = 0.851). Twelve eyes from the combined group (23%) and one eye from the PPV-only group presented CME (p = 0.001). There were no differences between postoperative CME occurrence in combined versus consecutive group (12 vs 7, p = 0.38). The presence of cotton-ball sign predicted the development of CME [OR 2.86 (95%CI 1.01-8.18), p = 0.049] while separated ERM-ILM complex was found to be protective [OR 0.25 (95%CI 0.08-0.77), p = 0.015]. CONCLUSIONS: Functional and anatomical results of PPV with ERM and ILM peeling combined with cataract surgery was equivalent to the consecutive procedure, with both strategies being effective. Separated ERM-ILM complex has prognostic value in these patients, as its presence at baseline was found to be protective for postoperative CME.

Optical Coherence Tomography Biomarkers: Vitreous Status Influence in Outcomes for Diabetic Macular Edema Therapy with 0.19-mg Fluocinolone Acetonide Implant.

BACKGROUND: The 0.19-mg fluocinolone acetonide (FAc) implant (ILUVIEN®; Alimera Sciences Ltd., Hampshire, UK) was approved for the treatment of vision impairment associated with chronic and refractory diabetic macular edema (DME). OBJECTIVES: To quantitatively assess functional and structural features in nonvitrectomized and vitrectomized DME patients after being treated with an FAc implant. METHODS: Retrospective review of patients with DME receiving a single intravitreal injection of the FAc implant. The study was designed to analyze the presence of quantitative structural OCT biomarkers at baseline and 12 months after FAc therapy according to vitreous status. RESULTS: A total of 41 eyes from 30 patients were included in this study. At 12 months after injection, vitrectomized patients had a lower central foveal thickness (p = 0.017) and fewer hyperreflective dots (p = 0.028) compared with nonvitrectomized. Thirty (73%) patients presented a significant functional improvement with 17 (42%) increasing at least 15 ETDRS letters. Overall, 22 (54%) eyes had a complete resolution of DME at the 12-month visit. Patients who needed additional therapy had a higher prevalence of subretinal fluid (42 vs. 3%, p = 0.005) at baseline. CONCLUSIONS: This study supports the effectiveness of the FAc implant and reports significant changes at 12 months after FAc injection.

Inverted internal limiting membrane flap technique in the surgical treatment of macular holes: 8-year experience.

PURPOSE: To evaluate the ellipsoid zone (EZ) structural recovery, hole closure rate, and visual acuity improvement after inverted internal limiting membrane (ILM) flap technique. METHODS: Retrospective cohort of eyes affected by idiopathic macular holes (MH) that underwent pars plana vitrectomy combined with inverted ILM flap technique in a tertiary center, over an 8-year period (2011-2019). The main outcomes were the postoperative qualitative analysis of EZ structure on spectral-domain optical coherence tomography, hole closure rate, and best-corrected visual acuity (BCVA) improvement of ≥ 0.3 units in the logarithm of minimal angle of resolution (logMAR) scale. RESULTS: Our study included 76 eyes of 72 patients; 65% were female, with a mean age of 70 ± 8 years-old. Median (range) follow-up was 21 (3-92) months. Hole closure rate was 92%. Structural defects in EZ were observed in 66% of closed holes (EZ atrophy in 33%, EZ disruption in 22%, and EZ thinning in 11%). The mean final BCVA was 0.5 ± 0.4 logMAR (Snellen 20/63), but visual acuity improvement occurred in 80% of the eyes. Final BCVA was significantly worse in eyes with EZ atrophy compared with eyes with EZ disruption (0.75 vs. 0.36 logMAR, p = 0.004) and EZ thinning (0.75 vs. 0.32 logMAR, p = 0.015). In multivariate regression, minimum linear diameter (OR 1.01; IC 95% 1.01-1.02) independently predicted a final BCVA (logMAR) < 0.3 units. CONCLUSION: Inverted ILM flap technique provided a hole closure rate above 90%, similar to previous studies. Although the modest value of the final BCVA, a significant visual acuity improvement occurred in most eyes. Structural defects of EZ were found in more than half of closed MHs after surgery. Evidence of postoperative retinal atrophy was associated with a worse visual outcome.

Dealing with rhegmatogenous retinal detachment in patients under 40 years old: a tertiary center results.

PURPOSE: The risk of rhegmatogenous retinal detachment (RRD) increases with age, but some studies report a secondary peak in younger patients. Since visual recovery in RRD depends on surgical treatment and, considering the personal, social and economic burden of low vision in the working-age population, our purpose was to analyze the features and outcomes of RRD in young patients. METHODS: Clinical data of patients under 40 years old submitted to surgery for first time RRD, consecutively selected between 2016 and 2019, was analyzed. Patients with less than 3 months follow-up were excluded. RESULTS: Eighty-nine eyes from 89 patients were included. Mean age was 31.2 ± 7.8 years (minimum 10 years) and 56% were female gender. Most patients (63%) had high myopia. Pars plana vitrectomy (79%) alone, combined with scleral buckling (1%) or scleral buckling alone (20%) was performed. Primary anatomical success was 72%, and final anatomical success was 91%. Final visual acuity of 20/40 or better was achieved in 29% of cases, but 28% remained under 20/400. The presence of myopia (p = 0.022), localized RRD (p = 0.007) and attached macula at presentation (p < 0.001) was associated with a better final visual acuity. CONCLUSION: Management of RRD in young patients must be thorough. In younger patients, anatomical outcomes may be worse than in older patients. Myopia may be recognized as a major risk factor for RRD in this age group, but also as a protective factor for retinal function after surgery.

Vitrectomy Outcomes in Eyes with Tractional Diabetic Macular Edema.

PURPOSE: To evaluate pars plana vitrectomy (PPV) outcomes in cases with tractional diabetic macular edema (tDME). METHODS: We conducted a single-center retrospective study with a follow-up of 12 months. Forty-six eyes with tDME of 38 patients submitted to PPV between 2013 and 2015 were assessed. A standard PPV was performed and surgical outcomes were registered at the 3-, 6-, and 12-month follow-up. RESULTS: The baseline median best corrected visual acuity (BCVA) in ETDRS (Early Treatment Diabetic Retinopathy Study) letters and the median central foveal thickness (CFT) were 43.0 letters and 491.0 µm, respectively. At the 12-month follow-up, a median decrease in CFT of 232.7 µm was observed. A CFT < 300 µm was achieved in 65.2% of the cases (52.2% needing no further treatment); a BCVA improvement by ≥10 letters was achieved in 60.0%, but there was a decrease of ≥10 letters in 13.0% of the cases. DME recurrence was observed in 10.9% of the cases, with a median time of development after vitrectomy of 6 months. As a major postoperative complication, a macular hole was observed in 1 patient (2.1%). CONCLUSIONS: In our series, PPV for tDME induced an improvement in retinal thickening and visual outcome in more than 50% of the cases, with low recurrence rates and a low number of postoperative complications.

Prophylactic Chorioretinectomy in Open Ocular Trauma: A Series of 36 Eyes.

PURPOSE: The aim of this paper was to report the outcomes of prophylactic chorioretinectomy in open-globe injuries where a foreign body penetrated the choroid or perforated the globe. METHODS: We conducted a retrospective, consecutive, noncomparative, and descriptive study of patients registered in the ocular trauma database between January 2006 and December 2014, who underwent vitrectomy with chorioretinectomy. RESULTS: Thirty-six patients (33 male, 3 female) with a mean age of 40 years and a median of follow-up of 13 months were included. Twenty-one cases had penetrating globe injuries with an intraocular foreign body and 15 cases had perforating globe injuries. A concomitant chorioretinectomy was performed in all eyes, although it was only partial in 8 eyes. At the end of follow-up, proliferative vitreoretinopathy (PVR) rates were 6.5%, anatomical success was 80.6%, and the globe survival rate was 96.8%. CONCLUSION: Prophylactic chorioretinectomy is a surgical procedure that may decrease posttraumatic PVR, thus improving final visual acuity and increasing globe survival rates.

Fluocinolone Acetonide Intravitreal Implant 190 µg (ILUVIEN®) in Vitrectomized versus Nonvitrectomized Eyes for the Treatment of Chronic Diabetic Macular Edema.

PURPOSE: To compare the functional and anatomical outcomes after a 0.2 µg/day fluocinolone acetonide (FAc) implant between vitrectomized and nonvitrectomized eyes with chronic diabetic macular edema (DME). METHODS: This is a retrospective, comparative analysis of 43 eyes with chronic DME. All eyes were treated with a single 0.2 µg/day FAc implant and followed up for a mean period of 8.5 months (median, 6.0 months; range, 1-21 months). The patients with a 0.2 µg/day FAc implant were divided into 2 groups: 24 eyes which had undergone pars plana vitrectomy prior to 0.2 µg/day FAc (group 1) and 19 eyes which had not been vitrectomized (group 2). Outcome measures included mean changes in best corrected visual acuity (BCVA) in Early Treatment Diabetic Retinopathy Study letters, central subfield foveal thickness (CSFT), and intraocular pressure (IOP), and were measured prior to administration of the 0.2 µg FAc implant, in the first week, at month 1, and quarterly thereafter. RESULTS: Following the 0.2 µg/day FAc implant, the mean change in BCVA at the last observation point, from baseline, was +16.9 ± 3.39 (mean ± SE) letters (p ≤ 0.001) in group 1 and +8.2 ± 4.62 letters (p = 0.092) in group 2. From baseline, a gain of ≥15 letters was achieved in 37.5 and 36.8% of the eyes in group 1 and group 2, respectively. Additionally, an improvement in vision ≥20/40 in 29.2% of group 1 and 15.8% of group 2 was observed. The mean change in CSFT was -217.7 ± 40.8 µm and -155.6 ± 43.4 µm in group 1 and group 2, respectively. The mean change in IOP was +1.6 ± 0.7 mm Hg in group 1 and +0.8 ± 1.3 mm Hg in group 2, relative to baseline. At the last observation point, there were no significant differences between groups 1 and 2 (p > 0.05) in terms of their changes in BCVA, CSFT, and IOP. CONCLUSION: The results from the real-life practice study demonstrate that the 0.2 µg/day FAc implant is effective and well tolerated in vitrectomized and nonvitrectomized eyes of patients with chronic DME. Our results support the use of a 0.2 µg/day FAc implant to obtain long-term functional and anatomical improvements (mean, 8.5 months; median, 6.0 months) in vitrectomized and nonvitrectomized eyes.

The Portuguese Experience with Ocriplasmin in Clinical Practice.

AIM: Evaluate the real-life experience with ocriplasmin on vitreomacular traction (VMT) release and full-thickness macular hole (FTMH) closure in Portugal. METHODS: Multicentric, retrospective study of 83 eyes of 78 patients who were treated with intravitreal ocriplasmin for VMT with and without FTMH. Primary outcomes were VMT release and FTMH closure. Secondary outcomes included visual acuity changes and structural features on spectral-domain ocular coherence tomography. RESULTS: VMT resolved in 47 of the 83 eyes (56.6%) and 6 of the 12 FTMH were closed (50.0%). Mean best-corrected visual acuity (BCVA) improved from 65.1 at baseline to 70.8 ETDRS letters at the end of follow-up (p < 0.0001) with a mean follow-up of 138.8 days. Improvement in BCVA was significantly better in eyes with VMT release (p = 0.021). Approximately 73% of patients had normal ellipsoid zone integrity at the end of follow-up, 87% had no neurosensorial detachment and 40% had no intra- or subretinal fluid. CONCLUSION: VMT release and FTMH closure were achieved in more than half of the treated eyes and were correlated with significant BCVA improvements and favorable baseline characteristics. In fact, if a careful patient selection is carried out, VMT resolution with ocriplasmin can be optimized, tailoring the best approach to each patient.

Outcome of vitrectomy and chorioretinectomy in perforating eye injuries.

PURPOSE: To evaluate the anatomical and functional results of patients who underwent pars plana vitrectomy for perforating eye injuries as well as to analyze the benefit of the chorioretinectomy procedure. METHODS: Retrospective and descriptive study of 24 eyes of 22 patients with perforating eye injuries operated on at the Centro Hospitalar do Porto between January 2006 and December 2012. RESULTS: An early vitrectomy was accomplished in 67% of the eyes and a delayed vitrectomy in 33% of the eyes. A concomitant chorioretinectomy was carried out in 78%. Final proliferative vitreoretinopathy (PVR) was found in 11%. The anatomical success was 83%. At the final follow-up, 78% had best-corrected visual acuity equal to or superior to 5/200. Of the eyes that underwent early vitrectomy, 58% regained a visual acuity of 40/200 or better, versus 17% of the cases that underwent delayed vitrectomy. CONCLUSION: Early vitrectomy with prophylactic chorioretinectomy seems to be an effective approach to prevent PVR and improve the visual outcome and globe survival in perforating injuries.

Oct biomarkers for early prognosis in diabetic macular edema treatment with ranibizumab.

BACKGROUND: Diabetic macular edema is the main cause of vision loss in patients with diabetic retinopathy. In this work, we aimed to assess the role of Optical Coherence Tomography (OCT) biomarkers in patients treated with ranibizumab. METHODS: A prospective study enrolling 46 eyes with DME under ranibizumab intravitreal therapy with 12 months of follow-up. The primary endpoint was to assess the association between OCT biomarkers at baseline and the type of treatment response. RESULTS: Good responders, compared with partial/non responders, had lower number of inner nuclear layer cysts (INLc) at baseline, (26.5% vs 73.5%, p = 0.035) and presented, at 12 months of follow-up, lower percentage of disorganization of retinal inner layers (12.0% vs 88.0%, p = 0.001), lower disruption of outer plexiform layer (8.7% vs 91.3%, p < 0.001) and lower outer nuclear layer cysts (17.4% vs 82.6%, p = 0.013). At the end of follow-up, it was observed a higher frequency of inner nuclear layer cysts in patients with higher glycated haemoglobin (p = 0.028). CONCLUSION: This study showed the value and importance of OCT parameters, such as absence of INLc, as a prognostic therapeutic response. A normalization of the macular anatomy with ranibizumab is more likely to happen in early complete responders. The association between INLc and higher glycated haemoglobin levels showed the importance of systemic metabolic control in systemic diabetic manifestations. Clinicaltrials.gov NCT04387604.

ILUVIEN® in diabetic macular edema that persists or recurs despite treatment: Results from the Retina.pt® RIVER audit.

PURPOSE: Persistent diabetic macular edema (DME) remains a problem in clinical practice, with many patients having a suboptimal response to the standard of care (SOC). Evidence supports the long-term efficacy of intravitreal fluocinolone acetonide (FAc) implant (ILUVIEN®) in patients that have responded sub-optimally, although there is still scarce data from real-world Portuguese practices. We aimed to monitor the current SOC in selected Portuguese practices prior to FAc implantation and then assess the long-term effectiveness and safety of the FAc implant. SETTINGS: The study included patient data from five Portuguese public hospitals. DESIGN: This was a non-interventional, multicenter audit of data collected from Retina.pt registry from patients with persistent or recurrent DME despite treatment. METHODS: Outcome measures included changes in best-corrected visual acuity (BCVA), central macular thickness (CMT), and intraocular pressure (IOP). Results were compared at regular times over 36 months. RESULTS: This study included 222 eyes from 152 patients. A significant decrease in BCVA (P < 0.001) and a significant increase in CMT (P = 0.013) were observed prior to FAc. A significant increase in BCVA was registered at 6 months after FAc implant administration (P < 0.001), which was maintained during follow-up. No relevant changes in IOP were observed. Treatment burden was reduced as a result of treatment with FAc (P < 0.001 for anti-VEGF, corticosteroids, or both treatments) in the full population. CONCLUSIONS: In Portuguese practice, data showed that pre-FAc implantation, some patients did not respond to SOC treatment and/or they were undertreated. Following FAc implant administration, there were rapid, sustained, long-term visual and anatomical improvements, and a marked reduction in treatment burden.

Valsalva Retinopathy after a Vomiting Episode.

This case presents a minimal invasive alternative for the treatment of subhyaloid hemorrhages. Young, female, 32 years old, with no regular medication and with no personal or ophthalmological history, reports a sudden and profound decrease in visual acuity after an episode of vomiting, with 2 days of evolution. After funduscopic observation and complementary diagnostic tests, subhyaloid hemorrhage was detected and laser hyaloidotomy was performed, with restoration of visual acuity after 1 week. Nd:YAG laser treatment made it possible to quickly restore the visual acuity of the patient after following diagnostic procedures, avoiding other types of treatments, such as pars plana vitrectomy. This case reports a Valsalva retinopathy with clinical presentation in the form of subhyaloid hemorrhage after an episode of self-limited vomiting, effectively treated with Nd: YAG laser.

Intrascleral Knotless Zigzag Suture Fixation of Four-Haptic Hydrophilic Acrylic Foldable IOL: Clinical Outcomes.

BACKGROUND: The main options for intraocular lens (IOL) placement without capsular bag support and/or zonular weakness are iris-fixated IOL and scleral-fixated IOL (SFIOL). PURPOSE: To describe the surgical technique and the outcomes of intrascleral knotless zigzag suture fixation of Akreos AO60 foldable IOL. METHODS: Retrospective cohort study of consecutive cases. RESULTS: Ninety-nine eyes of 92 patients were retrospectively studied. The mean age was 72.1±15.2 years (range 18-94), and the median follow-up duration was 19.5 months (range 3-81). The best-corrected visual acuity improved from a mean±SD of 1.34±0.70 logarithm of the minimum angle of resolution (logMAR) units at baseline to 0.49±0.56 logMAR at the end of follow-up (p<0.001). The mean±SD final SE was -1.24±1.82 diopters. The mean±SD prediction error was -0.51±1.16 diopters. The overall perioperative complications rate was 44.4% (n=44). The rate of complications requiring invasive treatment was 19.2% (n=19). The most common perioperative complications were ocular hypertension (OHT, 20.2%, n=20), and cystoid macular edema (CME, 15.2%, n=15). The rate of IOL dislocation was 7% (n=7). CONCLUSION: This knotless technique avoids the risks of haptics fixation but is more prone to IOL dislocation in cases of suture deterioration. Past ophthalmic history needs to be carefully considered in candidates who underwent SFIOL implantation.

Inverted Internal Limiting Membrane Flap Technique: Is It the Best Option for Macular Holes?

Surgical treatment is generally necessary to repair full-thickness macular holes (FTMH). Although vitrectomy with or without internal limiting membrane (ILM) peeling remains the standard surgical technique, the inverted ILM flap procedure has increasingly assumed a role in the primary surgical repair of FTMHs. Some vitreoretinal surgeons reserve this technique to treat large or myopic holes, whereas others use it routinely in all cases. This paper is a comprehensive review of the current scientific evidence on the anatomical and functional outcomes of the inverted ILM flap technique in the repair of macular holes, following the International Vitreomacular Traction Study (IVTS) group classification.