POSTTREATMENT POLYP REGRESSION AND RISK OF MASSIVE SUBMACULAR HEMORRHAGE IN EYES WITH POLYPOIDAL CHOROIDAL VASCULOPATHY.

PURPOSE: To study the association between the risk of massive submacular hemorrhage (SMH) and polyp regression after initial treatment of polypoidal choroidal vasculopathy using long-term follow-up data. METHODS: Retrospective study of 223 patients who were diagnosed with polypoidal choroidal vasculopathy and were followed up for up to 11 years. Subjects were categorized into "regression" and "no regression" groups, according to their polyp status after the initial treatment. Kaplan-Meier survival analyses were performed on development of massive SMH. The association between treatment methods and the occurrence of massive SMH was also analyzed. RESULTS: The incidence rates of massive SMH at 3, 6, and 9 years in the "no regression" group were 6.50, 22.59, and 38.03%, respectively, and in the "regression" group were 1.14, 6.47, and 10.92%, respectively (P = 0.005, log-rank test). The hazard ratio of massive SMH was 3.677 for cluster-type polyps and 0.271 for polyp regression after initial treatment. A higher rate of polyp regression was associated with photodynamic therapy (PDT) than anti-VEGF monotherapy (64.4 vs. 33.3%, P < 0.001). Additional anti-VEGF treatments after initial PDT showed lower risk of massive SMH than PDT only. (9.5 vs 38.5%, P = 0.005). CONCLUSION: The long-term risk of massive SMH after initial treatment on polypoidal choroidal vasculopathy is significantly higher in eyes with persistent polyps than those with regressed polyps. Ophthalmologists should pay attention to the risk of massive SMH and the polyp status when treating polypoidal choroidal vasculopathy.

CORRELATION BETWEEN INNER-RETINAL CHANGES AND OUTER-RETINAL DAMAGE IN PATIENTS WITH IDIOPATHIC EPIRETINAL MEMBRANE.

PURPOSE: To investigate correlations between the inner-retinal irregularity index and interdigitation zone (IZ) defects preidiopathic and postidiopathic epiretinal membrane (ERM) surgery. METHODS: The authors retrospectively assessed ophthalmic parameters in 89 eyes of 89 patients with ERM. They divided patients into the no-IZ defect (51, 57%) and IZ defect (38, 43%) groups. The IZ defect group was subdivided into recovered (22, 58%) and remaining IZ defect (16, 42%) subgroups, according to IZ recovery status at final examination. The inner-retinal irregularity index of each group was measured before and 1-, 3-, and 6-month postsurgery. RESULTS: Clinical characteristics were similar in both groups. The IZ defect group had a statistically significant higher inner-retinal irregularity index than the no-IZ defect group before (P = 0.023), but not after ERM surgery. The inner-retinal irregularity index of the recovered and remaining IZ defect subgroups was similar before surgery, but differed markedly 6 months after surgery (P = 0.048). Changes in the inner-retinal irregularity index quantitatively correlated with IZ defect size before and after ERM surgery (P < 0.001). CONCLUSION: The inner-retinal irregularity index differed significantly according to the IZ status and also correlated with the IZ defect before and after ERM surgery. The inner-retinal irregularity index may reflect the outer-retinal damage in ERM.

Type of the recurrent exotropia after bilateral rectus recession for intermittent exotropia.

BACKGROUND: The aim of this study was to investigate the type of exotropia (XT) based on the distance-near (D/N) difference in recurrent XT after bilateral lateral rectus (BLR) recession to treat intermittent XT (IXT) to look into the possibility of secondary convergence insufficiency (CI)-type strabismus. METHODS: A total of 121 patients with recurrent XT after BLR recession for basic-type and divergence excess (DE)-type IXT were retrospectively enrolled at a single institution. The distributions in the XT types were compared according to the D/N difference between primary and recurrent XT. RESULTS: Preoperatively, the population comprised 14 divergence excess (DE) types and 107 basic types. After the BLR recession, the XT-type composition changed to 59 basic types, 33 CI types, and 29 DE types. In one of the 14 preoperatively identified DE-type XT cases, the XT type changed to CI type, it changed to basic type in four cases, and the remaining nine cases showed no change in the DE type. The 107 preoperatively identified basic-type XT cases postoperatively became 55 basic-type, 32 CI-type, and 20 DE-type recurrent XT cases, and their postoperative distance XT control grades and near stereoacuity values did not significantly differ. CONCLUSION: The XT type composition changed after the BLR recession. The XT types in recurrent XT after BLR recession showed an increasing proportion of CI-type. We suspect that an individual fusion mechanism might also influence the XT-type in recurrent XT in view of the somewhat increased DE-type in recurrent XT.

Analysis of postoperative intraocular pathologies in patients with mature cataracts.

PURPOSE: To examine the prevalence and risk factors of intraocular pathologies after mature cataract surgery. METHODS: The medical records of 115 patients (115 eyes) diagnosed with brunescent or white cataracts, who underwent surgery at a single primary center between January 2018 and August 2021 were retrospectively reviewed. Dense cataracts precluded preoperative fundus examination in all eyes; however, patients with fundus examination results within 3 months after cataract surgery were included. Logistic regression analyses were performed to identify factors associated with intraocular pathologies. RESULTS: Intraocular pathologies were observed in 37 eyes (32.2%) 11.8 ± 13.9 days postoperatively. The most common abnormalities were drusen (6.1%), myopic degeneration (5.2%) and diabetic retinopathy (4.3%). Intraocular pathology in the fellow eye was associated with posterior segment pathology in mature cataract eyes (odds ratio, 47.72; P < 0.001). CONCLUSIONS: The prevalence of each intraocular pathology found after mature cataract surgery was unremarkable. This study provides clinically useful evidence for clinicians to explain the risk of posterior segment pathology in patients with mature cataracts.

Do the primary surgical options for basic-type exotropia cause differences in distance-near discrepancy of recurrent exotropia after surgery?

PURPOSE: Most ophthalmologists appear to have no distinct preference between unilateral recess-resect (R&R) and bilateral lateral rectus (BLR) recessions to treat basic-type exotropia. This study aimed to determine whether differences in distance-near discrepancy and resultant exotropia types of recurrent exotropia following surgery for primary basic-type exotropia exist between the two surgical options. METHODS: Ninety-three patients with recurrent exotropia following BLR recessions for basic-type exotropia (BLR group) and 95 following R&R for basic-type exotropia (R&R group) were included in this retrospective study. The exotropia types in recurrent exotropia were classified into three types according to distance-near discrepancy: basic, divergence-excess, and convergence-insufficiency. The BLR and R&R groups were compared. RESULTS: After surgery for basic-type exotropia, the type composition changed differently in each group (p < 0.001). The basic-type of primary exotropia was more often maintained in recurrent exotropia in the R&R group than in the BLR group. The incidence of postoperative convergence-insufficiency type exotropia in the BLR group was 28.0% and 8.4% in the R&R group (p = 0.001). Postoperative near stereopsis and fusion control grade of distance deviation did not differ between the two groups (p > 0.05). CONCLUSIONS: Convergence-insufficiency type recurrent exotropia occurred more frequently after BLR recessions than after R&R for basic-type exotropia. The high rate of secondary convergence-insufficiency type exotropia after BLR recessions should be considered when clinicians select a surgical option to treat exotropia.

Nonarteritic anterior ischemic optic neuropathy is associated with cerebral small vessel disease.

We investigated the presence of cerebral small vessel disease (SVD) in patients with nonarteritic anterior ischemic optic neuropathy (NAION) compared to control subjects without NAION to identify the association between NAION and cerebral SVD. We retrospectively reviewed the cases of 63 patients with NAION and 2749 control subjects without any neurologic and ocular diseases including NAION who underwent careful medical interviews, ophthalmic examinations, and magnetic resonance imaging (MRI) studies of the brain. We assessed and compared the degree of cerebral SVD on the MRIs. The patients with NAION presented with cerebral SVD more frequently than controls (68% versus 37%, respectively, p<0.001), which was also observed after adjusting for age, sex, comorbid conditions including hypertension, diabetes, and dyslipidemia, and smoking using the standardized mortality ratio (68% vs. 37%, p<0.001). A multivariate logistic regression analysis showed that the odds of cerebral SVD were 4.86 (95% CI, 2.10 to 11.24, p<0.001) times higher in patients with NAION than in the controls. We found that there was an association between cerebral SVD and NAION even after adjusting for age, sex, and medical histories. Clinicians should consider brain MRI scans in patients with NAION to prevent neurological impairment after cerebral SVD.

Bevacizumab versus Dexamethasone Implant Followed by Bevacizumab for the Treatment of Macula Edema Associated with Branch Retinal Vein Occlusion.

PURPOSE: To compare visual and anatomical outcomes of intravitreal injections of bevacizumab and dexamethasone implant (Ozurdex) treatment for macular edema associated with branch retinal vein occlusion (BRVO). METHODS: We retrospectively reviewed patients who underwent intravitreal bevacizumab administered monthly on a pro re nata (PRN) basis (26 eyes, IVB group) or an initial 700-µg dexamethasone implant followed by a bevacizumab PRN injection (20 eyes, IVD group) for treatment of macular edema associated with BRVO. We compared best-corrected visual acuity (BCVA) and central macular thickness (CMT). We also measured ellipsoid zone recovery rate and ganglion cell-inner plexiform layer volume within the center 6 mm zone. A linear mixed model analysis was performed to compare serial changes in BCVA and CMT. RESULTS: Both groups showed significant improvement in BCVA and significant reduction in CMT. However, BCVA in the first month was significantly better in the IVD group (logarithm of the minimum angle of resolution, IVD group 0.21 ± 0.26 vs. IVB group 0.39 ± 0.30, p = 0.038) and the 1-month CMT was thinner in the IVD group (IVD group 270.0 ± 62.0 µm vs. IVB group 338.9 ± 122.6 µm, p = 0.028), and these trends were maintained during the 6-month follow-up. The IVD group showed more rapid macular edema resolution (p = 0.049); however, there were no significant differences in ellipsoid zone recovery rate (p = 0.268) or ganglion cell-inner plexiform layer volume between the two groups (p = 0.459). CONCLUSIONS: There were no significant differences in final visual or anatomical outcomes between the two groups; however, initial dexamethasone implant injection followed by bevacizumab PRN injection initially showed more rapid improvement in vision and BRVO-associated macular edema resolution compared to intravitreal bevacizumab administered monthly on a PRN basis.

Retinal Vein Occlusion as the Surrogate Marker for Premature Brain Aging in Young Patients.

Purpose: We investigated cerebral small vessel disease (SVD) in patients with incidental retinal vein occlusion (RVO). Methods: This retrospective, case-control, observational trial included 125 patients with RVO who underwent brain magnetic resonance imaging (MRI) and 1105 age-matched controls who underwent comprehensive medical interviews and MRI. Underlying cardiovascular diseases and MRI findings were investigated in the patients with RVO according to age (<60 or ≥60 years) and RVO occlusion level (central or branch). The characteristics of underlying cardiovascular disease and MRI findings were compared between the younger patients with RVO and age-matched controls. The cerebrovascular burden also was assessed in the younger patients with RVO. Results: The mean age of the patients with RVO was 63.9 ± 12.1 years and the predominant underlying disease was hypertension (72/125, 58%). The older RVO group had a longer history of hypertension and less smoking history. The prevalence of cerebral SVD in the RVO group was 54% (68/125), and was significantly higher in older than in younger patients with RVO (62% [53/86] vs. 38% [15/39], P = 0.016). However, the latter had a significantly higher prevalence of cerebral SVD than their age-matched controls (38% [15/39] vs. 4% [47/1105], P < 0.001). There was no difference in prevalence of cerebral SVD between the central and branch RVO groups (P = 0.478). Conclusions: Cerebral SVD presented frequently in patients with RVO and was magnified in young patients, suggesting that RVO is a surrogate marker for cerebral SVD.

Ischemic Injury of the Papillomacular Bundle Is a Predictive Marker of Poor Vision in Eyes With Branch Retinal Artery Occlusion.

PURPOSE: To propose a novel prognostic feature of spectral-domain optical coherence tomography (SDOCT) in macula-involving branch retinal artery occlusion (BRAO). DESIGN: Retrospective comparative case study. METHODS: We analyzed 66 eyes diagnosed with acute BRAO involving the macula from our hospital RAO registry. At presentation, a detailed ophthalmic and medical history was obtained from all patients, and all underwent a comprehensive ophthalmic evaluation, which included visual acuity examination, fundus photography, fluorescein angiography, and SDOCT. This evaluation was performed at each follow-up visit. RESULTS: The 66 eyes diagnosed with acute BRAO involving the macula were divided into 2 groups according to initial vision: Good Vision (≥20/40, 29 eyes, 44%) and Poor Vision (<20/40, 37 eyes, 56%). The Poor Vision group was further divided into Improvement (18 eyes, 27%) and Nonimprovement (19 eyes, 28%) groups, according to visual recovery at the final examination. Among multiple OCT parameters, the involvement of papillomacular bundle, but not that of the central fovea, was consistently observed in the Poor Vision group (P < .001) and more significantly in the Nonimprovement group (P < .001). Papillomacular bundle involvement features included signs of inner retinal ischemia, including inner retinal thickening, inner retinal hyperreflectivity, and loss of layer-by-layer integrity. Loss of layer-by-layer integrity was seen consistently in the Nonimprovement group. Quantitative analysis of inner retinal thickness also supported this association. CONCLUSION: In eyes with macula-involving BRAO, ischemic injury of the papillomacular bundle at the acute stage, as seen on OCT, correlates closely with poor vision and can explain the poor visual prognosis.

Inner-Retinal Irregularity Index Predicts Postoperative Visual Prognosis in Idiopathic Epiretinal Membrane.

PURPOSE: To investigate the correlation between the inner-retinal irregularity index and visual outcomes before and after idiopathic epiretinal membrane (ERM) surgery. DESIGN: Retrospective cohort study. METHODS: We analyzed 66 eyes of 66 patients with idiopathic ERM. Ophthalmic examinations included best-corrected visual acuity (BCVA) measurements, metamorphopsia assessment, and spectral-domain optical coherence tomography before surgery and 1, 3, and 6 months post-surgery. Correlations between the inner-retinal irregularity index, defined as the length ratio between the inner plexiform layer and retinal pigment epithelium, and visual outcomes before and after ERM surgery were evaluated and compared with the correlation between the central foveal thickness, ganglion cell-inner plexiform layer (GC-IPL) thickness, interdigitation zone defect, and visual outcomes. RESULTS: Inner-retinal irregularity index and central foveal thickness were significantly correlated with BCVA and metamorphopsia at each follow-up examination (all P < .05). The interdigitation zone defect correlated with BCVA at 3 and 6 months post-surgery (P < .001 and P < .015, respectively). However, GC-IPL thickness was not correlated with visual outcomes at any follow-up examination. The preoperative interdigitation zone defect was correlated with 6-month BCVA (P = .035) and the preoperative inner-retinal irregularity index was significantly correlated with the 6-month BCVA and marginally correlated with the 6-month metamorphopsia (P = .018 and P = .097, respectively). CONCLUSION: The inner-retinal irregularity index was significantly correlated with visual outcomes before and after ERM surgery. This index can be used as a new surrogate marker for inner-retinal damage and a predictive prognostic marker in ERM.

Cerebral Small Vessel Disease in Branch Retinal Artery Occlusion.

PURPOSE: We investigated the pathophysiology of branch retinal artery occlusion (BRAO) by evaluating the retina, brain, and carotid artery in patients with BRAO. METHODS: This study was a retrospective registry study. We used 46 eyes from 46 patients with acute BRAO and evaluated the medical history, including previous cardiovascular disease, and compared brain magnetic resonance images (MRI) and carotid artery stenosis state between the embolic BRAO group and nonembolic BRAO group. We measured differences in cerebrovascular characteristics, including brain MRI, according to the existence of retinal emboli. RESULTS: The embolic BRAO group tended to have a significantly higher likelihood of cardiovascular disease history, including ischemic heart disease and smoking history (P = 0.018 and P < 0.001, respectively). In addition, the embolic group had a higher frequency of acute cerebral infarctions and stenotic carotid arteries (P = 0.017 and P = 0.028, respectively). Although the overall frequency of cerebral small vessel disease (SVD) did not differ between embolic and nonembolic groups, the nonembolic BRAO group showed a significantly higher prevalence of cerebral SVD without large vessel pathology (P = 0.008). CONCLUSIONS: Patients with BRAO showed different cerebrovascular characteristics following retinal emboli, including brain MRI findings. The results suggest that we must consider SVD etiology as well as large vessel disease mechanisms in the pathophysiology of BRAO.

Incidence Rate of Massive Submacular Hemorrhage and its Risk Factors in Polypoidal Choroidal Vasculopathy.

PURPOSE: To investigate the incidence rate of massive submacular hemorrhage (SMH) in patients with polypoidal choroidal vasculopathy (PCV) and analyze the associated risk factors. DESIGN: Retrospective cohort study. METHODS: Patients diagnosed with PCV from May 2003 to May 2014 were included. Two hundred forty-five eyes of 245 patients were enrolled. The time between the initial visit to the clinic with subjective visual symptoms and the date of massive SMH was recorded. SMH larger than 4 disc diameters was defined as massive SMH. Age; hypertension; visual acuity (VA); indocyanine green angiography findings, including the greatest linear dimension, largest polyp size, and PCV type (cluster vs non-cluster); and treatment methods were reviewed for risk factor analysis using Kaplan-Meier survival and Cox regression analyses. RESULTS: The incidence rate of massive SMH within 1 year after the initial visit was 2.45%. Massive SMH occurred within 3, 5, and 10 years after the first visit in 6.17%, 11.09%, and 29.85% of patients, respectively. Cox regression analysis revealed that the cluster type of PCV was significantly associated with massive SMH (hazard ratio [HR], 3.418; P = .003). Photodynamic therapy followed by anti-vascular endothelial growth factor injection lowered the risk of massive SMH (HR = .242; P = .047]. Final VA in eyes with massive SMH was significantly lower than that in patients without massive SMH (1.34 ± 0.66 vs 0.63 ± 0.53 logMAR; P < .001). CONCLUSIONS: Patients with PCV who develop massive SMH experience severe vision loss. The incidence rate of massive SMH in PCV increases with time. The cluster type of polyp in PCV is a significant risk factor for massive SMH.

The Characteristics of Retinal Emboli and its Association With Vascular Reperfusion in Retinal Artery Occlusion.

PURPOSE: To analyze the characteristics of retinal emboli and their association with vascular reperfusion in retinal artery occlusion (RAO). METHODS: In this retrospective comparative case series, we analyzed emboli in patients with acute central retinal artery occlusion (CRAO) or branch retinal artery occlusion (BRAO) and visible emboli, and analyzed vascular reperfusion in patients with visible emboli causing blockage of perfusion. The patients were divided into emboli "movement" and "no movement" groups and their vascular reperfusion states were compared. RESULTS: There were 52/248 (21%) eyes with RAO and visible retinal emboli (31/187 [17%] eyes with CRAO and 21/61 [34%] eyes with BRAO) showing various embolic features. Platelet-fibrin emboli were observed most commonly, and showed the earliest and highest rate of movement. In the movement group, which comprised platelet-fibrin (60%) and cholesterol (40%) emboli, early complete reperfusion was observed in 80% of eyes; however, 67% of eyes in the no movement group, comprising cholesterol (67%) and calcific (33%) emboli, showed late incomplete reperfusion. There were no cases of permanent vascular blockage. The mechanisms of vascular reperfusion could be summarized as complete degradation, peripheral migration, partial dislodgement, angiophagy, and collateral circulation. CONCLUSIONS: Retinal emboli in RAO patients have various characteristics that affect their movement. Movement of emboli may affect vascular reperfusion. Various mechanisms are associated with vascular reperfusion, including in cases without movement of emboli. These mechanisms may apply to cerebrovascular occlusion and stroke in general.

Changes in postoperative refractive outcomes following combined phacoemulsification and pars plana vitrectomy for rhegmatogenous retinal detachment.

PURPOSE: To evaluate changes in postoperative refractive outcomes following combined phacoemulsification and pars plana vitrectomy for rhegmatogenous retinal detachment (RRD) compared with other retinal diseases. DESIGN: Retrospective observational case-control study. METHODS: A total of 55 patients who had combined surgery between January 2007 and December 2012 were enrolled. The 25 patients who underwent combined surgery for RRD were included in the RRD group, and 30 patients who underwent combined surgery for other vitreoretinal pathology were included in the control group. Refractive axial length and intraocular pressure (IOP) measurements were performed, and the factors influencing the postoperative refractive outcomes were analyzed. RESULTS: The mean differences between the postoperative and predicted refractive outcomes in the RRD group and the control group were -0.43D±0.67 (P=.046) and -0.08D±0.53 (P=.767), respectively. The mean preoperative IOPs of the affected eye and the fellow eye in the RRD group were 11.44 mm Hg±3.15 and 13.16 mm Hg±2.73 (P=.045), but no differences were found in the affected eyes and fellow eyes of the control group. The differences were 14.20 mm Hg±2.95 and 14.17 mm Hg±3.50, respectively (P=.974). The mean postoperative IOPs in the affected eyes and the fellow eyes of the 2 groups were not significantly different. For all eyes, the refractive differences correlated with IOP changes in the RRD group. (r=.659, r2=.435, P<.001). CONCLUSIONS: The postoperative refractive outcomes in the RRD group shifted toward myopia by a mean of 0.35 diopters compared with the control group. Normalizing preoperative lowered IOP after combined surgery in RRD may be the key factor in understanding this myopic shift.