Outcomes of Combined Phacovitrectomy Without Corneal Suturing.

BACKGROUND: During combined phacovitrectomy, it is common practice to suture the main corneal incision to prevent intraoperative and postoperative wound leak. However, it may be possible to avoid suturing using a self-sealing corneal incision technique as in standard cataract surgery. OBJECTIVES: To evaluate the clinical outcome, safety, and complications of combined phacovitrectomy without preventive suturing. METHODS: This retrospective case series study included consecutive patients who underwent combined phacovitrectomy between January 2018 and June 2019 for mixed indications. Surgeries were performed at a tertiary university hospital. All surgeries were performed by the same two retinal surgeons. Cataract surgery was performed first, followed by insertion of trocars and vitrectomy. Corneal sutures were not planned but were used at the discretion of the surgeon. RESULTS: The cohort included 106 eyes of 102 patients. Suturing of the main corneal incision was deemed necessary in five cases (5%) because of a main incision leak or anterior chamber shallowing during trocar insertion. No other complications related to the absence of prophylactic corneal sutures were encountered during surgery or follow-up. CONCLUSIONS: Preventive corneal suturing may not be necessary in combined phacovitrectomy surgery and can be used in the few cases in which it is indicated during surgery.

FULL-THICKNESS MACULAR HOLE IN AGE-RELATED MACULAR DEGENERATION PATIENTS WITH TWO DISTINCT ENTITIES: A Multicenter Study.

PURPOSE: To describe optical coherence tomography characteristics of full-thickness macular holes (FTMHs) in age-related macular degeneration patients. METHODS: A multicenter, retrospective, observational case series of patients diagnosed with age-related macular degeneration and FTMHs seen between January 1, 2009, and January 3, 2020. Clinical charts and spectral-domain optical coherence tomography images were reviewed. Optical coherence tomography findings included FTMH-inverted trapezoid or hourglass appearance, central macular thickness (CMT), complete retinal pigment epithelium and complete retinal outer retinal atrophy, and presence of pigment epithelium detachment and epiretinal membrane. The mean outcome was the morphologic and functional characterization of different subtypes of FTMHs. RESULTS: A total of 86 eyes of 85 consecutive patients, with mean age of 80.31 ± 8.06 and mean best-corrected visual acuity of 1.17 ± 0.58 logarithm of the minimal angle of resolution. Two different subtypes of FTMHs were identified: tractional and degenerative. Fifty (58%) degenerative FTMHs characterized with inverted trapezoid appearance and 36 (42%) tractional FTMHs characterized with hourglass appearance. Degenerative FTMHs presented with 66% of CMT < 240 µm, 14% of CMT > 320, and 70% of complete retinal outer retinal atrophy, in comparison with 41% of CMT < 240 µm, 42.9% of CMT > 320%, and 20% of complete retinal outer retinal atrophy in the tractional FTMH group (P = 0.002, 0.003, <0.001, respectively). The presence of epiretinal membrane and pigment epithelium detachment where significantly higher in tractional FTMHs (P = 0.02, 0.03, respectively). CONCLUSION: Degenerative and tractional FTMHs may be two distinct clinical entities. Discerning degenerative from tractional FTMHs is possible by using optical coherence tomography features including shape of the FTMHs, CMT, internal-external ratio of FTMHs, and presence of complete retinal outer retinal atrophy, pigment epithelium detachment, and epiretinal membrane.

Ocular Trauma Caused by Confetti Cannons.

BACKGROUND: Eye trauma is an unfortunate and often preventable cause of vision loss. Confetti cannons are common causes of injury. Awareness of ocular hazards of confetti cannons remains low because of limited reports describing ophthalmic injuries following their use. OBJECTIVES: To describe outcomes of ocular trauma caused by confetti cannons and to increase recognition of their ocular risks. METHODS: A retrospective analysis was conducted of eye injuries caused by confetti cannons presenting to a single medical center between 2016 and 2020. Data collected included age, gender, eye injured, ocular damage, visual outcome, and details of surgeries performed. RESULTS: Overall, six consecutive patients (2 males, mean age 19.5 ± 9.74 years) were identified and studied. In all patients only one eye was injured (3 right eyes) during a private celebration, most commonly (n=5) to a bystander while in the vicinity of a cannon operated by someone else. Most common eye injuries included corneal erosion (n=4), traumatic hyphema (n=4), and retinal edema (n=3). Mean initial logMAR visual acuity in the injured eye was 0.73 ± 0.18, improving to 0.25 ± 0.16 at the final visit (P = 0.125). Two patients underwent eye surgery due to their trauma: one to repair globe penetration and another to undergo intravitreal injection of tissue plasminogen activator and C3F8 for submacular hemorrhage, followed 8 months later by intravitreal bevacizumab injection for choroidal neovascularization. CONCLUSIONS: Confetti cannons pose hazards that can cause severe ocular trauma resulting in permanent vision loss. Increasing awareness of device hazards is necessary to prevent eye injuries.

PATIENTS WEARING FACE MASKS DURING INTRAVITREAL INJECTIONS MAY BE AT A HIGHER RISK OF ENDOPHTHALMITIS.

PURPOSE: To investigate the safety of face masks worn by patients during intravitreal injections. METHODS: A prospective, qualitative, interventional study performed in a tertiary university hospital. Healthy volunteers were asked to wear three different professional surgical face masks while air leaks around the eyes were monitored. Three types of masks were investigated as follows: 1) surgical face mask with four tying strips, 2) surgical face mask with elastic ear loops and 3) 2200 N95 tuberculosis particulate face mask. For each session the periocular area was inspected for air leak during normal respiration, speech, and deep respiration. Detection of air leak was performed using the following two professional thermal cameras: FLIR A310-thermal camera and EyeCGas 2.0-super sensitive infrared camera used for detection of minute fugitive emissions of industrial gases. RESULTS: Ten healthy volunteers were enrolled in this study. The experiment was repeated 45 times for each camera; 3 times for each of 3 mask types, on 5 volunteers, for a total of 90 trials. Air jets were detected originating from the superior edges of the masks radiating toward the eyes in 81% (73/90) of cases in total; 71% (32/45) with the FLIR camera and 91% (41/45) with the OPGAL camera. Air leaks were detected with all investigated mask types. CONCLUSION: Patients wearing face masks during intravitreal injections may be at a higher risk of endophthalmitis. Until further data are available, we recommend verifying proper face mask fitting and either taping the upper edges of the face masks with a medical adhesive tape or using an adhesive surgical drape around the injected eye.

Is Performing Femtosecond Laser-Assisted In Situ Keratomileusis on the Day of the Initial Consultation Visit Safe, Predictable and Efficacious?

OBJECTIVES: Our aim is to evaluate the safety, efficacy, predictability, and clinical outcome of femtosecond laser-assisted in situ keratomileusis (FS-LASIK) procedures performed on the day of the initial consultation relative to procedures performed at subsequent visits. METHODS: A retrospective cohort study design was used. The study group included patients with myopia of different severities who were treated with FS-LASIK in 2013 through 2014 in an optical outpatient clinic of a large private medical service. Inclusion criteria were at least 18 years of age, a stable refraction for 12 months, no history of autoimmune disease, ocular surgery, or eye disease, and complete medical records. Background, clinical, and outcome data were collected from the patient files. RESULTS: Femtosecond laser-assisted in situ keratomileusis was performed in 80 patients (160 eyes) at the first visit and 361 patients (719 eyes) at a subsequent visit. The mean±SD spherical equivalent (SE) refraction before surgery was -3.74±2.03 D in the first-visit group and -3.73±1.87 D in the subsequent-visit group (P=0.99). Efficacy index values were 0.97±0.15 in the first-visit group and 0.98±0.13 in the subsequent-visit group (P=0.92), and corresponding safety index values were 0.99±0.15 and 0.99±0.12 (P=0.81). The final SE measured -0.09±0.58 D in the first-visit group and -0.19±0.55 D in the subsequent-visit group (P=0.05). Types and rates of complications were similar in the two groups. CONCLUSIONS: There is no significant difference in the results of refractive surgery with FS-LASIK between procedures performed at the initial or subsequent visits. In both conditions, FS-LASIK surgery is associated with excellent safety, efficacy, and predictability profiles.

Research productivity across different ophthalmic subspecialties in the United States.

BACKGROUND: The purpose of this study was to compare the h-index, and subsequently the research productivity, among different ophthalmic subspecialties in the United States. METHODS: A cohort of over 15,000 academic ophthalmologists residing in the United States (US) was identified out of the physician list of the American Academy of Ophthalmology. Of them, 1000 ophthalmologists with at least one publication were randomly retrieved, 100 in each of the following 10 subspecialties: cataract, cornea/external disease, glaucoma, medical retina, neuro-ophthalmology, pediatric ophthalmology, plastic/reconstructive ophthalmology, refractive surgery, retina/vitreous surgery and uveitis. Data collected included: number of published papers, h-index score, annual increase in h-index and the mean number of authors on each paper. RESULTS: The mean h-index amongst all subspecialties was 9.87 ± 13.90, and the mean average annual increase in h-index was 0.22 ± 0.21. The mean number of papers published was 37.20 ± 80.08 and the mean number of authors on each paper was 3.39 ± 0.84. Uveitis was the most prolific subspecialty in mean number of papers (74.78 ± 131.37), in mean h-index (16.69 ± 20.00) and in mean annual increase in h-index (0.35 ± 0.28). The least fertile subspecialty with regards to research was cataract with 11.06 ± 27.65 mean number of papers, a mean h-index of 3.89 ± 5.84, and a mean annual increase in h-index of 0.11 ± 0.11. CONCLUSIONS: This study describes the research productivity in each ophthalmic subspecialty in the US, thus providing information on the research performance of each field and on the expected academic accomplishments within it.

Retinal Penetration of Intravitreally Injected Tissue Plasminogen Activator: A Rat Model Study.

PURPOSE: To determine whether intravitreal unconjugated tissue plasminogen activator (tPA) (alteplase) can penetrate the intact neural retina and reach the subretinal space in an experimental model. METHODS: This study was performed in 24 Sprague-Dawley rats aged 12 weeks. Under general anesthesia, the right eye was injected with either 0.75 µg of 3 µL tPA (14 rats; study group) or saline (10 rats, control group) into the vitreous. Animals were euthanized at 3, 24, and 48 h. The eyes were enucleated, and cryosections were prepared for immunofluorescence staining. Goat anti-tPA antibody was used to detect tPA. RESULTS: In the study group, staining for tPA was detected in the deep retinal layers in all eyes. The staining was deeper and more intense at 3 and 24 h than at 48 h. There was no tPA staining in the retina of eyes injected with saline. CONCLUSIONS: This experimental study shows that unconjugated tPA administered into the vitreous is capable of penetrating the deep retinal layers and the subretinal space. These findings suggest that further clinical research is warranted on the benefits of intravitreal tPA in the treatment of submacular hemorrhage.

Possible involvement of NETosis in inflammatory processes in the eye: Evidence from a small cohort of patients.

Purpose: To evaluate whether NETosis is involved in cytokine-induced ocular inflammation and to track neutrophil extracellular traps (NET) complexes in patients with proliferative diabetic retinopathy (PDR). Methods: For the animal model, the eyes of C57BL/6J mice were intravitreally injected with interleukin-8 (IL-8), tumor necrosis factor alpha (TNF-α), or saline. Histology and immunofluorescence staining for CD11b, neutrophil elastase (NE), myeloperoxidase (MPO), citrullinated histone 3 (H3Cit), and net-like structure were performed. Vitreous samples were collected from patients with PDR; the PDR1 group had no need for repeated surgical intervention, and the PDR2 group had repeated vitreous bleeding or other complication and controls. Levels of MPO, H3Cit-MPO, and NE-MPO complex were measured with enzyme-linked immunosorbent assay (ELISA). Results: Massive influx of CD11+ inflammatory cells, involving the anterior and posterior chambers, was observed in the murine eyes 24 h after the IL-8 or TNF-α injections. Cells excreted to their surroundings an extracellular net-like structure positive for NE, MPO, and H3Cit. H3Cit staining was abolished with the DNase I treatment, indicating the presence of extracellular DNA in the net-like structures. The vitreous samples of the patients with PDR2 contained statistically significantly higher levels of MPO (173±230) compared to those of the patients with PDR1 (12.0±33.0, p<0.05) or the controls (0.00, p<0.01). The levels of H3Cit-MPO and NE-MPO complexes were also statistically significantly higher in the patients with PDR2 (776.0±1274, 573.0±911.0, respectively) compared to those in the patients with PDR1 (0, p<0.05) and the controls (0, p<0.05). Conclusions: This study showed the existence of NETosis in cytokine-induced ocular inflammation in a mouse model and human samples. Furthermore, the extent of NET complex formation was higher in a subset of patients who exhibited more complicated PDR.

Bevacizumab clearance through the iridocorneal angle following intravitreal injection in a rat model.

Antivascular endothelial growth factor (Anti-VEGF) agents have been widely used for a variety of ocular disorders. The etiology of sustained ocular hypertension following intravitreal administration of anti-VEGF agents is yet to be unraveled. Our study investigates and characterizes the presence of intravitreally injected bevacizumab in the aqueous outflow channels of a rat model. Choroidal neovascularization (CNV) was induced by diode laser photocoagulation to the right eye of twelve Brown Norway rats. Bevacizumab (25 mg/ml) was injected intravitreally after 3 days. Immediately after bevacizumab injection, and 3, 6, 24 and 48 h later, animals were euthanized for immunofluorescence staining. Donkey anti-human IgG labeled with Alexa Fluor(®) 488 was used for bevacizumab immunoreactivity detection. Anti-CD31 antibody was used as a marker for Schlemm's canal endothelial cells. Untreated eyes were used as negative controls. The intensity of the immunostaining was analyzed qualitatively. Bevacizumab immunoreactivity was found in the aqueous outflow channels including the trabecular meshwork and Schlemm's canal immediately after injection, and declined incrementally within the following hours. Forty-eight hours after the injection, no bevacizumab staining was detected in the aqueous outflow channel structures. Our manuscript demonstrates the presence of bevacizumab in the trabecular meshwork and Schlemm's canal structures after intravitreal injection in a CNV induced rat model. Bevacizumab molecules passed through the aqueous outflow channels within 48 h after intravitreal bevacizumab injection.

The Effectiveness of Intravitreal Ranibizumab in Patients with Diabetic Macular Edema Who Have Failed to Respond to Intravitreal Bevacizumab.

PURPOSE: To investigate the response to intravitreal ranibizumab after failure of intravitreal bevacizumab in patients with diabetic macular edema (DME). METHODS: Demographics, visual acuity (VA), central macular thickness (CMT), and HbA1C were retrospectively collected from DME patients treated with second-line intravitreal ranibizumab at a tertiary hospital in 2012-2013 and followed for at least 3 months. RESULTS: Twenty-two patients (26 eyes) were included in the study, with a mean (±SD) age of 66 ± 8.1 years and followed for an average of 28.36 months. The mean number of intravitreal bevacizumab injections was 7.3 ± 2.8, and of intravitreal ranibizumab injections 5.11 ± 2.4. After 3 ranibizumab injections, 57% of eyes showed improvement in VA. The change in VA was statistically significant (p = 0.044) in those eyes where the pretreatment acuity for the second-line therapy was <20/40 (logMAR 0.3). CMT decreased from 435.95 ± 83.28 to 373.69 ± 44.39 µm (p = 0.01). The number of ranibizumab injections was significantly correlated with the change in CMT (p = 0.037). CONCLUSION: Intravitreal treatment with ranibizumab can be efficacious in eyes with DME that have failed to respond to bevacizumab.

Intracameral cefuroxime and the incidence of post-cataract endophthalmitis: an Israeli experience.

PURPOSE: The European Society of Cataract & Refractive Surgeons (ESCRS) study reported a decrease in endophthalmitis rates from 0.34 % to 0.08 % with the use of intracameral cefuroxime. The purpose of this study was to compare the endophthalmitis rates before and after the introduction of intracameral cefuroxime (ICC) routinely at the end of cataract surgery. METHODS: A retrospective consecutive cohort study. We compared the rates of endophthalmitis between the years 2000-2006, and the years 2007-2014, after the pivotal publication of the ESCRS. Data collected included age, gender, culture results, initial and final visual acuity, and complications. Only patients that presented with endophthalmitis following cataract surgery performed at the two centers were included. RESULTS: Twenty-two cases of endophthalmitis occurred between the years 2000 and 2006, out of 26,663 cataract operations performed at the two centers, a rate of 0.083 %. Ten cases occurred between the years 2007 and 2014 out of 29,431 cataract operations, a rate of 0.034 %. The difference was statistically significant (p = 0.03) CONCLUSIONS: The introduction of prophylactic use of intracameral cefuroxime was associated with a significant reduction in post-operative endophthalmitis rates in our centers. We strongly recommend adoption of this routine by for all cataract operations except when contraindicated.

Mechanical impact of epiretinal membranes on the retina utilizing finite element analysis.

BACKGROUND AND OBJECTIVE: Epiretinal membrane (ERM) is a transparent membrane that forms on the surface of the neurosensory retina, causing tangential traction on the retinal surface, which may contribute to cell proliferation and contraction. Epiretinal membranes (ERMs) may be asymptomatic in some patients, while in others the membranes can progress, resulting in macular thickening and macular traction, thus distorting and inducing loss of central visual function and metamorphopsia. Currently, treatment options include follow-up or pars plana vitrectomy with an ERM peel, aiming to relieve the macular traction and improve vision and metamorphopsia. No specific criteria exist for predicting which patients might progress and need early surgery to improve and maintain good vision. The decision for surgery is based on the individual's symptoms and the physician's judgment. This study aimed to evaluate the mechanical impact in terms of stress and deformations of the ERM and to qualitatively compare them with the clinical progression of fovea thickening observed through optical coherence tomography (OCT) images. METHODS: Numerical simulation on a three-dimensional geometrical retina and ERM model was applied to isolate factors that can be used to predict its progression and prognosis. OCT images of 14 patients with ERM were used to derive the fovea thickness progression before and after vitrectomy surgery with ERM peeling. RESULTS: The results clearly show that the increase in ERM contractility level increases the developed stress at the fovea, which spreads and advances toward its base. The highest stress level (2.1 kPa) was developed at the highest and asymmetric contractility, producing non-uniform distributed deformations that distort the fovea structure. CONCLUSIONS: These findings imply that high and asymmetric ERM contractility should be evaluated clinically as a factor that might signal the need for early vitrectomy surgery to avoid irreversible visual loss. Moreover, the OCT images revealed that in some cases, the thickness of the fovea indeed remains high, even after ∼12 months postoperatively, which also indicates that the deformation of the fovea in these cases is irreversible.

Timing of acute macula-on rhegmatogenous retinal detachment repair.

PURPOSE: To determine if same-day or next available surgery changed the outcome of patients presenting with acute macula-on rhegmatogenous retinal detachments. METHODS: A retrospective review of patients presenting with acute macula-on rhegmatogenous retinal detachments treated with small-gauge vitrectomy was performed. Data collection included subjects' demographics, duration of symptoms, location and extent of the retinal detachment, and timing of surgery. The primary outcome was anatomical and functional success rate for patients having same-day surgery compared with those for whom surgery was delayed. RESULTS: One hundred and fourteen patients were included in this study. Sixty-two patients operated on day of presentation, 46 patients operated the day after presentation, and in 6 patients, surgery was delayed from 2 to 5 days. Time to surgery in hours ranged between 1 and 120 hours (mean 14.5 ± 15.05 hours). Retinal reattachment was achieved in 95.6% of patients, with 80% requiring only one procedure. Mean initial visual acuity was logarithm of the minimum angle of resolution 0.42 (SD 0.6), and mean final visual acuity was logarithm of the minimum angle of resolution 0.39 (SD 0.67) (P = 0.53). Time to surgery was not found to effect final anatomical outcome (P = 0.56). No statistically significant association was observed between change in visual acuity and time to surgery (P = 0.99). CONCLUSION: Modest delay in timing of surgery for macula-on rhegmatogenous retinal detachment did not adversely impact on patients' outcome.

LASER PHOTOCOAGULATION FOR THE TREATMENT OF OPTIC NERVE HEAD PIT-RELATED MACULOPATHY IN A PATIENT WITH BILATERAL CHORIORETINAL COLOBOMA.

PURPOSE: To report a case of laser photocoagulation for the treatment of a combined coloboma and optic nerve head pit-related maculopathy in a patient with bilateral chorioretinal coloboma. METHODS: A case report. RESULTS: A 15-year-old woman, presented with the visual acuity of 20/100 in her right eye for six weeks. She was diagnosed with macular detachment secondary to optic nerve head pit in her right eye and bilateral chorioretinal coloboma. Multimodal imaging, including color photography, fluorescein angiography, and spectral-domain optical coherence tomography, was used to identify and demonstrate the location of the tract of fluid from the optic nerve head pit, isolated from the coloboma. Optical coherence tomography-guided laser photocoagulation treatment at the location of the tract resulted in complete resolution of macular fluid with visual recovery to 20/25. CONCLUSION: Our case stresses the value of correct diagnosis directing photocoagulation treatment of combined optic nerve head pit-related maculopathy in eyes with chorioretinal coloboma using multimodal imaging.

Visual acuity outcome in patients with subretinal hemorrhage - office procedure vs. surgical treatment.

PURPOSE: To evaluate the effects of intravitreal injection of tissue plasminogen activator (tPA) and gas vs. pars plana vitrectomy (PPV) surgery as first-line treatment for subretinal hemorrhage. METHODS: Retrospective study of 107 adults treated for subretinal hemorrhage at a tertiary hospital during 2008-2019; 51 received injection of tPA and gas and 56 underwent PPV. RESULTS: No between-group differences were found in age and sex, medical history, use of anticoagulants or antiplatelets, history of ocular surgeries, and previous use of intravitreal anti-VEGF. Overall follow-up time was longer in the PPV group (median 4.9 vs 3.28 years, p = 0.005). The hemorrhage was displaced in a similar percentage of patients in the tPA-and-gas group (n = 40, 78.4%) and the PPV group (n = 45, 80.4%) (p = 0.816). Approximately 80% of patients in the tPA-and-gas group were able to forgo PPV surgery. Visual acuity (in LogMAR) was similar in the two groups prior to the diagnosis of subretinal hemorrhage but better in the tPA-and-gas group at the end of follow-up (p < 0.001). CONCLUSION: Injection of gas and tPA can be done immediately following diagnosis of subretinal hemorrhage as an office procedure. Visual acuity outcome is good, with a high rate of blood displacement. About 20% of patients might require additional PPV as secondary intervention.

Optical coherence tomography angiography patterns of type 1 macular neovascularization in age-related macular degeneration patients.

PURPOSE: To compare morphologic characteristics of type 1 macular neovascularization (MNV) flow pattern in treatment-naïve and previously treated patients with age-related macular degeneration (AMD) as assessed by optical coherence tomography angiography (OCTA). STUDY DESIGN: Cross-sectional study. MATERIALS AND METHODS: Macular OCT angiography images were acquired using RTVue XR Avanti with AngioVue. Distinct morphologic biomarkers and quantifiable features of the neovascular membranes were studied on en-face projection images comparing treatment-naïve and previously treated patients. RESULTS: The study included 68 eyes of 58 patients. Among them, 24 eyes were treatment-naïve, and the remaining eyes had received a mean of 19.6 injections. Immature lesions were more associated with treatment-naïve eyes and hyper-mature lesions were associated with previously treated eyes (p = 0.005). Tangle pattern was associated with treatment-naïve eyes (p = 0.013), whereas mature core vessels and sea fan pattern were associated more with previously treated eyes (p = 0.001 and p = 0.044, respectively). Vascular density of the neovascular membrane was higher in the treatment-naïve group (p = 0.036) and the average MNV area was similar between the 2 groups (p = 0.683). CONCLUSIONS: Based on OCTA, morphologic biomarkers of type 1 MNV might be an indication of previous treatment. The MNV pattern can improve our understanding of its maturation under anti-VEGF treatment and might be valuable to better guide therapeutic decisions and provide more personalized care to patients with AMD.

Prognostic factors for visual acuity improvement after treatment of submacular hemorrhage secondary to exudative age-related macular degeneration.

PURPOSE: To recognize prognostic factors for better final visual acuity (VA) in patients presenting with submacular hemorrhage (SMH) secondary to exudative age-related macular degeneration. METHODS: This retrospective study included patients who presented to a tertiary ophthalmology department between 2012 and 2019 with SMH and were treated by pars plana vitrectomy (PPV) or injection of tissue plasminogen activator (tPA) with pneumatic displacement. Baseline characteristics included demographic data, VA and optical coherence tomography (OCT) characteristics of the SMH. Patients were divided into groups by improvement of at least 2 lines in BCVA (best corrected visual acuity), and by having a final BCVA better than 20/200. RESULTS: Forty-three eyes of 43 patients were included. Mean age was 86.72 ± 7.18. Prognostic factors for final VA better than 20/200 included better VA at presentation (1.25 vs 1.90 logMAR, p < 0.001), smaller area of SMH in the infra-red image (19.47 mm2 vs 38.45 mm2, p = 0.024), and lower height of SMH as measured by OCT (713.5 µm vs 962.5 µm, p = 0.03). Third of the patients improved in ≥2 lines from presentation, all in the group of the pneumatic and TPA displacement. CONCLUSION: Smaller SMHs with good VA at presentation have a better chance for improvement and result in a better final VA. These patients may benefit the most from pneumatic displacement of the SMH with intravitreal tPA and gas.

Anatomical and Functional Outcomes with Prompt versus Delayed Initiation of Anti-VEGF in Exudative Age-Related Macular Degeneration.

PURPOSE: To investigate the correlation between time from diagnosis of treatment-naïve exudative age-related macular degeneration (AMD) to the introduction of anti-VEGF treatment and anatomical and functional outcomes. DESIGN: Retrospective cohort study. METHODS: Included were treatment-naïve exudative AMD patients who presented to a single tertiary medical center between 2012 and 2018. All patients were treated within the first 30 days of their diagnosis with three monthly intravitreal injections of bevacizumab. Patients were divided into three groups: group 1 (prompt anti-VEGF) were injected with bevacizumab within ten days, group 2 (intermediate anti-VEGF) within 11-20 days, and group 3 (delayed anti-VEGF) within 21-30 days from diagnosis. Baseline characteristics and clinical outcomes were compared up to two years from treatment. RESULTS: 146 eyes of 146 patients were included. Sixty-eight patients were in the prompt anti-VEGF group, 31 in the intermediate anti-VEGF group, and 47 in the delayed anti-VEGF group. Following the induction phase of three intravitreal bevacizumab injections, the mean central subfield macular thickness (328.0 ± 115.4 µm vs. 364.6 ± 127.2 µm vs. 337.7 ± 150.1 µm, p = 0.432) and the best-corrected visual acuity (0.47 ± 0.38 vs. 0.59 ± 0.48 vs. 0.47 ± 0.44 logMAR units, p = 0.458) were comparable between the prompt, intermediate and delayed anti-VEGF groups. Anatomical and functional outcomes, treatment burden, number of relapses and eyes with second-line anti-VEGF therapy were comparable between the groups at both 1-year and 2-year timepoints. CONCLUSIONS: Our real-world evidence data emphasize that even if anti-VEGF induction cannot be initiated promptly within ten days from diagnosis of naïve exudative AMD, the visual and anatomical prognosis of the patients may not worsen if the treatment is started within one month of diagnosis.

Visual function following photodynamic therapy for central serous chorioretinopathy: a comparison of automated macular microperimetry versus best-corrected visual acuity.

BACKGROUND: The study compares the change in best-corrected visual acuity with the change in central retinal sensitivity before treatment and 6 months after treatment with photodynamic therapy in patients with symptomatic central serous chorio retinopathy. DESIGN: Prospective, single-centre, interventional case series. PARTICIPANTS: Eleven consecutive patients with previously untreated central serous chorio retinopathy. METHODS: Patients had microperimetry and best-corrected visual acuity recorded before and 6 months after treatment with photodynamic therapy. Refracted best-corrected visual acuity was assessed at 2 m and adjusted to give the number of letters read at 1 m. Threshold microperimetry was performed by presenting a Goldman III stimulus to 29 points over the central 12° around fixation. Significant visual improvement at 6 months was defined as a best-corrected visual acuity ≥10 letters or, microperimetry change in mean retinal sensitivity ≥2 decibels (dB). MAIN OUTCOME MEASURES: Improvement in best-corrected visual acuity compared with microperimetry following photodynamic therapy treatment in patients with central serous chorio retinopathy. RESULTS: All patients reported a subjective improvement in vision and had complete resolution of subretinal fluid at 6 months. Two patients had a significant improvement in best-corrected visual acuity (mean ± SD +4.2 ± 5.8 letters), compared with all 11 patients who recorded a significant improvement in mean retinal sensitivity (mean ± SD 4.6 ± 1.9 dB) (P < 0.001). CONCLUSIONS: These data suggest that compared with microperimetry, best-corrected visual acuity is underestimating the effectiveness of photodynamic therapy in the treatment of central serous chorio retinopathy.

Impaired ocular blood flow regulation in patients with open-angle glaucoma and diabetes.

BACKGROUND: To elucidate the potential impact of diabetes mellitus on primary open-angle glaucoma pathology through vascular deficiency. DESIGN: Cross-section analysis from a longitudinal, prospective study. PARTICIPANTS: Eighty-four open-angle glaucoma patients (20 diabetic open-angle glaucoma patients and 64 non-diabetic open-angle glaucoma patients) METHODS: Patients were analyzed for ocular structure, ocular perfusion pressure (OPP), retrobulbar blood flow and retinal capillary perfusion. Statistical analysis was performed by SPSS version 18.0. Comparisons between groups were made as well as multivariate linear regression analysis. MAIN OUTCOME MEASURE: Retrobulbar blood flow and the retinal microcirculation. RESULTS: Central retinal artery peak systolic velocity was 13.5% lower in diabetic patients (P = 0.007). In diabetic open-angle glaucoma patients, ocular perfusion pressure positively correlated with central retinal artery and temporal posterior ciliary artery peak systolic velocity (R = 0.476, P = 0.039 and R = 0.529, P = 0.02, respectively), and with central retinal artery and nasal posterior ciliary artery resistance index (R = 0.537, P = 0.018 and R = 0.566, P = 0.012 respectively). Average retinal nerve fibre layer positively correlated with central retinal artery peak systolic velocity and temporal posterior ciliary artery end diastolic velocity (R = 0.501, P = 0.029 and R = 0.553, P = 0.019, respectively), and negatively correlated with superior and inferior retinal avascular space in the diabetic group (R = -0.498, P = 0.030 and R = -0.700, P = 0.001, respectively); no correlations were found in the non-diabetic group. Negative correlations between retrobulbar and retinal circulations were only found in the diabetic open-angle glaucoma patients, whereas positive correlations between retinal flow and non-flow were only found in non-diabetic open-angle glaucoma patients. CONCLUSION: Diabetes may interfere with normal vascular regulation and contribute to glaucoma progression.