Treatment responses for branch retinal vein occlusion predicted by semi-automated fluorescein angiography quantification.

BACKGROUNDS: Branch retinal vein occlusion (BRVO) is one of the most important causes of visual loss in retinal vascular diseases. The aim of this study is to predict the treatment response of anti-vascular endothelial growth factor (anti-VEGF) therapy in BRVO using semi-automated quantified fluorescein angiography (FA) features. METHODS: This retrospective case-control study enrolled patients with BRVO who are receiving anti-VEGF therapy and have been followed up for > 1 year. Those receiving < 5 anti-VEGF injections in the first year were classified as the responsive group, while those receiving ≥5 injections were the refractory group. The FA images were subjected to semi-automated pre-processing. Fluorescein leakages at the 5-min image were represented by mean gray value over parafoveal and perifoveal regions. FA leakages and central retinal thickness (CRT) on optical coherence tomography (OCT) were used for predicting the treatment response and compared using area under receiver operating characteristic curve (AUC). RESULTS: Eighty-nine patients (56 males, 33 females, mean age 62.5 ± 10.9 years) with BRVO were enrolled. Of the 89 eyes, 47 (53%) were in the responsive group and 42 (47%) were in the refractory group. The refractory group had a significantly higher number of anti-VEGF injections in the first year (5.9 ± 1.6 versus 2.4 ± 1.2, p < 0.001) when compared with that of the responsive group. It had thicker pre-treatment CRT (p = 0.011), post-treatment best CRT (p < 0.001) and CRT at 1-year (p < 0.001). It also had a higher mean gray value over the parafoveal (p < 0.001) and the perifoveal (p < 0.001) regions. The mean gray value over perifoveal (AUC 0.846) and parafovel (AUC 0.818) had significantly larger AUC than that of the pre-treatment OCT (AUC 0.653; p = 0.005 and p = 0.016, respectively) when predicting treatment response. CONCLUSION: The refractory group had a more severe fluorescein leakage over the parafoveal and the perifoveal regions than the responsive group had. Semi-automated quantified FA leakage can be used as a biomarker for the prediction of anti-VEGF treatment response in macular edema due to BRVO.

Baseline clinical features predict visual outcome in young patients with central retinal vein occlusion.

PURPOSE: To evaluate prognostic factors in young patients with central retinal vein occlusion (CRVO). METHODS: Retrospective case series. CRVO patients aged ≤ 50 and follow-up ≥ 6 months were enrolled. The best corrected visual acuity (BCVA) and central retinal thickness (CRT) at baseline, 3 months, 6 months, and last visit were documented. Severity of retinopathy was graded by comparing to standard photos. Prognostic factors associated with visual outcome at 6 months were evaluated by multiple linear regression models. RESULTS: A total of 73 eyes from 69 patients with mean age 37.6 ± 8.5 were enrolled. Forty-seven (68%) patients were male. The mean follow-up duration was 25.9 ± 23.0 months. LogMAR BCVA improved from 0.979 ± 0.785 at baseline to 0.594 ± 0.748 at the 6 months (p < 0.001) and CRT improved from 475 ± 222 µm to 299 ± 104 µm (p < 0.001). Forty-eight (66%) eyes required anti-vascular endothelial growth factor (anti-VEGF) treatment. The mean number of injections was 2.25 ± 1.41 in the first 6 months and 75% of eyes received ≦ 3 injections during the clinical course. The baseline BCVA (coefficient 0.518, p < 0.001), grade of retinal hemorrhage (coefficient 0.230, p = 0.006), grade of retinal venous engorgement (coefficient 0.238, p = 0.011), grade of optic disc edema (coefficient - 0.226, p = 0.005), and diabetes mellitus (coefficient 0.264, p = 0.047) were the independent factors associated with visual outcome at 6 months. CONCLUSIONS: Baseline clinical features are useful for the prediction of visual outcome at 6 months in young CRVO patients.

ExPRESS miniature glaucoma shunt for intractable secondary glaucoma in superior vena cava syndrome - a case report.

BACKGROUND: The aim of this study was to clarify the pathogenic mechanism and to evaluate an intervention for intractable secondary glaucoma in superior vena cava (SVC) syndrome. CASE PRESENTATION: A 66-year-old female with underlying hypertension, diabetes mellitus, ischaemic heart disease and end-stage renal disease complained of bilateral puffy eyelids for 3 months. Over three years, the patient experienced a progressive, marked face and neck swelling, which was accompanied by dyspnoea and nocturnal coughing. The patient has been under haemodialysis for the past 5 years; there were several occurrences of vascular access re-establishment for susceptibility to vascular thrombosis, and she was also diagnosed with SVC syndrome 2 years after haemodialysis. The patient's best-corrected visual acuity (BCVA) was 20/60 in the right eye and 20/400 in the left eye. Pneumatic tonometry revealed a gradual increase in the intraocular pressure (IOP), even with the use of three types of anti-glaucoma agents. The ratio was 0.7 and bilaterally symmetric; optical coherence tomography indicated a thinning of the superior and inferior retina nerve fibre layers, and standard automated perimetry showed partial to generalized depression in both eyes. Filtering surgery for the left eye was performed, but postoperatively, the IOP increased gradually over three months. The subsequent placement of the ExPRESS miniature glaucoma device p200 effectively lowered the IOP. Postoperatively, the IOP of the left eye remained under 20 mmHg without a further decrease in visual acuity, while the right eye, which was controlled with only medication, had an IOP of greater than 30 mmHg. Because this patient refused cardiovascular intervention, conventional trabeculectomy was used to redirect the aqueous humour to the subconjunctival space to form a bleb, but failed. Fortunately, the subsequent ExPRESS implant effectively facilitated aqueous outflow through the intrascleral space, resulting in the maintenance of a normal IOP at 6 months, postoperatively. CONCLUSION: Sustained high IOP may occur after conventional filtration surgery for secondary glaucoma in SVC syndrome. To facilitate aqueous outflow, an ExPRESS glaucoma implant can be used to effectively control the IOP.

Effect of hinge position on corneal sensation and dry eye parameters after femtosecond laser-assisted LASIK.

PURPOSE: To evaluate the effect of superior- versus nasal-hinged flaps on corneal sensation and dry eye after femtosecond laser-assisted LASIK. METHODS: A total of 43 patients who had undergone bilateral femtosecond laser-assisted LASIK for myopia were evaluated in a prospective, nonrandomized, contralateral eye study to compare the difference between different hinges on corneal sensation and dry eye. Corneal esthesiometry, Schirmer basic tear secretion test (BST), tear break-up time (BUT), ocular surface stainings, and the Ocular Surface Disease Index (OSDI) questionnaire were used to evaluate corneal sensation and dry eye parameters preoperatively as well as at 1 week and 1, 3, and 6 months postoperatively. RESULTS: Corneal sensation decreased significantly in both groups 1 week after surgery (P<.05 in the nasal hinge group; P<.01 in the superior hinge group) and gradually recovered over the first 3 months. No significant change was noted in BUT after surgery in either group (P>.05). Significant increases were noted in BST values at 1 and 3 months (P<.05) and 6 months (P<.01) postoperatively in both groups. Corneal fluorescein staining increased significantly in both groups at 1 week (P<.01) and returned to baseline by 6 months. Conjunctival Rose Bengal staining decreased significantly by 6 months in the superior hinge group only (P<.05). The OSDI significantly increased 1 week after surgery (P<.01) and did not completely return to baseline by 6 months postoperatively in either group (P<.05). No significant differences were noted in any of the parameters between groups at any time point (P>.05). CONCLUSIONS: Hinge position had no significant effect on corneal sensation or dry eye parameters. Aggressive dry eye regimens are needed for patients with preoperative dry eye.

Preliminary Report on Interleukin-22, GM-CSF, and IL-17F in the Pathogenesis of Acute Anterior Uveitis.

Purpose:Anterior uveitis is the most common anatomic subset of uveitis. We developed a novel multi-parametric flow cytometry panel to identify immune dysregulation signatures in HLA B27-associated acute anterior uveitis (AAU) and axial spondyloarthritis (AxSpA).Methods: We used fluorescence activated cell sorting to characterize T cell cytokine expression in stimulated T cell subsets from patients with AAU (n = 4) compared to healthy controls (n = 14) or subjects with AxSpA (n = 6).Results: Positive findings among subjects with AAU included a statistically significant increase in stimulated granulocyte-macrophage colony stimulating factor (GM-CSF), IL-17, and IL-22 synthesized by CD8 cells, a trend for stimulated ILC (innate lymphoid cells)-3 cells to synthesize more IL-22 (p = .07), and stimulated MAIT (mucosa associated innate lymphoid cells)-like cells that express the T cell receptor V alpha 7.2 to express IL-17A, IL-17F, and IL-22 in a greater percentage of cells relative to controls. IL-17F, GM- CSF, and IL-22 represent potentially novel targets in AAU.Conclusion: Our report is arguably the first to implicate IL-17F or ILC-3 and MAIT cells in the pathogenesis of AAU.Abbreviations AAU: acute anterior uveitis; AxSpA: axial spondyloarthritis; BASDAI: Bath ankylosing spondylitis disease activity index; CCR: chemokine receptor; DMSO: dimethylsulfoxide; EULAR:European League Against Rheumatism; FACS: fluorescence activated cell sorter; FBS: fetal bovine serum; FSC: orward light scatter; GM-CSF: granulocyte-macrophage colony stimulating factor; HC: healthy control; ILC: innate lymphoid cell; KIR: killer immunoglobulin receptor; MAIT: mucosal associated immune T cell; ND: not detected; NK: natural killer cell; OHSU-Oregon Health & Science University; PBMC: peripheral blood mononuclear cell; SSC: side light scatter; TCR: T cell receptor.

Foveal Microvascular Integrity Association With Anti-VEGF Treatment Response for Diabetic Macular Edema.

Purpose: To investigate the association between foveal microvascular integrity and anti-vascular endothelial growth factor (VEGF) treatment response for diabetic macular edema (DME). Methods: This retrospective study enrolled 58 eyes (from 45 patients) with DME. Treatment strategy was three to five monthly anti-VEGF injections followed by a PRN protocol. Treatment with an intravitreal corticosteroid would be considered for persistent DME after five consecutive anti-VEGF injections. Eyes achieving a treatment-free interval ≥ four months within two years were classified into the good clinical course group (group 1). Eyes with frequent recurrent edema (treatment-free interval < four months) or requiring an intravitreal corticosteroid within two years were classified into the suboptimal clinical course group (group 2). Foveal microvascular integrity was evaluated by two continuous variables, that is, vessel density (%) within a width of 300 µm around the foveal avascular zone (FD-300) on optical coherence tomography angiography (OCTA) and perifoveal leakage (area %) on fluorescein angiography (FA). Results: There were 37 eyes in group 1 and 21 eyes in group 2. FD-300 (odds ratio 0.733, 95% CI 0.620-0.867, P < 0.001) and perifoveal leakage (odds ratio 1.064, 95% CI 1.007-1.124, P = 0.027) were significantly associated with suboptimal clinical course. Area under curve (AUC) was 0.820 for FD-300 and 0.723 for perifoveal leakage in predicting clinical course. FD-300 was negatively correlated with perifoveal leakage (coefficient = -0.325, P = 0.014). Conclusions: Compromised foveal microvascular integrity, represented by lower FD-300 and more severe perifoveal fluorescein leakage, was associated with suboptimal clinical course in anti-VEGF treatment for DME. A negative correlation between FD-300 and perifoveal leakage existed.

Intravitreal loading injection of ganciclovir with or without adjunctive oral valganciclovir for cytomegalovirus anterior uveitis.

BACKGROUND: A pilot study was conducted to evaluate the therapeutic results of intravitreal ganciclovir injection as a loading dose with or without the following oral valganciclovir for the treatment of cytomegalovirus (CMV) anterior uveitis in immunocompetent patients. METHODS: Six consecutive patients in whom active CMV anterior uveitis was detected by polymerase chain reaction assay of the aqueous humor were enrolled between January 2006 and December 2008. These patients received an intravitreal injection of ganciclovir (2 mg/0.05 ml) as a loading dose. Subsequent use of oral valganciclovir (900 mg twice a day) was determined according to the severity of the post-injection aqueous inflammation. Immune status and anterior chamber reaction of individual patients, visual acuity, intraocular pressure (IOP) at study entry, and follow-up intervals were examined. RESULTS: The mean patient-month follow-up period after intravitreal injection was 14.7 months (range, 12-22 months). Two patients received only the intravitreal ganciclovir injection once and four patients had received the following oral valganciclovir for average 2.3 months (range, 1-4 months). With this treatment strategy, the best-corrected visual acuity of the patients improved or stabilized; the IOP and the inflammation of anterior chamber of the patients were well controlled at all time points and there were no treatment-associated complications by the end of follow-up. CONCLUSIONS: In patients with CMV anterior uveitis, intravitreal ganciclovir injection as a loading dose with or without the following oral valganciclovir can control the inflammation and IOP well.

Retinal neurovascular changes in chronic kidney disease.

PURPOSE: To examine retinal neurovascular changes in patients with chronic kidney disease (CKD). METHODS: Case-control study. A total of 171 CKD cases and 40 controls were recruited (mean age 62.9 ± 10.3 versus 60.8 ± 9.2, p = 0.257). Retinal neural parameters, including parafoveal retinal thickness (PfRT), macular ganglion cell complex thickness (GCCt), global loss volume (GLV), focal loss volume (FLV) and peripapillary retinal nerve fibre layer thickness (RNFLt), were measured using optical coherence tomography (OCT). Microvascular parameters, including foveal avascular zone size, vessel density over the parafoveal superficial vascular plexus (SVP-VD), parafoveal deep vascular plexus (DVP-VD) and radial peripapillary capillary (RPC-VD), were measured using OCT angiography. RESULTS: Chronic kidney disease (CKD) patients showed reduced PfRT, GCCt and RNFLt and increased GLV and FLV compared with the controls (all p < 0.005). Among patients with CKD, estimated glomerular filtration rate was an independent factor associated with PfRT (coefficient 0.19, p = 0.015), GCCt (coefficient 0.10, p = 0.006), GLV (coefficient - 0.08, p = 0.001), FLV (coefficient - 0.02, p = 0.006) and RNFLt (coefficient 0.15, p = 0.002). Parafoveal retinal thickness (PfRT), GCCt, GLV, FLV and RNFLt were correlated with SVP-VD (all p < 0.001) but not with DVP-VD (all p > 0.1). CONCLUSIONS: Chronic kidney disease (CKD) patients demonstrated a significant reduction in macular thickness and changes in retinal neural parameters. These changes were associated with the severity of CKD and correlated with the microvascular rarefaction in the parafoveal SVP.

Noninfectious uveitis in the Asia-Pacific region.

Uveitis is a sight-threatening disease. Up to 35% of patients may have impaired vision. Inflammation of the uvea tissue has more than 60 etiologies. Previous reports have shown that 20-40% of uveitis cases were noninfectious. Some of them may be associated with systemic rheumatological and autoimmune diseases but some may affect the eyes only. The epidemiology and clinical situations of some specific uveitis entities vary worldwide because they are influenced by genetic, ethnic, environmental, and socioeconomic factors. The Asia-Pacific region comprises more than 30 countries. Epidemiology and patterns of uveitis vary greatly in this region. However, some uveitis entities, such as Behcet's disease, sarcoidosis, and Vogt-Koyanagi-Harada disease, are more common in this region. Many studies on the epidemiology, risk factors, and immune pathogenesis of this disease have been conducted. In this article, we review the epidemiology of noninfectious uveitis and special situations of these three uveitis entities in the Asia-Pacific region.

Bilateral retinal pigment epithelial rips in hypertensive choroidopathy.

Severe systemic hypertension can cause significant damage to the eye. Although hypertensive retinopathy is a well-known complication, hypertensive optic neuropathy and hypertensive choroidopathy are much less common. The aim of this article is to report an unusual case of hypertensive choroidopathy with bullous exudative retinal detachments in both eyes. The retinal detachments spontaneously resolved after blood pressure was controlled. However, multiple large retinal pigment epithelial (RPE) rips were found in both eyes. These RPE rips may be related to severe choroidal ischemia, and their locations may be compatible with the watershed zones of the choroidal perfusions.