CFH and VIPR2 as susceptibility loci in choroidal thickness and pachychoroid disease central serous chorioretinopathy.

Central serous chorioretinopathy (CSC) is a common disease affecting younger people and may lead to vision loss. CSC shares phenotypic overlap with age-related macular degeneration (AMD). As recent studies have revealed a characteristic increase of choroidal thickness in CSC, we conducted a genome-wide association study on choroidal thickness in 3,418 individuals followed by TaqMan assays in 2,692 subjects, and we identified two susceptibility loci: CFH rs800292, an established AMD susceptibility polymorphism, and VIPR2 rs3793217 (P = 2.05 × 10-10 and 6.75 × 10-8, respectively). Case-control studies using patients with CSC confirmed associations between both polymorphisms and CSC (P = 5.27 × 10-5 and 5.14 × 10-5, respectively). The CFH rs800292 G allele is reportedly a risk allele for AMD, whereas the A allele conferred risk for thicker choroid and CSC development. This study not only shows that susceptibility genes for CSC could be discovered using choroidal thickness as a defining variable but also, deepens the understanding of differences between CSC and AMD pathophysiology.

Genome-wide association study identifies seven novel susceptibility loci for primary open-angle glaucoma.

Primary open-angle glaucoma (POAG) is the leading cause of irreversible blindness worldwide for which 15 disease-associated loci had been discovered. Among them, only 5 loci have been associated with POAG in Asians. We carried out a genome-wide association study and a replication study that included a total of 7378 POAG cases and 36 385 controls from a Japanese population. After combining the genome-wide association study and the two replication sets, we identified 11 POAG-associated loci, including 4 known (CDKN2B-AS1, ABCA1, SIX6 and AFAP1) and 7 novel loci (FNDC3B, ANKRD55-MAP3K1, LMX1B, LHPP, HMGA2, MEIS2 and LOXL1) at a genome-wide significance level (P < 5.0×10-8), bringing the total number of POAG-susceptibility loci to 22. The 7 novel variants were subsequently evaluated in a multiethnic population comprising non-Japanese East Asians (1008 cases, 591 controls), Europeans (5008 cases, 35 472 controls) and Africans (2341 cases, 2037 controls). The candidate genes located within the new loci were related to ocular development (LMX1B, HMGA2 and MAP3K1) and glaucoma-related phenotypes (FNDC3B, LMX1B and LOXL1). Pathway analysis suggested epidermal growth factor receptor signaling might be involved in POAG pathogenesis. Genetic correlation analysis revealed the relationships between POAG and systemic diseases, including type 2 diabetes and cardiovascular diseases. These results improve our understanding of the genetic factors that affect the risk of developing POAG and provide new insight into the genetic architecture of POAG in Asians.

Predictive factors for corrective effect of inferior rectus recession for congenital superior oblique palsy.

PURPOSE: To identify preoperative factors associated with the surgical corrective effect of contralateral inferior rectus recession (IRR) for vertical deviation in patients with congenital superior oblique palsy (SOP). METHODS: This retrospective study included 20 treatment-naïve patients with unilateral congenital SOP (age range, 6-79 years) who underwent contralateral IRR according to our basic policy to select IRR for paretic eye fixation. The corrective effect (°/mm) of IRR was defined as the difference in the vertical deviation at the primary gaze position between before and 6-18 months after surgery per distance of recession. We also measured the preoperative vertical deviation at primary and secondary gaze positions, and vertical deviation with head-tilting, and calculated the difference in vertical deviation between these positions. We analyzed the correlation between the corrective effect of IRR and these study parameters. RESULTS: The mean corrective effect of IRR was 2.4 ± 1.6°/mm, which had a significant correlation with preoperative differences in vertical deviation between the primary gaze position and the downward (P = 0.004, r = -0.61) and contralateral gaze positions (P = 0.03, r = -0.48); and the presence of preoperative stereopsis (P = 0.02, r = -0.51). After excluding a statistical outlier, the correlation between the corrective effect and the difference between the primary and contralateral gaze positions was no longer significant (P = 0.07), while the other two relationships remained significant. CONCLUSIONS: Our findings suggest that preoperative differences in vertical deviation between the primary and downward gaze positions and the presence of preoperative stereopsis are important considerations prior to performing IRR for congenital SOP, particularly with paretic eye fixation.

Association of Bruch's membrane opening and optic disc morphology to axial length and visual field defects in eyes with primary open-angle glaucoma.

PURPOSE: To examine the morphology of Bruch's membrane opening (BMO), optic disc, and peripapillary atrophy (PPA) by scanning laser ophthalmoscopy (SLO) and spectral-domain optical coherence tomography (SD-OCT), and to determine their association with the axial length and visual field defects. METHODS: This was a cross-sectional study of 94 eyes of 56 subjects; 77 eyes were diagnosed with primary open-angle glaucoma and 17 eyes as normal. The margins of the optic disc were determined in the SLO images, and that of the BMO in the SD-OCT images. The ovality and area of the BMO and the optic disc were measured. The beta and gamma-PPA areas were also measured. The association of each parameter with the axial length and the mean deviation (MD) of the visual field tests was determined by generalized estimating equations (GEEs). RESULTS: The optic disc ovality was associated with the axial length and the MD (ß = -0.47, P = 7.6 × 10-4 and ß = 0.12, P = 0.040). The BMO ovality was not significantly associated with the axial length and the MD. The BMO area was associated with the axial length (ß = 0.30, P = 0.029). A larger BMO area was associated with a thinner BMO-based neuroretinal rim width (BMO-MRW) after adjustments for the MD (ß = -0.30, P = 2.1 × 10-4). The beta- and gamma-PPA areas were associated with the axial length (ß = 0.50, P = 7.4 × 10-5 and ß = 0.62, P = 4.2 × 10-6). CONCLUSIONS: The optic disc ovality was associated with both the axial length and MD, whereas BMO ovality was not. Attention should be paid to the influence of the axial length-related enlargement of the BMO.

When do myopia genes have their effect? Comparison of genetic risks between children and adults.

Previous studies have identified many genetic loci for refractive error and myopia. We aimed to investigate the effect of these loci on ocular biometry as a function of age in children, adolescents, and adults. The study population consisted of three age groups identified from the international CREAM consortium: 5,490 individuals aged <10 years; 5,000 aged 10-25 years; and 16,274 aged >25 years. All participants had undergone standard ophthalmic examination including measurements of axial length (AL) and corneal radius (CR). We examined the lead SNP at all 39 currently known genetic loci for refractive error identified from genome-wide association studies (GWAS), as well as a combined genetic risk score (GRS). The beta coefficient for association between SNP genotype or GRS versus AL/CR was compared across the three age groups, adjusting for age, sex, and principal components. Analyses were Bonferroni-corrected. In the age group <10 years, three loci (GJD2, CHRNG, ZIC2) were associated with AL/CR. In the age group 10-25 years, four loci (BMP2, KCNQ5, A2BP1, CACNA1D) were associated; and in adults 20 loci were associated. Association with GRS increased with age; ß = 0.0016 per risk allele (P = 2 × 10-8 ) in <10 years, 0.0033 (P = 5 × 10-15 ) in 10- to 25-year-olds, and 0.0048 (P = 1 × 10-72 ) in adults. Genes with strongest effects (LAMA2, GJD2) had an early effect that increased with age. Our results provide insights on the age span during which myopia genes exert their effect. These insights form the basis for understanding the mechanisms underlying high and pathological myopia.

Microstructure of Peripapillary Atrophy and Subsequent Visual Field Progression in Treated Primary Open-Angle Glaucoma.

PURPOSE: To investigate the relationship between the microstructure of ß-zone peripapillary atrophy (PPA) and the subsequent visual field (VF) progression in eyes with primary open-angle glaucoma (POAG), including highly myopic eyes. DESIGN: Retrospective cohort study. PARTICIPANTS: A total of 129 patients with POAG who had been followed up for a minimum of 2 years and had undergone at least 5 reliable standard automated perimetry tests after spectral-domain (SD) optical coherence tomography (OCT) examination. METHODS: ß-Zone PPA was evaluated from 3 SD OCT scans centered on the optic disc. Upper and lower scans were defined as scans at 30° above and below the horizontal scan, respectively. From 3 scans of each eye, ß-zone PPA was classified as PPA(+BM) or PPA(-BM) on the basis of the presence or absence of Bruch's membrane (BM), respectively. Eyes were classified into 3 groups according to the horizontal scan images: group A (only PPA(+BM)), group B (both PPA(+BM) and PPA(-BM)), and group C (only PPA(-BM)). Factors associated with the subsequent mean deviation (MD) slope after OCT examination were analyzed, and the hemifield total deviation (TD) slope was assessed in eyes with unilateral hemifield VF defects in the corresponding direction. MAIN OUTCOME MEASURES: Subsequent MD slope after OCT examination. RESULTS: The VF progression in group A was faster than in group C (P = 0.004). A larger PPA(+BM) width was associated with a faster MD slope in all eyes (P < 0.001) and highly myopic eyes (P < 0.001) and with a faster TD slope in eyes with superior or inferior hemifield VF defects in the corresponding direction (P = 0.002 and P = 0.035, respectively). A larger PPA(-BM) was correlated with a slower MD slope in all eyes (P = 0.030 and P = 0.034) but not in highly myopic eyes. CONCLUSIONS: There were significant differences in VF progression according to the microstructure of the ß-zone PPA in eyes with POAG. The PPA(+BM) width may be an important risk factor for VF progression in POAG, including high myopia, and the PPA(-BM) width may have a protective effect for VF progression in this subtype of POAG.

Clinical and Genetic Characteristics of Japanese Patients with Age-Related Macular Degeneration and Pseudodrusen.

PURPOSE: To investigate differences in clinical characteristics and genotype distribution in Japanese patients with age-related macular degeneration (AMD) and pseudodrusen using multimodal imaging. DESIGN: Retrospective, observational case series. PARTICIPANTS: A total of 101 patients (101 eyes) with AMD and pseudodrusen. METHODS: Patients underwent complete ophthalmologic examination, including color fundus photography, infrared reflectance (IR) imaging, fundus autofluorescence, confocal blue reflectance, fluorescein and indocyanine green (ICG) angiography, and spectral-domain optical coherence tomography (SD OCT). Pseudodrusen subtype was identified with multiple imaging techniques. Patients were genotyped to identify major single nucleotide polymorphisms associated with AMD (CFH Y402, CFH I62V, and ARMS2 A69S). MAIN OUTCOME MEASURES: Clinical characteristics and genetic distributions of patients with pseudodrusen. RESULTS: At least 1 imaging technique identified dot pseudodrusen in all 101 eyes and ribbon pseudodrusen in 53 eyes (52.5%). Forty-eight eyes (47.5%) had only dot pseudodrusen, but no eyes had only ribbon pseudodrusen or midperipheral drusen. Forty-five of 49 bilateral cases (91.8%) had the same pseudodrusen subtype in both eyes. Pseudodrusen subtype did not change during the observation period in 100 eyes (99.0%), but dot-dominant type changed to dot-ribbon type in 1 eye (1.0%). The dot and ribbon subtypes were detected in 84 (83.1%) and 51 (96.2%) eyes, respectively, using color fundus photographs. Detection sensitivity of dot pseudodrusen was high for IR (97.0%), confocal blue reflectance (95.1%), fundus autofluorescence (93.1%), and ICG (100%) imaging. Detection sensitivity for ribbon pseudodrusen was high for color fundus photography (96.2%), confocal blue reflectance (94.3%), and fundus autofluorescence (90.6%), but not for IR imaging and ICG angiography. Risk allele frequency of the CFH I62V polymorphism was 79.8% and 67.0% in patients with dot-dominant and dot-ribbon pseudodrusen, respectively (P = 0.053). The genotype frequency of CFH Y402H and ARMS2 A69S polymorphisms was not significantly different between the patients with dot-dominant type and dot-ribbon type (P = 0.647 and P = 0.354, respectively). CONCLUSIONS: Patients with pseudodrusen can be classified with dot-dominant or dot-ribbon type, and these subtypes usually are the same in both eyes. The distribution of CFH I62V polymorphisms may have an association with pseudodrusen subtypes.

Factors Associated with Recurrence of Age-Related Macular Degeneration after Anti-Vascular Endothelial Growth Factor Treatment: A Retrospective Cohort Study.

PURPOSE: To investigate the predictive factors associated with recurrence after anti-vascular endothelial growth factor (VEGF) treatment for neovascular age-related macular degeneration (AMD). DESIGN: Retrospective cohort study. PARTICIPANTS: A total of 343 eyes of 326 patients with subfoveal neovascular AMD who were treated with an as-needed regimen after 3 monthly loading doses of intravitreal ranibizumab. METHODS: Patients were followed up by an as-needed regimen for more than 1 year after the first injection. Baseline data and CFH I62V and ARMS2 A69S polymorphisms were analyzed for their association with recurrence after anti-VEGF treatment. Regression analysis was used to identify independent predictors of visual acuity (VA) prognosis. MAIN OUTCOME MEASURES: The primary end point was the presence or absence of recurrence. The secondary end point was VA improvement. RESULTS: In total, 236 eyes (68.8%) showed complete resolution of retinal exudative change after the 3 loading injections, and 81 eyes (34.3%) experienced no recurrence during the first year. Of the 236 eyes, 139 (58.9%) were followed for more than 2 years and 35 (25.2%) showed no recurrent retinal exudation during 24 months. Visual acuity improvement was significantly better in eyes without recurrence than in eyes with recurrence during the 2-year period. Baseline characteristics and genotypes had no influence on response to ranibizumab loading treatment. Stepwise analysis revealed that age (P<0.001), subtype of AMD (P=0.041), and VA at baseline (P<0.001) were associated with VA at 24 months. Older patients (P=0.006) and male patients (P=0.018) tended to require re-treatment for recurrence during the first year, yet the statistical significance disappeared when evaluated in 2 years. The subtypes of neovascular AMD were solely associated with the interval to the recurrence, which was shorter in eyes with polypoidal choroidal vasculopathy (PCV) than in eyes with typical AMD (P=0.015). CONCLUSIONS: Older age and male sex may predict recurrence after 3 monthly ranibizumab injections, and PCV may be associated with shorter interval to recurrence. Predicting the risk of recurrence would help us to choose the most appropriate follow-up treatment strategy for patients with AMD.

MMP20 and ARMS2/HTRA1 Are Associated with Neovascular Lesion Size in Age-Related Macular Degeneration.

PURPOSE: Age-related macular degeneration (AMD) is the leading cause of severe visual impairment. Despite treatment, a central scotoma often remains. The size of the scotoma depends on the lesion size of the choroidal neovascular membrane and significantly affects the patient's quality of life, and the lesion size of neovascularization also affects response to treatments. The aim of this study was to identify genes associated with the neovascular lesion size in neovascular AMD. DESIGN: A genome-wide association study (GWAS). PARTICIPANTS: We included 1146 Japanese patients with neovascular AMD. METHODS: We performed a 2-stage GWAS for the lesion size of AMD as a quantitative trait among 1146 (first stage: 727, second stage: 419) Japanese patients with neovascular AMD. Lesion size was determined by the greatest linear dimension measured with fluorescein angiography examination before treatment. We examined the association between the genotypic distribution of each single nucleotide polymorphism (SNP) and the trait using an additive model adjusted for age and sex. To evaluate the associations between AMD development and SNPs associated with lesion size, we also performed a case-control study by using the genotype data from these 1146 Japanese patients as case subjects and the fixed dataset from the Nagahama Study as control subjects. MAIN OUTCOME MEASURES: Genes associated with the lesion size in neovascular AMD. RESULTS: In the discovery stage, rs10895322 in MMP20 showed a genome-wide significant P value of 6.95×10(-8), and rs2284665 in ARMS2/HTRA1 showed a P value of 1.55×10(-7). The associations of these 2 SNPs were successfully replicated in the replication stage, and a meta-analysis of both stages showed genome-wide significant P values (2.80×10(-9) and 4.41×10(-9), respectively). In a case-control study using 3248 Japanese subjects as controls, we could not find contribution of MMP20 rs10895322 for AMD development. Although MMP20 has been thought to be expressed only in dental tissues, we confirmed MMP20 expression in the human retina and retinal pigment epithelium/choroid with polymerase chain reaction. CONCLUSIONS: The growth of choroidal neovascularization in AMD would be affected by 2 genes: MMP20, a newly confirmed gene expressed in the retina, and ARMS2/HTRA1, a well-known susceptibility gene for AMD.

Effects of aflibercept for ranibizumab-resistant neovascular age-related macular degeneration and polypoidal choroidal vasculopathy.

PURPOSE: To evaluate visual and anatomic outcomes in response to the conversion of treatment in patients with neovascular age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV) refractory to previous treatment. We also investigated the effect of genetic factors. METHODS: We recruited patients with AMD or PCV refractory to ranibizumab and initiated aflibercept treatment. Changes in the logarithm of minimum angle of resolution (logMAR) and central retinal thickness (CRT) measured using optical coherence tomography (OCT) 6 months after the conversion were compared between the AMD and PCV groups. We also genotyped each patient for the ARMS2 A69S, CFH Y402H, and I62V alleles, and investigated the association between genotype and treatment response. RESULTS: Mean age of the participants was 75.6 ± 8.0 years. There were 15 patients with AMD and 26 patients with PCV. While PCV patients gained about 1 line of vision (0.40 ± 0.37 to 0.31 ± 0.40, P = 0.003), AMD patients did not show significant improvement (0.41 ± 0.37 to 0.42 ± 0.39, P = 0.699) despite the decrease in CRT (202.1 ± 113.7 to 131.2 ± 55.7 µm, P = 0.003). The prevalence of dry retina after treatment was higher among PCV patients (80.8 vs 46.7 %, P = 0.024). There was no significant difference between patients with risk and non-risk alleles for ARMS2 A69S, CFH Y402H, and I62V. CONCLUSION: In AMD or PCV patients refractory to ranibizumab, switching to aflibercept is generally effective regardless of patient genotype. PCV patients may benefit more significantly than AMD patients.

Association between retinal venular dilation and serous retinal detachment in diabetic macular edema.

PURPOSE: To study the relationship between retinal vessel diameter and qualitative and quantitative evaluations on spectral-domain optical coherence tomography in patients with diabetic macular edema. METHODS: One hundred and eight consecutive eyes of 80 patients, with clinically significant macular edema underwent optical coherence tomography and color fundus photography. The authors evaluated the retinal thickness of the Early Treatment Diabetic Retinopathy Study grid and foveal pathomorphologies including cystoid macular edema and serous retinal detachment on the optical coherence tomography images. The diameters of the superotemporal or inferotemporal retinal vessels originating from the optic disk were measured using a computer-assisted technique. RESULTS: The mean diameters of the superotemporal and inferotemporal venules were larger in eyes with diabetic macular edema than in healthy eyes. The mean diameter of the temporal venules but not the arterioles was associated with perifoveal thickening in the inferior subfield in eyes with diabetic macular edema (P = 0.014). Although the retinal thickening in the central subfield was not correlated with the diameters of the retinal vessels, eyes with foveal serous retinal detachment had larger mean diameters of superotemporal and inferotemporal venules than those without serous retinal detachment (P < 0.001). CONCLUSION: The mean diameters of the superotemporal and inferotemporal venules were significantly associated with foveal serous retinal detachment in diabetic macular edema.

Local biometric features and visual prognosis after surgery for treatment of myopic foveoschisis.

PURPOSE: To identify the local biometric factors associated with postoperative best-corrected visual acuity (BCVA) after surgical treatment of myopic foveoschisis by using spectral-domain optical coherence tomography. METHODS: Eleven eyes of 10 patients that underwent vitrectomy combined with internal limiting membrane peeling for treatment of myopic foveoschisis were investigated. We measured the height and lateral width of the foveal detachment, subfoveal choroidal thickness, and height of the posterior staphyloma using spectral-domain optical coherence tomography. RESULTS: Foveal detachments found in 8 eyes were not significantly related to postoperative BCVA. Intraclass correlation coefficients of spectral-domain optical coherence tomography measurements were substantial to nearly perfect (0.786-0.951). The postoperative BCVA 12 months after surgery was significantly correlated with age (r(s) = 0.616, P = 0.044), preoperative BCVA (r(s) = 0.833, P = 0.001), preoperative subfoveal choroidal thickness (r(s) = -0.661, P = 0.027), and posterior staphyloma height (r(s) = 0.642, P = 0.033). Neither postoperative BCVA nor changes in BCVA showed significant correlations with the axial length or height or lateral width of the foveal detachment. CONCLUSION: These results at least raise the possibility that a thin choroid and likely severe posterior staphyloma before surgery can predict postoperative BCVA after vitrectomy for the treatment of myopic foveoschisis.

Long Term Follow-Up of Prototheca keratitis: A Case Report.

BACKGROUND: Prototheca spp. are rare human pathogens, and only three cases of Prototheca keratitis have been reported. They were treated with anti-fungal drugs and surgical excision. Two of the three cases were successful, and the case of an immunocompromised patient was not successful. Thus, the best treatment of Prototheca keratitis is still undetermined, and further investigations are needed. The purpose of this report is to present our findings in a case of Prototheca keratitis that was successfully treated with topical medications without surgical excision. METHODS: This study was performed in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of Hidaka Medical Center, Toyooka Hospital. A written informed consent was obtained from the patient before beginning the medical treatments. CASE REPORT: A 75-year-old man with a history of stage 4 prostate carcinoma and bilateral limbal stem cell deficiency had undergone keratoepithelioplasty on his left eye for the deficiency. Postoperatively, a greyish-white epithelial opacity was noted on the central cornea of his left eye, and he had been treated with topical fluorometholone and oral dexamethasone together with a therapeutic contact lens. Corneal smears and contact lens swabs were positive for Prototheca spp. He required a continuous treatment with amphotericin B (AMPH-B) ointment, topical fluconazole (FLCZ), and voriconazole (VRCZ). This treatment protocol was effective, but recurrences developed when his general condition worsened. CONCLUSION: Our findings indicate that Prototheca keratitis can be successfully treated but not cured with topical AMPH-B, FLCZ, and VRCZ without surgical treatment. However, recurrences can develop when the general condition of the patient worsens. Thus, continuous monitoring and treatment are necessary in cases of Prototheca keratitis.

Characteristics of pachychoroid neovasculopathy.

Recently, several research groups have reported a newly recognized clinical entity of choroidal neovascularization, termed pachychoroid neovasculopathy. However, its characteristics have yet to be well described. The purpose of this study was to investigate the clinical and genetic characteristics of pachychoroid neovasculopathy regardless of treatment modality. This study included 99 eyes of 99 patients with treatment-naïve pachychoroid neovasculopathy. Mean initial best-corrected visual acuity (BCVA) was 0.20 ± 0.32 logMAR, and did not change (P = 0.725) during follow-up period (mean ± SD, 37.0 ± 17.6 months). Subretinal hemorrhage (SRH) (≥ 4 disc areas in size) occurred in 20 eyes (20.2%) during follow-up. Age, initial BCVA, central retinal thickness, SRH (≥ 4 disc areas in size) and treatment (aflibercept monotherapy) were significantly associated with the final BCVA (P = 0.024, < 0.001, 0.031, < 0.001, and 0.029, respectively). Multiple regression analysis showed initial BCVA and presence of SRH to be significant predictors of final BCVA (both P < 0.001). Polypoidal lesions were more common in the SRH group than in the non-SRH group (85.0% vs 48.1%, P = 0.004). There was no significant difference in the frequency of the risk allele in ARMS2 A69S, CFH I62V, CFH Y402H between these groups (P = 0.42, 0.77, and 0.85, respectively). SRH (29.1% vs 9.1%, P = 0.014) and choroidal vascular hyperpermiability (65.5% vs 43.2%, P = 0.027) were seen more frequently in the polypoidal lesion (+) group than in the polypoidal lesion (-) group. There was considerable variation in lesion size and visual function in patients with pachychoroid neovasculopathy, and initial BCVA and presence of SRH at the initial visit or during the follow-up period were significant predictors of final BCVA.

Keratoconus-susceptibility gene identification by corneal thickness genome-wide association study and artificial intelligence IBM Watson.

Keratoconus is a common ocular disorder that causes progressive corneal thinning and is the leading indication for corneal transplantation. Central corneal thickness (CCT) is a highly heritable characteristic that is associated with keratoconus. In this two-stage genome-wide association study (GWAS) of CCT, we identified a locus for CCT, namely STON2 rs2371597 (P = 2.32 × 10-13), and confirmed a significant association between STON2 rs2371597 and keratoconus development (P = 0.041). Additionally, strong STON2 expression was observed in mouse corneal epithelial basal cells. We also identified SMAD3 rs12913547 as a susceptibility locus for keratoconus development using predictive analysis with IBM's Watson question answering computer system (P = 0.001). Further GWAS analyses combined with Watson could effectively reveal detailed pathways underlying keratoconus development.

Five-year visual outcomes after anti-VEGF therapy with or without photodynamic therapy for polypoidal choroidal vasculopathy.

BACKGROUND/AIMS: To evaluate the 5-year visual and anatomical outcomes after anti-vascular endothelial growth factor (VEGF) therapy alone or in combination with photodynamic therapy (PDT), followed by pro re nata (PRN) anti-VEGF therapy with or without PDT, for polypoidal choroidal vasculopathy (PCV). METHODS: This retrospective, observational study included 61 consecutive patients with treatment-naïve symptomatic PCV who were followed for 5 years. Twenty eyes (20 patients) initially received PDT and intravitreal injection of ranibizumab (IVR), followed by a PRN regimen of anti-VEGF therapy with or without PDT (combination group), while 41 eyes (41 patients) initially received only IVR every 3 months, followed by a PRN regimen of anti-VEGF monotherapy (IVR group). Macular atrophy including the fovea was confirmed using colour fundus photography and spectral-domain optical coherence tomography. RESULTS: In both groups, the visual acuity (VA) at 1 year was better than the baseline VA, whereas the 3-year, 4-year and 5-year VA values were similar to the baseline VA. There was no significant difference in the 5-year VA, 5-year central retinal thickness and incidence of macular atrophy between the two groups (p=0.63, 0.72 and 0.06, respectively). In the combination group, the 5-year VA was correlated with the 5-year incidence of macular atrophy (p=0.02, r=0.51). CONCLUSIONS: A PRN regimen for PCV may have a limited effect for the long-term maintenance of improved VA. Macular atrophy may occur more frequently with combination therapy and is possibly associated with the 5-year VA. Thus, combination therapy should be carefully selected for patients susceptible to macular atrophy.

Abnormal Outer Choroidal Vasculature in Amblyopia.

PURPOSE: Several studies have indicated morphological changes in the choroid in amblyopia cases. This study investigates whether choroidal vasculature was different among amblyopic and fellow eyes in unilateral amblyopia patients and healthy eyes, using en face images acquired via swept-source optical coherence tomography (SS-OCT). DESIGN: Prospective, observational case-control study. METHODS: This study included 14 consecutive patients with unilateral amblyopia and 22 age- and axial length-matched healthy eyes. Using SS-OCT, we obtained en face images of choroidal vasculature midway through the subfoveal inner and total choroid, corresponding to the vasculature of the choriocapillaris and Sattler's layer (inner choroid) and Haller's layer (outer choroid), respectively. We analyzed the en face images of the inner and outer choroidal vascular areas in 3 × 3 mm squares adjusted from 6 × 6 mm squares, using Littmann's magnification correction, after binarization of the images as a portion of the whole area. RESULTS: The outer choroidal vascular areas were larger in both amblyopic and fellow eyes than in healthy eyes (both P < 0.001), although there were no significant differences in inner (56.35 ± 2.46% and 56.27 ± 3.75%, respectively) or outer (61.49 ± 4.95% and 61.48 ± 3.73%, respectively) choroidal vascular area between amblyopic and fellow eyes (P=0.98 and 0.91, respectively). An outer choroidal vascular area of 59% was set as an appropriate cutoff value for distinguishing patients from controls. CONCLUSIONS: The outer choroidal vascular area was larger in both amblyopic eyes and fellow eyes compared to healthy eyes. Our findings may help clarify the etiology of amblyopia.

Pilot study assessing the structural changes in posttrabecular aqueous humor outflow pathway after trabecular meshwork surgery using swept-source optical coherence tomography.

This study evaluated the morphological change in aqueous humor outflow (AHO) pathways using swept-source optical coherence tomography (SS-OCT) volumetric scans in glaucoma patients before and after glaucoma surgery. In this prospective observational case series, 15 eyes (13 patients) with glaucoma were treated with 120-degree Trabectome or 360-degree suture trabeculotomy and followed up for 3 months. B-scan images of the posttrabecular AHO pathway were reconstructed and the pathway areas were evaluated, before and after surgery. Changes in posttrabecular AHO pathway were qualitatively classified as "increased", "non-significant change", and "decreased" on reconstructed B-scan images. Quantitative measurements of the posttrabecular AHO pathway areas were performed pre- and postoperatively. Factors associated with both qualitative and quantitative changes in AHO pathway were investigated. From 30 regions (15 nasal and 15 temporal regions) in the 15 eyes, AHO pathways were analyzable in 20 regions pre- and postoperatively. Qualitative assessments of the pathway changes were "increased" in 8 regions, "non-significant change" in 9 regions, and "decreased" in 3 regions. Quantitative assessments of the average pathway area did not change significantly (from 3155±1633 pixels preoperatively to 3212±1684 pixels postoperatively, P = 0.50). All parameters relating to intraocular pressure changes or the surgical location were not associated with postoperative AHO pathway change. The intrascleral AHO pathway could be well visualized in glaucoma patients pre- and postoperatively using swept-source optical coherence tomography. However, structural changes in the AHO pathway assessed by SS-OCT were not significant after trabecular-targeted glaucoma surgery. Functional assessments of AHO are needed in future studies.

Pachychoroid Geographic Atrophy: Clinical and Genetic Characteristics.

PURPOSE: To describe the clinical and genetic characteristics of pachychoroid geographic atrophy (GA) and to compare them with those of conventional GA associated with age-related macular degeneration (AMD). DESIGN: Observational case series. PARTICIPANTS: Ninety-two eyes of 92 consecutive patients with GA who underwent a full ophthalmologic examination, including best-corrected visual acuity measurement, spectral-domain OCT, and fundus autofluorescence imaging. Their blood samples were genotyped for the major AMD-associated single nucleotide polymorphisms. METHODS: Pachychoroid GA was diagnosed if all of the following criteria were met: (1) GA in either eye; (2) clinical and anatomic features of the pachychoroid phenotype, such as reduced fundus tessellation and dilated choroidal vessels; and (3) no drusen in both eyes. Drusen-related GA was defined as conventional GA. MAIN OUTCOMES AND MEASURES: Comparison of clinical and genetic characteristics between pachychoroid GA and conventional GA. RESULTS: Twenty-one patients (22.8%) were diagnosed with pachychoroid GA. These patients were significantly younger than those with conventional GA (mean age, 70.5 vs. 78.5 years; P < 0.001), had a smaller GA area (mean, 0.9 mm2 vs. 4.0 mm2; P < 0.001, age-adjusted), had greater subfoveal choroidal thickness (mean, 353.3 µm vs. 175.6 µm; P = 0.009, age-adjusted), and were more likely to have choroidal vascular hyperpermeability (47.4% vs. 6.3%; P < 0.001). Pseudodrusen were found in 40 of 71 patients (56.3%) with conventional GA, but not in any of the patients with pachychoroid GA. The risk allele in ARMS2 A69S was less common in patients with pachychoroid GA than in those with conventional GA (31.6% vs. 68.8%; P < 0.001). The genetic risk score calculated from the single nucleotide polymorphisms of 11 AMD susceptibility genes indicated that patients with pachychoroid GA were less genetically prone to AMD than the conventional GA group (P = 0.001). CONCLUSIONS: Pachychoroid GA was diagnosed in 23% of patients with GA. Differences in the phenotypic and genetic characteristics of pachychoroid GA and conventional GA were identified. These 2 conditions should be differentiated when considering prevention and therapeutic strategies.

Prevalence of posterior staphyloma and factors associated with its shape in the Japanese population.

Myopia is increasing rapidly worldwide. We performed a cross-sectional study to investigate the prevalence of posterior staphyloma, a complication of myopia, and its shape characteristics in relation to age, sex, and axial length (AL) in a Japanese community-based cohort. The right eyes of 3748 participants who underwent fundus photography and optical coherence tomography (OCT) examination were evaluated. Posterior staphyloma prevalence was evaluated using fundus photographs and OCT images. Furthermore, fundus shapes were analyzed by measuring local fundus curvatures on 6 mm cross-line OCT images at intervals of 1 µm. The mean and variance of the curvatures were calculated to represent the fundus shape of each eye for investigation of the relationship between fundus curvature and age, sex, and AL. Seventy-seven eyes (2.05%) had posterior staphyloma. The mean and variance of the fundus curvatures were significantly greater in women than in men and became greater with age, suggesting that the shape of the staphyloma was steeper and less smooth in women and elderly subjects. AL and mean curvature showed a significant correlation (P = 2 × 10-16, R = 0.480), which was significantly affected by age (P < 2 × 10-16). Quantitative analysis of fundus shapes was useful for statistical analysis of posterior staphyloma in relation to age, sex, and AL.