Choroidal manifestations of non-ocular sarcoidosis: an enhanced depth imaging OCT study.

BACKGROUND: Although choroidal thickening was reported as a sign of active inflammation in ocular sarcoidosis, there has been no research on the choroidal changes in non-ocular sarcoidosis (defined as systemic sarcoidosis without overt clinical signs of ocular involvement). Therefore, this study aimed to investigate choroidal structural changes in patients with non-ocular sarcoidosis. METHODS: This retrospective case-control study was conducted at Asan Medical Center, a tertiary referral center. We evaluated 30 eyes with non-ocular sarcoidosis and their age- and spherical equivalent-matched healthy control eyes. The subfoveal choroidal thickness, area ratio (Sattler layer-choriocapillaris complex [SLCC] area to Haller layer [HL] area), and choroidal vascularity index (CVI, luminal area to choroidal area) were analyzed using enhanced depth imaging in optical coherence tomography. Systemic and ocular factors associated with the choroidal thickness were investigated. RESULTS: Compared with the healthy control group, the non-ocular sarcoidosis group had significantly thicker subfoveal choroid (total and all sublayers [SLCC and HL]) and lower area ratio. There were no significant differences in the CVIs at all sublayers between groups. In the non-ocular sarcoidosis group, eyes under oral steroid treatment had thinner choroid than eyes under observation. In the control group, eyes with older age and more myopic spherical equivalent had thinner choroidal thickness. CONCLUSION: Total and all sublayers of the subfoveal choroid were significantly thicker without significant vascularity changes in non-ocular sarcoidosis eyes than in healthy control eyes. The degree of choroidal thickening was disproportionally greater at HL than at SLCC. These characteristic choroidal changes may be the subclinical manifestations in non-ocular sarcoidosis.

Surgical Management of Full-Thickness Macular Holes in Macular Telangiectasia Type 2: A Global Multicenter Study.

PURPOSE: To report on macular hole repair in macular telangiectasia type 2 (MacTel2). DESIGN: Global, multicenter, retrospective case series. PARTICIPANTS: Patients undergoing surgery for MacTel2-associated full-thickness macular hole (MTMH). METHODS: Standardized data collection sheet distributed to all surgeons. MAIN OUTCOME MEASURES: Anatomic closure and visual outcomes of MTMH. RESULTS: Sixty-three surgeries in 47 patients with MTMH were included from 30 surgeons. Mean age was 68.1 years, with 62% female, 72% White, 21% East or South Asian, 2% African American, and 2% Hispanic or Latino. Procedures included 34 internal limiting membrane (ILM) peeling alone, 22 ILM flaps, 5 autologous retinal transplantations (ARTs), 1 retinotomy, and 1 subretinal bleb. For ILM peeling, preoperative visual acuity (VA) was 0.667 ± 0.423 logarithm of the minimum angle of resolution (logMAR). Minimum hole diameter (MHD) was 305.5 ± 159.4 µm (range, 34-573 µm). Sixteen of 34 ILM peels (47%) resulted in MTMH closure. At postoperative month 6, VA was stable at 0.602 ± 0.516 logMAR (P = 0.65). VA improved by at least 2 lines in 43% and at least 4 lines in 24%. For ILM flaps, preoperative VA was 0.878 ± 0.552 logMAR. MHD was 440.8 ± 175.5 µm (range, 97-697 µm), which was significantly larger than for ILM peels (P < 0.01). Twenty of 22 ILM flaps (90%) resulted in MTMH closure, which was significantly higher than for ILM peels (P < 0.01). At postoperative month 6, VA improved to 0.555 ± 0.405 logMAR (P < 0.05). VA improved by at least 2 lines in 56% and at least 4 lines in 28%. For ARTs, preoperative VA was 1.460 ± 0.391 logMAR. MHD was 390.2 ± 203.7 µm (range, 132-687 µm). All 5 ARTs (100%) resulted in MTMH closure. At postoperative month 6, VA was stable at 1.000 ± 0.246 logMAR (P = 0.08). Visual acuity improved at least 2 lines in 25%. CONCLUSIONS: Surgical closure of macular holes improved VA in 57% of MTMHs. Internal limiting membrane flaps achieved better anatomic and functional outcomes than ILM peeling alone. Autologous retinal transplantation may be an option for refractory MTMHs. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Factors Affecting Intensive Aflibercept Treatment Response in Diabetic Macular Edema: A Real-World Study.

Objective: To investigate the systemic and ocular factors that affect the response to intensive aflibercept treatment in diabetic macular edema (DME) in a real-world setting. Methods: This retrospective cohort study evaluated 30 eyes of 23 patients with DME who underwent intensive intravitreal aflibercept injections (five monthly loading doses). Treatment response was assessed by central retinal thickness (CRT) and best-corrected visual acuity (BCVA) at each monthly visit. The patients were categorized as good (<300 µm) and suboptimal (≥300 µm) responders based on CRT after the loading phase. Baseline systemic and ocular factors associated with treatment response were investigated. Results: The mean CRT and BCVA significantly improved after five loading injections (486.87 ± 95.46 to 334.90 ± 69.47 µm and 0.51 ± 0.30 to 0.35 ± 0.25 LogMAR, respectively, all p < 0.05). During 12 months of follow-up, 16 eyes (53.33%) maintained CRT without additional treatment. Eyes with diabetes mellitus (DM) for ≥15 years, estimated glomerular filtration rate (eGFR) < 80 mL/min/1.73 m2, serum creatinine ≥ 0.95 mg/dL and potassium ≥ 4.7 mmol/L, and presence of epiretinal membrane (ERM) were more likely to have a suboptimal response to the treatment. Conclusions: Five monthly loading doses of intravitreal aflibercept injection provided significant anatomical and visual improvements in patients with DME. Patients with longer DM duration, lower eGFR, higher serum creatinine or potassium levels, or ERM were predisposed to a suboptimal treatment response. Individual response to intensive aflibercept treatment for DME can be predicted by these systemic and ocular risk factors.

Clinical feature and visual prognosis of acute retinal necrosis according to the initially involved zone and extent: 10-year experience.

PURPOSE:: We aimed to analyze the visual prognosis and clinical characteristics of acute retinal necrosis according to the initially involved zone and extent. STUDY DESIGN:: Retrospective, consecutive, cross-sectional study. METHODS:: We retrospectively reviewed acute retinal necrosis patients who were treated with systemic antiviral treatment, and assessed the visual prognosis of acute retinal necrosis following antiviral treatment based on the initially involved zone and the extent of acute retinal necrosis at the time of diagnosis. Moreover, we evaluated whether prophylactic laser photocoagulation had preventive effects on retinal detachment. RESULTS:: A total of 43 eyes from 35 patients with acute retinal necrosis were included. Eyes with zone I involvement/extensive retinal lesions showed poor visual prognosis (logMAR: 1.17 ± 0.97 vs 0.49 ± 0.81; p = 0.014) and a higher incidence of retinal detachment (9/30 (30.0%) vs 0/13 (0%); p = 0.039) after treatment. Retinal detachment was observed in 20.9% of cases, and its incidence was significantly lower in eyes that had undergone prophylactic laser photocoagulation. CONCLUSION:: The overall visual prognosis of acute retinal necrosis is poor and can be determined at the time of diagnosis. Prophylactic laser photocoagulation exhibits preventive effects with regard to the development of retinal detachment. Therefore, laser photocoagulation should be actively considered in eyes with extensive retinal lesions to prevent retinal detachment and thus eventually improve the overall visual prognosis of acute retinal necrosis.

Influence of Vitrectomy-related Factors on the Outcome of Ahmed Glaucoma Valve Implantation.

PURPOSE: To evaluate the outcome of Ahmed glaucoma valve (AGV) implantation in eyes with refractory secondary glaucoma following pars plana vitrectomy (PPV) and the associated prognostic factors. METHODS: A total of 146 eyes in 146 patients who underwent AGV implantation after PPV (followed up for ≥1 year) were included. AGV implantation was considered successful when the intraocular pressure (IOP) was 6 to 21 mmHg regardless of using IOP-lowering medication. The hazard ratios (HRs) associated with surgical failure were determined with Cox proportional analysis. RESULTS: The most common cause for PPV was complications of proliferative diabetic retinopathy (50%). The mean and peak IOPs between PPV and AGV implantation were 26.9 ± 6.6 and 35.9 ± 10.2 mmHg, respectively. AGV implantation was performed on average 18.7 months after PPV, and its overall success rate was 80.1% during a mean follow-up period of 43.6 months. In multivariate analyses, rubeosis observed before AGV implantation (HR, 4.07; 95% confidence interval, 1.57 to 10.6; p = 0.004) and higher peak IOP before AGV (HR, 1.04; 95% confidence interval, 1.00 to 1.07; p = 0.034) were predictive of failure. However, no PPV-related factors were associated with the surgical outcome of AGV implantation. CONCLUSIONS: The outcome of AGV implantation is good in refractory glaucoma following PPV. Rubeosis after PPV and higher peak IOP before AGV are risk factors for poor outcomes. Patients who undergo PPV should be followed for the development of rubeosis and IOP control.

Glaucoma Progression and its Relationship with Corrected and Uncorrected Intraocular Pressure in Eyes with History of Refractive Corneal Surgery.

PURPOSE: To investigate glaucoma progression and its relationship with corrected and uncorrected intraocular pressure (IOP) in patients with a history of refractive corneal surgery (RCS). METHODS: Totally, 56 eyes of 56 primary open-angle glaucoma patients who had a history of RCS were included. Mean keratometry and central corneal thickness were measured at the time of glaucoma diagnosis. Three IOP measurements, i.e., uncorrected IOP (UCIOP) and corrected IOP calculated by applying the Kohlhaas (CKIOP) and Ehlers (CEIOP) formulas, were used. Participants were categorized into two groups (low-teen [<15 mmHg] and high-teen [≥15 mmHg] groups) according to the mean follow-up IOP, in each of the three IOP measurements. Glaucoma progression was determined based on either structurally or functionally by stereoscopic optic disc/retinal nerve fiber layer photographs or visual field tests. Kaplan-Meier survival curves were compared between the low-teens group and high-teens group for each IOP measurement. Risk factors for glaucoma progression, including uncorrected and corrected IOP measurements, were analyzed using a Cox proportional-hazards model. RESULTS: Among total eyes, glaucoma progression was found in 19 (34%) eyes during 4.3 years of mean follow-up period. Individual values of uncorrected IOP and corrected IOP showed significant differences (p < 0.001). Incidence of glaucoma progression was higher in high-teens group than in low-teens group by corrected IOP values (both Kohlhaas and Ehlers, p = 0.006, 0.003), but not by uncorrected IOP values (p = 0.749). The cumulative probability of glaucoma progression was significantly greater in the high-teens group than in the low-teens group using the Elhers formula determined by Kaplan-Meier analysis (p = 0.030). CONCLUSIONS: For glaucoma eyes with history of RCS, high-teen group by corrected mean follow-up IOP showed more glaucoma progression than low-teen group. More intensive IOP-lowering treatment will be required for patient with high-teen follow-up corrected IOP to prevent glaucoma progression.

Macular capillary plexuses after macular hole surgery: an optical coherence tomography angiography study.

AIMS: To investigate the structural changes of the superficial capillary plexuses (SCP) and deep capillary plexuses (DCP) using optical coherence tomography (OCT) angiography (OCTA) in patients with idiopathic macular hole (MH) after surgery, determine the factors related to changes of macular capillary plexuses and evaluate its association with postoperative visual outcomes. METHODS: Thirty-three patients with unilateral MH who were followed for ≥6 months after surgery were included. Ophthalmologic evaluations included best corrected visual acuity (BCVA) and spectral-domain OCT before surgery and 6 months postsurgery. En face OCTA images were obtained for both eyes at 6 months postsurgery, and the postoperative foveal avascular zone (FAZ) area and parafoveal vascular density were identified. RESULTS: Compared with fellow eyes, eyes after MH surgery had a smaller FAZ area in both SCP and DCP (p<0.05 for all). The FAZ area was positively correlated with postoperative foveal thickness of the whole, inner and outer layers (p<0.05 for all). In the parafoveal region, eyes after MH surgery had a tendency to have lower parafoveal vascular density, particularly in DCP (p=0.019). The parafoveal vascular density in DCP was positively correlated with retinal thickness of the whole, inner and outer layers (p<0.05 for all). Correlations between BCVA and FAZ area in both SCP and DCP were significant 6 months after MH surgery (p<0.05 for all). CONCLUSION: Assessment of macular capillary plexuses using OCTA may be useful for monitoring retinal structural and functional changes in MH.

Scleral Buckling Using a Non-contact Wide-Angle Viewing System with a 25-Gauge Chandelier Endoilluminator.

PURPOSE: To report the outcome of scleral buckling using a non-contact wide-angle viewing system with a 25-gauge chandelier endoilluminator. METHODS: Retrospective analyses of medical records were performed for 17 eyes of 16 patients with primary rhegmatogenous retinal detachment (RRD) without proliferative vitreoretinopathy who had undergone conventional scleral buckling with cryoretinopexy using the combination of a non-contact wide-angle viewing system and chandelier endoillumination. RESULTS: The patients were eight males and five females with a mean age of 26.8 ± 10.2 (range, 11 to 47) years. The mean follow-up period was 7.3 ± 3.1 months. Baseline best-corrected visual acuity was 0.23 ± 0.28 logarithm of the minimum angle of resolution units. Best-corrected visual acuity at the final visit showed improvement (0.20 ± 0.25 logarithm of the minimum angle of resolution units), but the improvement was not statistically significant (p = 0.722). As a surgery-related complication, there was vitreous loss at the end of surgery in one eye. As a postoperative complication, increased intraocular pressure (four cases) and herpes simplex epithelial keratitis (one case) were controlled postoperatively with eye drops. One case of persistent RRD after primary surgery needed additional vitrectomy, and the retina was postoperatively attached. CONCLUSIONS: Scleral buckling with chandelier illumination as a surgical technique for RRD has the advantages of relieving the surgeon's neck pain from prolonged use of the indirect ophthalmoscope and sharing the surgical procedure with another surgical team member. In addition, fine retinal breaks that are hard to identify using an indirect ophthalmoscope can be easily found under the microscope by direct endoillumination.

Peripapillary Microvascular Improvement and Lamina Cribrosa Depth Reduction After Trabeculectomy in Primary Open-Angle Glaucoma.

Purpose: To evaluate peripapillary microvascular changes in patients with primary open-angle glaucoma (POAG) after trabeculectomy using optical coherence tomography (OCT) angiography, and to determine the influence of lamina cribrosa (LC) displacement on changes in peripapillary microvasculature. Methods: The peripapillary retinal microvasculature and LC were imaged using OCT angiography and OCT-enhanced depth imaging, respectively. The microvasculature and LC depth (LCD) were measured before, and 1 week, 1 month, and 3 months after trabeculectomy. The microvascular improvement was arbitrarily defined as a reduction >30% of the area of vascular dropout (blue/black areas with <20% vessel density on the color-coded vessel density map). LCD was determined as the mean of vertical distance between the anterior LC surface and a reference plane of Bruch's membrane. Results: Thirty-one eyes of 31 POAG patients were included. At 3 months postoperatively, intraocular pressure (IOP) and LCD were significantly decreased from 26.3 ± 11.8 mm Hg to 12.5 ± 3.6 mm Hg, and 501.1 ± 130.2 µm to 455.8 ± 112.7 µm, respectively (all P < 0.001), compared with baseline. The microvascular improvement was observed in 19 eyes (61.3%) at 3 months after trabeculectomy. The maximal reductions in IOP and LCD were significantly greater in eyes with improved microvasculature compared to eyes without improvement (P = 0.020 and P = 0.005). The microvascular improvement was significantly associated with maximal reduction in LCD (odds ratio, 1.062; P = 0.026). Conclusions: Trabeculectomy can improve peripapillary retinal microcirculation in patients with POAG. This finding suggests that the reduction of LCD induced by lowering IOP may affect peripapillary microvascular improvement in eyes with POAG.

COMPARISON OF VISUAL PROGNOSIS AND CLINICAL FEATURES OF CYTOMEGALOVIRUS RETINITIS IN HIV AND NON-HIV PATIENTS.

PURPOSE: To compare the visual prognosis and clinical features of cytomegalovirus (CMV) retinitis between HIV and non-HIV patients. METHODS: Retrospective cross-sectional study on patients diagnosed with CMV retinitis. Depending on the presence of HIV infection, best-corrected visual acuity (VA) and clinical feature of CMV retinitis were analyzed. The clinical characteristics associated with poor visual prognosis after antiviral treatment were also identified. RESULTS: A total of 78 eyes (58 patients) with CMV retinitis were included in this study: 21 eyes and 57 eyes in HIV and non-HIV patients, respectively. Best-corrected VA was not significantly different between HIV and non-HIV patients. The rate of foveal involvement, retinal detachment, involved zone, and mortality did not significantly differ between the two groups. Visual acuity after antiviral treatment was significantly worse (pretreatment logarithm of the minimal angle of resolution best-corrected VA, 0.54 ± 0.67 [Snellen VA, 20/63]; posttreatment logarithm of the minimal angle of resolution best-corrected VA, 0.77 ± 0.94 [Snellen VA, 20/125]; P = 0.014). Poor visual prognosis was significantly associated with Zone 1 involvement, retinal detachment, and a poor general condition. CONCLUSION: The overall visual prognosis and the clinical features of CMV retinitis do not differ between HIV and non-HIV patients. The visual prognosis of CMV retinitis still remains quite poor despite advancements in antiviral treatment. This poor prognosis after antiviral treatment is associated with retinal detachment during follow-up, Zone 1 involvement, and the poor general condition of the patient.