Impact of COVID-19 Confinement on Quality of Life of Patients with Age-Related Macular Degeneration: A Two-Wave Panel Study.

Age-related macular degeneration (AMD) is the leading cause of blindness in developed countries. Intravitreal injections of antiangiogenic agents (anti-VEGF) can stop vision loss in the neovascular form of the disease (nAMD). The aim of this study was to assess the general health-related quality of life (HRQoL) in a cohort of patients with nAMD treated with intravitreal anti-VEGF injections and to detesrmine to what extent their HRQoL was affected by COVID-19. This was an observational, analytical, and longitudinal study performed with a two-wave panel survey. Clinical outcomes, HRQoL, and tangible support were evaluated. In the final survey, changes in living conditions and medical visits due to the COVID-19 pandemic were also examined. Of the 102 patients initially interviewed in the before-COVID survey, 24 were lost after 30 months of follow-up. In the initial assessment, the mean health index was 0.73 ± 0.2. The EQ VAS score worsened at the final survey (p = 0.048). Patients needing treatment in both eyes (p = 0.007) and with lower levels of bilateral visual acuity (p = 0.018) reported an increase in social support at the final survey. In conclusion, patients perceived a worsening in HRQoL after confinement. However, patients enjoyed good social support that improved in the after-COVID survey.

Modifiable Determinants of Satisfaction with Intravitreal Treatment in Patients with Neovascular Age-Related Macular Degeneration.

BACKGROUND: The success of intravitreal treatment for neovascular age-related macular degeneration (nAMD) depends on maximal adherence to treatment, which in turn requires patient satisfaction. OBJECTIVE: The aim of this study was to assess the factors associated with nAMD patient satisfaction to implement actions to improve treatment experiences and increase adherence. DESIGN: This was a prospective, observational, analytical, cross-sectional study. SUBJECTS: Our study included 100 consecutive nAMD patients under intravitreal treatment for at least 1 year. METHODS: Patients completed the Macular Disease Treatment Satisfaction Questionnaire (MacTSQ) and the EuroQol Visual Analog Scale (EQ VAS). A logistic regression was estimated to model the low values of the satisfaction score (MacTSQ < 50). RESULTS: The mean age of patients was 82.1 ± 7.8 years and 62% were female. Males (p = 0.002) and patients who improved their visual acuity (p = 0.004) were more satisfied, while patients who received a higher number of injections (p = 0.036) and treatment in both eyes (p = 0.001) were less satisfied. Higher health-related quality of life was related to higher satisfaction. The sensitivity and specificity of the predictive model were 75.8% and 76.1%, respectively. Factors independently associated with low satisfaction were female sex (odds ratio [OR] 6.84), going to the clinic alone (OR 8.51), longer duration of treatment (OR 0.62), receiving treatment in both eyes (OR 3.54), and suffering a decline in visual acuity (OR 3.30). The questionnaire revealed patients' needs for more information and injection points closer to their homes. CONCLUSIONS: Well-defined areas for improvement were identified, i.e. to improve the information offered to each patient, to incorporate new long-acting drugs, and to establish locations for injection services in peripheral areas.

Silicone microbubbles after anti-vascular endothelial growth factor injections in patients with wet age-related macular degeneration: incidence, quantification and secondary optical coherence tomography artfacts.

PURPOSE: To report the incidence and quantity of silicone oil microbubbles and the relationship with the number of intravitreal anti-vascular endothelial growth factor (VEGF) injections and evaluate if microbubbles induce artefacts on optical coherence tomography (OCT) images. METHODS: Observational, descriptive, cross-sectional study. Patients with wet age-related macular degeneration were included who had been treated for 1 year minimally with anti-VEGF injections repackaged in the hospital pharmacy. Detection and quantification of silicone microbubbles by mydriatic biomicroscopic examination were conducted 1 month after the last injection. The numbers of microbubbles were quantified on a scale of 0-3: 0, none; 1 scarce (1-10 microbubbles); 2 moderate (10-30); or 3 numerous (>30). Shadowing on OCT images was classified as 0-3: 0, none; 1 obscuring some retinal layers; 2 obscuring all retinal layers; or 3 obscuring the retinal thickness. RESULTS: The study included 142 eyes of 98 patients (mean age, 82.4 years + 7.3; range, 65-97) treated with 2377 injections. Microbubbles were detected in 127 (89.4%) eyes, 62 (43.6%) with numerous microbubbles and 36 (25.4%) and 29 (20.4%), respectively, with scarce and moderate numbers. A positive correlation was found between the numbers of injections and intravitreal silicone (rho, 0.7). Optical coherence tomography (OCT) artefacts were detected in 11 eyes; the artefacts obscured all retinal layers in three eyes. No significant relationship could be established between the appearance of floaters and the microbubbles. CONCLUSION: The presence and number of silicone microbubbles were correlated with the number of intravitreal injections. Microbubbles can produce OCT artefacts, which can hinder the treatment decision.

Progression of myopic maculopathy in a Caucasian cohort of highly myopic patients with long follow-up: a multistate analysis.

PURPOSE: This study aims to determine the probability of progression of myopic maculopathy according to age. METHODS: This is a longitudinal observational study of single-center retrospective cohort of Caucasian patients formed by 212 consecutive adults with high myopia. Main outcome measures were age, visual acuity (VA), refractive error (RE), follow-up time, and the macular status assessed at least 5 years apart according to the Meta-Analysis of Pathologic Myopia Study Group. The progression rate was calculated based on per 1000 eyes/year. Multistate models were fitted to identify the predictive factors and to calculate the most probable age of progression onset using the Aalen-Johansen estimator. RESULTS: We studied 220 eyes of 122 Caucasian patients. Mean age was 48.18 ± 14.1, mean follow-up 12.73 ± 5.81 years. One-hundred and fifty-two (69.1%) eyes progressed of category, and 96 (44%) worsened a mean of 0.3 logMAR units during follow-up. The progression rate was 32.21/1000 eyes/year. The probability of progressing increased with age; it was higher in women if there was a family history of myopia, worse VA, higher RE, or wide macular staphyloma. The probability of progressing from category 1 was > 0.6 after 70 years of age; from category 2, it was 0.7 after 70 years; and 0.5 from category 3 after 75 years. If choroidal neovascularization (CNV) appeared, this probability exceeded 0.7 between ages 45 and 55 for all categories. CONCLUSION: The progression rate is lower than in a Japanese series. The vision worsened with disease progression, and the probability of both happening increased after the age of 70-75. If CNV appears, the risk of progression is very high at the age of 45-55.

Fluorescein Angiography Indications: Changes after Optical Coherence Tomography and Antiangiogenics.

SIGNIFICANCE: The present study provides quantitative data regarding the change of indications of fluorescein angiography in a tertiary hospital. Exhaustively compiled data over more than 10 years concerning all the angiographic studies including diagnosis, first-visit/follow-up, possible relation with antiangiogenics approval, and optic coherence tomography (OCT) are presented. PURPOSE: The aim of this study was to determine the frequency and indications of fluorescein angiography before and after OCT and anti-vascular endothelial growth factor (anti-VEGF) treatment implantation. METHODS: This was a retrospective and descriptive study of all fluorescein angiographies performed in a tertiary hospital between 2005 and 2016. Demographic data, diagnosis, follow-up, and type of angiograms were analyzed in relation with the implantation of time domain OCT (2006), spectral domain OCT (SD-OCT) (2013), and anti-VEGF (2007). RESULTS: Of 3263 angiograms (2342 patients) analyzed, 72% were baseline angiograms, and 28% were follow-up angiograms. After anti-VEGF initiation, the number of angiograms per year increased progressively with peaks that matched with the approval of anti-VEGF for wet age-related macular degeneration (2007) (164.2%), macular edema secondary to retinal vein occlusions (2010) (102.2%), and diabetic macular edema (2011) (123.8%). After using SD-OCT, fluorescein angiographies decreased up to 57%. CONCLUSIONS: Anti-VEGF introduction led to an increase in the indication of angiograms, which did not vary significantly after time domain OCT. Nevertheless, since SD-OCT became available, the indication of fluorescein angiography has halved in the hospital of reference.

Loss of Visual Acuity after Successful Surgery for Macula-On Rhegmatogenous Retinal Detachment in a Prospective Multicentre Study.

Purpose. To quantify the frequency of visual loss after successful retinal detachment (RD) surgery in macula-on patients in a multicentric, prospective series of RD. Methods. Clinical variables from consecutive macula-on RD patients were collected in a prospective multicentric study. Visual loss was defined as at least a reduction in one line in best corrected visual acuity (VA) with Snellen chart. The series were divided into 4 subgroups: (1) all macula-on eyes (n = 357); (2) macula-on patients with visual loss at the third month of follow-up (n = 53) which were further subdivided in (3) phakic eyes (n = 39); and (4) pseudophakic eyes (n = 14). Results. Fifty-three eyes (14.9%) had visual loss three months after surgery (n = 39 phakic eyes; n = 14 pseudophakic eyes). There were no statistically significant differences between them regarding their clinical characteristics. Pars plana vitrectomy (PPV) was used in 67.2% of cases, scleral buckle in 57.7%, and scleral explant in 11.9% (36.1% were combined procedures). Conclusions. Around 15% of macula-on RD eyes lose VA after successful surgery. Development of cataracts may be one cause in phakic eyes, but vision loss in pseudophakic eyes could have other explanations such as the effect of released factors produced by retinal ischemia on the macula area. Further investigations are necessary to elucidate this hypothesis.

External validation of existing formulas to predict the risk of developing proliferative vitreoretinopathy: the Retina 1 Project; report 5.

PURPOSE: To externally validate the accuracy of previously published formulas for predicting proliferative vitreoretinopathy development after retinal detachment surgery. METHODS: Clinical variables from consecutive retinal detachment patients (n = 1,047) were collected from the Retina 1 Project conducted in 17 Spanish and Portuguese centers. These data were used for external validation of four previously published formulas, F1 to F4. Receiver-operating characteristic curves were used to validate the quality of formulas, and measures of discrimination, precision, and calibration were calculated for each. Concordance among the formulas was determined by Cohen kappa index. RESULTS: The areas under the receiver-operating characteristic curves were as follows: F1, 0.5809; F2, 0.5398; F3, 0.5964; and F4, 0.4617. F1 had the highest accuracy, 74.21%. Almost 19% of proliferative vitreoretinopathy cases were correctly classified by F1 compared with 13%, 15%, and 10% for F2, F3, and F4, respectively. There was moderate concordance between F2 and F3 but little between the other formulas. CONCLUSION: After external validation, none of the formulas were accurate enough for routine clinical use. To increase its usefulness, other factors besides the clinical ones considered here should be incorporated into future formulas for predicting risk of developing proliferative vitreoretinopathy.

A propensity score matching application: indications and results of adding scleral buckle to vitrectomy: The Retina 1 Project: Report 3.

PURPOSE: To identify the indications and differences in outcomes for adding a scleral buckle (SB) to pars plana vitrectomy (PPV) in a prospective series of rhegmatogenous retinal detachment (RD) by using propensity score matching (PSM) to analyze causal effects in observational studies. METHODS: Data were collected from the Retina 1 Project, a prospective, interventional, nonrandomized study of consecutive RDs. Case selection was based upon treatment with PPV or PPV+SB. Surgeons followed personal criteria for the inclusion of SB in the PPV. Propensity score matching corrected for selection biases. Outcomes were assessed by anatomic and visual criteria and the development of proliferative vitreoretinopathy. RESULTS: Of 523 patients analyzed, 251 had PPV and 272 had PPV+SB. Surgeons used PPV+SB more frequently in younger patients with RD, in those with posterior or unidentified breaks, in phakic eyes, in eyes with the posterior vitreous attached, and for more extended RDs. Overall single surgery anatomic success rate was 86.4%. Based on PSM, there were no difference in reattachment rates of the PPV group, 86.9%, and the PPV+SB group, 85.93%. The incidence of PVR was similar in both groups, with 8.5% in the PPV group and 10.5% in the PPV+SB group. CONCLUSIONS: Data from the Retina 1 Project established the indications for adding SB to PPV in treating primary RD in this series. No anatomic or visual differences between PPV and PPV+SB were found.

Variations in Functional and Anatomical Outcomes and in Proliferative Vitreoretinopathy Rate along a Prospective Collaborative Study on Primary Rhegmatogenous Retinal Detachments: The Retina 1 Project-Report 4.

Purpose. To analyse variations in the anatomical and functional outcomes and in proliferative vitreoretinopathy (PVR) rate of a prospective multicentric study that was primarily designed for identification of clinical risk factors for PVR. Methods. 1,046 retinal detachment (RD) cases were analysed. Cases were divided into two series based upon variation in PVR rate determined by logistic regression analysis. Series 1 (S1) included RD treated during 2004-2005 (n = 481) and Series 2 (S2) during 2006-2008 (n = 565). Pre-, intra-, and postoperative characteristics were recorded. Results. There were few differences in the preoperative characteristics. S2 had more vitrectomies and scleral bands and fewer explants and associated cataract extractions than S1. Anatomic reattachment improved from 87.9% to 92.9% in S1 and S2, respectively, (P = 0.006). Visual acuity at 3 months ≥20/40 increased from 36.5% of S1 to 44.2% in S2 (P = 0.049). PVR rate diminished from 14.1% in S1 to 8.1% in S2 (P = 0.002). Centres with higher rates of PVR in S1 showed the greatest reductions in S2. Conclusion. An improvement in anatomical and functional outcome and PVR rate occurred in participating centres cannot be attributed to the learning curve of surgeons. We speculated that it could be an effect of their participation in the study.

Training and professional profile of retinologists in Spain: Retina 2 project, Report 4.

BACKGROUND: Uniform postresidency systems to train medical specialists have not been developed in most European countries. Before developing a framework for such a system, we established the learning and professional profiles of Spanish ophthalmologists dedicated to medical retina and vitreoretina subspecialties. METHODS: After identification of presumed subspecialists by experts from different autonomous regions, a self-administered questionnaire was mailed in 2006. A reminder was sent three weeks later. Postal mail was used. Nonresponder bias was determined. RESULTS: Of 492 possible retina subspecialists, 261 replied to the questionnaires. While about 86% received specific retinal training, standardized fellowship programs were uncommon for both medical retina and vitreoretina (around 10%). Of the responders, 24.5% performed only medical retina, 11.8% vitreoretina, and 63.6% both. Most (60.5%) practiced anterior segment surgery, and 78.7% declared skills in vitrectomy. CONCLUSION: We have developed a database of Spanish ophthalmologists dedicated to retinal pathologies and identified some characteristics of their professional profile. Although most of them have received specific retinal training, standardized mastership programs are still uncommon. These data will be useful in creating a standardized Retina Mastership, an important goal of the European Higher Education Area.

A strong genetic association between the tumor necrosis factor locus and proliferative vitreoretinopathy: the retina 4 project.

OBJECTIVE: To assess the genetic contribution to proliferative vitreoretinopathy (PVR) and report the strong association observed in the tumor necrosis factor (TNF) locus. DESIGN: As a component of The Retina 4 Project, a case-controlled, candidate gene association study in the TNF locus was conducted. PARTICIPANTS AND CONTROLS: Blood from 450 patients with (138 cases) and without (312 controls) post-rhegmatogenous retinal detachment (RD) PVR was genotyped to determine polymorphisms located in the TNFα gene. METHODS: Single nucleotide polymorphisms (SNPs) with correlation coefficients of ≥ 0.8 and a minor allelic frequency of ≥ 10% were studied. Functional SNPs or SNPs previously described in association with other inflammatory diseases were also added for analysis. The SNPlex Genotyping System (Applied Biosystems, Foster City, CA) was used for genotyping. Single nucleotide polymorphism and haplotype analyses were performed. Bioinformatic tools were used to evaluate those SNPs that were significantly associated. MAIN OUTCOME MEASURES: Single and haplotypic significant associations with PVR. RESULTS: A total of 11 common tag SNPs in the following genes were analyzed: lymphotoxin alpha (LTA), TNFα, leukocyte-specific transcript 1 (LST1), and the activating natural killer receptor p30 (NCR3). After permutation, there was a significant association in the non-synonymous polymorphism rs2229094(T→C) in the LTA gene (P = 0.0283), which encodes a cysteine to arginine change in the signal peptide. This marker was also present in all significant haplotypic associations and was not observed in any nonsignificant associations. When this SNP was analyzed using bioinformatic tools, the hydropathy profile changed, as well as the transmembrane region and the splicing site predictions. CONCLUSIONS: The strong association found in the rs2229094(T→C) of the LTA gene may indicate an important role of this polymorphism in the development of PVR. If supported in extended studies, the rs2229094(T→C) may have significant implications regarding the genetic risk of the retinal repairing process.

Oct findings in torpedo maculopathy.

BACKGROUND: Torpedo maculopathy, also called solitary hypopigmented nevus, is a rare though benign disorder. To our knowledge, there are no previous optical coherence tomography (OCT) descriptions in the literature. METHODS: Results of ophthalmologic examinations (including retinography, OCT, and visual field testing) for 2 girls aged 12 years and 13 years throughout 5 years of follow-up were reviewed. RESULTS: In both cases, anterior and posterior segment evaluation was unremarkable except for the presence of a flat, fishtail-shaped, hypopigmented lesion temporal to the macula, pointing to the fovea. In case 1, OCT disclosed faint thinning of the retina above the lesion especially in the outer retina and hyperreflectivity of the retinal pigment epithelium (RPE) associated with a posterior hyperreflective signal deep in the choroids. In case 2, OCT showed an atrophic retina with reduced thickness probably due to the absence of the photoreceptor layer. Shallow serous neurosensory detachment, increased RPE reflectivity, and higher penetration of light to the choroid were also evident. CONCLUSION: In both cases of torpedo maculopathy studied by OCT, we found a variable amount of retinal degeneration, and a serous retinal detachment was found in one case.

Photodynamic therapy in subfoveal and juxtafoveal idiopathic and postinflammatory choroidal neovascularization.

PURPOSE: To evaluate the efficacy of photodynamic therapy (PDT) in the treatment of idiopathic and inflammatory choroidal neovascularization (CNV). METHODS: This study represents a non-randomized, multicentre, interventional case series. Sixteen eyes of 16 patients with classic or predominantly classic sub- and juxtafoveal idiopathic CNV and 26 eyes of 24 patients with classic or predominantly classic sub- and juxtafoveal CNV secondary to inflammatory conditions were treated with PDT with verteporfin. Best corrected visual acuity (BCVA) before and after PDT, the number of lines gained or lost and the number of PDT sessions were analysed. RESULTS: The mean follow-up periods were 20 months (SD 11) and 16 months (SD 9) for the idiopathic and inflammatory groups, respectively. The mean BCVA in idiopathic CNV changed from 0.63 logMAR (SD 0.37) before treatment to 0.82 logMAR (SD 0.43) after treatment (p = 0.16; Student's t-test paired data). The number of treatments performed averaged 2.1 (range 1-4, SD 0.9). The mean BCVA in postinflammatory CNV changed from 0.60 logMAR (SD 0.4) before treatment to 0.57 logMAR (SD 0.6) after treatment (p = 0.79; Student's t-test paired data). The mean number of treatments was 2.6 (range 1-6, SD 1.2). CONCLUSIONS: Photodynamic therapy with verteporfin may be useful in stabilizing BCVA in patients with sub- and juxtafoveal postinflammatory CNV and subfoveal idiopathic CNV.