Are intravitreal injections essential during the COVID-19 pandemic? Global preferred practice patterns and practical recommendations.

Tertiary outpatient ophthalmology clinics are high-risk environments for COVID-19 transmission, especially retina clinics, where regular follow-up is needed for elderly patients with multiple comorbidities. Intravitreal injection therapy (IVT) for chronic macular diseases, is one of the most common procedures performed, associated with a significant burden of care because of the vigorous treatment regimen associated with multiple investigations. While minimizing the risk of COVID-19 infection transmission is a priority, this must be balanced against the continued provision of sight-saving ophthalmic care to patients at risk of permanent vision loss. This review aims to give evidence-based guidelines on managing IVT during the COVID-19 pandemic in common macular diseases such as age-related macular degeneration, diabetic macula edema and retinal vascular disease and to report on how the COVID-19 pandemic has affected IVT practices worldwide.To illustrate some real-world examples, 18 participants in the International Retina Collaborative, from 15 countries and across four continents, were surveyed regarding pre- and during- COVID-19 pandemic IVT practices in tertiary ophthalmic centers. The majority of centers reported a reduction in the number of appointments to reduce the risk of the spread of COVID-19 with varying changes to their IVT regimen to treat various macula diseases. Due to the constantly evolving nature of the COVID-19 pandemic, and the uncertainty about the normal resumption of health services, we suggest that new solutions for eye healthcare provision, like telemedicine, may be adopted in the future when we consider new long-term adaptations required to cope with the COVID-19 pandemic.

Pupil dilation using drops vs gel: a comparative study.

PURPOSE: To compare the efficacy in pupil dilation and degree of discomfort between topical instillation of mydriatic drops and gel. METHODS: The study included 60 patients with no previous ocular history of trauma and surgery. One eye was dilated with two drops (tropicamide 0.5% and phenylephrine 10%), and the other with one drop of gel (tropicamide 0.5%+phenylephrine 5%). Pupil size was measured by a Colvard pupillometer at baseline and 5, 15, 30, and 45 min following instillation. Pain upon instillation was measured by visual analog scale (VAS). RESULTS: There was no difference in pupil size at baseline. Use of the gel achieved greater mydriasis than drops (P=0.01), and was also associated with lower pain scores (P=0.003). In diabetic patients, pupil size was smaller at baseline and following instillation of drops and gel. Use of the gel achieved an even greater degree of pupil dilation in this subset of patients than drops (P=0.019). CONCLUSIONS: Gel formulation achieved significantly greater pupil dilation than drops, despite a lower concentration of phenylephrine, and was also associated with significantly lower patient discomfort. This study is the first report of improved mydriatic efficacy in diabetic patients.

Evaluation of pain during intravitreal Ozurdex injections vs. intravitreal bevacizumab injections.

PURPOSE: The purpose was to evaluate the pain associated with intravitreal Ozurdex injections, and to compare it with that associated with intravitreal bevacizumab injections. METHODS: The study included 57 eyes of 57 patients who received an intravitreal Ozurdex injection at our institution. Pain was measured by the visual analog scale (VAS). Additional parameters recorded included age, sex, indication for the injection, number of previous Ozurdex injections in the study eye, presence of diabetes mellitus, and lens status. Data were compared with a 2 : 1 sex- and age-matched control group of 114 patients who received intravitreal bevacizumab injections. RESULTS: Indications for injection included diabetic macular edema (40.4%) and macular edema secondary to central and branch retinal vein occlusion (28% and 31.6%, respectively). Pain scores on the VAS ranged from 0 to 90, with a mean of 20.8±20.3. There was no significant difference in pain between Ozurdex and bevacizumab injections. Pseudophakia was correlated with increased pain in Ozurdex injections. CONCLUSIONS: This is the first series evaluating the pain associated with intravitreal Ozurdex injections. Despite a larger needle gauge and tunneled injection technique, intravitreal injection of Ozurdex is not associated with increased pain compared with bevacizumab. This finding may be a potential advantage for Ozurdex, and may serve to improve patient compliance with future long-term treatment protocols.

Pharmacological approach to diabetic macular edema.

Diabetic macular edema (DME) is a highly prevalent cause of vision loss and has a remarkable impact on public health, and on the quality of life of diabetic patients. Even though laser photocoagulation has been the standard of care for decades, a substantial group of patients are unresponsive and fail to improve after laser treatment. Recently, new pharmacological approaches based on the use of intravitreal drugs, such as corticosteroids and anti-vascular endothelial growth factor, have revolutionized the treatment of DME. The use of intravitreal drugs is supported by the improvement in visual acuity reported by several clinical trials and can limit the potentially destructive effects of the laser treatment. Encouraging results also emerged from studies evaluating the use of a combination therapy, or the association of intravitreal drugs and laser treatment. This review aims at providing a brief synopsis of the main investigations regarding the current pharmacological approach to DME.

Long-term evaluation of patients treated with dexamethasone intravitreal implant for macular edema due to retinal vein occlusion.

PURPOSE: To evaluate the long-term visual prognosis and complications of patients who received intravitreal Ozurdex injections for the treatment of macular edema (ME) due to retinal vein occlusion (RVO). METHODS: A total of 17 patients who received Ozurdex injections in our institution as part of the GENEVA study were recalled for examination. Recorded parameters included final visual acuity (VA), final retinal thickness by optical coherence tomography, persistence of ME, and the occurrence of any complications. RESULTS: Mean follow-up time was 50.5 months. Patients with branch RVO (BRVO) had a more favorable prognosis than central RVO (CRVO), and their mean VA had improved significantly, whereas the mean VA for the patients with CRVO did not improve significantly. Retinal thickness had reduced significantly in the whole group and in each subgroup separately. Complications included 10 patients with cataract progression, 1 with elevated intraocular pressure, and 1 with neovascularization and vitreous hemorrhage. CONCLUSIONS: This is the first reported long-term evaluation of patients treated with Ozurdex. Our results indicate that it has favorable long-term safety profile, and may have a beneficial effect on the visual prognosis in BRVO even in the absence of continuous treatment. Further research is required to establish the optimal retreatment schedule for Ozurdex.

Reconsidering the connection between vitamin D levels and age-related macular degeneration.

PURPOSE: Recent evidence has suggested a correlation between reduced vitamin D levels and delayed angiogenesis and reduced inflammatory response, which are known to have a major role in the development and progression of age-related macular degeneration (AMD). DESIGN: Cross-sectional study. PARTICIPANTS: Members of the Maccabi Healthcare Services (MHS, one of the four largest Israeli Health Maintenance Organization) aged ≥60 years, whose vitamin D levels were taken as part of routine examinations between 2000 and 2008. METHODS: All data for this study were obtained from MHS databases that include medical information on 1.8 million subscribers. MAIN OUTCOME MEASURES: Serum 25-OH vitamin D levels. RESULTS: The total study population comprised of 1045 members diagnosed as having AMD, and 8124 as non-AMD, for whom there was information on vitamin D levels. The mean±SD level of 25-OH vitamin D was 24.1±9.41 ng/ml (range 0.8-120) for the AMD patients and 24.13±9.50 ng/ml (range 0.0-120) for the controls (P=ns). One-third (33.6%) of the AMD patients and 32.86% of the controls had a 25-OH vitamin D level <16 ng/ml, and the proportions of tests in which the 25-OH vitamin D level was >74 ng/ml were 0.19 and 0.14%, respectively (P=ns). CONCLUSIONS: No association was detected between vitamin D levels and the presence of AMD in this cross-sectional study. These results raise some doubt about an association between reduced vitamin D levels and the prevalence of AMD.

Retinal pigment epithelial tear following photodynamic therapy for choroidal neovascularization secondary to AMD.

PURPOSE: To describe retinal pigment epithelial tear following photodynamic therapy (PDT) for subfoveal choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD). DESIGN: Retrospective interventional case series. METHODS: A retrospective study in an institutional practice. We describe seven cases of retinal pigment epithelial (RPE) tear, which developed in seven eyes of seven patients following PDT. All eyes had subfoveal CNV secondary to AMD. RESULTS: Six eyes had occult subfoveal CNV, and one eye had recurrent classic subfoveal CNV. In five patients, the eye that developed the tear was the second eye, whereas the first eye had a disciform scar. In four eyes, the RPE tear developed after one PDT, in one eye the RPE tear developed after the second PDT, and in two eyes the RPE tear developed after the third PDT. In five of seven cases, there was a significant visual deterioration following the RPE tear. CONCLUSIONS: RPE tear is a complication that may occur following PDT in particular when the PDT is applied to an occult subfoveal CNV.

Hyperhomocysteinemia in patients with diabetes mellitus with and without diabetic retinopathy.

OBJECTIVE: To evaluate the prevalence of hyperhomocysteinaemia in diabetic patients with no diabetic retinopathy (no DR), with non-proliferative diabetic retinopathy (NPDR) and with proliferative diabetic retinopathy (PDR). RESEARCH DESIGN AND METHODS: This prospective, case-control study, included 179 diabetic patients and 156 age-matched controls with no diabetes and no history of ocular disease, who were undergoing routine physical checkups. Plasma homocysteine levels of all study participants were measured using high-performance liquid chromatography (HPLC). Hyperhomocysteinaemia was defined when homocysteine levels were higher than 15 micromol/l. RESULTS: The mean plasma homocysteine level was 11.75+-0.24 in the control group,13.46+0.74 in the no DR group, 14.56 + 0.64 in the NPDR group and 15.86 + 1.34 in the PDR group. Mean homocysteine levels were significantly elevated in the NPDR and PDR groups compared to the control group(P = 0.001 and <0.0001, respectively). The prevalence of hyperhomocysteinaemia was also higher in the NPDR and PDR groups compared to the control group (P = 0.032 and 0.011, respectively). No statistically significant difference was found between the no DR and the control group. CONCLUSIONS: Our findings suggest that hyperhomocysteinaemia may be associated with diabetic retinopathy and partially explain the increased risk of microvascular angiopathy occurring in these patients.

Axial length, refractive error, and keratometry in patients with branch retinal vein occlusion.

PURPOSE: To evaluate ocular parameters that may predispose to the development of branch retinal vein occlusion (BRVO). METHODS: This prospective study included patients with unilateral BRVO evaluated in the authors' clinic. The mean period from the acute phase was 2.29 +/- 1.57 years (range 1-6 years). All patients underwent a complete ophthalmologic examination including subjective refraction, axial length measurements, and keratometry readings. The fellow eye served as a control in each patient. The variables of interest were compared between the affected eye and the fellow eye using the parametric t-test and the nonparametric Wilcoxon test. RESULTS: Twenty-four consecutive patients (14 women, 10 men, mean age 62.4 years) were included in the study. The mean axial length in the affected eye was significantly shorter compared to the mean fellow eye length. No difference was found between the two eyes in mean subjective refraction or mean keratometry readings. CONCLUSIONS: The authors found that eyes with BRVO have a shorter axial length compared to the fellow eye in the same patient.

Area-specific amblyopic effects in human occipitotemporal object representations.

The role of early visual experience in the establishment of human high-order visual areas is poorly understood. Here we investigated this issue using human amblyopia--a developmental visual disorder, which manifests a central vision (acuity) deficit. Previous fMRI studies of amblyopes have described abnormal functional activations in early retinotopic areas. Here we report the surprising finding of a selective object-related abnormality in high-order occipitotemporal cortex. Specifically, we found that face-related cortical areas show a severe disconnection from the amblyopic eye, while building-related regions remain essentially normal. The selectivity of the deficit highlights the differential computations performed in the different object-related areas and is compatible with the suggested association of face regions with analysis of fine detail.

Massive choroidal hemorrhage associated with low molecular weight heparin therapy.

An 84-year-old woman with unstable angina pectoris was treated with subcutaneous enoxaparine (Clexane) for several days before presenting with severe pain and decreased vision in her left eye. The intraocular pressure was 70 mmHg, and fundus examination showed a pigmented choroidal lesion and associated choroidal and retinal detachment. Ultrasonography was consistent with choroidal hemorrhage, and she was diagnosed as having acute glaucoma secondary to massive subchoroidal hemorrhage. Medical control of the intraocular pressure resulted in a significant clinical improvement. Intraocular hemorrhage and angle-closure glaucoma are rare and previously unreported complications in patients treated with low molecular weight heparin. It is important to be aware of this ocular complication as these drugs are so often used.

Characteristics and outcomes of paediatric rhegmatogenous retinal detachment treated by segmental scleral buckling plus an encircling element.

PURPOSE: To evaluate the outcome of paediatric rhegmatogenous retinal detachment treated by segmental scleral buckling plus an encircling element. METHODS: A retrospective review was carried out of 15 consecutive paediatric patients (16 eyes). RESULTS: Thirteen of the 15 patients were male (87%), 2 (13%) were female. Their average age was 10.9 years (range 6-18 years; median 10 years). Retinal detachment was caused by trauma in 9 of 16 eyes (56%), high myopia in 5 of 16 eyes (31%) and had an unknown cause in 2 of 16 eyes (13%). Diagnosis was delayed by more than 1 month in 10 of 16 eyes (63%). The visual acuity was 6/60 or worse and the macula was detached on presentation in 13 of 16 eyes (81%). Two of 16 eyes (13%) had mild proliferative vitreoretinopathy. Final reattachment was achieved in all cases. Of 11 eyes with a follow-up of 6 months or more, there was improvement in visual acuity in 7 (63%), and a best-corrected visual acuity of 6/20 or better in 5 (46%). CONCLUSION: Paediatric rhegmatogenous retinal detachment is characterised by a delay in diagnosis and a high degree of macular involvement on presentation. Anatomical reattachment with segmental scleral buckling plus an encircling element was successful in all eyes, and improvement of visual acuity was achieved in one-half of the eyes which had a follow-up of 6 months or more.

Retinal toxicity of gentamicin after subconjunctival injection performed adjacent to thinned sclera.

OBJECTIVE: To investigate the potential toxicity to the retina of gentamicin injected near surgically thinned scleral areas in a rabbit model. DESIGN: Experimental study. METHODS: Scleral scraping to half thickness was performed in the superotemporal scleral area in both eyes of adult rabbits (n = 10). Gentamicin sulfate was injected subconjunctivally to the right eye and saline to the left eye, which always served as a control eye. Four weeks after the procedure, electroretinography (ERG) was performed to assess retinal function. Then, the eyes were enucleated and prepared for histologic evaluation of structural damage. In four eyes of two additional rabbits, vitreous gentamicin concentrations were measured using a fluorescence polarization assay. MAIN OUTCOME MEASURES: Dark- and light-adapted ERG responses and histopathologic damage. RESULTS: Dark- and light-adapted ERG responses in all rabbits were similar in the experimental and control eyes. Gentamicin levels were more than 10 microg/ml after subconjunctival injection of gentamicin with scraping and 0.29 microg/ml after subconjunctival injection of gentamicin with no scraping. Histopathologic examination revealed significant local damage to the photoreceptors adjacent to the area of scraping and subconjunctival injection. A significantly lesser degree of damage was seen if gentamicin was injected in pigmented rabbits or in albino rabbits, but only 4 weeks after scleral scraping. CONCLUSIONS: Increased penetration of gentamicin through thinned sclera may lead to toxic levels of the drug in a localized area adjacent to the site of injection. These toxic effects are also influenced by the degree of pigmentation and acute inflammation.

Laser in situ keratomileusis to correct hyperopic shift after radial keratotomy.

PURPOSE: To assess the safety and efficacy of excimer laser in situ keratomileusis (LASIK) to correct hyperopic shift following radial keratotomy (RK). SETTING: Ophthalmic Health Center, Tel Aviv, Israel. METHODS: The study comprised 15 eyes of 12 patients who had uneventful RK and subsequently developed a hyperopic shift. Laser in situ keratomileusis was performed using the Chiron Automated Corneal Shaper and the Nidek EC-5000 excimer laser with 5.5 mm central and 7.5 mm peripheral ablation zones. The corneal flap was 160 microm in thickness and 8.5 mm in diameter. The refractive correction corresponded to the patients' refractive errors. RESULTS: The mean time after RK was 10.46 years +/- 2.21 (SD) and the mean follow-up after LASIK, 7.3 months (range 1 to 42 months). The mean spherical equivalent refraction was corrected from +3.08 +/- 1.02 diopters (D) to -0.16 +/- 0.73 D after LASIK. At the last examination, 12 eyes (80%) had a refractive error within +/-1.00 D of emmetropia and an uncorrected visual acuity of 20/40 or better. No wound dehiscence, epithelial ingrowth, or other significant complication developed in any eye. CONCLUSIONS: Early postoperative results of the correction by LASIK of a hyperopic shift after RK are encouraging, but long-term studies of a larger population group are required to evaluate the method's clinical value.