Autonomous artificial intelligence versus teleophthalmology for diabetic retinopathy.

Purpose: To assess the role of artificial intelligence (AI) based automated software for detection of Diabetic Retinopathy (DR) compared with the evaluation of digital retinography by two double masked retina specialists. Methods: Two-hundred one patients (mean age 65 ± 13 years) with type 1 diabetes mellitus or type 2 diabetes mellitus were included. All patients were undergoing a retinography and spectral domain optical coherence tomography (SD-OCT, DRI 3D OCT-2000, Topcon) of the macula. The retinal photographs were graded using two validated AI DR screening software (Eye Art TM and IDx-DR) designed to identify more than mild DR. Results: Retinal images of 201 patients were graded. DR (more than mild DR) was detected by the ophthalmologists in 38 (18.9%) patients and by the AI-algorithms in 36 patients (with 30 eyes diagnosed by both algorithms). Ungradable patients by the AI software were 13 (6.5%) and 16 (8%) for the Eye Art and IDx-DR, respectively. Both AI software strategies showed a high sensitivity and specificity for detecting any more than mild DR without showing any statistically significant difference between them. Conclusions: The comparison between the diagnosis provided by artificial intelligence based automated software and the reference clinical diagnosis showed that they can work at a level of sensitivity that is similar to that achieved by experts.

Predictors of 24-month onset of macular fibrosis in type 3 macular neovascularisation.

AIMS: To explore prognostic multimarker models for progression to macular fibrosis (MF) over 24 months specific to type 3 macular neovascularisation (T3 MNV). METHODS: This retrospective, exploratory, single-centre, cohort study comprised 65 eyes of 43 Caucasian patients with treatment naive T3 MNV, all with a 24-month follow-up post anti-VEGF therapy using a strict pro-re-nata (PRN) regimen. Data on demographic features, clinical findings, frequency of intravitreal treatments and optical coherence tomography biomarkers were collected at baseline and after 12 and 24 months of follow-up. Logistic regression models (LRM) and receiver-operating curve (C-index) analyses were performed to evaluate the prognostic ability of the studied biomarkers in discriminating between MF affected and unaffected patients. RESULTS: At final follow-up, MF was present in 46.2% of eyes. Subretinal hyper-reflective material (SHRM) and subretinal pigment epithelium multilaminar hyper-reflectivity (multilaminae) emerged as significant predictors for MF, with adjusted odds ratios (OR) of 18.0 (95% CL 13.4 to 24.1) and 11.8 (95% CL 8.66 to 16.0), respectively. Additionally, the presence of multifocal lesions (OR 0.04, 95% CL 0.01 to 0.30) appeared to decrease the likelihood of MF. C-indexes for the selected LRMs ranged between 0.92 and 0.88, indicating a comparably high discriminant ability. Despite consistent treatment schedules between the two groups (MF: median intravitreal treatment (IVT) number=10.5, IQR=7; non-MF: median IVT=10, IQR=6), a decline in best-corrected visual acuity was noted in the group with MF onset over the 24-month follow-up (-13.0 ETDRS letters; 95% CL -22.1 to -3.9; p=0.006). CONCLUSION: Our study identifies SHRM and multilaminae as relevant predictors of 24-month onset of MF in patients with T3 MNV. These findings enrich our understanding of the development of MF in T3 MNV and can guide improved risk prognostication. Future research should consider larger samples and prospective designs to validate these predictors.

The multifaceted presentation of syphilitic chorioretinitis examined by multimodal imaging: A case series.

Ocular syphilis is also known as the 'great masquerader' for the wide variety of clinical features associated with this infection. Although chorioretinitis represents the most frequent manifestation in the posterior pole, other clinical entities can be described, including retinal vasculitis, optic disc disorders, necrotizing vasculitis and acute syphilitic posterior placoid chorioretinopathy (ASPPC).This latter is an infrequent ocular manifestation of syphilis, whose pathophysiology remains still unknown; however, multimodal imaging, including optical coherence tomography angiography (OCTA), has enabled us to better describe its pathophysiology and clinical course.In this study we report a case series of 3 different patients with syphilis-related chorioretinopathies; in this regard, the role of multimodal imaging has emerged has an extremely useful approach in order to better understand the pathophysiology of syphilitic chorioretinopathies. This could help clinicians (both ophthalmologist and infectious disease specialists) to early treat and prevent the severe ocular complications related to this fearsome disease.

Bilateral choroidal detachment and myopic shift after acetazolamide intake for laser capsulotomy.

INTRODUCTION: To report a case of bilateral choroidal effusion after laser capsulotomy. CASE DESCRIPTION: A healthy 85 years old white woman was referred to our hospital with a diagnosis of posterior capsule opacification in the left eye. The patient was treated with laser capsulotomy and oral acetazolamide was administered after the procedure. The day after, the patient visited the emergency room complaining bilateral blurred vision. A myopic shift and peripheral choroidal detachment was noted in both eyes. Discontinuation of acetazolamide and treatment with topical steroid and cyclopentolate resulted in a significant improvement in visual acuity and the complete resolution of the choroidal detachment in 1 week. CONCLUSION: To the best of our knowledge, this is the first reported case of choroidal detachment and acute transient myopia following the administration of oral acetazolamide after laser capsulotomy.

Delayed Re-epithelialization After Epithelium-Off Crosslinking: Predictors and Impact on Keratoconus Progression.

Purpose: To investigate the demographic and corneal factors associated with the occurrence of delayed reepithelialization (DRE) after epithelium-off crosslinking (epi-off CXL). Design:Retrospective case series. Methods:A chart review was performed to identify patients treated with epi-off CXL. DRE was defined as a corneal epithelial defect detected by fluorescein staining that persisted for more than 10 days. Slit-lamp examination, anterior segment optical coherence tomography, corneal topography, and corneal in vivo confocal microscopy (IVCM) were always performed preoperatively and at each follow-up visit (1, 3, 6, 12 months). A generalized estimating equation was used to assess the baseline factors associated with DRE. Results:Data from 153 eyes were analyzed. The mean age of patients was 24.9 ± 8.5 years, and 47 (30.7%) were women. The average reepithelization time was 4.7 ± 1.8 days. Six eyes (3.9%) experienced DRE. In the multivariate model, both the age of the patient (OR = 1.30; p = 0.02) and the corneal steepest meridian (OR = 0.44, p = 0.047) were associated with DRE. Baseline nerve count was also associated with DRE (0.87, p = 0.03). Male gender was associated with a slower early nerve regrowth (1-6 months) (p = 0.048), but not with the occurrence of DRE (p = 0.27). Preoperative central corneal thickness was not related to DRE (p = 0.16). DRE was not associated with keratoconus progression after epi-off CXL (p = 0.520). Conclusions:The association between DRE and age may reflect the age-related decrease in the corneal healing response. Also, low baseline corneal nerve count is associated with DRE. Gender seems to affect reinnervation measured by IVCM but not the reepithelization time. DRE does not seem to affect the efficacy of epi-off CXL.

Real-Life Management of Diabetic Macular Edema with Dexamethasone Intravitreal Implant: A Retrospective Analysis of Long-Term Clinical Outcomes.

PURPOSE: Inflammation plays a key role in the pathogenesis of diabetic macular edema (DME), and intravitreal corticosteroids are among the recommended therapies. The goal of this retrospective analysis was to describe outcomes with dexamethasone intravitreal implant (DEX implant) in real life. METHODS: Medical digital records of DME patients treated with DEX implant and followed up for 3 years were analyzed. Treatment with DEX implant was started either as first-line therapy in pseudophakic patients and in patients with cardiovascular comorbidities or as second-line therapy in patients refractory to the inhibitor of the vascular endothelial growth factor (anti-VEGF) therapy. Analyzed outcomes included central macular thickness (CMT) and best-corrected visual acuity (BCVA). Mean number of implant injections per patient and mean duration of the interval between injections were also estimated. RESULTS: Seventy-five patients (mean age 65.7 (±12.3) years; 53 phakic and 22 pseudophakic) with DME were included. Overall, 84 eyes were treated. Mean CMT improved from 380.1 (±100.3) µm at baseline to 306.8 (±77.0) µm at 36 months (p=0.0003). Mean BCVA improved for up to 6 months (p=0.08) and then started to decrease reaching values lower than baseline after 24 months. In pseudophakic patients, BCVA improvements were more pronounced and sustained up to 36 months (p=0.6). Over 36 months, each patient received on average 2.4 (±1.6) intravitreal injections of DEX implant. The time interval between consecutive injections was included between 180 and 240 days. No unexpected safety issues were reported. CONCLUSIONS: With fewer than 3 injections per patient over a 3-year period, DEX implant was able to improve anatomic outcomes in DME patients. Only pseudophakic eyes showed also a long lasting functional benefit at 36 months.

Real-Life Data in the Treatment of Neovascular Age-Related Macular Degeneration: Results from the Imaculaweb Registry Evaluated in a Single Italian Medical Retina Center.

INTRODUCTION: The aim of this study is to assess and compare the long-term clinical efficacy of anti-VEGF drugs using the Imaculaweb registry. METHODS: In this observational study based on the Imaculaweb registry, outcome measures were the number of injections, the change in mean visual acuity (VA) and central macular thickness (CMT), and the time between diagnosis and the first injection. RESULTS: In total, 126 eyes of 109 patients were included in the study. The mean VA was 49.4 ± 21.4, 54.1 ± 22.2, 51.6 ± 24.9, and 48.3 ± 25.7 letters at baseline and at the 1-, 2-, and 3-year follow-ups, respectively. Significant VA increases (p = 0.0002 for the first year and p = 0.045 for the second year) were documented at years 1 and 2 but not at year 3 (p = 0.8). The mean number of injections was 5.2, 2.6, and 2.3 at the 1-, 2-, and 3-year follow-ups, respectively. In the first year, 30% of the patients received at least 7 injections, while only 6.4% received <3 injections. CMT decreased significantly during the overall follow-up period, and intra- and subretinal fluid decreased (p < 0.0001). CONCLUSION: Imaculaweb turned out to be an effective tool to collect and share clinical data as well as to monitor patient outcome.

Chorioretinal folds: a proposed diagnostic algorithm.

PURPOSE: To create a diagnostic algorithm for the management of chorioretinal folds. METHODS: We reviewed the existing literature about chorioretinal folds focusing our attention on three specific conditions and created a diagnostic algorithm in order to otpimize the choice and the number of investigations. RESULTS: Chorioretinal folds are visible striations of the fundus usually arranged in parallel lines and disposed horizontally. They may be either unilateral or bilateral, symptomatic or asymptomatic and are often associated with different possible ocular and extra ocular pathologies, including systemic diseases like autoimmune disorders and intracranial hypertension. They are named idiopathic when no apparent cause for their development is detectable. However, with improved diagnostic testing, the patients with idiopathic choroidal folds are likely to represent only a smaller portion of the total. CONCLUSIONS: Since choroidal folds be the sole sign of an underlying disease possibly requiring a multidisciplinary approach, an appropriate work-up varying according to the specific clinical features of each case is needed to define the etiology and the treatment. A diagnosting algorithm may be useful in order to optimize the diagnostic approach and management.

Real-Life Management of Patients with Retinal Vein Occlusion Using I-Macula Web Platform.

AIM: Real-life evaluation in the management of patients affected by macular edema secondary to retinal vein occlusion. MATERIAL AND METHODS: A retrospective, observational study using the I-Macula Web platform. RESULTS: Thirty-five patients (37 eyes; 15 females and 20 male) affected by RVO were analysed. At 12 months, there was a statistically significant improvement of best-corrected visual acuity (p = 0.0235) and central macular thickness (p < 0.0001). The mean change in visual acuity was 8.9 letters. Twenty-seven eyes underwent DEX implant (n = 62; mean: 2.29) only. Of these, 8, 4, 14, and 1 eyes underwent 1, 2, 3, and 4 DEX implants, respectively. The remaining 10 eyes were also injected with ranibizumab (n = 49; mean: 4.9). At 12 months, 12 eyes (32.5%) presented a dry macula, whereas the remaining 25 eyes (67.5%) still had macular edema. Mean interval between the first and second treatment (T1) and between the second and third treatment (T2) were 5.15 and (T2) 3.7 months, respectively. Where only DEX implants were received, T1 and T2 was 5.1 and 4.9 months, respectively. CONCLUSIONS: This study confirms that DEX implants and/or anti-VEGF drugs improve visual acuity and central macular thickness in patients affected by RVO.

Choroidal Vascular Flow Area in Central Serous Chorioretinopathy Using Swept-Source Optical Coherence Tomography Angiography.

Purpose: To report the choroidal vascular flow area in eyes with central serous chorioretinopathy (CSC) compared with healthy subjects and unaffected fellow eyes using swept-source (SS) optical coherence tomography (OCT) angiography. Methods: Prospective case series of 19 eyes of 19 consecutive patients affected by CSC, compared with 15 unaffected fellow eyes and 20 eyes of 10 healthy subjects. Patients underwent SS-OCT angiography in order to evaluate the choroidal vascular flow area of choriocapillaris (CC) and deeper choroidal layers. Results: The choroidal vascular flow area was higher in eyes with CSC than in control eyes (53.4 ± 5.8% vs. 49.45 ± 8.16%; P = 0.0001). Within the choroid of CSC patients choroidal vascular flow area of the CC was significantly lower than the deeper level (50.97 ± 2.8% vs. 54.22 ± 6.3%; P = 0.025). There were no differences within the choroid of control eyes. The choroidal vascular flow area at the level of the CC was higher in the unaffected fellow eye (50.74 ± 0.9%; P = 0.019) than in control eyes. Choroidal vascular flow area of unaffected fellow eyes did not differ from CSC eyes (P = 0.17). The choroidal vascular flow area at the level of the CC was higher in the CSC eyes (P = 0.0009) compared with unaffected fellow eyes. Conclusions: Choroidal vascular flow area is larger in CSC eyes compared with control eyes. However, within the choroid of eyes with CSC, there might be some differences in flow area between CC and deeper choroidal levels. This difference might be secondary to a compensatory mechanism of the choroid.

I-Maculaweb: A Tool to Support Data Reuse in Ophthalmology.

This paper intends to present a Web-based application to collect and manage clinical data and clinical trials together in a unique tool. I-maculaweb is a user-friendly Web-application designed to manage, share, and analyze clinical data from patients affected by degenerative and vascular diseases of the macula. The unique and innovative scientific and technological elements of this project are the integration with individual and population data, relevant for degenerative and vascular diseases of the macula. Clinical records can also be extracted for statistical purposes and used for clinical decision support systems. I-maculaweb is based on an existing multilevel and multiscale data management model, which includes general principles that are suitable for several different clinical domains. The database structure has been specifically built to respect laterality, a key aspect in ophthalmology. Users can add and manage patient records, follow-up visits, treatment, diagnoses, and clinical history. There are two different modalities to extract records: one for the patient's own center, in which personal details are shown and the other for statistical purposes, where all center's anonymized data are visible. The Web-platform allows effective management, sharing, and reuse of information within primary care and clinical research. Clear and precise clinical data will improve understanding of real-life management of degenerative and vascular diseases of the macula as well as increasing precise epidemiologic and statistical data. Furthermore, this Web-based application can be easily employed as an electronic clinical research file in clinical studies.

Early Swept-Source Optical Coherence Tomography Angiography Findings in Unilateral Acute Idiopathic Maculopathy.

Unilateral acute idiopathic maculopathy (UAIM) is a rare disorder presenting in young people with an acute onset of unilateral central visual loss often associated with a prodromal flu-like illness. The authors present the early anatomical findings of a 35-year-old man clinically diagnosed with UAIM using swept-source optical coherence tomography (SS-OCT) and SS-OCT angiography.

Yellow micropulse laser in diabetic macular edema: a short-term pilot study.

PURPOSE: To evaluate the effects of yellow micropulse laser in eyes with diabetic macular edema (DME). METHODS: In this retrospective interventional case series, 22 eyes of 17 patients with visual impairment secondary to persistent DME received one single session of yellow micropulse laser. Patients were divided into 2 groups: group 1, naive eyes; and group 2, previously treated eyes. Main outcome measures included changes in central retinal thickness (CRT) and best-corrected visual acuity (BCVA). Possible atrophic changes of the retinal pigment epithelium as a result of yellow micropulse laser application were evaluated with fundus autofluorescence. RESULTS: At baseline, the mean logMAR BCVA was 0.39 ± 0.18 and the mean CRT was 361.8 ± 70.95. The mean BCVA improved to 0.31 ± 0.19 (p = 0.0091) and 0.31 ± 0.19 (p = 0.0078) at 3 and 6 months of follow-up, respectively. The mean CRT improved to 331.3 ± 48.46 (p<0.0001) and 328.1 ± 53.25 (p<0.0001) at 3 and 6 months of follow-up. Subgroup analysis showed that only in naive eyes was there a beneficial effect on visual acuity and central macular thickness. CONCLUSIONS: In eyes with DME, yellow micropulse laser produces a statistically significant improvement in BCVA and CRT in the short term.

Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy.

PURPOSE: To compare the efficacy and safety of half-fluence vs half-dose photodynamic therapy (PDT) in chronic central serous chorioretinopathy (CSC). DESIGN: Multicenter retrospective comparison study. METHODS: Retrospective review of 56 patients affected by chronic CSC, including 28 patients (31 eyes) who received half-fluence PDT and 28 patients (29 eyes) who received half-dose PDT. Best-corrected visual acuity (BCVA), central foveal thickness (CFT), and resolution of subretinal fluid on optical coherence tomography at 1 and 12 months were assessed. RESULTS: The mean logMAR BCVA improved significantly (P < .001), both in the half-fluence group (from 0.187 [± 0.187] to 0.083 [± 0.164]) and in the half-dose group (from 0.126 [± 0.091] to 0.068 [± 0.091]), at 12 months, without significant difference between the 2 groups. At 1 month a complete resolution of subretinal fluid was observed in 19 half-fluence-treated eyes (61.3%) and in 25 half-dose-treated eyes (86.2%) (P = .04). At 12 months, a complete resolution of subretinal fluid was achieved in 26 half-fluence-treated eyes (83.9%) and 29 half-dose-treated eyes (100%) (P = .0529). Nine eyes (29%) in the half-fluence group and 5 eyes (17.2%) in the half-dose group had at least 1 recurrence of subretinal fluid during the follow-up. Overall there were 15 and 5 recurrences in the half-fluence PDT and half-dose PDT groups, respectively (P = .07). In no eye of either groups was atrophy of the retinal pigment epithelium observed in the area of treatment. CONCLUSION: Half-dose PDT induced a more rapid reabsorption of the fluid, a more lasting effect, and equal safety with respect to half-fluence PDT.