LONGITUDINAL ANALYSIS OF MICROVASCULAR CHANGES IN SICKLE CELL DISEASE USING SWEPT-SOURCE OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY.

PURPOSE: To analyze the changes in macular vascular densities (VDs) and foveal avascular zone (FAZ) over a 6-year period using swept-source optical coherence tomography angiography in patients with sickle cell disease compared with unaffected control subjects. METHODS: Thirty eyes of patients with sickle cell disease and 12 eyes of unaffected control subjects matched for age and ethnicity were examined at a 6-year interval using the same imaging protocol, including ultra-wide-field angiography, swept-source OCT, and 3 × 3-mm optical coherence tomography angiography. The macular VD and FAZ were measured on ImageJ software according to previously reported algorithms. RESULTS: In sickle cell eyes, the mean FAZ significantly increased ( P < 0.01), and the VD decreased in the foveal (within a circle of 1.5 mm in diameter around the foveal center) and temporal areas in both the superficial and the deep capillary plexuses ( P < 0.01). The VD did not change over time in the parafoveal area (annulus between two circles of 1.5 and 3 mm in diameter) and in the superior, inferior, and nasal sectors. No worsening of peripheral retinopathy was observed in the cohort during the follow-up, except for one eye that developed sea-fan. In the control eyes, no microvascular change was observed over time in FAZ size and VD. CONCLUSION: These longitudinal optical coherence tomography angiography findings in patients with sickle cell disease showed an enlargement of the FAZ and a decrease in VD in the temporal and perifoveal regions despite the absence of progression of peripheral retinopathy, suggesting a worsening of the macular nonperfusion over time in sickle cell disease.

Proliferative Sickle Cell Retinopathy in the Retinal Periphery Detected by Ultra-Widefield Imaging: A Case Report.

Sickle cell proliferative retinopathy usually presents first in the peripheral retina and the ability to extend and enhance our visualization of the peripheral retina would allow for superior clinical decision-making. In our practice, we had a 28-year-old patient diagnosed with major sickle cell disease of the homozygous type SS (HbSS) that presented with sickle cell proliferative retinopathy detected by ultra-widefield imaging in the nasal side of the left fundus. At follow-up, neovascularization was detected in the extreme nasal periphery of the left eye by ultra-widefield imaging fluorescein angiography with right gaze. The case was graded as Goldberg stage 3, and the patient was administered photocoagulation treatment. With further advancements in the quality and modality of peripheral retinal imaging, novel proliferative lesions can be detected and appropriately managed much earlier than was previously possible. Ultra-widefield imaging allows for the visualization of the central 200 degrees of the retina but, with gaze view, peripheral retina beyond 200 degrees can be reached.

Real-World Outcomes of Ranibizumab Treatment in French Patients with Visual Impairment due to Macular Edema Secondary to Retinal Vein Occlusion: 24-Month Results from the BOREAL-RVO Study.

INTRODUCTION: Information about real-world ranibizumab use is needed to optimize treatment of macular edema secondary to retinal vein occlusion (RVO). The BOREAL-RVO study assessed treatment use, effectiveness, and safety of 24-month treatment with ranibizumab 0.5 mg in patients with visual impairment due to macular edema secondary to RVO in a real-world setting. METHODS: This was a multicenter, post-authorization, observational study in France, including patients starting ranibizumab for RVO. Primary endpoint was mean change from baseline in best-corrected visual acuity (BCVA) at month 6. Secondary endpoints were mean changes from baseline in BCVA at month 24 and central retinal thickness (CRT) at months 6 and 24, and treatment use in real-world setting. RESULTS: 226 branch RVO (BRVO) and 196 central RVO (CRVO) patients were enrolled; 71.7% and 70.9% completed the 24-month follow-up, respectively. In BRVO, mean (SD) baseline BCVA was 55.2 (18.7) letters, with gains of 14.3 (13.7), 14.1 (16.5), 13.0 (17.5), and 11.4 (20.1) letters at months 3, 6, 12, and 24, respectively. In CRVO, mean (SD) baseline BCVA was 40.4 (25.6) letters, with gains of 16.0 (21.2), 9.5 (25.4), 9.2 (27.7), and 8.3 (23.8) letters at months 3, 6, 12, and 24, respectively. At month 24, 52% of BRVO and 41% of CRVO patients had gains of 15 or more letters. In BRVO, mean (SD) CRT values at baseline and months 3, 6, 12, and 24 were 550 (175), 315 (104), 343 (122), 335 (137), and 340 (105) µm. In CRVO, mean (SD) CRT values at baseline and months 3, 6, 12, and 24 were 643 (217), 327 (152), 400 (203), 379 (175), and 348 (161) µm. On average, BRVO patients had 3.8 injections for 6.9 visits by month 6, and 7.2 injections for 19.7 visits by month 24. CRVO patients had 2.7 injections for 4.2 visits by month 6 and 7.1 injections for 21.1 visits by month 24. Factors predictive of better BCVA gain at month 6 were age under 60 at baseline, lower baseline BCVA and BCVA gain at month 3. There were no new safety findings. CONCLUSION: Major improvements in BCVA and CRT were observed at month 3 after the induction phase and then were sustained up to month 24, with a slight decrease, probably due to under-treatment. This study demonstrated ranibizumab to be a safe and effective treatment for BRVO and CRVO in the real-world setting, although more regular or proactive treatment could further improve outcomes.

Ultra-Wide-Field Fluorescein Angiography Assessment of Non-Perfusion in Patients with Diabetic Retinopathy Treated with Anti-Vascular Endothelial Growth Factor Therapy.

Purpose: To follow the evolution of peripheral ischemia by fluorescein angiography (FA) on ultra-wide-field (UWF) images in diabetic patients treated with anti-vascular endothelial growth factor (anti-VEGF) for macular edema. Methods: Prospective, non-interventional cohort study analyzing UWF-FA images of 48 patients with diabetic retinopathy (48 eyes) treated for diabetic macular edema. UWF-FA was performed at baseline and after one year of anti-VEGF therapy (M12). The primary endpoint was the change in the non-perfusion index. Results: Of the 48 patients included in this study, 25 completed the one-year follow-up, and 20 had FA images of sufficient quality to be interpreted. The non-perfusion index did not significantly change from baseline after one year of anti-VEGF treatment (0.7% of the non-perfused area at baseline versus 0.5% at M12; p = 0.29). In contrast, the diabetic retinopathy severity score improved significantly between baseline and M12. Conclusions: Anti-VEGF treatment with aflibercept for diabetic macular edema had no impact on the retinal perfusion assessed by FA, but it allowed for artificially improving diabetic retinopathy severity scores.

Multimodal Imaging of Unilateral Acute Maculopathy Associated with Hand, Foot, and Mouth Disease: A Case Series.

We described clinical and multimodal imaging findings in 4 patients with unilateral acute idiopathic maculopathy (UAIM) associated with hand, foot, and mouth disease. Four eyes of 4 patients (3 women and 1 man) with a mean age of 35 years (range: 24-40 years) were included. A bacillary detachment was observed in 3 out of the 4 eyes and was strongly suspected in the remaining eye. This particular detachment was resolved within 5-10 days in our series. A choriocapillaris involvement was supported by the multimodal imaging findings. On indocyanine green angiography, a hypofluorescence was observed throughout the sequence, and OCT angiography showed a defect of the choriocapillaris perfusion. In this case series, a complete multimodal retinal assessment allowed identifying the choriocapillaris as the primary tissue involved in UAIM associated with coxsackie virus infection. In 3 out of our 4 cases, a bacillary detachment with a transient evolution was identified.

Reduced Vessel Density in the Mid-Periphery and Peripapillary Area of the Superficial Capillary Plexus in Non-Proliferative Diabetic Retinopathy.

Our aim in this study was to assess the vessel density (VD) and vessel skeleton density (VSD) in the nasal area of the superficial capillary plexus (SCP) of diabetic subjects without diabetic retinopathy (DR), or in those with a non-proliferative diabetic retinopathy (NPDR), and to evaluate the relationship between the VD and VSD and the severity of DR. In this prospective study, the VD and VSD in the SCP were measured and analyzed on 6 × 6-mm macular and nasal optical coherence tomography angiography scans. The three concentric circles of the Early Treatment of Diabetic Retinopathy Study (ETDRS) grid were used and divided into zones numbered from 1 to 9 in the macular area and from 1 to 8 in the nasal area. The VD was significantly lower in the nasal peripapillary area (p = 0.0028), and both the VD and VSD were significantly lower in the macular area (p = 0.0131 and p = 0.0132, respectively) in patients with more severe DR. The SD was significantly lower in zones 5 (p = 0.0315) and 6 (p = 0.0324) in the nasal grid in patients with more severe DR. We showed a lower superficial capillary flow in the nasal periphery and peripapillary area in patients with more severe DR.

Comparison of Ultra-Wide Field Photography to Ultra-Wide Field Angiography for the Staging of Sickle Cell Retinopathy.

Sickle cell retinopathy (SCR) is classified by Goldberg based on peripheral vascular changes. Ultra-wide field (UWF) imaging has enhanced visualization of the peripheral retina. However, there is no consensus on the optimal imaging technique for the screening of SCR. We performed a monocentric observational cross-sectional study to compare UWF fundus photography (UWF-FP) with UWF angiography (UWF-FA). All patients who underwent UWF-imaging (Optos, PLC, Scotland, UK) for screening of sickle cell retinopathy between January 2016 and December 2019 were retrospectively included. Eyes with previous laser treatment or concomitant retinal disease were excluded. UWF-FP images were graded based on the Goldberg classification by four graders with various degrees of experience. UWF-FA pictures were reviewed by an independent retina specialist. Differences in Goldberg staging across UWF-FP and UWF-FA were assessed. A total of 84 eyes of 44 patients were included. Based on UWF-FA, most eyes were stage 2 (77.4%) and 19 were stage 3 (22.6%). The pre-retinal neovascularization detection sensitivity on UWF-FP was 52.6 to 78.9%, depending on the graders. UWF-FA led to a later Goldberg stage of retinopathy, in most cases from stage 1 to stage 2. Neovascularization (stage 3) was not detected by our graders on UWF-FP in 21.1 to 57.9% of eyes. UWP-FP tends to underestimate Goldberg stages of retinopathy compared with UWF-FA and is less accurate when detecting neovascularization in sickle cell retinopathy, which has a direct impact on therapeutic management and prognosis.

Visual Acuity Gain Profiles and Anatomical Prognosis Factors in Patients with Drug-Naive Diabetic Macular Edema Treated with Dexamethasone Implant: The NAVEDEX Study.

The purpose of this study is to evaluate the visual acuity (VA) gain profiles between patients with drug-naive diabetic macular edema (DME) treated by dexamethasone implant (DEX-implant) and assess the baseline anatomical and functional factors that could influence the response to the treatment in real-life conditions. A retrospective, multi-center observational study included 129 eyes with drug-naive DME treated by DEX-implant. The Median follow-up was 13 months. Two groups of VA gain trajectories were identified-Group A, with 71% (n = 96) of patients whose average VA gain was less than five letters and Group B, with 29% (n = 33) of patients with an average gain of 20 letters. The probability of belonging to Group B was significantly higher in patients with baseline VA < 37 letters (p = 0.001). Ellipsoid zone alterations (EZAs) or disorganization of retinal inner layers (DRILs) were associated with a lower final VA (53.0 letters versus 66.4, p = 0.002) but without a significant difference in VA gain (4.9 letters versus 6.8, p = 0.582). Despite a low baseline VA, this subgroup of patients tends to have greater visual gain, encouraging treatment with DEX-implant in such advanced-stage disease. However, some baseline anatomic parameters, such as the presence of EZAs or DRILs, negatively influenced final vision.

Real-World Outcomes after 36-Month Treatment with Ranibizumab 0.5 mg in Patients with Visual Impairment due to Diabetic Macular Edema (BOREAL-DME).

PURPOSE: To assess the efficacy, safety, and follow-up of 36-month treatment with ranibizumab in patients with diabetic macular edema (DME) in real-life setting. METHODS: This is a prospective phase 4 observational study. Between December 2013 and April 2015, 84 ophthalmologists enrolled a total of 290 adult patients initiating ranibizumab for visual impairment due to DME and treated them according to their routine practice. The primary outcome (mean change in best-corrected visual acuity [BCVA] after 12 months) was previously reported. Here, we present outcomes after 36 months of follow-up for BCVA and change in central subfield thickness (CSFT) and report how participating ophthalmologists treated DME over a 3-year period (number of visits and injections and evolution of treatment strategy). RESULTS: Of the 290 patients enrolled, 187 (64.5%) completed the 36 months of the study (entire cohort). In the entire cohort, 97 patients were treated exclusively with ranibizumab throughout the study, and 90 patients switched to other intravitreal treatments. Mean BCVA was 64.2 (20.1) letters, representing a gain of +4.1 (19.9) letters from baseline to month 36 (M36). CSFT improved over the study, and by M36 had decreased by 127 (138) µm compared to baseline. Over the 36 months of follow-up, patients in the entire cohort paid their ophthalmologists a mean of 30.9 (12.2) visits and had a mean of 7.6 (5.2) any injections. Results for quality of life questionnaires NEI-VFQ25 and HUI-3 remained stable throughout the study. Multivariate analysis on the 145 patients with evaluable BCVA data at M36 found that male gender and milder baseline DME characteristics (BCVA ≥59 and CSFT <500 µm) were predictive factors for achieving a BCVA of ≥70 letters at M36. This study did not find any new safety signals, compared to the known profile of ranibizumab. CONCLUSIONS: Gains in BCVA in this real-life study were lower than those observed in randomized clinical trials with ranibizumab, mainly due to undertreatment. Safety analysis of ranibizumab did not yield any new safety concerns.

Outer Foveal Microdefects.

PURPOSE: To report a spectral-domain (SD) OCT clinical sign, outer foveal microdefect (OFMD), corresponding to a focal disruption of the foveal photoreceptors in association with various macular conditions. DESIGN: Retrospective cohort study. PARTICIPANTS: Forty-five patients with OFMD. METHODS: All patients were imaged with color photography and SD OCT, and some were imaged with autofluorescence imaging, fluorescein angiography, indocyanine green angiography, or a combination thereof. Patient demographics, OFMD imaging, courses, and outcomes were analyzed retrospectively. MAIN OUTCOME MEASURES: Demographics, conditions associated with OFMD, and diameter of OFMD. RESULTS: Fifty-one eyes of 45 patients (15 men and 30 women; age range, 10-88 years) were included. Symptoms included central scotoma, metamorphopsia, and mild to moderate visual loss. Outer foveal microdefects were observed in association with various macular conditions: presumed posterior vitreous detachment, vitreomacular interface changes, or both (24 eyes); sequelae of macular edema (3 eyes); blunt trauma (2 eyes); retinal phototoxicity resulting from laser or solar maculopathy (5 eyes); and macular telangiectasia type 2 (2 eyes). An improvement with a reduction in OFMD diameter was documented in 9 of 14 eyes that could be followed up. CONCLUSIONS: We suggest renaming the condition outer foveal microdefect instead of macular microhole, which is usually associated with a vitreomacular disorder. The pattern indeed also was observed in traumatic or degenerative conditions. We assumed that various injuries led to changes in foveal morphologic features and that a full recovery of the foveal architecture could be altered, especially in eyes with findings suggestive of the pachychoroid spectrum of disorders.

Comparison of the Effect of Ranibizumab and Aflibercept on Changes in Macular Choroidal Thickness in Patients Treated for Diabetic Macular Edema.

PURPOSE: The aim of this study was to assess the effect of intravitreal injections (IVI) of ranibizumab and aflibercept on the choroidal thickness (CT) in patients with treatment-naive diabetic macular edema (DME) before and after monthly IVI. Patients and Methods. Prospective monocenter study. Inclusion criteria were treatment-naive DME eyes without concomitant panretinal photocoagulation, associated with a decrease in best-corrected visual acuity ≤75 letters on the Early Treatment Diabetic Retinopathy Study (ETDRS) scale. DME was defined by a central retinal thickness ≥300 µm on swept-source OCT (Triton DRI OCT, Topcon Corporation, Itabashi, Japan). Patients received 5 IVI of ranibizumab or aflibercept. The primary endpoint was the change in the central subfield CT (CSCT) between inclusion (M0) and 1 month after the fifth IVI (M5). The secondary endpoint was the CT changes between M0 and M5 in other locations of the macular ETDRS grid. RESULTS: Twenty-four eyes of 24 patients with a mean age of 61.1 years were included. Eleven and 13 patients were, respectively, treated with ranibizumab and aflibercept, and 86.4% had type 2 diabetes. The overall CSCT decreased significantly by -12 µm between M0 and M5 (231.7 µm at M0 and 219.7 µm at M5) (p=0.03). It decreased by -15.2 µm (p=0.02) in the aflibercept group (206.9 µm at M0 and 191.7 µm at M5) and by -7.3 µm (p=0.4) in the ranibizumab group (267.5 µm at M0 and 260.2 µm at M5). The CSCT decreased by -4.9 µm in noninjected contralateral eyes (242.3 µm at M0 and 237.4 µm at M5). CT changes between M0 and M5 in the superior, temporal, inferior, and nasal macular inner ring were significant in the aflibercept group but not in the ranibizumab and control groups. CONCLUSION: In DME patients, the CSCT decreases after 5 IVI of anti-VEGF, especially after aflibercept treatment.

Ethnic differences in normal retinal capillary density and foveal avascular zone measurements.

BACKGROUND: The purpose of this study was to quantify retinal capillary density and foveal avascular zone (FAZ) area in healthy subjects according to their ethnicity, using optical coherence tomography angiography (OCTA). METHODS: In this cross-sectional study, all eyes underwent swept-source OCTA (Triton, Topcon, Tokyo, Japan). Macular OCTA scans (3 × 3 mm) were obtained in healthy white Caucasian and black African subjects. The FAZ area and capillary density in both the superficial (SCP) and deep capillary plexuses (DCP) were automatically measured using a custom-made software combining vessel binarization and skeletonization. RESULTS: Twelve eyes of 12 healthy Caucasians and 15 eyes of 15 healthy black Africans were included in the analysis. The mean FAZ area was significantly smaller, and the overall vessel density (VD) was higher in the SCP and DCP of Caucasians compared to black Africans. The mean FAZ area was 0.26 ± 0.008 mm2 in the SCP and 0.25 ± 0.05 mm2 in the DCP in Caucasians versus 0.33 ± 0.08 mm2 in the SCP (p = 0.01) and 0.37 ± 0.1 mm2 in the DCP (p = 0.03) in Africans. In the SCP and DCP, the mean VD was, respectively, 40.5 ± 0.8% and 47.1 ± 0.5% in Caucasians versus 34.3 ± 1% (p = 0.008) and 40.6 ± 0.9% in Africans (p < 0.001). DISCUSSION/CONCLUSION: In the SCP and DCP, VD is lower in black Africans compared to Caucasians. In OCTA studies on vascular diseases, ethnicity-matched measurements from healthy subjects should be used for comparisons.

Expectations and fears of patients with diabetes and macular edema treated by intravitreal injections.

AIMS: Clinical outcomes of diabetic macular edema (DME) have been widely described, but data on diabetic retinopathy perceptions by diabetes patients are limited. The aim of this survey was to explore the lived experience, knowledge, fears and expectations about disease, and treatment in patients with diabetes and macular edema treated with intravitreal injections (IVTI) and to characterize patient profiles. METHODS: Cross-sectional survey including a preliminary qualitative phase (20 patients with DME, treated or treatment-naive, 5 female and 15 male, age 36-74 years) followed by a quantitative survey (116 patients treated with IVTI for DME). Data ASKIA Analyze (version 5.3.3.5) was used for descriptive statistics, and R software (version 3.4.1) for multiple correspondence analysis. RESULTS: The qualitative phase identified the wording used by patients and information helpful to propose modalities of response in the quantitative phase. In the quantitative survey (116 patients, mean age 66.6 years), most patients were treated with anti-vascular endothelial growth factor. Overall, 71.9% reported that the disease negatively affected their daily activities and 33.1% considered that regular visits to the ophthalmologist were disrupting their life. Treatment expectations differed significantly between patients in terms of disease experience (visit and injection schedules), fears and feelings, and relationship with physicians, allowing three patient profiles to be identified: "Worried" patients (n = 45) felt isolated and were worried about the need for repeated treatment and possible side effects. They were mainly active men aged < 60 with type I diabetes (T1D) and DME diagnosed for > 2 years; "Curious" patients (n = 21) experienced insufficient support and requested more information on their disease and existing treatments. They were mainly single women aged 60-69 years; "Passive" patients (n = 50) felt sufficiently informed by their ophthalmologist and were not concerned by DME. They were older (mean age: 70 years) and mainly type 2 diabetic men. CONCLUSIONS: Patients with diabetes and macular edema treated with IVTI form a heterogeneous group regarding fears and expectations. Different patient profiles were identified and need to be confirmed in larger studies. A better understanding of psychological profiles may optimize compliance of diabetic patients.

Impact of ranibizumab on visual impairment in patients with bilateral diabetic macular edema.

AIMS: Diabetic macular edema (DME) frequently presents bilaterally. In case of bilateral retinal disease, the visual impairment (VI) and the visual acuity (VA) are strongly correlated to the better eye. The aim of this study was to assess the impact of ranibizumab intravitreal injections (IVR) on VI in patients with simultaneous VA loss due to DME. METHODS: This was a retrospective two-center study including consecutive DME patients with visual loss treated with ranibizumab since November 2011 and with a minimum follow-up of 6 months. Patients with bilateral visual decrease from DME undergoing IVR within 6 months of each other were included. RESULTS: Twenty-nine DME patients who received bilateral IVR within a 6-month interval in the second eye were included. At baseline, 82.8% (n = 24) of patients had a VA < 20/40 in their better eye versus 44.8% (n = 13) of patients at the end of follow-up, i.e. a reduction by 45.9% of VI. In the better eye, the mean VA was 57.3, 65.0 and 65.5 ETDRS letters, respectively, at baseline, month 3 and month 6 (mean VA gain +8.2 letters). In the worse eye, the mean VA was 44.2, 53.5 and 53.8 ETDRS letters, respectively, at baseline, M3 and M6 (mean VA gain +9.6 letters). CONCLUSIONS: In patients with bilateral DME, subsequent ranibizumab IVR reduced VI frequency.

OPTICAL COHERENCE TOMOGRAPHY, FLUORESCEIN ANGIOGRAPHY, AND DIAGNOSIS OF CHOROIDAL NEOVASCULARIZATION IN AGE-RELATED MACULAR DEGENERATION.

PURPOSE: To determine the sensitivity and specificity of different retinal imaging combinations for the diagnosis of choroidal neovascularization (CNV) in age-related macular degeneration. METHODS: Patients aged 50 years or older referred for suspicious recent-onset CNV related to age-related macular degeneration were prospectively included for 6 months. Data recorded included color fundus photographs (CFPs), spectral domain optical coherence tomography (SD-OCT), and fluorescein angiography (FA) images. Five retina specialists randomly interpreted SD-OCT combined with CFP, and then FA combined with CFP. The reference diagnosis of CNV was based on the agreement of two readers in the interpretation of the SD-OCT + FA + CFP combination. RESULTS: One hundred and forty-eight patients (148 eyes) were included. For the diagnosis of CNV, the sensitivity of both SD-OCT + CFP and FA + CFP was of 90.9%. Type 2 CNV was diagnosed in 98% to 100% of cases with SD-OCT + CFP or FA + CFP, whereas Type 1 CNV was diagnosed in 82.9% of cases with SD-OCT + CFP and 81.6% with FA + CFP. CONCLUSION: When used as a first diagnostic test, SD-OCT combined with CFP had sensitivity and specificity similar to those of FA combined with CFP, for the diagnosis of CNV in age-related macular degeneration. This shows the increasingly important role of SD-OCT as a first-line test in the diagnosis of CNV.

Treatment Efficacy and Compliance in Patients with Diabetic Macular Edema Treated with Ranibizumab in a Real-Life Setting.

PURPOSE: To assess real-life efficacy of ranibizumab and treatment compliance of patients with vision loss secondary to diabetic macular edema (DME). METHODS: A retrospective study was conducted in DME patients treated with ranibizumab. Patients were monitored every 4 weeks for visual acuity (VA) and central retinal thickness (CRT) by SD-OCT. All patients received a loading dose of 3 monthly injections followed by retreatments on an as-needed basis. The primary endpoint was the change in VA at M12. Patient compliance to the follow-up and the correlation between the injection number and VA were also investigated. Compliance was compared to that of neovascular age-related macular degeneration (nAMD) patients. RESULTS: Seventy-two eyes of 55 consecutive DME patients were included. At baseline, the mean VA was 56.5 letters and CRT was 470 µm. At M12, the mean VA was 63.4 letters (p < 0.0001), 31.1% of patients had a VA > 70 letters, the mean VA change was +6.9 letters, and the mean CRT was 361.9 µm (p = 0.0001) after a mean number of 5.33 intravitreal injections. In patients who received ≥7 injections, the VA gain and final VA were significantly higher than in patients who received <7 injections. At M12, 25.45% of DME patients were lost to follow-up versus 16.8% of nAMD patients (n = 55). DISCUSSION/CONCLUSION: Our study confirms the real-life efficacy of ranibizumab in DME at M12 and the need for a large number of injections to achieve better visual outcomes. We also showed a trend to a lower compliance in diabetic versus nAMD patients.

Clinical applications of optical coherence tomography angiography: What we have learnt in the first 3 years.

A review of the literature from 2014 to 2016 was conducted, focusing on the results of optical coherence tomography angiography in different chorioretinal diseases. In only 3 years, optical coherence tomography angiography has been shown to be an effective tool for diagnosing choroidal neovascularization complicating age-related macular degeneration, pathologic myopia, and inflammatory conditions. The technique has sometimes been considered superior to conventional multimodal imaging, for example, in choroidal neovascularization associated with chronic central serous chorioretinopathy or multifocal choroiditis. In retinal vascular diseases, optical coherence tomography angiography has helped to understand the condition described as paracentral acute middle maculopathy and has been considered highly effective for the analysis of retinal vascular macular changes secondary to retinal vein occlusion or macular telangiectasia. Changes in the foveal avascular zone, also reported in diabetic maculopathy, have been shown to occur before any angiographic signs. A reduction in capillary vascular density has been reported in the fovea of eyes with malignant melanoma, but not in eyes with choroidal nevus. However, optical coherence tomography angiography is a recent technique that probably needs refinements and further studies. Nevertheless, the first 3 years of optical coherence tomography angiography use suggest its clinical relevance and useful applications in daily clinical practice.

Evaluation of a new matrix regenerating agent in patients with Sjögren syndrome and superficial ulcerative keratitis resistant to conventional therapy: A report of 3 cases.

RATIONALE: Sjögren syndrome (SS) is frequently associated with ulcerative keratitis, which is difficult to treat due to lacrimal tear deficiency and inflammation of the ocular surface. PATIENT CONCERNS: We report the successful additive effect of a matrix regenerating agent (RGTA, Cacicol) in SS patients with severe superficial ulcerative keratitis resistant to conventional therapy. DIAGNOSES: Retrospective, noncomparative case series of patients with primary or secondary SS associated with chronic diffuse keratitis. INTERVENTIONS: All patients (3 women, aged 46, 59, and 84 years) had several years of dry-eye disease history and recurrent keratitis despite having used maximal dose topical therapies including artificial tear substitutes, topical vitamin A, and cyclosporine 0.05% emulsion. All patients suffered from dry, diffuse, and chronic superficial keratitis of at least 75% of the corneal surface, with no sign of corneal neovascularization or opacity. OUTCOMES: RGTA treatment led to a rapid and marked decrease of ocular pain, burning, irritation, foreign body sensation, and improvement of visual acuity. Total diffuse keratitis healing occurred after several months of treatment. Discontinuation of RGTA administration led to the recurrence of severe keratitis; re-introduction of RGTA was successful. No local or systemic adverse effects related to treatment were reported. LESSONS: RGTA treatment was effective and safe in this small series of 3 patients suffering from SS associated with recurrent or chronic superficial ulcerative keratitis resistant to conventional therapy.

Switching to Aflibercept in Diabetic Macular Edema Not Responding to Ranibizumab and/or Intravitreal Dexamethasone Implant.

PURPOSE: To assess short-term functional and anatomical outcomes of refractory diabetic macular edema (DME) following a switch from ranibizumab or dexamethasone to aflibercept. METHODS: We included retrospectively eyes with persistent DME after at least 3 ranibizumab and/or one dexamethasone implant intravitreal injections (IVI). The primary endpoint was the mean change in visual acuity (VA) at month 6 (M6) after switching. RESULTS: Twenty-five eyes were included. Before switching to aflibercept, 23 eyes received a median of 9.5 ranibizumab, and among them, 6 eyes received one dexamethasone implant after ranibizumab and 2 eyes received only one dexamethasone implant. Baseline VA, before any IVI, was 52.9 ± 16.5 letters, and preswitch VA was 57.1 ± 19.6 letters. The mean VA gain was +8 letters (p = 0.01) between preswitch and M6. The mean central retinal thickness was 470.8 ± 129.9 µm before the switch and 303.3 ± 59.1 µm at M6 (p = 0.001). CONCLUSION: Switching to aflibercept in refractory DME results in significant functional and anatomical improvement. The study was approved by the France Macula Federation ethical committee (FMF 2017-138).