Review on the Safety and Efficacy of Brolucizumab for Neovascular Age-Related Macular Degeneration From Major Studies and Real-World Data.

Frequent antivascular endothelial growth factor injections in neovascular age-related macular degeneration (nAMD) often lead to poor compliance and suboptimal outcomes. A longer-acting agent has been a pressing unmet need until recently. Brolucizumab, an antivascular endothelial growth factor agent, is a single-chain antibody fragment approved by the US Food and Drug Administration (FDA) on October 8, 2019, for treating nAMD. It delivers more molecules at equivalent volumes of aflibercept, thus achieving a longer-lasting effect. We reviewed literature published in English between January 2016 and October 2022 from MEDLINE, PubMed, Cochrane database, Embase, and Google scholar using the keywords: "Brolucizumab, real-world data, intraocular inflammation (IOI), safety, and efficacy". Brolucizumab showed reduced injection frequency, better anatomic outcomes, and noninferior vision gains compared with aflibercept in HAWK and HARRIER studies. However, post hoc studies on brolucizumab revealed a higher-than-expected incidence of IOI, leading to the early termination of 3 studies: MERLIN, RAPTOR, and RAVEN for nAMD, branch retinal vein occlusion, and central retinal vein occlusion, respectively. Contrastingly real-world data showed encouraging outcomes in terms of fewer IOI cases. The subsequent amendment of the treatment protocol resulted in reduced IOI. Thereafter US FDA approved its use in diabetic macular edema on June 1, 2022. Based on major studies and real-world data, this review shows that brolucizumab is effective for treating naive and refractory nAMD. The risk of IOI is acceptable and manageable, but proper preinjection screening and high-vigilance care of IOI are needed. More studies are warranted to evaluate further the incidence, best prevention, and treatment measures for IOI.

Rare case of large eccrine poroma of the eyelid.

Eccrine poroma is a rare tumor arising from sweat glands with common location being soles and palms. We are reporting a case of 70-year male patient with large lower lid mass lesion. Owing to its location and history of growth, malignancy was suspected. Biopsy proved it to be eccrine poroma which is a benign lesion. Complete excision with lid reconstruction was done. Eccrine poroma, though rare, should be kept in the differential diagnosis of eyelid tumors. Owing to the risk of malignant transformation and difficulty in clinical differentiation between poroma and porocarcinoma, wide excision should be done.

Binocular Triplopia Due to Decompensated Congenital Superior Oblique Paresis in A Patient with Marfan Syndrome; A Case Report and Review of Literature.

Binocular triplopia is a rare symptom and usually has a corneal or lenticular origin. Uniocular diplopia arising from ectopia lentis is quite common in Marfan syndrome. A visual phenomenon related to binocular triplopia due to strabismus was first reported in 1943 by Burian. Both monocular diplopia and binocular triplopia have been reported in concomitant strabismus. Strabismus is also common in Marfan syndrome but congenital superior oblique paresis has never been reported before. We report herein a rare case of binocular triplopia in a patient with Marfan syndrome arising from decompensation of his coexistent congenital superior oblique paresis triggered by his uniocular diplopia. This is the first report of congenital superior oblique paresis in a patient with Marfan syndrome. Though it is unlikely to have any etiological implications and is likely to be a mere coincidental simultaneous occurrence, it had a confounding effect on the clinical interpretation of the signs and symptoms posing an interesting diagnostic and management dilemma. Our case report emphasizes the necessity for careful evaluation of any patient with symptoms of triplopia. We further review and summarize all the causes of binocular triplopia published in English literature and propose an approach to its evaluation and management.

Aerobic exercise reduces intraocular pressure and expands Schlemm's canal dimensions in healthy and primary open-angle glaucoma eyes.

Purpose: Aerobic exercise (AE) has been reported to decrease intraocular pressure (IOP) in healthy subjects and there are concomitant morphological changes in the anterior segment of the eye including the Schlemm's canal (SC). However, its effects on IOP and SC morphology in glaucoma patients had not been studied before. We aim to investigate the effect of AE on the IOP and SC dimension in both healthy and primary open-angle glaucoma (POAG) eyes. Methods: The area and diameter of SC and IOP were measured in 35 primary open-angle glaucoma (POAG) patients (59 eyes) and 36 healthy subjects (72 eyes) before and after performing moderate intensity of AE by running on a treadmill for 30 min. SC was imaged by swept-source optical coherence tomography (SS-OCT) for evaluation. Results: In comparison with baseline values, mean IOP decreased significantly following AE in both POAG and healthy eyes (both P < 0.001), in which POAG eyes showed a greater degree of reduction compared to healthy eyes (P = 0.002). In comparison with baseline values, in both POAG and healthy eyes, the average cross-sectional area (POAG: 80.48 +/- 59.54 vs. 99.20 +/- 54.87 pixels; healthy: 151.84 +/- 52.76 vs. 198.23 +/- 53.70 pixels; both P < 0.001) and diameter (POAG: 3.73 +/- 1.69 vs. 4.33 +/- 1.74 pixels; healthy: 5.61 +/- 1.02 vs. 6.47 +/- 1.20 pixels; both P < 0.001) of SC significantly increased after AE. In POAG, both treated and untreated with IOP-lowering medications, a significant reduction in mean IOP and increase in SC dimensions following AE were observed (all P < 0.05), and there were no significant differences of such measurements between the two subgroups (all P > 0.05). Conclusion: AE-induced reduction in IOP and an increase in SC dimensions in POAG eyes as in healthy eyes. Further studies to evaluate the long-term effect of AE on IOP control and SC morphology in POAG seem warranted.

Fibrin Glue-Assisted Intraocular Lens Fixation in Weill-Marchesani Syndrome.

PURPOSE: To report visual and intraocular pressure (IOP) outcomes of 4 eyes in 2 patients with Weill Marchesani Syndrome having ocular fearures of spherophakia and secondary glaucoma who underwent fibrin glue assisted intrascleral fixation of intraocular lens (IOL). METHODS: Detailed anterior and posterior segment evaluation assessing best corrected visual acuity (BCVA), IOP, central corneal thickness was done in all. Lensectomy, vitrectomy with glued Intrascleral fixation of 3 piece intraocular lens was done. Post operative BCVA and IOP were assessed. RESULTS: Visual acuity and IOP control improved post-operatively. CONCLUSIONS: Glued IOL implantation is an effective method to visually rehabilitate and control glaucoma in patients with Weill Marchesani Syndrome.

A new surgical technique of intra-scleral tube fixation in Ahmed Glaucoma Valve implantation: 'Scleral Sleeve Method'.

PURPOSE: To present a new surgical technique 'Scleral Sleeve Method' which would reduce the risk of Ahmed Glaucoma Valve (AGV) tube related complications in patients undergoing AGV FP7 (New World Medical Inc., Rancho Cucamonga, CA) for refractory glaucoma. DESIGN: Prospective, Non-Randomized, hospital based interventional case series. SUBJECTS: A total of 16 eyes of adult patients (10 males and 6 females) with refractory glaucoma. METHODS: Instead of using sutures to fix the AGV tube to sclera, we devised a novel method of intra-scleral tube fixation by creating a scleral tunnel fashioned in form of sleeve. MAIN OUTCOME MEASURE: Post-operative tube related complications. RESULT: There were no tube related complications such as exposure, extrusion or retraction in any of the cases. CONCLUSION: Use of scleral sleeve method for tube fixation, along with graft to cover the tube, will provide additional safety measure and reduce the risks of tube related complications.

Two-Port Pars Plana Anterior and Central Core Vitrectomy (Lam Floaterectomy) in Combination With Phacoemulsification and Intraocular Lens Implantation Under Topical Anesthesia for Patients with Cataract and Significant Floaters: Results of the First 50 Consecutive Cases.

PURPOSE: To study the safety and efficacy of 2-port pars plana anterior and central core vitrectomy (Lam floaterectomy) in combination with phacoemulsification (phaco) and intraocular lens implantation (IOL) for patients with cataract and significant floaters under topical anesthesia. DESIGN: Retrospective review of the first 50 consecutive cases. METHODS: A standardized treatment protocol was used for patients with cataract and significant (moderate to severe) floaters (duration > 3 months). Data analysis included intraoperative and postoperative complications, floater status, and patient satisfaction. RESULTS: There were 50 eyes (38 patients) with a male-to-female ratio of 1 to 2.3. Twelve patients had bilateral eye surgeries. Mean age was 58.10 ± 9.85 years (range, 39-83). All patients completed the 3-month follow-up. One eye had mild vitreous hemorrhage at the end of surgery arising from sclerotomy wound oozing. No other intraoperative compli-cations were encountered. Postoperatively, there was 1 case of transient hypotony and 1 case of congestion at sclerotomy wound. No cases of retinal break or detachment, or clinically significant macular edema, were reported. There were 5 cases (10%) of mild residual floaters and 1 case (2%) of floater recurrence. Total floater clearance rate was 88%. Patient satisfaction rates were 80%, 14%, 6%, and 0% for very satisfied, satis-fied, acceptable, and unsatisfied, respectively. CONCLUSIONS: The 3-month results in terms of safety and efficacy of the Lam floaterectomy in combination with phaco and IOLfor patients with cataract and significant floaters under topical anesthesia are encouraging. Further larger-scale, prospective, multicenter studies seem warranted.