ESASO classification relevance in the diagnosis and evolution in diabetic macular edema patients after dexamethasone implant treatment.

PURPOSE: To assess the clinical relevance of The European School for Advanced Studies in Ophthalmology (ESASO) classification in patients with diabetic macular edema (DME) after their first dexamethasone implant (DEXI) treatment. METHODS: Retrospective real-world study conducted on consecutive DME patients who underwent DEXI treatment and were controlled at month-2. Subjects were initially classified according to the ESASO classification stages. The outcomes were anatomical biomarkers with spectral-domain optical coherence tomography (SD-OCT) and best-corrected visual acuity (BCVA). RESULTS: A total of 128 patients were classified according to ESASO classification stages as early (7; 5.5%), advanced (100; 78.1%), and severe (21; 16.4%). At baseline, there were significant differences between stages in BCVA, central macular thickness (CMT), and tomography anatomical biomarkers (p < 0.05). Initial BCVA (logMAR) was 0.33 ± 0.10, 0.58 ± 0.34, and 0.71 ± 0.35 in the early, advanced, and severe stages, respectively (p < 0.05). At month-2, BCVA was 0.17 ± 0.15, 0.46 ± 0.29, and 0.69 ± 0.27 in those classified as early, advanced, and severe stages, respectively. At month-2, DME was resolved or improved in 6 (85.7%), 60 (60%), and 12 (60%) patients classified as early, advanced, and severe stages, respectively. CONCLUSIONS: There was a good correlation between BCVA and ESASO classification stages. Patients in the severe stage did not achieve visual acuity improvement over the study period.

Influence of prior treatment protocol on intravitreal dexamethasone implant behavior in patients with diabetic macular edema in real-world practice.

BACKGROUND AND OBJECTIVE: Intravitreal dexamethasone implant (DEXI) has been placed as an effective option to treat diabetic macular edema (DME). However, there is no consensus on the best time to introduce it. We conducted a study to evaluate anatomical and functional behavior after the first DEXI according to previous treatment. RESEARCH DESIGN AND METHODS: This retrospective, real-world study between 2013 and 2020 investigated changes in best-corrected visual acuity (BCVA) and central macular thickness (CMT at months 2 and 6 after the first DEXI in DME. Patients were divided into naive, early switch (≤3 anti-VEGF injections), or late switch (>3 anti-VEGF injections) groups. RESULTS: Among 112 consecutive eyes, mean BCVA and CMT improved significantly in all groups at month 2, with no difference between them. However, this improvement was not maintained at 6 months. The Naíve group presented better BCVA all over the study period. The previously treated groups, which started with worse initial visual acuity, showed more visual gain without reaching the BCVA of the naive group. CMT performance was similar between groups. CONCLUSIONS: There was similar anatomical and functional behavior in all groups. Poorer visual acuity at baseline was associated with worse functional outcome despite good anatomic response.

Differential response to intravitreal dexamethasone implant in naïve and previously treated diabetic macular edema eyes.

BACKGROUND: To identify different response patterns to intravitreal dexamethasone implants (IDI) in naïve and previously treated (PT) diabetic macular edema (DME) eyes in a real-life setting. METHODS: 342 IDI injections (203 DME eyes) were included. Number of IDI injections, percentage (%) of eyes with 1, 2, 3 and ≥ 4 injections, time to reinjections, visual acuity (VA), intraocular pressure (IOP) and central retinal thickness (CRT) were evaluated for naïve and PT DME eyes over 24 months. RESULTS: Mean number of injections was significantly lower in naïve vs PT DME eyes (1.40 ± 0.9 vs 1.82 ± 0.9, p < 0.001). The percentage of eyes receiving 1 injection was significantly higher in naïve vs PT DME eyes (76.1 vs 47.7), (p < 0.001). However, it was significantly lower for 2 (16.4 vs 29.4), or 3 injections (1.4 vs 17.6) (both p < 0.001), with no differences in eyes receiving ≥4 injections (5.9 vs 5.1 respectively, p = 0.80). Mean time to reinjection was not significantly different between both groups for the second, third and fourth injection (9.6 ± 4.0 vs 10.0 ± 5.5, p = 0.75, 13.2 ± 4.0 vs 16.0 ± 3.5, p = 0.21 and 21.7 ± 3.8 vs 19.7 ± 5.8, p = 0.55). VA scores were consistently better in naïve vs PT DME eyes at all studied timepoints, with no significant differences in CRT reduction or adverse effect rates. CONCLUSION: Naïve DME eyes received lower number of IDI injections and showed better VA levels than PT DME eyes for 24 months in a real-world setting. This data supports the IDI use in early DME stages and provide further evidence of better IDI response when used as first-line therapy.

Surgical Options for Optic Disc Pit Maculopathy: Perspectives and Controversies.

Optic disc pit (ODP) is a rare congenital optic nerve head abnormality, which can be complicated by intraretinal and subretinal fluid at the macula (ODP-maculopathy) with progressive visual loss. The source of this fluid remains unclear and the most dominant hypotheses have pointed to vitreous cavity or cerebrospinal fluid. Although spontaneous resolution has been reported, the majority of untreated cases of ODP-maculopathy result in final visual acuity less than 20/200 or worse. A wide array of interventions, either individually or in combination with adjuvant treatments, have been tried with varying degrees of success. Recently, different surgical procedures to fill the ODP by self-sealing materials in combination with pars plana vitrectomy have been reported as an effective adjuvant treatment. However, given the relative rarity of this condition, the majority of reports describe a small retrospective case series, making it difficult to compare among different treatments options and create a consensus regarding the optimal treatment for ODP-maculopathy. In this situation, a mini-review about surgical treatment modalities and their results can be a useful approach to identify the most effective surgical option in the management of ODP-maculopathy.

Efficacy of Internal Limiting Membrane Flap Techniques with Vitrectomy for Macular Detachment Associated with an Optic Disc Pit.

PURPOSE: To compare the anatomical and functional outcome of adjuvant pars plana vitrectomy (PPV) procedures using the techniques of translocation of an internal limiting membrane (ILM) flap and transplantation of an inverted ILM flap for the treatment of chronic and/or refractory optic disc pit (ODP) maculopathy. METHODS: In this prospective interventional case series study, 9 patients (9 eyes) with chronic and/or refractory ODP maculopathy underwent PPV with either translocation of an ILM flap or transplantation of an inverted ILM flap as adjuvant techniques along with gas tamponade. The anatomical success, rates of macular reattachment, and visual improvement were assessed. RESULTS: The mean preoperative central retinal thickness (CRT) was 723.4 µm (range: 366-1,151). The mean postoperative CRT was 398.1 ± 212.2 µm (range: 210-758). An increased preoperative CRT was associated with a lower chance of postoperative reattachment of the macula (p = 0.047). The overall reattachment rate at the end of the follow-up period was 56% (n = 5). The mean preoperative visual acuity (logMAR unit [Snellen acuity]) was 0.48 (20/60) (range: 1.30 [20/400] to 0.10 [20/25]). The mean change in best corrected visual acuity (BCVA) was 0.48 ± 0.233 logMAR units (approx. 3 lines of visual improvement). CONCLUSIONS: ILM flap techniques are logical and straightforward approaches as adjuvants to PPV treatment of ODP maculopathy. They could be viable adjuvant treatments for improvement in BCVA and CRT in patients with ODP maculopathy.

Long-term probability of intraocular pressure elevation with the intravitreal dexamethasone implant in the real-world.

PURPOSE: To evaluate the long-term cumulative probability of intraocular pressure (IOP) elevation with the intravitreal dexamethasone implant (IDI) when used to treat different indications: diabetic macular edema, uveitis, retinal vein occlusion. METHODS: 705 IDI injections (429 eyes) were assessed and Kaplan-Meier graphs were generated to assess: the probability of different levels of IOP elevation (IOP≥21, ≥25 or ≥35 mmHg), IOP change ≥10 mmHg, initiation of IOP-lowering treatment, glaucoma surgery, IOP change with repeat injections and IOP elevation in eyes with glaucoma and ocular hypertension (OHT). RESULTS: The cumulative probability of IOP ≥21, ≥25 and ≥35 mmHg was 50%-60%, 25%-30% and 6%-7% at 12-24 months, respectively. The probability of initiating IOP-lowering medication was 31%-54% at 12-24 months. Glaucoma and OHT eyes had a higher probability of mild IOP elevation (≥21 mmHg, 65.1%, 75% and 57.8%, p = 0.01), yet a similar moderate (≥25 mmHg, 22.3%, 28% and 30.2%, p = 0.91) and severe elevation of IOP (≥35 mmHg, 3.7%, 7.1% and 4%, p = 0.71) as normal eyes. Glaucoma surgery was required in only 0.9% cases (4/429). At baseline, 8.8% of the treated eyes had glaucoma, 6.7% OHT and 16.9% were already on IOP-lowering medication. CONCLUSIONS: In the long-term (24 months), IOP elevation is common, generally mild (30% IOP, ≥25 mmHg) and well-tolerated, resolving with topical treatment (54%) and rarely requiring surgery (0.9%).

PREOPERATIVE VITREORETINAL INTERFACE ABNORMALITIES ON SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHY AS RISK FACTOR FOR PSEUDOPHAKIC CYSTOID MACULAR EDEMA AFTER PHACOEMULSIFICATION.

PURPOSE: We assessed the role of vitreoretinal interface status in the development of pseudophakic cystoid macular edema (PCME) after cataract surgery. METHODS: Prospective cohort study in which 112 patients (112 eyes) scheduled for cataract surgery were selected at random to undergo spectral domain optical coherence tomography (OCT) within 1 week preoperatively and at 1 and 3 months postoperatively. Spectral domain OCT macular images included no vitreoretinal contact, focal and diffuse vitreomacular adhesion, focal and diffuse vitreomacular traction, epiretinal membrane, macular hole, and macular edema. RESULTS: The incidence of PCME was 11.6% (13 eyes), all of them being diagnosed at 1 month, and 7 eyes resolved at 3 months. The only risk factor for PCME was detection of nonsurgical epiretinal membrane by spectral domain OCT before phacoemulsification, being developed in 5 of 16 eyes (χ = 0.08, odds ratio 4.53, 95% confidence interval 1.28-16.13). Other variables such as posterior vitreous detachment, subfoveal choroidal thickness, diabetes, or hypertension were not significantly associated with PCME. CONCLUSION: In this cohort, preoperative detection of epiretinal membrane by spectral domain OCT was a risk factor for PCME after cataract extraction. It is recommended to perform a spectral domain OCT before cataract surgery because the presence of an epiretinal membrane may be passed unnoticed by fundus examination.

Direct comparison of spectral-domain and swept-source OCT in the measurement of choroidal thickness in normal eyes.

OBJECTIVE: To compare spectral-domain optic coherence tomography (SD-OCT) and swept-source OCT (SS-OCT) in the study of choroidal thickness (CT) in healthy eyes. METHODS: Prospective, cross-sectional, single-centre study. 82 healthy eyes of 46 patients were included. In a single session, Topcon 3D-2000 SD-OCT and 1050 nm SS-OCT prototype devices were used to perform OCT scans using a single line protocol. Two masked investigators independently, manually determined 13 CT measurements consisting of one subfoveal (SFCT), and six measurements on either side of the fovea (nasal and temporal) taken every 500 microns apart. The mean CT (MCT) was the mean average of these 13 measurements. RESULTS: SD-OCT was able to reproducibly measure the CT in 74.4% of eyes vs 100% with SS-OCT (p<0.05; Fisher's Exact test). In those eyes measured by both systems, mean SFCT was 279.4 ± 96.9 µm (range, 84-506) with SD-OCT vs 285.7 ± 88.9 µm (range 130-527) with SS-OCT (p=0.11; Student's t test paired data). Mean MCT was 243.8 ± 78.8 µm (range 103.6-433.2) with SD-OCT vs 242.2 ± 81.8 µm (range 97.6-459) with SS-OCT (p=0.64; Student's t test paired data). The difference in SFCT and MCT was not statistically significant between both devices. Intraclass correlation coefficient was higher than 0.9 interobserver and interdevice measurements. SFCT Bland-Altman plots showed 95% interobserver measurement agreement within ±34 for SD-OCT, ±22 for SS-OCT and ±60 µm intersystems. CONCLUSIONS: SS-OCT permitted accurate identification of the choroido-scleral border in 100% of normal eyes, suggesting that SS-OCT was the superior modality for the measurement of CT.

Retinal thickness changes following photodynamic therapy in chronic central serous chorioretinopathy.

OBJECTIVE: To evaluate changes in neural retina (NR) thickness and best-corrected visual acuity (BCVA) induced by treatment of chronic central serous chorioretinopathy (CSC) by photodynamic therapy (PDT). PATIENTS AND METHODS: Retrospective study of 25 eyes of 25 patients with chronic CSC treated by "full-fluence" PDT. LogMAR BCVA and Stratus optical coherence tomography (OCT) were evaluated before treatment and 1 year after PDT. Twenty-four eyes from 24 patients with non-chronic, non-PDT-treated forms of CSC were evaluated as a control group. RESULTS: NR foveal thickness before PDT was 182 ± 43.4 µm (range, 92-246) vs 148.1 ± 30.9 µm (range, 101-220) 1 year after treatment (p = 0.004; Student's t-test paired data). NR foveal thickness in the untreated eyes was 204.6 ± 30.7 µ (range, 132-249) vs 192.5 ± 26.4 µ (range, 123-235) after self-resolution (p = 0.03; Student's t-test paired data). Basal NR thickness was statistically significant different between both groups (p = 0.04; Student's t-test); this difference continued to be significant at the end of the follow-up (p < 0.01; Student's t-test). All the patients with chronic CSC treated by PDT showed anatomic resolution, and BCVA improved from 0.38 ± 0.35 to 0.23 ± 0.29 (p = 0.007; Student's t-test paired data). Final BCVA and basal and final NR thickness showed poor correlation (Pearson = 0.2 and 0.1 respectively). CONCLUSIONS: The use of PDT in chronic CSC induces NR thickness thinning. This change is not correlated with a decrease in BCVA. Spontaneous resolution of classic CCS also showed significant NR thinning.