Anti-Vascular Endothelial Growth Factor Treatment in Diabetic Macular Edema-Results from a Large Single Center Cohort with Bevacizumab As First-Line Therapy.

PURPOSE: To explore visual acuity (VA) outcomes of anti-vascular endothelial growth factor (VEGF) intravitreal injections in treatment-naive eyes with diabetic macular edema (DME), with bevacizumab as first-line treatment. METHODS: Retrospective single-center cohort study over a three-year follow-up. 1765 eyes from 1179 patients treated with intravitreal injections were evaluated. The cohort was divided according to the treatment given: (1) bevacizumab monotherapy, (2) eyes switched to 2nd line agent, and (3) eyes switched to a 3rd line agent. RESULTS: 644 eyes of 444 patients met inclusion criteria. Mean age at presentation was 64.0±11.1 years. Mean follow-up period was 24.6±12.4 months. 67.1% of eyes were treated with bevacizumab monotherapy, 25.45% switched to a 2nd line agent, and 7.45% were switched to a 3rd line agent. Mean number of injections decreased significantly during each treatment year in the total cohort and within each treatment group (P<0.001). Mean VA for the total cohort and within each treatment group improved significantly throughout follow-up (P<0.001). No significant difference in VA found between the groups (P=0.373). CONCLUSIONS: This real-world study demonstrates robust and consistent VA gains over long-term follow-up in eyes with DME treated with either bevacizumab monotherapy or switching to alternative anti-VEGF agents in cases of suboptimal response.

Influence of Carotid Endarterectomy on Choroidal Perfusion: The INFLATE Study.

PURPOSE: Patients with clinically significant carotid artery stenosis (CAS) undergoing carotid artery endarterectomy (CEA) were imaged with swept-source OCT angiography (SS-OCTA) imaging protocol to determine if there were changes in choroidal blood flow after surgery. DESIGN: Prospective observational study. PARTICIPANTS: Patients with clinically significant CAS undergoing unilateral CEA. METHODS: All participants underwent SS-OCTA imaging using a 6 × 6-mm scan pattern on both eyes before CEA and within 1 week after CEA. Previously validated automated algorithms were used to measure the mean choroidal thickness (MCT) and choroidal vascular index (CVI) within 2.5-mm and 5-mm circles centered on the fovea. Multivariable regression analysis was conducted to evaluate the impact of various baseline factors including age, mean arterial blood pressure, and degree of stenosis, on both baseline of MCT and CVI, and the changes in MCT and CVI. MAIN OUTCOME MEASURES: Changes in MCT and CVI. RESULTS: One hundred sixteen eyes from 60 patients with a mean age of 71.57 ± 7.37 years were involved in the study. At baseline, MCT in both the 2.5-mm and 5-mm circles was significantly thinner on the surgical side compared with the nonsurgical side (P = 0.03), while no significant differences were seen in the CVI at baseline between the 2 sides (2.5-mm circle: P = 0.24; 5-mm circle: P = 0.09). Within 1 week after CEA, there were significant increases in the MCT on the surgical side, as compared with the nonsurgical side, in both the 2.5-mm (P < 0.001) and the 5-mm (P < 0.001) circles. No significant change in mean CVI was noted before and after CEA on the surgical side versus the nonsurgical side (2.5-mm circle: P = 0.30; 5-mm circle: P = 0.97). Multivariable regression analysis revealed that baseline MCT before CEA significantly decreased with age on both the surgical (P < 0.001) and nonsurgical sides (P = 0.003) while the changes in MCT and CVI after CEA were not associated with age, mean arterial blood pressure, or degree of stenosis. CONCLUSION: A rapid and significant increase in MCT was observed on the ipsilateral side of CEA, suggesting an improvement in choroidal perfusion within 1 week after surgery. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

The Impact of Carotid Endarterectomy on Choriocapillaris Perfusion.

Purpose: The impact of carotid endarterectomy (CEA) on choriocapillaris (CC) perfusion was investigated using swept-source optical coherence tomography angiography (SS-OCTA) imaging before and after surgery in patients with clinically significant carotid artery stenosis (CAS). Methods: In this prospective observational study, patients with clinically significant CAS undergoing unilateral CEA had SS-OCTA imaging performed in both eyes before and within 1 week after surgery. The percent CC flow deficits (CC FD%) and CC thickness were assessed using previously validated algorithms. Multivariable regression analysis was conducted to evaluate the impact of variables on the change in CC measurements. Results: A total of 112 eyes from 56 patients with an average age of 72.6 ± 6.9 years were enrolled. At baseline, significantly higher CC FD% and thinner CC thickness were observed on the surgical side (eyes ipsilateral to the side of CEA) versus the nonsurgical side (eyes contralateral to the side of CEA) (P = 0.001 and P = 0.03, respectively). Following CEA, a significant reduction in CC FD% and a significant increase in CC thickness were detected on the surgical as compared with the nonsurgical side (P = 0.008 and P = 0.01, respectively). Smoking status positively affected CC FD% change (coefficient of variation [CV] = 0.84, P = 0.01) on the surgical side and negatively affected CC thickness change on both the surgical side (CV = -0.382, P = 0.009) and the nonsurgical side (CV = -0.321, P = 0.04). The degree of stenosis demonstrated a positive influence on CC FD% change (CV = 0.040, P = 0.02) on the surgical side. Conclusions: Unilateral CEA on the side of clinically significant CAS increases carotid blood flow, which further results in improved CC perfusion.

Stacked implantation of two prosthetic iris devices for patients with iris defects: A modified surgical technique.

Purpose: Iris pigment deficiency in patients with oculocutaneous albinism (OCA) often causes debilitating photophobia, which is routinely managed by sequential intracapsular insertion of two aniridia rings. A common concern of this technique is the risk of segment interdigitation, which can lead to intraoperative complications. Observations: In this report, we describe a modified technique through which both rings were stacked together and inserted simultaneously in a 62-year-old male patient with oculocutaneous albinism and a mild cataract. The patient underwent bilateral phacoemulsification followed by implantation of two Morcher 50E aniridia rings simultaneously, prior to IOL implantation behind the implants within the capsular bag. Post-operatively, the patient's photophobia improved dramatically, and there were no post-operative complications. Conclusions and Importance: Simultaneous insertion of two stacked aniridia rings prior to IOL implantation was a safe and successful alternative surgical method for the management of photophobia in patients with oculocutaneous albinism and cataracts.

The Expanding Utility of Robotic-Assisted Flap Harvest in Autologous Breast Reconstruction: A Systematic Review.

The expansion of robotic surgery has led to developments in robotic-assisted breast reconstruction techniques. Specifically, robotic flap harvest is being evaluated to help maximize operative reliability and reduce donor site morbidity without compromising flap success. Many publications are feasibility studies or technical descriptions; few cohort analyses exist. This systematic review aims to characterize trends in robotic autologous breast reconstruction and provide a summative analysis of their results. A systematic review was conducted using PubMed, Medline, Scopus, and Web of Science to evaluate robot use in breast reconstruction. Studies dated from 2006 to 2022 were identified and analyzed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Full-text, peer-reviewed, English-language, and human subject studies were included. Non-breast reconstruction articles, commentary, expert opinion, editor's letter, and duplicate studies were excluded. A total of 17 full-text articles were analyzed. The two robotic breast procedures identified were the deep inferior epigastric perforator (DIEP) and the latissimus dorsi (LD) flap. Results showed comparable complication rates and increased operative times compared to NSQIP data on their corresponding open techniques. Additional findings reported in studies included patient reported outcomes, incision lengths, and downward trends in operative time with consecutive procedures. The available data in the literature confirms that robotic surgery is a promising alternative to traditional open methods of breast reconstruction following mastectomy.

Symmetry of Macular Fundus Features in Age-Related Macular Degeneration.

PURPOSE: The symmetry of major macular fundus features in both eyes of the same patient with age-related macular degeneration (AMD) was investigated using swept-source(SS)-OCT. DESIGN: Retrospective review of a prospective study. PARTICIPANTS: Patients with AMD. METHODS: Grading was performed on the first SS-OCT images obtained on the patients. Two graders diagnosed the presence of drusen, geographic atrophy (GA), and exudative AMD (eAMD) in each eye. Medical records were reviewed to assess prior exudation. To assess symmetry, 1 eye of each patient was randomly selected as the index eye and compared with the fellow eye. The kappa statistic (κ) was used to assess the symmetry of diagnosis. The intraclass correlation coefficient (ICC) was used to assess the symmetry of drusen area and volume. MAIN OUTCOME MEASURES: Interocular symmetry of the AMD stages: drusen, GA, and eAMD. RESULTS: A total of 1310 patients with AMD were included. The average age was 78 years (range, 50-102; 60% women). Of the 1310 subjects, 54% (701) presented with symmetric disease: 20% with bilateral drusen, 11% with bilateral GA, and 22% with bilateral eAMD. Only 0.5% of the subjects had both GA and eAMD in both eyes. Of the randomly selected index eyes, 825 (47%) were right eyes. Overall, limited interocular agreement was observed between the index and fellow eyes (54%; κ = 0.29). Kappa coefficients were poor (< 0.4) for index eyes diagnosed with drusen (κ = 0.27), eAMD (κ = 0.17), and mixed disease (κ = 0.03). There was moderate agreement between the index and fellow eyes for GA (κ = 0.50). Of the 265 patients with bilateral drusen, the symmetry of drusen area measurements had moderate ICC values of 0.70, 0.71, and 0.70 in the 3- and 5-mm diameter foveal-centered circles and in the total scan area, respectively. The ICC values for the drusen volumes were 0.65, 0.66, and 0.64, respectively. CONCLUSIONS: Interocular symmetry was poor for eyes with drusen, eAMD, and mixed disease, but moderate for GA. Although the diagnosis of drusen was not very symmetric between eyes, when present in both eyes, the drusen area and volume measurements were moderately symmetric. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

An Elderly Man with Atypical Multiple Evanescent White Dot Syndrome.

A rare occurrence of an atypical case of multiple evanescent white dot syndrome (MEWDS) in a 75-year-old man without viral prodrome or white dots on fundus that presented with acute, severe left eye visual loss, which returned to baseline without treatment in several weeks. Multimodal imaging, including fluorescein angiography (FA), fundus autofluorescence (FAF), indocyanine green angiography (ICG), and optical coherence tomography (OCT) demonstrated classical presentation of MEWDS with wreath-like lesions and inflammatory foci in the retinal pigment epithelium that correlated among modalities. Possible underlying systemic disorders were ruled out through extended work up. To the best of our knowledge, this is the first report to show atypical MEWDS in an elderly man with classic changes on FA, FAF, ICG, and OCT.

Regression of Bilateral Peripapillary Choroidal Neovascularization Associated with Idiopathic Intracranial Hypertension after Systemic Acetazolamide Treatment.

A rare occurrence of bilateral peripapillary choroidal neovascularization (CNV) in an 18-year-old idiopathic intracranial hypertension (IIH) patient regressed with systemic acetazolamide treatment alone. Multimodal imaging was done, including OCT angiography (OCTA), which showed CNV. No injections were given even though she had macular fluid in her left eye. Nonetheless, the subretinal fluid resolved, and visual acuity improved. This report shows that CNV secondary to IIH can be managed with systemic therapy alone. Moreover, we showed for the first time the ability to diagnose IIH-associated CNV using OCTA.

ASSOCIATION OF CHOROIDAL THICKNESS WITH RHEGMATOGENOUS RETINAL DETACHMENT REPAIR.

PURPOSE: To compare the choroidal thickness before and after pars plana vitrectomy for rhegmatogenous retinal detachment repair. METHODS: A retrospective case series of rhegmatogenous retinal detachment patients presenting between January 2015 and September 2020. Subfoveal choroidal thickness (SFCT) and anatomical success were measured in operated eyes and fellow eyes at presentation, as well as 3 months and 6 months after pars plana vitrectomy for rhegmatogenous retinal detachment repair. RESULTS: A total of 93 patients (males 59%) with a mean age of 61.8 ± 15.2 years were included. Eighty-one patients were anatomically successful (Group 1) and 12 redetached (Group 2). The mean SFCT of the operated eye at presentation was 258.3 ± 82.0 µm in comparison with 257.5 ± 83.7 µm in the fellow eye (P = 0.96). Group 2 presented with thicker SFCT than Group 1 at baseline (309.2 ± 56.2 vs. 250.7 ± 82.8 µm; P = 0.01). Both groups demonstrated thinning trend throughout follow-up. At 6-month follow-up, the mean SFCT was 225.6 ± 75.5 µm (P = 0.05). Fellow-eye SFCT was stable throughout follow-up (257 ± 83.7 at baseline vs. 255 ± 80.2 µm at 6 months). CONCLUSION: Eyes with rhegmatogenous retinal detachment demonstrated thinning in the SFCT after vitrectomy surgery. Eyes with recurrent retinal detachment presented with a thicker choroid at baseline. Thicker SFCT at presentation may play a role in retinal redetachment.

Post-SSRI Sexual Dysfunction (PSSD): Biological Plausibility, Symptoms, Diagnosis, and Presumed Risk Factors.

INTRODUCTION: Post-SSRI sexual-dysfunction (PSSD) is an iatrogenic syndrome, the underlying neurobiological mechanisms of which are unclear. Symptom onset follows cessation of serotonergic antidepressants i.e. Selective Serotonin and Norepinephrine Reuptake Inhibitors (SSRI's, SNRI's), and Tricyclic antidepressants (TCA's). PSSD symptoms include genital anesthesia, erectile dysfunction and orgasmic/ejaculatory anhedonia, and should be differentiated from depression-related sexual-dysfunction. Recently, accumulated data of numerous case-reports suggest additional non-sexual symptoms including, anhedonia, apathy, and blunted affect. PSSD gained official recognition after the European medical agency concluded that PSSD is a medical condition that persists after discontinuation of SSRI's and SNRI's. OBJECTIVE: To review possible underlying neurobiological mechanisms of this syndrome, update information on the pathophysiology, present a list of potential risk-factors and discuss potential management options for PSSD. METHODS: Extensive literature review on the main symptom-patterns of this disorder was undertaken using PubMed. It includes introductory explications of relevant neurobiology with the objective of generating hypothesis. RESULTS: Precipitating factors for PSSD include previous exposure to certain drugs, genetic predisposition, psychological stress or chemical stressful reaction to antidepressants along pre-existing medical conditions affecting neuroplasticity. Different theories have been proposed to explain the pathophysiology of PSSD: epigenetic gene expression, dopamine-serotonin interactions, serotonin neurotoxicity and hormonal changes. The diagnosis of PSSD is achieved by excluding all other etiologies of sexual-dysfunction. Treatment is challenging, and many strategies have been suggested without definitive outcomes. We offer the contours of a future neurobiological research agenda, and propose several underlying mechanisms for the various symptoms of PSSD which could be the foundation for a future treatment algorithm. CONCLUSION: There is a need for well-designed neurobiological research in this domain, as well as in the prevalence, pathophysiology, and treatment of PSSD. Practitioners should be alert to the distinctive features of PSSD. Misdiagnosing this syndrome might lead to harmful treatments including reinstatement of medications which generated PSSD. Sexual Medicine Reviews. Peleg LC, Rabinovitch D, Lavie Y, et al. Post-SSRI Sexual Dysfunction (PSSD): Biological Plausibility, Symptoms, Diagnosis, and Presumed Risk Factors. Sex Med Rev 2022;10:91-98.