Pro Re Nata brolucizumab for early onset and treatment-naïve diabetic macular edema: A prospective study.

OBJECTIVES: To determine the efficacy and safety of brolucizumab therapy administered on a pro re nata (PRN) basis without loading dose in treatment naïve patients with diabetic macular edema (DME) for 1 year follow-up. METHODS: Patients with recent DME (<6 months) received a mandatory brolucizumab injection at inclusion and other injections could be given on a PRN basis with an 8-week interval (between injections) at minimum. Rescue therapy with other anti-VEGF was possible in case of incomplete DME resolution after the second brolucizumab with a minimum of 1-month treatment free interval between 2 injections. The primary outcome measure was the change in (BCVA) at 12 months. Secondary outcome measures included the change in central subfield thickness (CST), the change in hard exudate surface area and microaneurysms at 1 year. RESULTS: A total of 53 patients were included. At 12 months, the mean (SD) number of injections was 2.6 (0.8) in addition to the first mandatory injection. The mean (SD) interval between 2 consecutive injections was 3.2 (1.4) months. The mean (SD) BCVA improved from 0.62 (0.1) logMAR to 0.40 (0.16) logMAR (p = 0.012). The mean CST reduced from 397.0 (47.2) µm to 224.5 (28.1) µm (p = 0.013). The hard exudate surface area decreased significantly (p = 0.012) as did microaneurysms (p = 0.02). Seven patients required at least 1 rescue therapy. No patients experienced intra-ocular inflammatory adverse events. CONCLUSION: Brolucizumab therapy for DME is a safe and effective modality for the treatment of recent DME and has the potential to reduce the number of injections.

Real-World Outcomes of the 0.19 mg Fluocinolone Acetonide Intravitreal Implant for Diabetic Macular Edema.

Purpose: To evaluate the real-world clinical and safety outcomes of a 0.19 mg fluocinolone acetonide intravitreal implant to treat diabetic macular edema (DME). Methods: This retrospective analysis comprised patients treated with a single fluocinolone acetonide intravitreal implant for the clinical indication of ME secondary to diabetic retinopathy. Primary outcomes included changes in best-corrected visual acuity (BCVA), central subfield thickness (CST), and the frequency of DME-related treatments 12 months before and up to 36 months after fluocinolone acetonide administration. Safety outcomes were also assessed. Results: One hundred forty-eight eyes (115 patients) were followed for a mean (±SD) of 12.3 ± 4.2 months before and 29.4 ± 14.5 months after fluocinolone acetonide administration. A 0.8-letter decrease (Early Treatment Diabetic Retinopathy Study) in the mean BCVA was observed at month 24. The BCVA was 70 letters (20/40 Snellen equivalent) or more in 20.6% of eyes at baseline and in 23.7% of eyes 24 months after implant administration. The mean CST was 379.9 µm and 323.7 µm, respectively. The CST was 300 µm or less in 58.7% of eyes at month 24 (P < .001). The mean frequency of intravitreal antivascular endothelial growth factor injections or laser photocoagulation decreased from 4.9 to 1.5 per year after fluocinolone acetonide administration (P < .001). Implant migration to the anterior chamber occurred in 3 eyes, 2 of which were vitrectomized and later required removal. Conclusions: The 0.19 mg fluocinolone acetonide intravitreal implant provided long-term stabilization of VA and macular anatomy in patients with DME, despite a significant reduction in treatment frequency.

Systemic Oxidative Stress Level as a Pathological and Prognostic Factor in Myopic Choroidal Neovascularization.

Purpose: To investigate the association of systemic oxidative stress level with myopic choroidal neovascularization (mCNV) and its clinical outcomes. Design: Retrospective case-control study. Participants: This retrospective study included 52 eyes of 52 healthy participants (mean age: 62.5 years), 30 eyes of 30 patients (mean age: 59.6 years) with high myopia (HM) but without mCNV, and 23 eyes of 23 patients (mean age: 61.8 years) with HM and mCNV who received intravitreal anti-VEGF antibody injections (IVIs) using a pro re nata regimen during the 6-month follow-up after the first IVI. Methods: Clinical findings, including oxidative stress parameters, such as diacron reactive oxygen metabolites (dROMs), biological antioxidant potential (BAP), and the BAP/dROM ratio (B/d ratio), were analyzed. Main Outcome Measures: Clinical features and oxidative stress parameters. Results: Both BAP and the B/d ratio were significantly lower in the HM/mCNV group than in the HM/no mCNV group (P = 0.002 and P = 0.012, respectively) and than in the control group (P = 0.001 and P = 0.026, respectively). In a multiple logistic regression analysis, axial length (odds ratio 1.878, P = 0.042) and the B/d ratio (odds ratio 0.470, P = 0.026) were significantly associated with mCNV. Dividing the patients into high and low B/d ratio groups (with a cutoff of 5.2) showed that subfoveal choroidal thickness (SFCT) was lower (P = 0.002) and the number of IVI treatments was higher (P = 0.029) in the low B/d ratio group than in the high B/d ratio group. In multiple regression analyses, only the B/d ratio was significantly associated with SFCT (ß = 0.684, P = 0.006). Conclusions: The oxidative stress level in eyes with HM differed according to mCNV, SFCT, and the number of IVI treatments. Measuring oxidative stress parameters might be useful in eyes with HM both for assessing the risk of developing mCNV and determining disease activity. Financial Disclosures: Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Calculated Drug Concentrations in Currently Available Intravitreal Therapies: Determination of Dilution Factor and Deviation From Recommended Doses.

In ophthalmology, intravitreal therapies are currently not personalized/customized and are not adjusted to the individual vitreous volume. With reference to the recently published calculation formula for a more accurate estimation of the vitreous body, we determined the dose of intravitreal medication for different vitreous volumes and compared them with the average volume. Using the axial length of the eye, the formula for the vitreous volume exact (VIVEX) can provide a more accurate indication of the vitreous volume in individual cases than an assumed standard volume of 4 mL. The concentration of active substances in small eyes may be twice as high as that in normal-sized emmetropic eyes. In contrast, large eyes may show less than half of the recommended drug concentration. The calculated concentrations of the investigated intravitreal drugs in small and large eyeballs showed impressive differences with large deviations from the recommended doses. Further systematic studies should follow to find out whether this has any impact on the effectiveness or side effects of the injected drugs.

Use of intravitreal antiviral injection during vitrectomy in the treatment of acute retinal necrosis: anatomic and visual outcomes.

PURPOSE: To investigate whether intravitreal antiviral injection (IAI) during vitrectomy reduces the postsurgical retinal detachment (RD) rate and improves the visual prognosis of patients with acute retinal necrosis (ARN). METHODS: This retrospective cohort study included ARN patients treated at a tertiary hospital between January 2013 and December 2020. Patients who underwent pars plana vitrectomy (PPV) alone or combined with intraoperative IAI were classified in PPV-only group and PPV + IAI group, respectively. The incidence of postsurgical RD and the best corrected visual acuity (BCVA) between the groups was compared. A multivariate Cox hazard analysis was employed to explore the risk factors of postsurgical RD. A multivariate logistic regression analysis was applied to assess the impact of intraoperative IAI on preventing severe vision loss (SVL). RESULTS: Fifty-seven eyes with ARN with a median follow-up of 18.5 months were included in the study. There was no significant association between intraoperative IAI during vitrectomy and a reduced risk of postsurgical RD (hazard ratio [HR], 2.65; 95% CI, 0.71-9.89) or SVL at the 6-month follow-up visit (odds ratio [OR], 0.92; 95% confidence interval [CI], 0.25-3.35). Better baseline best-corrected visual acuity (BCVA) was identified to associate with a higher risk of postsurgical RD (HR, 0.33; 95% CI, 0.14-0.81) and a lower risk of SVL at 6 months (OR, 2.28; 95% CI, 1.10-4.89). CONCLUSION: We did not observe a significant effect of intraoperative IAI on the anatomic and visual outcomes of ARN patients in this study. Intraoperative IAI may not be a necessary treatment option for ARN patients who receive vitrectomy.

Recurrence Rate during 5-Year Period after Suspension of Anti-Vascular Endothelial Growth Factor Treatment for Neovascular Age-Related Macular Degeneration.

Purpose: To determine the recurrence rate of neovascular age-related macular degeneration (nAMD) during a 5-year period after the suspension of anti-vascular endothelial growth factor (anti-VEGF) treatments. Methods: Thirty-four eyes of 34 nAMD patients who met the inclusion criteria and were treated by anti-VEGF drugs were studied. All met the treatment suspension criteria and were followed for 5 years after the suspension of the anti-VEGF treatment. Patients with a recurrence within one year were placed in Group A, and patients with a recurrence between 1 and 5 years were placed in Group B. The rate and time of a recurrence were analyzed using the Kaplan-Meier method. We also examined whether there were differences in the baseline factors of age, sex, subtype, treatment period, and treatment interval between Groups A and B. Results: Twenty-five of 34 eyes (73.5%) had a recurrence within 5 years of stopping the anti-VEGF treatments. Thirteen (52.0%) of the 25 eyes had a recurrence within 1 year, 4 (16.0%) eyes between 1 and 2 years, 4 (16.0%) eyes between 2 and 3 years, 2 (8%) between 3 and 4 years, and 2 eyes (8%) between 4 and 5 years. The baseline factors were not significantly different between Groups A and B. Conclusions: The results showed that the recurrence rate was highest within one year after the suspension of the anti-VEGF treatments, with a number of recurrences one year after the suspension. Clinicians should remember that nAMD may recur several years after the suspension of anti-VEGF treatments.

Impact of the Nationwide Avastin Ban at a Tertiary Eye Care Hospital in Pakistan.

OBJECTIVE:  To report the impact of a 10-week-long nationwide ban on intra-vitreal bevacizumab (IVB) injection (Avastin®) at a tertiary care hospital in Pakistan. METHODS: This was a single-center, retrospective, cohort study. Patients scheduled for IVB injections from October 25, 2023 to October 29, 2023 who arrived in OPD between November 28, 2023 and December 15, 2023 for their assessment were included in this study. RESULTS: Among the identified 412 patients, only 103 met the inclusion criteria. The mean age was 59.35 ± 9.5 (mean ± SD). About 60.2% were male (n = 62). Diabetic macular edema (DME) was the most common indication (n = 71, 68.9%). The mean total duration of treatment delay was 81.67 ± 17.15 days. While the delay due to the Avastin® ban was 67.47 ± 4.8 days. Eyes that had not received any prior injections were 46 (44.7%) while others had received at least 1 (n = 43, 41.7%) or 2 injections (n = 14, 13.6%) before. Mean central macular thickness (CMT) before and after treatment delay was 362.7 ± 113.4 µm and 398.38 ± 124 µm (p < 0.05), respectively. Among 20 patients with vitreous hemorrhage (VH), 14 patients showed marked improvement (70%), 5 showed no change in severity (20%) and 1 (5%) had further worsening. CMT difference was strongly correlated with the total duration of treatment delay (p < 0.01) and with the number of injections (p < 0.01). CONCLUSION: The nationwide ban on Avastin® heightened the severity of disease in the patients highlighting the delicate balance between safety precautions and timely access to essential medical interventions.

Multimodal imaging to distinguish microvascular and morphological changes in retinal vein occlusion after intravitreal ranibizumab with or without triamcinolone acetonide injection.

BACKGROUND: The study was designed to investigate microvascular and morphological changes in retinal vein occlusion (RVO) using multimodal imaging after intravitreal ranibizumab (IVR) with or without triamcinolone acetonide (IVTA) injections. METHODS: This was a retrospective and observational study. Fifty patients (52 eyes) diagnosed with RVO were enrolled. Best corrected visual acuity (BCVA), ophthalmoscopy, fundus fluorescein angiography (FFA), spectral domain optical coherence tomography (SDOCT), and optical coherence tomography angiography (OCTA) were employed sequentially both before treatment and at the last visit after treatment. RESULTS: The mean logMAR VAs in BRVO eyes decreased significantly after treatment (P = 0.029). OCTA showed there was a significant difference in foveal avascular zone (FAZ) in BRVO eyes (P = 0.024), superificial foveal vessel density in both CRVO (P = 0.0004) and BRVO eyes (P = 0.02155). OCT showed the foveal thickness had significant differences after treatment in both CRVO (P < 0.0001) and BRVO eyes (P = 0.0001). BCVA was associated most commonly with ellipsoid zone integrity (P = 0.022). The BCVA in eyes treated with IVR and IVTA was significantly decreased compared with IVR only in BRVO group (P = 0.021). However, the combination of IVR + IVTA significantly improved intraocular pressure (IOP) compared with IVR only in BRVO group (P = 0.037). CONCLUSION: Both IVR and IVR + IVTA can significantly improve the central vision, macular structure, and functions in BRVO group. Simultaneous IVR with IVTA can significantly increase BCVA compared with IVR only in BRVO group.

Long-Term Stability, Sterility, And Cost-Effectiveness of 0.05% Chlorhexidine Gluconate as Antisepsis for Intravitreal Injection.

Purpose: Commercially available chlorhexidine gluconate (CHG) has a beyond-use date of 24 h. This study evaluated the stability and sterility of 0.05% CHG for 30 days after opening and compared its cost to povidone iodine (PI) for intravitreal injection antisepsis. Methods: 0.05% CHG was aliquoted into 1-mL syringes and stored at room temperature or refrigerated. Turbidity, pH, high-performance liquid chromatography (HPLC), and sterility testing were performed. A cost analysis was conducted. Results: 0.05% CHG remained stable for at least 30 days. All samples had measured turbidity <0.5 nephelometric turbidity units. The pH of all samples remained between 5.0 and 7.0. HPLC demonstrated CHG concentration at day 30 relative to day 0 of 98.52% ± 4.16% at room temperature and 99.99% ± 3.38% at 2°C -6°C. The cost per week to perform 150 injections using 0.05% CHG was $463.25 when opening a new bottle daily compared with $16.73 for 5% PI. This cost decreased to $23.16 when utilizing a bottle of CHG for 30 days. Conclusion: 0.05% CHG remains stable and sterile for at least 30 days after opening. The ability to use CHG for at least 30 days after its opening significantly decreases its utilization expense.

Case report: heart failure related to intravitreal injection of anti-VEGF.

BACKGROUND: Intravitreal injection of anti-vascular endothelial growth factor is considered the first-line treatment for polypoidal choroidal vasculopathy. It has potential risks for circulatory system, which should be particularly carefully evaluated in older patients. In this case study, we aim to discuss the potential impact of this treatment regimen on cardiac health. CASE PRESENTATION: This case report describes an elderly patient with no prior history of heart disease who exhibited unexpected heart enlargement and dysfunction. Throughout the patient's hospital stay, various potential causes were investigated, leading to the hypothesis that a 10-year history of intravitreal injections of anti-vascular endothelial growth factor could be related to the observed clinical manifestations. The patient was advised to discontinue this treatment, and after a 2-month follow-up period, there was a gradual improvement in the patient's cardiac structure and function. CONCLUSION: This manuscript highlights the importance of conducting cardiac examinations before and after anti-vascular endothelial growth factor treatment, especially for individuals at risk of heart diseases like the elderly. It emphasizes the need to carefully weigh the benefits and risks of treatment regimens to ensure optimal therapeutic outcomes.

Two-year outcomes of intravitreal aflibercept injection for neovascular age-related macular degeneration with 'observe before treat-and-extend' method.

Purpose: To evaluate two-year outcomes of intravitreal aflibercept injection for neovascular age-related macular degeneration (nAMD) treated with 'observe before treat-and-extend' (O-TAE) strategy in the real-world setting. Methods: This retrospective study included treatment-naïve nAMD patients treated with aflibercept using O-TAE regimen and followed up for more than 2 years. Patients were observed bimonthly to check recurrence after 3 monthly loading injections. In case of recurrence, treatment was resumed using the treat-and-extend (TAE) regimen starting from the 4th injection. In case of non-recurrence, observation was continued. Best-corrected visual acuity (BCVA), central macular thickness (CMT), number of injections, TAE intervals, and proportion of recurrence after dry-up following 3 loadings were analyzed. Results: 38 eyes of 34 patients were included. Follow-up period was 37.0 ± 11.0 months. BCVA by logMAR improved from 0.33 ± 0.29 at baseline to 0.24 ± 0.23 in the 1st year (p = 0.01), and 0.25 ± 0.22 in the 2nd year (p = 0.054). CMT decreased significantly from 357.4 ± 74.5 at baseline to 269.6 ± 48.1 in the 1st year (p < 0.001), and 279.1 ± 54.6 in the 2nd year (p < 0.001). Numbers of injections were 5.1 ± 1.7 in the first year and 3.8 ± 2.4 in the second year. The percentage of eyes with a TAE interval of ≥12 weeks was 37.0% in the first year and 34.4% in the second year. Of the 36 eyes that dried up after 3 loadings, 28 eyes (78%) recurred, and the average period of recurrence was 6.5 months. The remaining 8 eyes (22%) had no recurrence during the mean follow-up period of 29.7 months. Conclusion: This study showed that the newly suggested O-TAE strategy can reduce the treatment burden significantly reducing the number of injections while improving BCVA and CMT in the first and second year.

Bevacizumab and External Beam Radiation Therapy for Diffuse Choroidal Hemangioma in Sturge-Weber Syndrome: A Case Report.

Introduction: Sturge-Weber syndrome, a congenital vascular disorder, is associated with diffuse choroidal hemangiomas in which the current mainstay of treatment is radiation therapy, including external beam radiation therapy (EBRT). The purpose of this case report was to present a novel combination of treatments for diffuse choroidal hemangioma. Case Presentation: A 37-year-old man with a history of Sturge-Weber-associated glaucoma presented with an acute-onset decrease in vision in the right eye. Best-corrected visual acuity (BCVA) at the presentation was 20/400 in the right eye. Examination revealed a total macula-off, bullous, folded exudative retinal detachment and findings consistent with diffuse choroidal hemangioma. The patient was treated with a single injection of intravitreal anti-vascular endothelial growth factor (anti-VEGF) agent bevacizumab and 10 fractions of EBRT of the right eye. Follow-up examination at 17 months demonstrated complete resolution of subretinal fluid and no evidence of choroidal elevation on B-scan. Final BCVA in the right eye was 20/1,000. Conclusion: This case uses simultaneous treatment with EBRT and bevacizumab in the treatment of diffuse choroidal hemangioma and associated exudative retinal detachment. Clinicians may use anti-VEGF agents early in the course of the disease in determining whether they may assist in preventing visual decline.

In Vitro Physicochemical and Pharmacokinetic Properties of Bevacizumab Dissolved in Silicone Oils Compared to Hydrogel-Substitutes and Porcine Vitreous Bodies.

Anti-VEGF agents, e.g., bevacizumab, are used in retinal surgery, while their interaction with silicone oils and novel hydrogels remains unclear. This study examines the in vitro pharmacokinetics of bevacizumab in silicone oil-filled eyes compared to various hydrogel replacements and the porcine vitreous body as well as its impact on the interface tension of silicone oils. An in vitro model filled with light or heavy silicone oil, porcine vitreous bodies, or hydrogels (alginate and polyethylene glycol (PEG)-based) was equilibrated with a balanced salt solution. Monitoring of bevacizumab in the aqueous phase was conducted for up to 24 h, and its effect on interfacial tension was studied. Significant differences in bevacizumab partitioning were observed across endotamponades after 24 h. In silicone oils, bevacizumab was found exclusively in the aqueous phase, while in the other endotamponades, it accumulated in the gel phase (96.1% in porcine vitreous body, 83.5% in alginate, and 27.6% in PEG-based hydrogel). Bevacizumab significantly reduced interfacial tension (40 to 8 mN/m), possibly enhancing silicone oil emulsification. The type of endotamponade heavily influenced the bevacizumab concentration in the aqueous. The vitreous body and replacement hydrogels likely serve as a drug reservoir, highlighting the need for in vivo studies to explore these interactions prior to clinical application.

Approved treatments for neovascular age-related macular degeneration: current safety and future directions.

INTRODUCTION: Age-related macular degeneration (AMD) is a progressive retinal degenerative disease that is implicated as one of the leading causes of visual impairment in the elderly population. Vascular endothelial growth factor (VEGF) has been identified as the main driver of AMD, and various therapeutics have revolutionized the treatment and management of neovascular AMD (nAMD) with favorable visual and anatomical outcomes. AREAS COVERED: Physicians have a variety of approved therapeutics in their arsenal for patients with varying disease progression and patient-specific needs, with the ultimate goal of achieving optimal visual and anatomic outcomes. The literature search was conducted using PubMed, Google Scholar, and sources from companies' websites, allowing us to locate findings recently presented at conferences. EXPERT OPINION: Scientific advancements in the field have led to newly approved therapeutics and devices, such as the port-delivery system with ranibizumab (PDS), and further investigation is ongoing in the realm of gene therapy for retinal diseases. In addition to efficacy and durability, newer agents must have comparable safety profiles to older agents in order to be used broadly. These options introduce a level of complexity in nAMD treatment; however, physicians to personalize treatment to improve vision in nAMD patients and reduce treatment burden overall.

Clinical prediction nomogram for steroid-induced ocular hypertension risk in patients with intravitreal dexamethasone implant.

Background: Recognizing the risk factors and understanding the mechanisms underlying steroid-induced ocular hypertension (SIOH) are vital to prevent potent vision loss and ensure the safety and effectiveness of dexamethasone (DEX) injections. The study aimed to develop a novel nomogram for predicting the risk of SIOH and determining safety zones for steroid injections. Methods: This single-center, retrospective, case-control study included a total of 154 eyes with available measured axial length that had undergone AS-OCT and DEX implantation at the Yonsei University Health System. The eyes were categorized into the SIOH (n = 39) and post-steroid normal IOP (n = 115) groups. We measured intraocular pressure (IOP) for all eyes prior to DEX implantation, at 1 week post-implantation, and at 1, 2, 3, 6, and 12 months thereafter. We used AS-OCT to analyze the trabecular meshwork (TM) height and ocular parameters. Results: The predictive nomogram, including TM height, yielded an AUC of 0.807 (95 % confidence interval [CI], 0.737-0.877) and demonstrated significantly higher predictive accuracy than that of previous nomograms, which did not consider TM height and had an AUC of 0.644 (95 % CI, 0.543-0.745) (p = 0.031). The calibration plot demonstrated a strong predictive accuracy for a predicted value of approximately 0.4. We established cutoff values to ensure different levels of sensitivity and specificity within the safety zone following DEX implantation. Conclusion: Our improved nomogram incorporating TM height as a newly identified risk factor, established a safety threshold for intravitreal DEX implantation, helping identify safe individuals from those who require caution.

Endophthalmitis caused by Hathewaya histolytica: A diagnostic dilemma.

A 76-year-old male presented with pain, redness, and decreased vision in the left eye for 5 days. The patient had undergone combined cataract extraction and vitrectomy for a macular hole 2 weeks back. The vision had reduced to the perception of light in the left eye. Clinical examination revealed lid edema, conjunctival congestion, hazy cornea, and exudative membrane in the pupillary axis with no view of the fundus. Ultrasound examination of the left eye showed plenty of moderate reflective dot echoes. The patient was diagnosed with postoperative endophthalmitis and underwent vitrectomy with intravitreal injection of antibiotics. Growth of Hathewaya histolytica was obtained from the vitreous sample. The organism was sensitive to imipenem. Three weeks following the presentation, visual acuity had improved to counting fingers at one meter in the left eye. This is the first report of endophthalmitis due to H. histolytica. Ophthalmologists should be aware of such ocular infections due to a rare microorganism.

Successful Treatment of Hemi-Retinal Vein Occlusion with Macular Edema following Spinal Surgery Using Intravitreal Aflibercept and Retinal Photocoagulation: A Case Report.

Introduction: Perioperative visual loss (POVL) owing to hemi-retinal vein occlusion (HRVO) following prone positioning during spinal surgery is rare. Here, we report a case of HRVO with macular edema (ME) after spinal surgery that was successfully treated with intravitreal aflibercept (IVA) injections and retinal photocoagulation (RP). Case Presentation: A 63-year-old Japanese man underwent spinal surgery for lumbar spinal canal stenosis. Surgery was performed with the patient in the prone position under general anesthesia; the operation time was 305 min. No complications were associated with intraoperative anesthesia. On postoperative day 4, the patient noticed decreased visual acuity in his left eye and visited the Department of Ophthalmology on postoperative day 9. The best-corrected visual acuity (BCVA) in the left eye was 0.1. Fundus and optical coherence tomography revealed HRVO and ME in the left eye. IVA injections and RP were performed in the eye, which substantially decreased the ME and improved the patient's BCVA to 0.8. Conclusions: HRVO can cause POVL after prone positioning during spinal surgery. This is the first case of HRVO with ME after spinal surgery, which was successfully treated with IVA injections and RP.

Unexpected Vision Loss following Six Intravitreal Injections for Neovascular Age-Related Macular Degeneration.

Introduction: We present a case of a patient with preceding vitreomacular traction (VMT) who developed a full-thickness macular hole (FTMH) following his sixth intravitreal aflibercept injection for the treatment of age-related macular degeneration and review the literature on risk factors and pathogenesis of this adverse event. Case Presentation: FTMH can occur after an extended number of repeat intravitreal injections in the setting of worsening vitreomacular adhesion or VMT. This patient's FTMH was successfully treated surgically in a timely manner, and additional injections were resumed safely. Conclusions: Patients with an unexpected decrease in vision after intravitreal injections should be reevaluated with optical coherence tomography to rule out alternative pathology including vitreomacular interface abnormalities. FTMH, if present, should be treated promptly to allow for resumption of therapy as needed and visual optimization.

The application of dexamethasone implants in uveitis treatment.

Uveitis refers to a group of ocular inflammatory diseases that can significantly impair vision. Although systemic corticosteroid therapy has shown substantial efficacy in treating uveitis, extensive use of corticosteroids is associated with significant adverse effects. Recently, a biodegradable, sustained-release implant, namely dexamethasone intravitreal implant (Ozurdex), has been reported for treating non-infectious and infectious uveitis. This review aims to summarize the experiences with Ozurdex treatment across various forms of uveitis and to assist readers in understanding the appropriate timing and potential side effects of Ozurdex in uveitis treatment, thereby maximizing patient benefits in uveitis management.

Unusual clinical features and histopathological findings in a case of Pseudo-endophthalmitis in neovascular glaucoma.

Objective: This case report aimed to describe the unusual clinical presentation and histopathological features of post-injection endophthalmitis. Methods: A 56-year-old male phakic patient with diabetic retinopathy received an intravitreal injection (Bevacizumab as per the patient) for neovascular glaucoma elsewhere and presented to our center one day after the dose with hypopyon. The eye was relatively white without pain or lid oedema. The patient was treated as a case of post-injection endophthalmitis with two doses of intravitreal antibiotics 48 hours apart. During the follow-up, he developed a Covid infection. After one week, when the media cleared, white exudates were seen in the vitreous cavity with a relatively healthy retina. He was taken up for pars plana vitrectomy and vitreous biopsy for histopathological study. Results: The microscopic examination of vitreous aspirate revealed crystalline deposits without any microorganisms. Two control slides, one with a mixture of intravitreal antibiotics, which were previously injected, and the other with fresh Triamcinolone were also examined. Although the findings of the drug mixture did not match the vitreous aspirate, they matched with triamcinolone, which established it as a case of pseudo endophthalmitis due to triamcinolone injected elsewhere. Discussion: Initially, it seemed like a straightforward case of post-injection endophthalmitis, but a further examination of the vitreous aspirate showed that it was pseudoendophthalmitis due to an intravitreal triamcinolone injection. Despite the patient being phakic, neovascularization or elevated intraocular pressure may have led to the disruption of the blood-ocular barrier and the migration of Triamcinolone into the anterior chamber. Conclusion: The case's uniqueness lies in being the first reported case of pseudo endophthalmitis in a phakic patient with an intact lens iris diaphragm. The case also highlighted the judicious use of available resources and out-of-the-box thinking to reach a diagnosis that may not always be obvious. Abbreviations: TA = Triamcinolone acetonide, AC = Anterior chamber, IVB = Intravitreal Bevacizumab, PL = Perception of light.