DEXAMETHASONE IMPLANT FOR DIABETIC MACULAR EDEMA IN NAIVE COMPARED WITH REFRACTORY EYES: The International Retina Group Real-Life 24-Month Multicenter Study. The IRGREL-DEX Study.

PURPOSE: To investigate efficacy and safety of repeated dexamethasone (DEX) implants over 24 months, in diabetic macular edema (DME) eyes that were treatment naive compared with eyes refractory to anti-vascular endothelial growth factor treatment, in a real-life environment. METHODS: This multicenter international retrospective study assessed best-corrected visual acuity and central subfield thickness (CST) of naive and refractory eyes to anti-vascular endothelial growth factor injections treated with dexamethasone implants. Safety data (intraocular pressure rise and cataract surgery) were recorded. RESULTS: A total of 130 eyes from 125 patients were included. Baseline best-corrected visual acuity and CST were similar for naive (n = 71) and refractory eyes (n = 59). Both groups improved significantly in vision after 24 months (P < 0.001). However, naive eyes gained statistically significantly more vision than refractory eyes (+11.3 ± 10.0 vs. 7.3 ± 2.7 letters, P = 0.01) and were more likely to gain ≥10 letters (OR 3.31, 95% CI 1.19-9.24, P = 0.02). At 6, 12, and 24 months, CST was significantly decreased compared with baseline in both naive and refractory eyes; however, CST was higher in refractory eyes than in naive eyes (CST 279 ± 61 vs. 313 ± 125 µm, P = 0.10). CONCLUSION: Over a follow-up of 24 months, vision improved in diabetic macular edema eyes after treatment with dexamethasone implants, both in eyes that were treatment naive and eyes refractory to anti-vascular endothelial growth factor treatment; however, improvement was greater in naive eyes.

Retinal pigment epithelial cell loss assessed by fundus autofluorescence imaging in neovascular age-related macular degeneration.

PURPOSE: To characterize retinal pigment epithelial (RPE) cell loss as evidenced by autofluorescence imaging in patients with neovascular age-related macular degeneration (AMD). DESIGN: Retrospective cohort study. PARTICIPANTS: There were 162 eyes of 116 consecutive patients with neovascular AMD examined in a retinal practice. METHODS: Each patient underwent a complete examination including autofluorescence imaging. Areas of confluent absence of autofluorescence signal of at least 0.5 mm in greatest linear diameter were measured within the macular area. Patient demographic and examination data were evaluated in relation to the autofluorescence data. MAIN OUTCOME MEASURES: Prevalence and progression of confluent areas of absent autofluorescence and the relationship these areas had with visual acuity. RESULTS: The mean age of the patients was 82.9 years, and the mean visual acuity was 20/71 (logarithm minimum angle of resolution [logMAR], 0.55). Confluent loss of autofluorescence was seen in 58.6% of eyes at baseline, and the median area of absent autofluorescence among those was 1.57 mm(2) (interquartile range [IQR], 0.62-4.32 mm(2)). Using generalized estimation equation modeling, the significant predictors for area of confluent absent autofluorescence at baseline were duration of disease and any previous treatment with photodynamic therapy. The significant predictor of baseline visual acuity was baseline area of confluent absent autofluorescence. Follow-up was available for 124 (76.5%) eyes, with a mean follow-up of 2.9 years. By then, the mean visual acuity was 20/90 (logMAR, 0.65), and 79% of eyes had confluent areas of absent autofluorescence, the large majority of which affected the central macula. The median area of absent autofluorescence was 3.61 mm(2) (IQR, 1.16-7.11 mm(2)). The best predictor of final visual acuity was the area of absent autofluorescence at the final follow-up. CONCLUSIONS: Confluent absence of autofluorescence, a measure signifying RPE loss, was a significant predictor of visual acuity both at baseline and at final follow-up. This is the first study to document the prevalence, rate of progression, and factors associated with measures of confluent RPE loss in patients with neovascular AMD. Application of strategies to limit RPE cell loss may prove useful in eyes with neovascular AMD.

Visual and anatomical outcomes of intravitreal aflibercept in eyes with persistent subfoveal fluid despite previous treatments with ranibizumab in patients with neovascular age-related macular degeneration.

PURPOSE: To assess the efficacy of intravitreal aflibercept (2.0 mg) in patients with treatment-resistant neovascular age-related macular degeneration. METHODS: Retrospective analysis of eyes treated with aflibercept with persistent subretinal and/or intraretinal fluid despite previous treatments with intravitreal ranibizumab (0.5 mg). All patients were switched to intravitreal aflibercept (2.0 mg) and analyzed after 3 consecutive injections and after 6 months of treatment. Main outcome measures included change in visual acuity, central foveal thickness, and the height and diameter of the pigment epithelial detachment on the subfoveal scan on optical coherence tomography. RESULTS: Thirty-four eyes of 33 patients were analyzed. Mean duration of symptoms and average number of previous injections with anti-vascular endothelial growth factor agents was 44.7 ± 29.8 months (interquartile range [IQR] 24-76 months) and 28.6 ± 20.1 (IQR 10-47), respectively. At the 6-month follow-up, mean visual acuity and central foveal thickness improved significantly from 20/75 (logarithm of minimum angle of resolution 0.57 ± 0.36; IQR 0.30-1.0) and 416 ± 217 µm (IQR 263-487 µm) at baseline to 20/60 (logarithm of minimum angle of resolution 0.47 ± 0.32; IQR 0.30-0.60) (P = 0.004) and 248 ± 171 µm (IQR 235-419 µm) (P < 0.001), respectively. Maximum pigment epithelial detachment height improved significantly from 260 ± 162 µm (IQR 129-368 µm) to 214 ± 142 µm (IQR 111-305 µm) (P < 0.001) and PED diameter decreased significantly from 3,265 ± 1,622 µm (IQR 2,353-4,555 µm) to 2,949 ± 1,653 µm (IQR 1,721-4,484 µm) (P = 0.04). CONCLUSION: Intravitreal injections of aflibercept resulted in a significant improvement in visual and anatomical outcomes in eyes with persistent subfoveal fluid despite previous treatment with ranibizumab.

Ketamine-associated corneal edema.

PURPOSE: To report a case of ketamine-associated corneal edema. METHODS: Case report. RESULTS: A 61-year-old man prescribed oral ketamine for refractory depression developed bilateral corneal edema. This immediately resolved off ketamine and recurred with rechallenge. Rapid corneal endothelial cell loss occurred during this period. CONCLUSIONS: Ketamine may induce potentially reversible corneal edema with endothelial cell loss. A thorough medication history of this and other drugs should be sought in patients with an otherwise unexplained corneal endothelial failure.