Comparison of central corneal thickness measured by automatic and manual analysis of optical coherence tomography.

PURPOSE: To compare central corneal thickness (CCT) measured with optical coherence tomography (OCT) using an automatic algorithm (A-OCT) vs. manual measurements (M-OCT) with respect to the gold standard ultrasound pachymetry (USP). METHODS: CCT measurements were performed on both eyes of 28 healthy subjects at four times of the day. A-OCT used an automatic software analysis of the corneal image, M-OCT was performed by two operators by setting a digital calliper on the corneal borders, and USP was performed after corneal anesthesia. Measurements were compared using a three-way repeated measures ANOVA. Bland-Altman plots were used to evaluate the agreement between OCT measurements and USP. RESULTS: Both A-OCT and M-OCT significantly underestimated the USP measures, with the mean difference, i.e., the systematic error, being larger for A-OCT (- 19.0 µm) than for M-OCT (- 6.5 µm). Good reproducibility between the two operators was observed. Bland-Altman plots showed that both OCT methods suffered from proportional errors, which were not affected by time and eye. CONCLUSIONS: Measuring CCT with OCT yielded lower values than USP. Therefore, clinicians should be aware that corneal thickness values may be influenced by the measurement method and that the various devices should not be used interchangeably in following up a given patient. Intriguingly, M-OCT had less systematic error than A-OCT, an important outcome that clinicians should consider when deciding to use an OCT device.

Vessel density, retinal thickness, and choriocapillaris vascular flow in myopic eyes on OCT angiography.

PURPOSE: To investigate foveal avascular zone area, macular vascular density, choroidal thickness, and outer retina and choriocapillaris flow in myopic eyes by OCT angiography. METHODS: Automated macular maps and flow calculations were retrospectively evaluated in 42 myopic and in 40 control eyes. RESULTS: Myopic eyes presented lower whole superficial vessel density (46.4 ± 4.9 vs. 51.6 ± 3.6%, P < 0.0001) and higher flow area in the outer retina (1.3 ± 0.2 vs. 1.1 ± 0.3 mm2, P = 0.0012). Between the myopic and non-myopic eyes, no significant differences could be detected in the choriocapillaris perfusion area (1.9 ± 0.07 vs. 1.9 ± 0.05 mm2, respectively; P = 0.55) and in the foveal avascular zone area (0.23 ± 0.1 vs. 0.26 ± 0.1 mm2, respectively; P = 0.12). The spherical correction positively correlated with superficial vessel density and negatively correlated with outer retina perfusion (P ≤ 0.0021). The superficial vessel density and the local retinal thickness positively correlated at all macular locations (P < 0.005), especially in the foveal region (P < 0.0001). CONCLUSIONS: Eyes with high myopia present reduced superficial vascular density and increased outer retina flow. Superficial vascular density and retinal thickness appear to be significantly correlated.

Intravitreal aflibercept for myopic choroidal neovascularization.

PURPOSE: To assess the use of aflibercept for the treatment of subfoveal myopic choroidal neovascularization (CNV). METHODS: Thirty-two patients (33 eyes) with myopic subfoveal CNV were consecutively enrolled in this prospective open-label case series. All patients were treated with an off-label 2-mg intravitreal injection of aflibercept. After the first injection, administration of aflibercept followed an "on demand" pro re nata (PRN) regimen. The primary outcome was change in best-corrected visual acuity (BCVA) score after 12 months. RESULTS: Mean follow-up was 12 months, and the median number of aflibercept injections was 2.0 (range 1-4). Overall, mean BCVA improved from 0.59 ± 0.37 logMAR at baseline to 0.38 ± 0.33 logMAR at 12 months, a change of -0.21 ± 0.23 logMAR (p < 0.0001), and from 70.5 ± 18.5 to 81.1 ± 16.4 letters, a change of 10.6 ± 11.4 (p < 0.0001). Improvements were similar among patients irrespective of previous PDT. The Increase in BCVA was greater in younger patients (aged < 50 years) and those with baseline BCVA of ≤ 75 letters. CONCLUSION: Intravitreal aflibercept in a PRN regimen is effective for the treatment of myopic CNV, with no apparent short-term safety effects. Treated eyes had BCVA gains after 12 months, with a median of two injections.

Intravitreal ranibizumab for choroidal neovascularization in a patient with angioid streaks and multiple evanescent white dots.

BACKGROUND: To report a patient with angioid streaks (ASs) and coincident multiple evanescent white dot syndrome (MEWDS) who developed choroidal neovascularization (CNV). CASE PRESENTATION: A 20-year-old woman presented with reduced vision (20/100) in her left eye (LE). Based on a complete ophthalmologic examination the patient was diagnosed with ASs and coincident MEWDS. Two weeks later best-corrected visual acuity (BCVA) improved up to 20/25 and the MEWDS findings almost disappeared. Two months later BCVA dropped again (20/100) due to the development of CNV which was treated by a single intravitreal injection of ranibizumab (0.5 mg/0.05 mL). One month after this BCVA improved up to 20/40, and there was regression of the CNV. There was no need for retreatment at the last follow-up visit, 1 year after the ranibizumab injection, when the patient showed further recovery of BCVA up to 20/25. CONCLUSIONS: In this case of ASs, MEWDS completely resolved after 2 weeks, but 2 months later CNV developed. A single intravitreal injection of ranibizumab had a long-lasting effect. Larger series are necessary to clarify the pathogenesis of CNV in such cases and the role of intravitreal ranibizumab.

A randomized trial of intravitreal bevacizumab vs. ranibizumab for myopic CNV.

AIMS: The aim was to compare the efficacy of intravitreal therapy with bevacizumab and ranibizumab for choroidal neovascularization (CNV) in pathologic myopia (PM). METHODS: This was a prospective multicenter randomized nonblinded trial. RESULTS: In seven centers, 78 eyes were randomized 1:1 to treatment with bevacizumab (group B, 40 eyes) or ranibizumab (group R, 38 eyes) given with an "on demand" regimen (PRN). The mean follow-up was 19 months (SD 2, range 12-24). The mean BCVA at baseline was 0.60 logMAR (20/80 Snellen equivalent, Seq) and 50 letter score (ls). Mean final BCVA was 0.51 LogMAR (20/63 Seq) and 57 ls (p = 0.0009 and p = 0.0002, respectively). In group B, mean basal BCVA was 0.52 logMAR (20/63 Seq) and 54 ls, and final BCVA was 0.51 logMar (20/63 Seq) and 57 ls. In group R, mean basal BCVA was 0.62 logMAR (20/80 Seq) and 45 ls, and the final values were 0.50 logMAR (20/63 Seq) and 58 ls. Statistical comparison of the two groups showed no significant difference (logMAR p = 0.90 and letters p = 0.78). Multivariate analysis showed no influence of age or previous photodynamic treatment (PDT) on final visual changes. The mean number of treatments in the first year was 2.7 in group B and 2.3 in group R (p = 0.09). CONCLUSION: Myopic CNV equally benefits from on-demand intravitreal injection of either bevacizumab or ranibizumab; the therapeutic effect is independent of previous PDT and age.

Imaging of naive myopic choroidal neovascularization by spectral-domain optical coherence tomography.

PURPOSE: To assess the tomographic features of myopic choroidal neovascularization by spectral-domain optical coherence tomography. METHODS: We consecutively reviewed the charts of patients with pathologic myopia, recent visual acuity deterioration and active macular neovascularization. Specific tomographic changes were studied in 25 eyes by two authors independently. RESULTS: The mean age of patients eligible for the study was 63.4 (± 18.2) years. Main tomographic outcomes were the hyperreflectivity of the lesion in 88% of cases (95% CI 0.74-1.02), absence of the external limiting membrane in 88% (95% CI 0.84-1.02), and retinal thickening in 83% (95% CI 0.67-0.99). The internal plexiform layer remained discernible in 83% (95% CI 0.67-0.99) of cases, the inner nuclear layer in 62% (95% CI 0.37-0.80), the external plexiform layer in 48% (95% CI 0.27-0.69). Retinal edema was noted in 48% (95% CI 0.26-0.70) of patients. CONCLUSIONS: Myopic choroidal neovascularization appears predominantly hyperreflective, causes thickening of the corresponding retina and mainly involves the external retinal segments. Retinal fluid is infrequent.

Structural and clinical changes in previously treated type 1 macular neovascularization in non-responder AMD eyes switched to brolucizumab.

PURPOSE: To examine structural and clinical changes in previously treated type 1 macular neovascularization (MNV) in non-responder age-related macular degeneration (nAMD) eyes switched to brolucizumab. Subretinal hyper-reflective material (SHRM), intraretinal (IRF) and subretinal fluid (SRF) presence, fibrovascular-pigment epithelium detachment (PED) height and central macular thickness (CMT) variation were analyzed using optical coherence tomography (OCT). METHODS: In this prospective study all patients underwent a complete ophthalmological evaluation including structural OCT at baseline (T0), one month (T1), three (T2), four (T3) and six months after switching to brolucizumab treatment (T4). Non-responder criterion was the persistence of IRF and SRF. Moreover, CMT and BCVA had shown worsening or no improvement before switching to brolucizumab. Clinical function and structural activity biomarkers were measured at each visit and changes were analyzed. P value <0.05 was considered statistically significant. RESULTS: Twenty eyes of twenty patients were enrolled. All the structural variables examined during the follow-up showed significant reductions. Decreases in IRF, SRF and PED were already significant at T1 (p < 0.05). SHRM was significantly reduced at T2 (p < 0.05). Structural biomarkers were absent at T3. At T4, all biomarkers remained stable while SHRM was no longer detectable in 18 patients. Changes in visual acuity from baseline to T4 were not significant. CONCLUSION: This short-term experience highlights that brolucizumab might be considered an effective treatment option in nAMD with type 1 MNV, as it can promote a reduction of structural activity biomarkers.

A rare case of simultaneous occurrence of non-arteritic anterior ischemic optic neuropathy and corpus callosum ischemia.

PURPOSE: To report a case of non-arteritic anterior ischemic optic neuropathy (NAION) in an elderly patient with ischemia of the left splenium of the corpus callosum, providing details of the diagnostic work-up and subsequent follow-up. METHODS SECTION: Case report. RESULTS: A pseudophakic 80 years-old woman referred complaining sudden visual impairment in the left eye (LE) in concomitance with episode of hypertensive crisis. Fundus examination showed diffuse swelling of optic disc associated with flame peripapillary hemorrhages in LE and small crowded disc in right eye (RE). A superior altitudinal defect with arcuate defect including the blind spot were detected at the visual field in the LE. The patient was diagnosed with NAION. Five days later the patient complained a further vision loss and a pathological area within the left splenium of corpus callosum, consistent ischemia, was depicted at magnetic resonance imaging of brain. Corpus callosum infarction was completely asymptomatic and neurological evaluation was normal. At 45 days follow-up fundus examination showed white ischemic nerve while visual field was irreversibly constricted with tubular defect in LE. CONCLUSION: In case of NAION linked with corpus callosum ischemia multimodal imaging and systemic work-up play a pivotal role for an early diagnosis.

Hellp syndrome-related hypertensive chorioretinopathy: A multimodal imaging and optical coherence tomography angiography (OCTA) study.

INTRODUCTION: Pregnancy may be associated to unique retinal disorders and is associated to worsening of retinal disease that also occurs in non-pregnant females. We report a case of chorioretinopathy caused by pre-eclampsia associated to HELLP (Hemolysis-Elevated-Liver enzymes and Low Platelet count) syndrome. METHODS: Multimodal Imaging features of HELLP syndrome-related hypertensive chorioretinopathy including retinography, Spectral Domain-Optical Coherence Tomography (SD-OCT), Fluorescein angiography (FA), Indocyanine-green angiography (ICG) along with OCT-angiography (OCTA) are presented and discussed. RESULTS: Multimodal imaging and OCTA show both retinal and choroidal involvement by HELLP syndrome, resolved after hypertension treatment. CONCLUSIONS: Multimodal imaging is useful to study HELLP syndrome-related hypertensive chorioretinopathy. Moreover, OCTA is a new technology able to study and follow the circulatory status of the choriocapillaris during the disease.

Management of presumed candida endophthalmitis during the COVID-19 pandemic: Case report and review of the literature.

PURPOSE: To report the management of a case of candida endophthalmitis following intubation for SARS-CoV-2 ARDS, during the first lockdown, underlining consequently the limited access to the gold standard of care. METHODS: Case report. RESULTS: We have described the case of a 56-year-old Hispanic man who developed bilateral Candida endophthalmitis after one month of hospitalization in the intensive care unit for severe SARS-CoV-2 pneumonia. Multimodal imaging was obtained. Full serological screening for infection was done resulting negative. A diagnostic vitrectomy was impossible due to the limited access at the surgery room. Diagnosis of presumed candida endophthalmitis was made, according to a highly qualified center, and therapy with intravenous liposomal amphotericin B was administered. At three months, we observed lack of vitreous opacities and atrophic scars with no active lesions. CONCLUSIONS: Diagnosis of candida endophthalmitis was a challenge in this pandemic scenario, given the impossibility of performing a diagnostic vitrectomy. Therefore, it was mainly based on patient's clinical manifestations, multimodal imaging and on unanimity of collegiality between our hospital and the highly specialized center.

PREDICTIVE ROLE OF SWEPT SOURCE OCT ANGIOGRAPHY IN RELAPSING VOGT-KOYANAGI-HARADA DISEASE.

PURPOSE: The purpose of this study was to describe the optical coherence tomography (OCT) angiography findings as a predictive role in the chronic relapsing stage of Vogt-Koyanagi-Harada disease and its comparison with other imaging modalities such as fluorescein angiography, indocyanine-green angiography, and spectral domain OCT. METHODS: A 37-year-old woman from Bangladesh was diagnosed with Vogt-Koyanagi-Harada disease. She was evaluated 8 months before for a routine examination when she was in clinical remission. Full ophthalmic evaluation with multimodal imaging and OCT angiography was performed. RESULTS: Ophthalmic evaluation was unremarkable. Spectral domain OCT disclosed increased choroidal thickness in both eyes while swept source OCT angiography imaging showed choroidal flow voids well-matching hypofluorescent round lesions found by indocyanine-green angiography. A week later the disease reactivated. CONCLUSION: Optical coherence tomography angiography may provide novel insights into inflammatory activity of the choroid and potentially have a predictive role in relapsing Vogt-Koyanagi-Harada disease.

OCTA in macular intraretinal microvascular abnormalities: Retinal vascular density remodeling after panretinal photocoagulation.

PURPOSE: To describe a case of macular intraretinal microvascular abnormality (IRMA) detected with Optical Coherence Tomography Angiography (OCTA) and to show its remodeling and vascular density changes after panretinal photocoagulation (PRP) during an 18-month follow-up. METHODS: Case report. RESULTS: A 22-year-old female patient with proliferative diabetic retinopathy was found to have a small hyperreflective formation with posterior shadow cone and signal flow, located at the temporal margin of the fovea avascular zone (FAZ), identified as macular IRMA with OCTA. Her best-corrected-visual acuity was 20/20. Four months later the macular IRMA was larger and, in its context, there was also an increase in the flow area in B-scan. The patient underwent PRP and after 18 months we observed a regression of macular IRMA and an increase in the superficial capillary plexus vessel density in all sectors in comparison to baseline. CONCLUSION: OCTA is a non-invasive tool that recognize macular IRMA in diabetic retinopathy patient and it could be helpful to follow their qualitative and quantitative vascular evolution over time.

Diffuse posterior scleritis associated with HLA-B14* managed with multimodal imaging: case report and review of the literature.

PURPOSE: To report a case of posterior scleritis (PS) in an HLA-B*14 positive patient highlighting the crucial role of multimodal imaging and of autoimmune systemic disease screening for the diagnosis. METHODS: Case Report. RESULTS: A 73-year-old woman, complaining of ocular discomfort in right eye (RE), presented conjunctival hyperemia, keratic precipitates involving the anterior segment and four chorioretinal elevations with macular folds at fundus examination. Multimodal imaging and systemic diagnostic work-up were performed. While awaiting results, topical corticosteroid was prescribed. Four days later, worsening of exudative chorioretinal was detected. Except for erythrocyte sedimentation rate, tests were negative, while molecular typing of HLA genes was positive for HLA-B*14. Diagnosis of PS was confirmed by ultrasound examination while diagnosis of ankylosing spondylitis was made by rheumatologist. The patient was given systemic corticosteroid and one month later the posterior segment was unremarkable. CONCLUSION: HLA-B*14 may configure as a causal factor so autoimmune systemic disease screening should rule this out in management of PS, which should be diagnosed on the basis of multimodal imaging.

Real-life patient journey in neovascular age-related macular degeneration: a narrative medicine analysis in the Italian setting.

OBJECTIVES: To investigate the real-life experience of patients affected by neovascular age-related macular degeneration (nAMD), in the healthcare pathway for the management of the disease, using a "patient journey" and narrative method approach. METHODS: The patient journey of subjects affected by nAMD was designed using a process-mapping methodology involving a team from 11 Italian centres. Subsequently, narratives were collected from nAMD patients and family members. The interviews were analyzed using the narrative medicine methodology. RESULTS: Eleven specialized retina centres across Italy were involved and 205 narratives collected. In 29% of cases, patients underestimated their symptoms or attributed them to non-pathological causes, thus delaying the specialist consultation. The delay in accessing to care was due to a lack of awareness of this disease (50% of the participants didn't know what nAMD is) and to critical issues faced at first visit (long waiting lists, failed diagnosis, underestimation of the problem). Despite anti-VEGF therapies were perceived as effective in improving or stabilizing vision in 91% of narratives collected, 77% of patients still reduced or ceased daily activities such as reading and driving. Within the pathway of care there was not a multidisciplinary approach, and the patients were treated just by the ophthalmologist. CONCLUSIONS: nAMD may significantly affect the quality of life of affected patients, both from a functional and psychological point of view. The narrative medicine approach highlights some critical points in the healthcare journey of nAMD patients and represents a useful background in implementing patient management algorithms and pathways of care.

A long-term study of photodynamic therapy with verteporfin for choroidal neovascularization at the edge of chorioretinal atrophy in pathologic myopia.

PURPOSE: To evaluate the effects of verteporfin photodynamic therapy (PDT) on choroidal neovascularization (CNV) at the edge of chorioretinal atrophy in eyes with pathologic myopia. PROCEDURES: Twenty eyes of 20 consecutive patients were treated according to Verteporfin in Photodynamic Therapy criteria. The patients were divided into 3 groups based on CNV location and were followed up with clinical and fluorescein angiographic examinations to evaluate visual acuity (VA) changes and number of treatments. RESULTS: The mean follow-up was 35 months. In group 1 (n = 8; subfoveal CNV), VA declined from 20/73 (0.56 ± 0.26 logMAR) to 20/115 (0.76 ± 0.30 logMAR; p = 0.192). In group 2 (n = 6; juxtafoveal CNV), VA improved from 20/69 (0.54 ± 0.25 logMAR) to 20/46 (0.36 ± 0.16 logMAR; p = 0.176). In group 3 (n = 6; extrafoveal CNV), VA worsened from 20/50 (0.40 ± 0.21 logMAR) to 20/91 (0.66 ± 0.49 logMAR; p = 0.292). CONCLUSIONS: PDT showed inhibitory effects on myopic CNV arising at the edge of chorioretinal atrophy, especially in young adult myopic eyes with juxtafoveal neovascular membranes.

Retinal photoreceptor focal disruption secondary to accidental Nd:YAG laser exposure.

Retinal injuries caused by accidental laser exposure include retinal or vitreous hemorrhages, macular holes and edema. We describe the imaging of a bilateral macular lesion secondary to accidental Nd:YAG laser exposure. Observational case report. We performed color photography, fluorescein angiography and autofluorescence (AF) with a scanning laser ophthalmoscope, as well as time-domain and spectral-domain optical coherence tomography (OCT). After accidental exposure to a 1064 nm Nd:YAG laser, a patient experienced blurred vision in the left eye (LE) with visual acuity of 20/60. Color, fluorescein angiography and OCT imaging showed a retinal hemorrhage in the foveal area of the left eye and in the inferomacular region of the asymptomatic right eye. Steroid therapy was then administered, and 5 days later there was rapid improvement with progressive re-absorption of the hemorrhages and functional recovery. At 6 month follow-up, visual acuity was 20/20 in both eyes with unremarkable biomicroscopy, except for focal foveal retinal pigment epithelium (RPE) atrophy in the LE. In comparison to previous hemorrhages, OCT could visualize focal disruption of the photoreceptor IS/OS junction in both eyes. Due to different macular pigment distribution and lesion localization, 787 nm near-infrared AF depicted a small hypofluorescent spot in both eyes, whilst at 488 nm AF a black spot became evident in the right eye only. Despite the re-absorption of foveal hemorrhage and the functional recovery, AF and OCT imaging highlighted the persistence of small focal disruptions of the photoreceptor outer segments and RPE.

Macular hemorrhage after laser exposure and cannabinoid intake during a disco party.

PURPOSE: To describe two cases of macular hemorrhage in young patients, both occurred after laser exposure and cannabinoid intake during a disco party. OBSERVATIONS: Case 1: a 21-year-old man was evaluated at our Emergency Unit for sudden vision loss in the right eye (RE). Best-corrected visual acuity (BCVA) was count fingers in the RE and 20/20 in the left eye (LE). Fundus examination revealed a broad pre-retinal hemorrhage in macular region of RE, confirmed by optical coherence tomography. The patient reported vision loss, suddenly occurred after fixation of a laser source and cannabinoid intake during a disco party the night before. We administered a macular supplement and closely followed up the patient. After two months BCVA of the right eye was 20/20. CASE 2: The following day another 21-year-old man was referred to our Emergency Unit complaining of sudden vision loss in LE. As in Case 1, he reported to have fixed a laser beam as well as the consumption of cannabinoids at the same disco. BCVA was count fingers in the LE and 20/20 in the RE. Fundus examination showed a broad pre-retinal hemorrhage in macular region of LE. He had taken the macular supplement for two months and then the hemorrhage was reabsorbed. CONCLUSION AND IMPORTANCE: Laser exposure must be considered as a possible cause of macular hemorrhage. Furthermore, low cost of drugs and lack of formal control of laser sources may increase the emergence of new cases of retinal injuries especially among young people.

Verteporfin PDT for non-standard indications--a review of current literature.

BACKGROUND: Verteporfin photodynamic therapy (PDT) is approved for the treatment of predominantly classic subfoveal choroidal neovascularization (CNV) due to age-related macular degeneration (AMD), as well as for subfoveal CNV due to pathologic myopia and ocular histoplasmosis syndrome. Verteporfin PDT addresses the underlying pathology of ocular vascular disorders through its angio-occlusive mechanism of action, which reduces both visual acuity loss and the underlying leakage associated with lesions. Verteporfin PDT has also been associated with encouraging treatment outcomes in case studies involving patients with choroidal vascular disorders such as polypoidal choroidal vasculopathy, central serous chorioretinopathy, choroidal haemangioma, angioid streaks, and inflammatory CNV, i.e. conditions currently considered as non-standard indications of verteporfin PDT. In many studies, outcomes were better than expected based on the natural courses of each of these conditions. Although the anti-vascular endothelial growth factor (VEGF) therapies, ranibizumab and pegaptanib, have been approved for CNV due to AMD, their role in these other choroidal vascular disorders remains to be established. We summarize current literature that has documented the use of verteporfin PDT in these conditions. CONCLUSIONS: The complex pathogenesis of CNV provides a rationale for investigating combination approaches comprising verteporfin PDT and anti-VEGF therapies. Randomized controlled studies are warranted to confirm the preliminary results of verteporfin PDT as a monotherapy or in combination with anti-VEGF therapies in the treatment of a variety of choroidal vascular conditions.