Prevalence and significance of fovea plana in patients with epiretinal membrane.

INTRODUCTION: Fovea plana is indicative of an immature inner retina, yet its association with epimacular membrane (ERM) remains unexplored. This study aims to investigate the prevalence of fovea plana in the contralateral eye of patients diagnosed with ERM. METHODS: A retrospective analysis was conducted on consecutive patients in a monocentric tertiary ophthalmic department between January and April 2021. The study included all patients referred for ERM, with dense optical coherence tomography (OCT) B-scans utilized to assess the incidence of fovea plana in the contralateral eye. Patients with bilateral ERM were excluded from the analysis. RESULTS: Out of 181 patients, 26 exhibited fovea plana in the contralateral eye, resulting in an incidence rate of 14.3%. Demographic characteristics, OCT patterns, and indications for surgery did not differ significantly between patients with and without fovea plana. DISCUSSION: The prevalence of fovea plana in patients with ERM did not exhibit a statistically significant increase compared to the reported incidence in patients undergoing preoperative cataract surgery. CONCLUSION: In our cohort, the incidence of fovea plana in patients with ERM was determined to be 14.3%.

Incidence and clinical significance of fovea plana in the French population with age-related cataract.

BACKGROUND: Fovea plana is defined as an immature macula diagnosed by OCT, showing the unusual shunt of the inner retinal layers into the fovea. The incidence of fovea plana in the adult population remains to be determined. The aim of this study was to determine the incidence of fovea plana in the French population with age-related cataract. METHODS: Consecutive patients who underwent cataract surgery in Rothschild Foundation Hospital, France, between January and March 2021, with preoperative analyzable OCT scans available, were retrospectively screened in order to determine the incidence of fovea plana in these population. Ophthalmological characteristics of patients were reported, and detailed. RESULT: Fovea plana was encountered in 20 out of 204 patients during the 3 months corresponding to an incidence of 9.8%. One of those patients had stage 2 fovea plana. CONCLUSION: Although fovea plana is defined as an immature macula, it is not rare in preoperative population. This macular aspect was not associated with poor visual acuity in our cohort.

Foveal hypoplasia in parents of patients with albinism.

BACKGROUND: Albinism is a group of genetic disorders characterized by general skin and retinal hypopigmentation. It is in most cases an autosomal recessive condition. Foveal hypoplasia (FH) is one of the main criteria for the diagnosis of albinism. The aim of this study was to analyze the macular profile of the parents of patients with albinism. METHODS: This study included a case series of 27 patients with albinism seen in Rothschild Foundation between April 2017 and February 2020. Spectral-domain optical coherence tomography (SD-OCT) and OCT angiography (OCT-A) were performed in every patient when possible and in every available parents. FH was graded according to Thomas' classification based on OCT. Next generation sequencing-based gene panel testing was performed in parents and children when a FH was detected on OCT in a parent. RESULTS: Twenty-seven patients with albinism were examined. Nine parents had FH based on the OCT B-scan (33%). In parents without FH based on the SD-OCT B-scan (67%), OCT-A showed a reduced avascular zone in the deep vascular plexus in 4 parents. Six parents carried variants that could explain their phenotype, including TYR R402Q hypomorphic alleles. CONCLUSION: This study showed the presence of FH in parents of patients with albinism, and aimed to genetically explain this phenotype.

[Treat-and-extend anti-angiogenic protocol in clinical practice for patients with exudative age-related macular degeneration: Consensus of French experts]. / Consensus d'experts français sur la mise en œuvre pratique du régime Treat-and-Extend par anti-angiogéniques chez les patients atteints de DMLA exsudative.

Optimizing treatment regimens for anti-angiogenic drugs is now a major issue in the management of patients with exudative AMD. The evolution of these approaches has led retinologists to favor so-called proactive administration regimens, such as Treat-and-Extend (T&E), which make it possible to anticipate recurrence and to plan intravitreal injections of anti-angiogenic drugs in advance. Nevertheless, a real need to standardize the application of this regimen has been identified. This article proposes a consensus based on the Delphi methodology, which might provide a guide for ophthalmologists to manage patients with exudative AMD using the T&E protocol. While some aspects remain debated to date, this article provides elements to guide the implementation of T&E. The experts recommend that a loading dose of 3 monthly injections should be administered before starting T&E. They also recommend adjusting the reinjection intervals by±2 weeks in a standardized fashion. The intervals are then decreased in the presence of anatomical and/or functional deterioration, maintained when the interval of recurrence is identified, and increased when anatomical and/or functional improvement is observed. A maximum interval between 3 and 4 months is recommended by the experts, with maintenance of the maximum interval for 1 year before considering a possible exit from the T&E protocol. In the event of a significant decrease in visual acuity related to the disease along with significant anatomical degradation, it is recommended to restart monthly injections. In the case of bilateral disease, when synchronized timing of injections for both eyes is desired, the experts recommend using the shorter of the two intervals.

[Systemic safety following intravitreal injections of anti-VEGF]. / Tolérance systémique des injections intravitréennes d'anti-VEGF.

The goal of this manuscript is to assess data suggesting that intravitreal injection of anti-vascular endothelial growth factors (anti-VEGFs) could result in systemic adverse events (AEs). The class-specific systemic AEs should be similar to those encountered in cancer trials. The most frequent AE observed in oncology, hypertension and proteinuria, should thus be the most common expected in ophthalmology, but their severity should be lower because of the much lower doses of anti-VEGFs administered intravitreally. Such AEs have not been frequently reported in ophthalmology trials. In addition, pharmacokinetic and pharmacodynamic data describing systemic diffusion of anti-VEGFs should be interpreted with caution because of significant inconsistencies reported. Thus, safety data reported in ophthalmology trials and pharmacokinetic/pharmacodynamic data provide robust evidence that systemic events after intravitreal injection are very unlikely. Additional studies are needed to explore this issue further, as much remains to be understood about local and systemic side effects of anti-VEGFs.

Measurement of full-thickness macular hole size using en face optical coherence tomography.

PurposeTo assess the feasibility and interest of measuring macular hole (MH) size using en face optical coherence tomography (OCT) compared with manual diameter measurements on B-scans.MethodsAmong our previously published series of 100 patients operated for primary MH, patients whose images were acquired with Cirrus 5000 HD-OCT (Carl Zeiss Meditec) with a quality signal strength >5/10 were included. Three segmentations (internal limiting membrane, horizontal, and retinal pigment epithelium (RPE)) were compared for obtaining the most appropriate en face image. MH surface areas were measured using ImageJ software. Mean diameters calculated from surface areas (diameter=2 × âˆš(surface area/π)) were compared with those measured on B-scans.ResultsNineteen patients were included with a mean age of 72±8 years (56-86) and a female predominance (3/16). The mean absolute difference between horizontal and vertical diameters measured on B-scans was of 54±47 µm (0-180) without reaching significance (P=0.874). RPE segmentation provided the best en face image and was feasible without and with adjustment, respectively, in 79% and 100% (cases with vitreomacular traction) of cases. No significant difference in mean diameters was observed between those calculated from en face images (435±143 µm (195-693)) and those measured on horizontal B-scans (426±139 µm (214-705), P=0.482).ConclusionMeasuring MH size on en face OCT images is feasible, reliable, and eliminates the potential bias related to manual measurements on B-scans. Its integration into OCT devices would offer an automated and easy-to-use option for clinical practice.

Prevalence of reticular pseudodrusen in age-related macular degeneration with newly diagnosed choroidal neovascularisation.

AIM: To investigate the prevalence of reticular pseudodrusen (RPD) in eyes of patients presenting with newly diagnosed choroidal neovascularisation (CNV) in age-related macular degeneration (AMD), and to analyse the association between RPD, age-related maculopathy (ARM) and AMD. METHOD: Two observational consecutive prospective series. In series 1, patients with AMD with newly diagnosed CNV were sampled to determine the incidence of RPD. Eyes with and without RPD were compared by the Mann-Whitney non-parametric test and Fisher's exact test for age, sex of patients, the eye involved and type of CNV. Series 2 comprised 100 patients referred for fundus photography, fluorescein and/or indocyanine green angiography, for whom pictures showed RPD. This second cohort was then selected from a larger group of patients. RESULTS: Patients with newly diagnosed CNV in series 1 comprised 67 women and 33 men, aged 57-96 years (mean 79.5). CNV was "classic" (32 eyes), "occult" (41) or exhibited vascularised pigment epithelial detachment (PED, 11), retinal angiomatous proliferation (RAP) with or without PED (13), or haemorrhagic or fibrovascular scarring (3). In all, 24 (24%) eyes had RPD. The prevalence of RAP was significantly higher in eyes with RPD than in those without (p = 0.0128), despite the small number of patients with RAP. In series 2, 100 patients with RPD were enrolled in 3 months, and corresponded to 8% of the overall cases referred to our centre (Centre Ophtalmologique d'Imagerie et de Laser, Paris, France). There were 77 women and 23 men, aged 54-93 years (mean 79.2). Eyes with RPD (n = 155) usually exhibited signs of ARM or AMD, including soft drusen (101 eyes) and/or retinal pigment epithelium abnormalities (70), geographical atrophy (27) and/or CNV (61). In both studies, examination of blue-light fundus pictures was extremely helpful in diagnosing RPD. CONCLUSION: RPD have a high prevalence among patients with AMD with newly diagnosed CNV (24% of cases). RPD were commonly associated with ARM or AMD. This study suggests that eyes with RPD could be classified as a phenotype of ARM.

Occurrence rate of retinal detachment after small gauge vitrectomy for idiopathic epiretinal membrane.

PurposeTo assess the occurrence rate of retinal detachment (RD) after small gauge vitrectomy for idiopathic epiretinal membrane (ERM).Patients and methodsRetrospective observational case series. The records of consecutive patients operated on for idiopathic ERM using small gauge pars plana vitrectomy between August 2012 and December 2014 with at least a 1-year follow-up were reviewed. All patients were contacted by phone to assess the occurrence of RD during the post-operative follow-up. The main outcome was the occurrence of RD. Patients who underwent surgery for senile cataract over the same period with at least a 1-year follow-up were also contacted by phone for comparison.ResultsTwo hundred and sixteen eyes of 212 patients who had undergone ERM surgery were included, with a mean follow-up of 892±211 days (216-1238). RD occurred in two eyes (0.92%). Over the same period, two RD occurred in the 203 eyes (0.98%) of 157 patients operated on for senile cataract in our department.ConclusionsThe occurrence of RD after 25-gauge vitrectomy for idiopathic ERM was <1%. Using small gauge sutureless vitrectomy systems has improved the safety of ERM surgery, with a RD rate similar to that observed after cataract surgery.

Efficacy of 0.2 µg/day fluocinolone acetonide implant (ILUVIEN) in eyes with diabetic macular edema and prior vitrectomy.

PurposeLimited data are available on the efficacy of the 0.2 µg/day fluocinolone acetonide (FAc) implant in eyes with prior vitrectomy. Here, we present a collection of 26 vitrectomized eyes treated with the 0.2 µg/day FAc implant.MethodsRetrospective study involving six centers from four European countries analyzing the safety and efficacy data from patients (26 eyes from 25 patients) with DME and a prior vitrectomy that had been treated with one 0.2 µg/day FAc implant.ResultsPrior intravitreal therapies included anti-VEGF (mean, 3.8 injections) and steroids (mean, 1.9 injections). Pars plana vitrectomy (PPV) was performed in these eyes primarily for abnormalities of vitreoretinal interface, followed by proliferative diabetic retinopathy and vitreous hemorrhage. The 0.2 µg/day FAc implant was injected 24.2 months, on average, after PPV and the mean duration of follow-up after injection was 255 days (range, 90 to 759 days). The mean change in BCVA was +11.7 ETDRS letters (range, -19 to +40 letters; P<0.0004) and the mean change in central foveal thickness (CFT) was -233.5 µm (range, -678 to 274 µm; P<0.0001). The mean change in IOP from baseline at the last visit was +1.4 mm Hg (range, -9 to +8 mm Hg; P=0.0090). Eight eyes initiated or continued IOP lowering medications.ConclusionsThese data suggest the 0.2 µg/day FAc implant is effective in vitrectomized patients with an acceptable safety profile. Further studies are still required to confirm the current findings and to assess the effect of the 0.2 µg/day FAc implant over a longer period of follow-up.

[A "fast track" to improve management of neovascular age related macular degeneration]. / Un « circuit court ¼ pour améliorer la prise en charge des patients atteints de dégénérescence maculaire liée à l'âge néovasculaire.

OBJECTIVE: To evaluate the role of a fast track for management of patients with neovascular age- related macular degeneration (nARMD) treated by intravitreal injection of anti-VEGF. PATIENTS: The records of 100 patients in the chronic maintenance phase of intravitreal anti-VEGF followed in the fast track and 63 patients followed in the standard protocol for at least 12 months were retrospectively analyzed. METHOD: Patients in the fast track underwent visual acuity (VA) testing by ETDRS, optical coherence tomography (OCT) and a physician assessment. The injection was performed the same day whenever possible. The primary endpoint to evaluate patient adherence was the time between the ideal date of visit or injection prescribed by the physician and the actual date of administration. RESULTS: The mean time between the ideal date of visit or injection prescribed by the physician and the actual date of administration was 4.1±7.5 days for the patients followed in the fast track and 5.6±18.7 days for the patients followed in the standard protocol. Mean VA remained stable for the patients followed in the fast track: 20/50 (20/800 to 20/20) at baseline vs. 20/50 (20/800 to 20/16) at the conclusion of follow-up. It dropped from 40/50 at baseline to 20/63 at the conclusion of follow-up for the patients followed in the standard protocol. CONCLUSION: In the context of a fast track, it was possible to improve the adherence of nARMD patients and maintain their VA gain or stabilization achieved after the induction phase.

Relationship between macular hole size and the potential benefit of internal limiting membrane peeling.

AIM: To investigate the relationship between the size of macular holes and the possible benefit of internal limiting membrane (ILM) peeling. METHODS: 84 consecutive cases of idiopathic macular hole followed up for at least 3 months were included in this retrospective study. Surgery comprised pars plana vitrectomy, peeling of any epiretinal membrane, 17% C2F6 (hexafluoroethane) gas filling and 10 days of positioning. 36 eyes had ILM peeling. The main outcome measure was the macular hole closure rate checked by optical coherence tomography. RESULTS: The overall postoperative closure rate was 90.5%. For macular holes > or =400 microm in diameter, the rate was 100% with ILM peeling versus 73.3% without (p = 0.015). For smaller macular holes, the rates were 100% in both groups. Postoperative gain in visual acuity was not significantly different in eyes with ILM peeling and those without. CONCLUSIONS: ILM peeling does not seem to be useful for macular hole <400 mum in diameter. Its likely benefit has to be investigated for larger macular hole sizes, for which the failure rate is higher.

Determinants of visual acuity outcomes in eyes with neovascular AMD treated with anti-VEGF agents: an instrumental variable analysis of the AURA study.

PurposeTo identify the strongest variable(s) linked with the number of ranibizumab injections and outcomes in AURA, and to identify ways to improve outcomes using this association.MethodsAURA was a large observational study that monitored visual acuity over a 2-year period in patients with neovascular age-related macular degeneration (AMD) who received ranibizumab injections. Baseline characteristics, resource use, and outcomes were analyzed using an instrumental variable approach and regression analysis.ResultsData were analyzed from 2227 patients enrolled in AURA. Optical coherence tomography (OCT) and ophthalmoscopy were the most common diagnostic tests used, and this combination was the strongest instrumental variable. Use of OCT and ophthalmoscopy affected the number of injections given and resulted in an increase in visual acuity gains from baseline of 17.6 letters in year 1 and 2.5 letters in year 2. Regression models using the instrumental variable (OCT and ophthalmoscopy combined) showed that ≥5.1 (95% CI: 3.3-11.4) ranibizumab injections were needed to maintain visual acuity from baseline to year 1 and ≥8.3 (95% CI: 5.3-18.8) injections were needed to maintain visual acuity from year 1 to year 2. To gain ≥15 letters, ≥7.9 (95% CI: 5.1-17.5) ranibizumab injections would be needed in year 1 and ≥16.1 (95% CI: 10.3-36.4) injections would be needed over 2 years.ConclusionsThese findings highlight the role that regular monitoring plays in guiding neovascular AMD therapy and they showed that the number of ranibizumab injections needed to maintain visual acuity is higher than that administered in AURA.

Comparison of optical coherence tomography models OCT1 and Stratus OCT for macular retinal thickness measurement.

AIMS: To compare the values measured for retinal macular thickness with the first and last generations of the optical coherence tomograph (OCT1 and Stratus OCT, Zeiss, Humphrey Division). METHODS: This was a cohort study. 59 eyes were examined: 17 had a normal macula and 42 had a diabetic macular oedema. In each eye, mean retinal thickness (RT) was measured automatically in the nine macular Early Treatment Diabetic Retinopathy Study areas and at the foveal centre, using OCT1 and Stratus OCT. The paired mean RT values for each area and the type and proportion of artefacts were compared. RESULTS: Of the 590 automatic measurements, 505 had no artefact, either with OCT1 or Stratus OCT. The mean difference between the OCT1 and Stratus OCT measurements was 25 (SD 26.2) microm (p<0.0001). With Stratus OCT, RT values were significantly higher, by 8.1% (7.8%), than with OCT1. Artefacts were only observed in cases of diabetic macular oedema and were significantly more frequent with OCT1 than Stratus OCT (10.5% versus 4.4, p<0.0001). CONCLUSION: The macular retinal thickness values measured with Stratus OCT were significantly higher than those measured with OCT1. Stratus OCT has the advantage of producing fewer artefacts than OCT1 in pathological cases.

[Epiretinal membranes]. / Les membranes épirétiniennes maculaires.

Idiopathic epiretinal membranes represent a common condition, and are present in approximately 10% of people over the age of 70 years. They are idiopathic in 80% of cases, or may be secondary to various conditions such as a prior retinal detachment, or vascular or inflammatory retinal diseases. The main symptoms are visual loss and metamorphopsia. The diagnosis of epiretinal membrane is currently facilitated by OCT, which provides prognostic and therapeutic decision-making assistance. Surgery for epiretinal membranes is currently well codified through sutureless vitrectomy and dyes. Dissection of the membrane (with or without associated peeling of the internal limiting membrane) ensures good anatomical and functional results, while being relatively minimally invasive.

[Management of macular edema secondary to retinal vein occlusion]. / Prise en charge de l'œdème maculaire secondaire à une occlusion veineuse rétinienne.

BACKGROUND: In recent years, intravitreal injections have added to the treatment modalities available for macular edema (ME) secondary to retinal vein occlusion (RVO). This article aims to provide an update regarding the management of ME secondary to RVO. METHODS: A work group met in order to analyze the literature available on Embase/PubMed, regarding treatments for venous occlusion that have received market approval and are reimbursed in France. In total, 33 articles were selected. Consensus within the group for recommendations was based on this data from the literature review and clinical experience and was reported in this article. RESULTS: The management of ME secondary to branch retinal vein occlusion (BRVO) or central vein occlusion of the retina (CRVO) differs on a number of points. Methods of best practice were discussed separately for BRVO and CRVO, taking into account various ocular and associated parameters. DISCUSSION: Ranibizumab and dexamethasone implant are the first-line treatments for visual impairment due to ME secondary to RVO. The choice of either of these drugs may take into account various ocular and extraocular parameters. A change of treatment to one or the other or to laser may also be considered during follow-up.

[Classification of vitreomacular adhesion and macular holes]. / Classification des adhérences vitréomaculaires et trous maculaires.

BACKGROUND: Optical coherence tomography has significantly changed the approach to vitreomacular diseases, including macular holes (MH). OCT provides information on differential diagnoses (lamellar hole, pseudo-hole), the MH size, the status of the vitreous, and the status of the various retinal layers. The evolution of diagnostic tools and treatment justifies the need for an update of the current classification of vitreomacular diseases. METHOD: A group of retina specialists met several times to discuss the international classification, recently published by The International Vitreomacular Traction Study Group, focusing on vitreomacular adhesion (VMA), vitreomacular traction (VMT) and MH. It was compared to the classification currently used in France, based on the ophthalmoscopic system of Gass, then further delineated by Gaudric's OCT studies, in order to suggest a French adaptation to the international classification. RESULTS: An adapted classification for clinical use in France and in connection with the international classification is proposed. VMA are classified as an "associated" or "isolated" VMA respectively with or without macular disease. MH are distinguished as "primary" or "secondary" MH depending on whether the etiology is known or not, and classified as "small", "medium" and "large" depending on the size of the hole, and according to the presence or absence of VMT. Finally, VMT are described according to presence or absence of an epimacular membrane and according to the width of the adhesion.

Visual hallucinations immediately after macular photocoagulation.

PURPOSE: To evaluate the incidence of visual hallucinations after macular photocoagulation for choroidal neovascularization. METHODS: After macular photocoagulation for choroidal neovascularization, 60 consecutive patients were asked to respond to an orally administered questionnaire. RESULTS: Twenty-seven patients (45%) described photopsias, flashing lights of various colors. Ten additional patients (16.6%) also described structured hallucinations, including known or unknown faces, flowers, and geometric patterns, which occurred hours or a few days after photocoagulation. Patients with structured hallucinations were older (P =.04) and more often had subfoveal choroidal neovascularization (P =.005) and severe macular disease in both eyes or at least in the treated eye (P =.01). CONCLUSIONS: Visual hallucinations appear to be a frequent, albeit unrecognized, side effect of macular photocoagulation of choroidal neovascularization. The provision of proper information to patients may avoid concern about a psychiatric origin of their hallucinations.

Visual hallucinations and Charles Bonnet syndrome after photodynamic therapy for age related macular degeneration.

AIMS: To report on visual hallucinations and Charles Bonnet syndrome (CBS) that may occur in patients with age related macular degeneration (AMD) treated by photodynamic therapy (PDT) with verteporfin for choroidal neovascularisation (CNV). METHODS: 100 consecutive patients were asked to respond to an orally administered questionnaire on visual hallucinations following PDT. Three groups of patients, respectively without visual hallucinations, with unstructured visual hallucinations, and with structured hallucinations-that is, CBS, were compared by ANOVA, Scheffe's test, or the chi(2) test, to establish whether age, sex, or visual acuity, as scored on ETDRS charts, are risk factors for the occurrence of visual hallucinations. RESULTS: Five patients (5%) described transient structured visual hallucinations, including known or unknown faces and geometric patterns. Fifteen patients (15%) reported photopsias and flashing lights of various colours. These symptoms usually occurred a few days after PDT. There was no significant difference between the group of patients with structured visual hallucinations and the two other groups, with regard to age (p =0.435), sex (p =0.406), or visual acuity (p =0.835). CONCLUSIONS: Visual hallucinations and CBS appear to be a possible, although unrecognised, side effect of PDT for CNV, which occur just after treatment. These results suggest the need to include the possibility of visual hallucinations in the information given to patients before PDT.

Evaluation of fluorescein-labeled autologous leukocytes for examination of retinal circulation in humans.

PURPOSE: Increased leukocyte-endothelium interaction have been suggested as a phenomenon contributing to capillary occlusion and/or rupture of the blood-retina barrier during human retinal vascular diseases. This study was performed to evaluate if fluorescein-labeled autologous leukocytes (FLALs) can be used for examination of leukocyte transit in the human retina. METHODS: The preparation consisted of human dextran-separated leukocytes mixed with fluorescein. After reinjection in normal subjects and in one diabetic patient, a confocal scanning laser ophthalmoscope was used to visualize them in the retinal circulation. The changes between FLALs and control leukocytes in the expression of leukocytes adhesion molecules CD11b and CD62L were evaluated by flow cytometry. RESULTS: The circulating FLALs were clearly visible in retinal vessels. The mean (+/- SD) capillaries velocity was 1.43 (+/- 1.3) mm/s in the macula and 1.82 (+/- 1.4) mm/s in the peripapillary area. No leukostasis was detected in the normal subjects, while it was detected in te diabetic patient. Flow cytometry revealed an increase in CD11b and a decrease in CD62L expression of leukocytes after labeling, suggesting that compared to normal leukocytes FLALs are more susceptible to interact with vascular endothelium. CONCLUSIONS: The use of FLAL is presently the only technique applicable in humans for study of leukocyte transit in the retina. Their preparation is technically simple and unexpensive. Precise measurement of the velocity of leukocytes in small vessels can be obtained. Despite evidence of a certain degree of leukocyte activation after the labeling procedure, no leukostasis was detected in vivo in normal subjects. Potential applications for this technique may include the detection of leukostasis in the human retina during severe forms of diabetes and retinal phlebitis.