Long-Term Efficacy of a Treat-and-Extend Regimen with Ranibizumab in Patients with Neovascular Age-Related Macular Disease: An Open-Label 12-Month Extension to the CANTREAT Study.

INTRODUCTION: The objective of this study is to assess the long-term effectiveness of a treat-and-extend (T&E) anti-vascular endothelial growth factor regimen in patients with neovascular age-related macular degeneration who remain on T&E and those switched from once-monthly (OM) dosing to T&E (OM-T&E). METHODS: In this 12-month extension of the 2-year CANTREAT study, patients received intravitreal ranibizumab 0.5 mg in a T&E regimen. Main outcome measures included mean change in best-corrected visual acuity (BCVA) from baseline and from month 24 to month 36; percentages of patients who gained ≥5, ≥10, or ≥15 Early Treatment of Diabetic Retinopathy Study (ETDRS) letters or lost ≥5, ≥10, or ≥15 letters from baseline and from month 24 to month 36; and number of injections administered from baseline and from month 24 to month 36 for both groups. RESULTS: Of the 139 patients (73 T&E, 66 OM-T&E) in the extension, 121 (68 T&E, 53 OM-T&E) completed 36 months. Mean (standard deviation [SD]) BCVA changes from baseline to the extension last visit (month 33-36) were +6.6 (11.4) letters in the T&E group and +4.8 (14.3) letters in the OM-T&E group, representing maintenance of 24-month gains. The mean (SD) numbers of injections during the extension were 7.3 (2.7) for T&E and 7.1 (2.8) for OM-T&E. DISCUSSION/CONCLUSION: These findings suggest that after 36 months of treatment, the mean BCVA improvement achieved at 24 months is maintained for both the patients exclusively treated with the T&E regimen and those that switched to T&E after 24 months in the OM regimen.

PHACOVITRECTOMY FOR PRIMARY RHEGMATOGENOUS RETINAL DETACHMENT REPAIR: A Retrospective Review.

PURPOSE: To analyze the single surgery success rate and anterior segment complications related to phacoemulsification and intraocular lens implantation in a series of patients undergoing phacovitrectomy for all types of primary rhegmatogenous retinal detachment. METHODS: We performed a retrospective interventional case series on 302 eyes undergoing phacovitrectomy for primary rhegmatogenous retinal detachment repair between November 1, 2016, and February 2, 2019, in Edmonton, Canada. Primary outcomes included single surgery retinal reattachment rate and anterior segment complications. Secondary outcomes included the effects of proliferative vitreoretinopathy and macula and/or peripheral internal limiting membrane peeling on the rate of surgical success. RESULTS: The single surgery success rate of phacovitrectomy for all types of primary rhegmatogenous retinal detachment was 85.1%. The presence of proliferative vitreoretinopathy was associated with lower surgical success (odds ratio, 0.33; P = 0.01). Macular internal limiting membrane peeling was associated with higher surgical success (odds ratio, 2.4; P = 0.05). Anterior segment complications included posterior capsular opacification (28.8%), posterior synechiae (10.9%), and posterior capsular rupture (2.3%). CONCLUSION: Phacovitrectomy is a safe and effective treatment option for the primary repair of rhegmatogenous retinal detachments. This study provides evidence to support the safe incorporation of phacoemulsification and intraocular lens implantation with retinal surgery.

Canadian Treat-and-Extend Analysis Trial with Ranibizumab in Patients with Neovascular Age-Related Macular Disease: One-Year Results of the Randomized Canadian Treat-and-Extend Analysis Trial with Ranibizumab Study.

PURPOSE: To compare the efficacy of ranibizumab using a treat-and-extend (T&E) regimen with monthly dosing in treatment-naive patients with neovascular age-related macular degeneration (nAMD). DESIGN: Prospective, randomized, open-label, multicenter, noninferiority, postauthorization study. PARTICIPANTS: Treatment-naive patients with choroidal neovascularization secondary to AMD. METHODS: Patients with nAMD were randomized 1:1 to receive intravitreal ranibizumab at a dose of 0.5 mg in either a T&E or monthly dosing regimen. The noninferiority of T&E compared with the monthly dosing regimen was to be shown using a margin of 5 letters in best-corrected visual acuity (BCVA) improvement. MAIN OUTCOME MEASURES: Mean change in BCVA in Early Treatment Diabetic Retinopathy Study letters from baseline to month 12. RESULTS: Baseline and 12-month visual acuity data are available for 526 patients (T&E, n = 268; monthly, n = 258). At baseline, mean age was 78.8 years (standard deviation [SD], 7.8 years), 60.3% were women, and 94.3% were white. No significant between-group baseline differences were observed. The primary outcome of noninferiority regarding visual acuity was met with mean BCVA improvement of 8.4 letters (SD, 11.9 letters) and 6.0 letters (SD, 11.9 letters; P = 0.017) in the T&E and monthly regimens, respectively, with a between-group mean difference of 2.38 letters (95% confidence interval, 0.32-4.45 letters). Per protocol, a secondary analysis was performed to test for superiority of number of injections received up to month 12. This analysis demonstrated significantly fewer injections with T&E versus monthly dosing (9.4 and 11.8 injections, respectively), with a mean difference of -2.46 injections (95% confidence interval, -2.68 to -2.23 injections). CONCLUSIONS: The 12-month results of this 2-year study demonstrated that regarding visual outcomes, the T&E regimen was noninferior to a monthly dosing regimen. Similar visual outcomes in the T&E group as in the monthly dosing group were achieved with significantly fewer injections.

Food dependent exercise induced anaphylaxis triggered by inhaled antigen.

We present a unique case of food dependent exercise induced anaphylaxis (FDEIA) triggered by an inhaled allergen in a 23- year-old professional cyclist. FDEIA is considered a rare form of anaphylaxis in which the state of exercise can trigger mast cell degranulation to an allergen which normally does not cause a reaction. It is closely related to exercise induced anaphylaxis, which occurs with exercise but in the absence of a food trigger. The patient experienced an anaphylactic reaction during a bicycle race when the race went through an almond orchard in full bloom. He was successfully stabilized with aggressive measures including steroids, fluids, anti-histamines and multiple doses of epinephrine.

Optimal Treatment of Retinal Vein Occlusion: Canadian Expert Consensus.

BACKGROUND: The availability of new therapeutic approaches, particularly intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapies, has prompted significant changes to the established treatment paradigms for retinal vein occlusion (RVO). Better visual outcomes and significantly lower rates of adverse events have been noted in multiple large randomized clinical trials and have led to a new standard of care for this sight-threatening condition. OBJECTIVE: To develop an expert consensus for the management of RVO and associated complications in the context of recent clinical evidence. METHODS: The development of a Canadian expert consensus for optimal treatment began with a review of clinical evidence, daily practice, and existing treatment guidelines and algorithms. The expert clinicians (11 Canadian retina specialists) met on February 1, 2014, in Toronto to discuss their findings and to propose strategies for consensus. RESULTS: The result of this expert panel is a consensus proposal for Canadian ophthalmologists and retina specialists treating patients presenting with RVO. Treatment algorithms specific to branch and central RVO (BRVO and CRVO) were also developed. CONCLUSIONS: The consensus provides guidelines to aid clinicians in managing RVO and associated complications in their daily practice. In summary, laser remains the therapy of choice when neovascularization secondary to RVO is detected. Adjunctive anti-VEGF could be considered in managing neovascularization secondary to RVO in cases of vitreous hemorrhage. Intravitreal anti-VEGF should be considered for symptomatic visual loss associated with center-involving macular edema on optical coherence tomography. Patients with BRVO and a suboptimal response to anti-VEGF could be treated with grid laser, and those with CRVO and an inadequate response to anti-VEGF may be candidates for intravitreal steroids.

Contemporary management of diabetic retinopathy in Canada: from guidelines to algorithm guidance.

Recent advances in the therapeutic options and approaches for diabetic retinopathy (DR) and diabetic macular edema (DME) have resulted in improved visual outcomes for many patients with diabetes. Yet, they have also created many clinical dilemmas for treating ophthalmologists and retina specialists, including treatment selection, initiation, frequency and duration. With this in mind, a panel of Canadian retina specialists met and discussed the current clinical evidence as well as specific situations and scenarios commonly encountered in daily practice. They also shared their experiences and therapeutic approaches. This document, containing a consensus on treatment algorithms for various clinical scenarios, is the result of their lengthy and in-depth discussions and considerations. The intent is to provide a step-by-step approach to the treatment of DR and DME. Although clinicians are encouraged to use and refer to these algorithms as a guide for various situations, they are not meant to be a replacement for sound clinical judgment.

Effect of Macular Internal Limiting Membrane Peeling on Single Surgery Success Rates of Vitrectomy for Uncomplicated, Primary Macula-Off Retinal Detachment.

Purpose: To determine the anatomic and visual outcomes of pars plana vitrectomy for uncomplicated, primary macula-off rhegmatogenous retinal detachment (RRD) with and without internal limiting membrane (ILM) peeling. Methods: This retrospective chart review comprised 129 patients with uncomplicated, primary macula-off RRD presenting between January 1, 2016, and May 31, 2021. Thirty-six patients (27.9%) had ILM peeling and 93 (72.0%) did not. The primary outcome was the rate of recurrent RRD. Secondary outcomes included preoperative and postoperative best-corrected visual acuity (BCVA), epiretinal membrane (ERM) formation, and macular thickness. Results: No significant difference was found in the risk for recurrent RRD between patients who had ILM peeling and those who did not (2.8% [1/36] and 5.4% [5/93], respectively) (P = 1.00). The final postoperative BCVA was better in eyes that did not have ILM peeling (P< .001). No ERM occurred in the group with ILM peeling, whereas ERM occurred in 27 patients (29.0%) who did not have ILM peeling. The temporal macular retina was thinner in eyes in which ILM peeling was performed. Conclusions: The risk for recurrent RRD was not statistically lower in eyes having ILM peeling of the macula in uncomplicated, primary macula-off RRD. Despite a reduction in postoperative ERM formation, eyes having macular ILM peeling had worse postoperative VA.

Acute Cycling Injuries.

The overall activity of cycling, although profoundly heterogenous, often occurs with mechanisms consistent with motor vehicle collisions. Advanced trauma life support is the standard of care. Traumatic brain injury is the leading cause of death, and concussions are common in cyclists. Road rash is the most common injury, and management should be synonymous with other kinds of burns. A unique aspect of cycling medicine is that it often is done on public roadways in close proximity to the athletes during competition. Clinicians who care for cyclists in the field setting should be prepared to manage a broad spectrum of traumatic injuries.

INTERNAL CHANDELIER-ASSISTED MACULAR BUCKLING FOR MYOPIC FOVEOSCHISIS.

PURPOSE: To present a surgical technique and case presentation of internal chandelier-assisted macular buckling for myopic foveoschisis. METHODS: Review of patient clinical features, visual acuity, and optical coherence tomography results after internal chandelier-assisted macular buckling for myopic foveoschisis. RESULTS: A 48-year-old highly myopic woman (axial length 29.85 mm) underwent internal chandelier-assisted macular buckling for myopic foveoschisis with macular detachment. The best-corrected visual acuity improved from 20/150 to 20/40. Postoperative optical coherence tomography confirmed central buckle positioning and demonstrated resolved foveoschisis and macular detachment. There were no complications. CONCLUSION: Internal chandelier-assisted macular buckling is a valuable tool to optimize buckle position and patient outcomes.

Pneumatic Vitreolysis With Intravitreal Air for Focal Vitreomacular Traction.

Purpose: To determine whether pneumatic vitreolysis with intravitreal air is effective for focal vitreomacular traction (VMT). Methods: We conducted a retrospective consecutive case series of 20 eyes from 19 individuals with focal VMT who underwent pneumatic vitreolysis with intravitreal air (January 2017 to November 2018). We analyzed patients via spectral-domain optical coherence tomography before intravitreal air injection and at 1 month. The primary outcome measure was release of VMT. Results: We observed release of VMT in 55% of individuals. An analysis limited to phakic eyes demonstrated release of VMT in 69%, and 65% developed improved best-corrected visual acuity. Individuals with persistent VMT and visual improvement had a significant reduction in angle of vitreoretinal insertion (P < .01), area under VMT (P < .05), and subfoveal cyst area (P < .05). Conclusions: Intravitreal air is an effective treatment for focal VMT. In individuals with persistent VMT, visual-acuity improvement was associated with a reduction in overall VMT.

Efficacy of a Treat-and-Extend Regimen With Ranibizumab in Patients With Neovascular Age-Related Macular Disease: A Randomized Clinical Trial.

Importance: Although the Canadian Treat-and-Extend Analysis Trial With Ranibizumab in Patients With Neovascular Age-Related Macular Disease (CANTREAT) reported herein and the Treat and Extend study provided data to show noninferiority of treat-and-extend (T&E) at 12 months, to date there are few data on 24-month T&E trials compared with monthly dosing. Objective: To compare the efficacy of ranibizumab using a T&E regimen to monthly dosing in treatment-naive patients with neovascular age-related macular degeneration (nAMD) after 24 months. Design, Setting, and Participants: A randomized, open-label, multicenter, noninferiority intention-to-treat trial with a margin of -5 letters in best-corrected visual acuity (BCVA) from baseline to 12 months between groups was conducted at 27 treatment centers in Canada. Participants included 580 patients with treatment-naive choroidal neovascularization secondary to AMD. The study was conducted from May 8, 2013, to August 28, 2018, and data analysis was performed between August 29 and September 12, 2018. Interventions: Patients with nAMD were randomized 1:1 to receive intravitreal ranibizumab, 0.5 mg, in either a T&E or monthly dosing regimen. Main Outcomes and Measures: Mean change in BCVA in Early Treatment of Diabetic Retinopathy Study letters from baseline to month 24. Results: Of the 580 randomized patients, 350 were women (60.3%) and 547 were white (94.3%). Mean (SD) age was 78.8 (7.8) years. By the end of month 24, 466 of the 580 randomized patients (80.3%) had completed the study and participants in the T&E arm received a mean of 17.6 injections compared with 23.5 injections for the monthly arm, for a difference of 5.9 injections and visits over 2 years (95% CI, 5.4-6.5; P < .001). The mean (SD) BCVA improvement was not worse with the T&E arm, 6.8 (14.1) letters vs 6.0 (12.6) letters, compared with the monthly arm (difference, 0.9; 95% CI, -1.6 to 3.3; P = .21). There was a gain of 15 or more letters in 25.5% of the T&E group and 23.1% of the monthly treatment group (difference, 2.4%; 95% CI, -6.8% to 11.6%; P = .59) and a loss of 15 or more letters in 6.5% of the T&E group and 5.8% of the monthly treatment group (difference, -0.7%; 95% CI, -9.9% to 8.5%; P = .85). Conclusions and Relevance: These findings suggest that change in vision from baseline is not worse with a T&E compared with a monthly regimen of ranibizumab for nAMD through 24 months, achieving clinically meaningful improvements in BCVA despite fewer injections and visits. Trial Registration: ClinicalTrials.gov identifier: NCT02103738.

Macular buckle without vitrectomy for myopic macular schisis: a Canadian case series.

OBJECTIVE: To determine the effectiveness of a macular buckle procedure without vitrectomy for the treatment of symptomatic myopic macular schisis. DESIGN: Retrospective case series. PARTICIPANTS AND METHODS: All patients who underwent surgery with placement of an NPB macular buckle (AJL Ophthalmic, Miñano, Álava, Spain) without vitrectomy for symptomatic myopic macular schisis were included. Visual acuity and anatomical outcomes based on optical coherence tomography (OCT) were reviewed. RESULTS: Eight consecutive eyes from 7 patients were included. Six of the 7 patients were female and the mean age was 59 ± 6 years (range, 49-66 years). The mean follow-up duration was 11 ± 7 months (range, 3-23 months). Mean preoperative axial length was 29.54 ± 1.28 mm (range, 27.88-31.96 mm). Mean preoperative best-corrected visual acuity (BCVA) was 0.71 ± 0.29 logMAR (Snellen equivalent 20/103); mean postoperative BCVA was 0.46 ± 0.44 (Snellen equivalent 20/58; p = 0.19) and 87.5% of patients maintained or improved vision. Pre- and postoperative OCT images are included and discussed within. Preoperative ellipsoid zone status and postoperative central macular buckle indentation appear to be important in visual outcomes. Two patients required a buckle repositioning for persistent schisis. One patient developed a macular hole postoperatively that resolved with subsequent vitrectomy. There were no other complications. CONCLUSIONS: The macular buckle is an effective and promising therapeutic option for myopic macular schisis.

A retrospective cohort study of radial optic neurotomy for severe central retinal vein occlusions.

BACKGROUND: Radial optic neurotomy (RON) is a new surgical procedure that has, until now, been studied only in a case series format. This study was designed to evaluate the efficacy of RON in improving visual acuity in patients suffering from central retinal vein occlusion (CRVO) with visual acuity equal to or worse than 20/100. METHODS: A retrospective cohort study was conducted of consecutive CRVO patients, consisting of 19 who underwent RON and 38 observation subjects matched on presenting visual acuity. RESULTS: The observation group worsened by 0.25 logMAR units from baseline, whereas the surgery group improved by 0.29 logMAR. Multivariate linear regression modelling found that, having controlled for other significant predictors and confounders, the change in visual acuity in the surgery patients was 0.63 logMAR units better than in the observation patients. INTERPRETATION: Our data suggest that RON is a promising treatment for visual acuity loss in severe CRVO causing visual acuity equal to or worse than 20/100. These results should be interpreted cautiously because of the limitations of the study, including the retrospective study design and the use of Snellen visual acuity. Our data suggest that further evaluation of RON is warranted.

Web-based grading of compressed stereoscopic digital photography versus standard slide film photography for the diagnosis of diabetic retinopathy.

PURPOSE: To evaluate the ability of Joint Photographic Experts Group (JPEG) compressed, stereoscopic, digital photography to identify clinical levels of diabetic retinopathy, detect clinically significant macular edema (CSME), and make appropriate referral recommendations as compared with Early Treatment Diabetic Retinopathy Study (ETDRS) standard film photography. DESIGN: Prospective, clinic-based, comparative photographic format validation study. PARTICIPANTS: Two hundred four eyes from 102 consecutive, new, diabetic patients with a median duration of diabetes of 12.5 years were enrolled and analyzed. METHODS: After pupillary dilation, a trained ophthalmic photographer obtained 2 sets of images: standard ETDRS, stereoscopic 7-field 35-mm film photographs and high-resolution, digital images of the same 7 standard fields (stereoscopic images of fields 1 and 2). Two masked readers graded both sets of images. The 35-mm film photographs were graded by hand using a written template. Digital photographs were compressed, uploaded to a web site, and graded by a web-based, computer-assisted ETDRS algorithm. The ETDRS level of diabetic retinopathy, presence of retinal thickening, and referral recommendation based on these 2 diagnoses were recorded and compared. MAIN OUTCOME MEASURES: The presence of CSME, ETDRS level of diabetic retinopathy, and referral threshold diabetic retinopathy. RESULTS: Film and compressed digital grading levels were compared using a simplified ETDRS categorization scheme. Film and digital gradings were highly correlated with exact agreements for level of diabetic retinopathy, CSME, and referral thresholds >87% and kappa levels >0.71. McNemar's testing found no statistically significant difference between compressed digital images and film when comparing referral thresholds (defined as the presence of CSME and/or ETDRS level > or = 61; P = 0.76). CONCLUSIONS: A modified ETDRS protocol (stereoscopic images of fields 1 and 2 only) with 16:1 JPEG image compression and computer-assisted ETDRS grading algorithm has excellent reproducibility when compared to standard ETDRS stereoscopic slide-film photography. An internet-based teleophthalmology system can correctly and reliably (kappa = 0.78) identify patients requiring referral for CSME and proliferative diabetic retinopathy (PDR; ETDRS level > or = 61).

Rationale and implementation of the SLICK project: Screening for Limb, I-Eye, Cardiovascular and Kidney (SLICK) complications in individuals with type 2 diabetes in Alberta's First Nations communities.

OBJECTIVE: Identifying diabetes complications through screening using portable laboratory equipment in Aboriginal communities, and providing education and client empowerment for improved follow-up care and self-care. PARTICIPANTS: First Nations people with known diabetes. SETTING: Screening was carried out in temporary clinics and laboratories set up at the local health centre in each of Alberta's 44 First Nations. INTERVENTION: Two mobile units ("SLICK vans"), equipped with professionally trained staff, portable lab instruments and a retinal camera, travelled to all 44 Alberta First Nations communities to facilitate implementation of the Canadian Diabetes Association Clinical Practice Guidelines (CPGs). The project provided relevant education and counselling in conjunction with screening activities. OUTCOMES: SLICK screened 1,151 clients between December 2001 and July 2003, and the project remains ongoing. A preliminary evaluation of the project's 19-month implementation period showed screening activities and satisfaction with diabetes services were low prior to SLICK. There were modest improvements in some program outcomes at 6-12 months follow-up. CONCLUSION: The SLICK project is designed to address the impact of diabetes by utilizing evidence-based CPGs with respect to screening for complications at the community level. It had a successful implementation period facilitated by community acceptance.

Injury prevention.

Emergency medicine plays a significant role in injury prevention through the use of public health models that link injury data to prevention programming, research, and advocacy. The day-to-day experiences in the emergency department provide a picture of the injury problem in a given community and give the emergency practitioner a real-world basis for injury prevention efforts. This article covers the basics or injury prevention, including defining the problem, discussing data and conceptual aspects of injury prevention, and systematically identifying successful approach to reducing the burden of injuries.

Bilateral exudative retinal detachments as initial presentation of sympathetic ophthalmia in Turner syndrome.

CASE REPORT: Sympathetic ophthalmia typically presents as bilateral granulomatous panuveitis that occurs after penetrating ocular injury. We describe a case of bilateral exudative retinal detachments in a patient with Turner syndrome and sympathetic ophthalmia. COMMENTS: To our knowledge, this is the first report of sympathetic ophthalmia in Turner syndrome.

Benefits of stereopsis when identifying clinically significant macular edema via teleophthalmology.

BACKGROUND: The need to incorporate stereopsis into a teleophthalmology system is controversial. Detection of hard exudate in the macula is suggested by some as an adequate surrogate for direct observation of retinal thickening. This study was designed to determine how accurate the detection of hard exudate is as a surrogate for stereoscopic detection of clinically significant macular edema (CSME). METHODS: 120 patients with diabetes underwent clinical retinal examination with contact-lens biomicroscopy by a retinal specialist. The presence or absence of CSME was recorded. On the same day as clinical grading, 30 degrees stereoscopic digital photographs of the macula were captured. At least 2 months after clinical examination, the digital images were viewed by masked graders for the presence or absence of hard exudate and retinal thickening. RESULTS: 207 eyes of 106 patients had complete data sets for both diagnostic modalities. The sensitivity of hard exudate (93.9%) in predicting the presence of CSME was similar to that of direct stereoscopic observation of retinal thickening (90.9%), with p = 0.5. On the other hand, digital stereopsis was significantly more specific (92.9%) than was hard exudate (81.6%) in predicting the presence of CSME (p < 0.001). This difference was maintained even when controlling for image quality. INTERPRETATION: Although the presence of hard exudate within the macula is a sensitive surrogate marker for CSME, it is less specific than stereoscopic evaluation. Any American Telemedicine Association category 3 teleophthalmology system that utilizes hard exudate as a surrogate marker for CSME may refer patients unnecessarily for clinical evaluation.