Outcomes of switching treatment to aflibercept in patients with macular oedema secondary to central retinal vein occlusion refractory to ranibizumab.

PURPOSE: To assess the treatment outcome of switching from ranibizumab to aflibercept intravitreal injections in patients with macular oedema secondary to central retinal vein occlusion (CRVO). METHODS: A prospective interventional study was conducted in a tertiary retina service in Leicester Royal Infirmary, UK, where patients with CRVO and associated macular oedema were recruited. First-line treatment involved three monthly ranibizumab injections. Non-responders were defined as patients who despite a minimum of three consecutive injections had persistent intraretinal fluid one month after the last injection. In these cases, a treatment change to aflibercept injections on a per-needed basis was decided. Best-corrected visual acuity (BCVA) and central retinal thickness (CRT) were measured before and after switching of treatment. Follow-up period lasted for a minimum of 24 weeks after switching. RESULTS: Twenty-nine eyes of 29 patients with refractory macular oedema secondary to CRVO were included. All eyes had an average of 4.5 ranibizumab intravitreal injections in a mean period of 6 months without reduction in intraretinal fluid and/or no visual acuity gain. A significant decrease in mean CRT from 633.67 ± 242.42 to 234.62 ± 78.28 µm and improvement in mean BCVA from 1.34 ± 0.66 log MAR to 0.91 ± 0.73 log MAR were noticed after switching treatment to aflibercept. The average number of aflibercept injections needed for oedema resolution was 2.19. CONCLUSIONS: Aflibercept is an effective alternative treatment for macular oedema secondary to CRVO refractory to ranibizumab. Good anatomical and functional result can be achieved with few injections. The maintenance of these results after 6 months is yet to be investigated.

Optical coherence tomography-guided classification of epiretinal membranes.

To study and classify epiretinal membranes (ERMs) based on spectral domain optical coherence tomography (SD-OCT) findings. One hundred and twelve patients with ERMs were examined clinically and underwent OCT examination. The anatomical structure of the macula and vitreoretinal interface was studied. ERMs were classified in two categories: A, with posterior vitreous detachment (PVD) (91 cases), and B, with the absence of PVD (21 cases). Category A was divided into two subcategories: A1, without contraction of the ERM (37 cases), and A2, with the presence of membrane contraction (54 cases). A2 was further subdivided into A2.1, with retinal folding (15 cases), A2.2, with edema (23 cases), A2.3, with cystoid macular edema (9 cases), and A2.4, with lamellar macular hole (7 cases). Category B was divided in two subcategories: B1, without vitreomacular traction (VMT) (4 cases), and B2, with the presence of VMT (17 cases). Category B2 was subdivided into B2.1, with edema (9 cases), B2.2, presenting retinal detachment (5 cases), and B2.3, with schisis (3 cases). OCT classification of ERMs provides useful information on the anatomical structure of the retina, and the accurate estimation of vitreoretinal interface.

Feasibility and clinical utility of handheld fundus cameras for retinal imaging.

BACKGROUND/OBJECTIVES: Handheld fundus cameras are portable and cheaper alternatives to table-top counterparts. To date there have been no studies comparing feasibility and clinical utility of handheld fundus cameras to table-top devices. We compare the feasibility and clinical utility of four handheld fundus cameras/retinal imaging devices (Remidio NMFOP, Volk Pictor Plus, Volk iNview, oDocs visoScope) to a table-top camera (Zeiss VisucamNM/FA). SUBJECTS/METHODS: Healthy participants (n = 10, mean age ± SD = 21.0 ± 0.9 years) underwent fundus photography with five devices to assess success/failure rates of image acquisition. Participants with optic disc abnormalities (n = 8, mean age ± SD = 26.8 ± 15.9) and macular abnormalities (n = 10, mean age ± SD = 71.6 ± 15.4) underwent imaging with the top three scoring fundus cameras. Images were randomised and subsequently validated by ophthalmologists masked to the diagnoses and devices used. RESULTS: Image acquisition success rates (100%) were achieved in non-mydriatic and mydriatic settings for Zeiss, Remidio and Pictor, compared with lower success rates for iNview and oDocs. Image quality and gradeability were significantly higher for Zeiss, Remidio and Pictor (p < 0.0001) compared to iNview and oDocs. For cup:disc ratio estimates, similar levels of bias were seen for Zeiss (-0.09 ± SD:0.15), Remidio (-0.07 ± SD:0.14) and Pictor (-0.05 ± SD:0.16). Diagnostic sensitivities were highest for Zeiss (84.9%; 95% CI, 78.2-91.5%) followed by Pictor (78.1%; 95% CI, 66.6-89.5%) and Remidio (77.5%; 95% CI, 65.9-89.0%). CONCLUSIONS: Remidio and Pictor achieve comparable results to the Zeiss table-top camera. Both devices achieved similar scores in feasibility, image quality, image gradeability and diagnostic sensitivity. This suggests that these devices potentially offer a more cost-effective alternative in certain clinical scenarios.

Rare presentation of central retinal vein occlusion sparing the superotemporal quadrant in a patient with congenital cardiovascular disease.

A young Asian man with a diagnosis of complex congenital heart disease and visceral situs inversus presented to the eye casualty with a recent onset of blurred vision in his left eye. Funduscopic examination of the left eye showed the presence of intraretinal haemorrhages in the inferior and superonasal quadrants, sparing the superotemporal arcade. Optical coherence tomography showed presence of macular oedema and fundus fluorescein angiography confirmed the diagnosis of central retinal vein occlusion sparing the superotemporal branch. Intravitreal antivascular endothelial growth factor treatment was administered, with favourable anatomic and functional outcomes. The presentation of an incomplete central retinal vein occlusion is extremely unusual, especially in a patient with significant cardiac malformation. With the current advances in interventional cardiac procedures, more patients are having longer lifespan and are presenting to ophthalmologists with ocular consequences of circulatory disorders, emphasising the need for multidisciplinary management.

Branch Retinal Vein Occlusion as a Rare Presentation of Antisynthetase Syndrome.

A 52-year-old woman developed branch retinal vein occlusion (BRVO) in her right eye, resulting in blurred vision with visual acuities of 6/9 and 6/6-2 in the affected and unaffected eye respectively (Snellen). The patient was successfully treated with a course of eight intravitreal aflibercept injections, improving binocular visual acuity to 6/6. During the course of her ocular management, she was admitted for acute dyspnoea secondary to interstitial lung disease (ILD). The patient was diagnosed with the antisynthetase syndrome (ASS), testing positive for PL-7 auto-antibodies. ASS may have a systemic association with BRVO; although ASS is a rare condition, it should be suspected and investigated in patients with risk factors, particularly if they present with symptoms of ILD. Early ocular intervention is associated with excellent visual outcomes, and prompt diagnosis and treatment of ASS may potentially reduce risks of further retinal vaso-occlusive episodes.

Ophthalmic photographer virtual clinics in medical retina.

AIM: To determine whether ophthalmic photographers (OPs) can conduct virtual clinics (VCs) in medical retina appropriately and whether this increases clinic capacity. METHODS: Three OPs underwent a training programme to learn how to assess and manage macular edema secondary to diabetes or retinal vein occlusion. The 300 consecutive patients over a 7-month observation period in 2018 were assessed in VCs by both OPs and medical retina consultants. The degree of agreement in treatment decisions between doctors and photographers, as well as adverse events, was recorded. The change in number of patients seen in VCs over two years was also measured. RESULTS: There was 100% agreement in management decisions between doctors and photographers during the 300-patient observation period. No adverse events were recorded. In 2017, 572 patients were seen in VCs by doctors. After OP clinics were introduced in 2018, this number increased by 24% to 709 patients seen by both photographers and doctors. There was a significant increase in mean number of patients seen per month between 2017 (47.7±11.7) and 2018 (59.1±14.4; P=0.045, 95%CI -22.5 to -0.296). CONCLUSION: OPs can manage certain medical retina patients in VCs appropriately and can increase clinic capacity significantly for particular conditions.

Real-World Cost Savings Demonstrated by Switching Patients with Refractory Diabetic Macular Edema to Intravitreal Fluocinolone Acetonide (Iluvien): A Retrospective Cost Analysis Study.

INTRODUCTION: It is hypothesized that using fluocinolone acetonide (FAc) implants such as Iluvien for the treatment of diabetic macular edema (DME) may reduce the total number of intravitreal injections and clinic visits, resulting in an overall treatment cost reduction. The primary aim of this study is to identify the real-world cost savings achievable in a tertiary National Health Service (NHS) hospital. METHODS: A retrospective cost analysis study was conducted. The inclusion criteria were patients with refractory DME who were switched to Iluvien. The average yearly costs were calculated both before and after the switch to Iluvien. All costs including medicines, investigations, clinics, and management of raised intraocular pressure (IOP) were calculated. The cost differences over the 3 years' worth of Iluvien treatment were calculated and analyzed. To ensure non-inferiority of this treatment intervention, the best corrected visual acuity (BCVA) and central retinal thickness (CRT) were also analyzed. Statistical analysis was conducted with a Student t test where appropriate and statistical significance is identified where p < 0.05. RESULTS: Fourteen eyes of 13 patients met the inclusion criteria. Switching patients to Iluvien achieved on average a saving of £2606.17 per patient (p = 0.33) over the 3 years. However, seven cases (50%) had a rise in IOP after Iluvien that warranted medical treatment and two cases (14.3%) required glaucoma surgery. Incorporating the costs of glaucoma management reduced the overall savings over 3 years to £1064.66 per patient. The BCVA and CRT analysis showed a non-inferiority relationship between Iluvien and any previous treatment. CONCLUSIONS: The use of Iluvien in refractory DME patients represents a cost- and time-saving procedure, while showing non-inferiority in terms of efficacy.

Real-World Results of Switching Treatment from Ranibizumab to Aflibercept in Macular Oedema Secondary to Branch Retinal Vein Occlusion.

INTRODUCTION: To investigate treatment outcomes after switching from ranibizumab to aflibercept intravitreal injections in patients with macular oedema (MO) secondary to branch retinal vein occlusion (BRVO). METHODS: Eligible patients with refractory MO secondary to BRVO, post treatment with a minimum of three intravitreal injections of ranibizumab at 4-weekly intervals were recruited. Suboptimal or non-responders were defined as patients who had persistent intraretinal fluid (< 75% decrease from baseline) despite a minimum of three consecutive injections. These patients were switched to aflibercept injections on an as-needed basis. The primary study outcomes assessed trends in best-corrected distance visual acuity (BCVA) and central retinal thickness (CRT). To compare means of BCVA and CRT, a paired t test two-tailed with a level of significance set at 0.05 was used. Pearson correlation coefficient was also applied to demonstrate correlation. Participants were followed up for a period of 24 weeks after switching. RESULTS: Thirty-eight eyes of 38 patients were included in the study. Patients had an average of 8.37 ranibizumab intravitreal injections over a mean period of 12 months presenting suboptimal or no response. A significant decrease of mean CRT from 388.63 ± 93.4 µm to 290.29 ± 93.5 µm (p < 0.001) and an improvement in mean BCVA from logMAR 0.66 ± 0.38 to logMAR 0.57 ± 0.27 (p = 0.025) was achieved after an average of 2.27 aflibercept injections. CONCLUSIONS: Given the spectrum of therapies available to date for the management of MO secondary to BRVO, aflibercept appears to be an effective treatment option in cases refractory to ranibizumab. This study based on a small cohort of patients indicates that satisfactory results on retinal anatomy and visual outcomes can be accomplished with a smaller number of injections. Larger-scale studies are needed to extrapolate these promising results.

Long-term results of intravitreal bevacizumab and dexamethasone for the treatment of punctate inner choroidopathy associated with choroidal neovascularization: A case series.

INTRODUCTION: To present a case series of three female patients with punctate inner choroidopathy. We report the outcomes after an essentially long follow-up period of up to 14 years and provide evidence of the effectiveness of intravitreal injections of bevacizumab and dexamethasone 0.7 mg in punctate inner choroidopathy patients with choroidal neovascular membrane formation. CASE SERIES PRESENTATION: This is a retrospective case series of three female patients with punctate inner choroidopathy who were treated with intravitreal injections anti-vascular endothelial growth factor agent (bevacizumab, 1.25 mg/0.05 mL). Two patients also received intravitreal dexamethasone 0.7 mg. Once a choroidal neovascular membrane developed, the outcome was poor with a best-corrected visual acuity of 6/60 or counting fingers in the affected eyes. The patients were followed up for 5, 14 and 8 years. CONCLUSION: The use of dexamethasone 0.7 mg in punctate inner choroidopathy yielded encouraging results and long periods of stability. When choroidal neovascular membrane complicates the primary disease, the prognosis is unfavourable, especially if the macula integrity has already been considerably affected. On the contrary, aggressive early therapy and continued monthly monitoring can prevent severe fibrosis, as showed in previous reports. Further larger-scale studies are needed to evaluate the efficacy of intravitreal dexamethasone 0.7 mg and bevacizumab as an alternative treatment in non-infectious uveitis.

Bilateral sensorineural hearing loss secondary to sympathetic ophthalmia in a human leukocyte antigen-A2 positive patient.

We report a case of sympathetic ophthalmia 1 month following trauma in a 71-year-old immunocompetent female patient of Indian origin. The patient was hospitalized with signs and symptoms of meningism, ataxia, and neurosensory deafness. We explore and provide further clinical evidence in supporting the hypothesis of antigen cross-reactivity derived from tissues with common neural crest embryological background such as the uvea and cells of the labyrinth. The patient was human leukocyte antigen-A2 positive and treatment with oral steroids and cyclosporine has managed to have favorable results and control the inflammation.

The concept of virtual clinics in monitoring patients with age-related macular degeneration.

PURPOSE: To present clinical results regarding the treatment of patients with age-related macular degeneration (neovascular form) after the implementation of a 'virtual' type of follow-up in a single retina service centre. METHODS: Retrospective study based on the clinical records of the Leicester Royal Infirmary Retina department. Two periods were compared, the 2-year period of 2011-2012 and the following one of 2012-2013 when the 'virtual' clinics model applied in the department. Primary outcomes were as follows: the time between two appointments, follow-up or treatment and the number of patients with significant (>15 letters) improvement of their best corrected distance visual acuity. Secondary parameters of interest were as follows: mean number of injections per patient/year and the average duration of a 'virtual' vs. a regular visit. RESULTS: The mean time interval between two appointments was 5.3 weeks following the implementation of the 'virtual' clinics compared to 6.9 weeks in the previous period of regular appointments. Mean visual acuity improvement >15 letters was achieved in 6.9% of the patients compared to 23.1% of the 'virtual' appointments period. The results regarding injections/patient/year were as follows: 5.6 before the model of 'virtual' appointments and 5.9 after the implementation. The average time a patient spent for a conventional visit was 71.4 ± 24.1 min, and the respective time needed in the virtual clinic was 47.3 ± 18.6 min. CONCLUSION: The model of 'virtual' (without actual consultation) follow-up appointments assisted our service to contend with the increased number of patient. In general, the specific pattern of patients' management could be widely considered obviously after comprehensive and all-embracing assessment of its safety and efficiency.

Diagnosis and Monitoring of Choroidal Osteoma through Multimodal Imaging.

A 16-year-old Caucasian female with a 6-month history of decreased visual acuity and metamorphopsia in the left eye is reported. The fundus of the left eye revealed a well defined lesion in the macula region. Diagnosis of choroidal osteoma was established using spectral domain optical coherence tomography (OCT), fundus fluorescein angiography (FFA), indocyanine green angiography (ICG), and B-scan ultrasonography. Subretinal fluid (SRF) and retinal pigment epithelium (RPE) detachment were noted in the absence of obvious classic choroidal neovascularisation (CNV). The patient was followed up for over 13 months without any treatment in the interim and the lesion was noted to have enlarged but visual acuity and SRF had remained stable. We report an interesting case where subretinal fluid was noted in the absence of evident choroidal neovascularisation and provide an example of the imaging modalities application in the era of "optical biopsy."

Incidence of Retinal Pigment Epithelial Tears and Associated Risk Factors After Treatment of Age-Related Macular Degeneration with Intravitreal Anti-VEGF Injections.

PURPOSE: To study the incidence and risk factors for retinal pigment epithelium tears following intravitreal anti-vascular endothelial growth factor (VEGF) injections. METHODS: Retrospective longitudinal study. 4027 intravitreal anti-VEGF injections in 628 patients (676 eyes) for choroidal neovascularisation associated with age related macular degeneration in a period of 18 months were studied. RESULTS: Seventeen patients (mean age 83.95±5.84) developed retinal pigment epithelium tears. The incidence rate was 0.4%. Fibrovascular pigment epithelium detachment (PED) was previously observed in all cases. In 88 % (15/17) of AMD patients that had a RPE tear, PED height was found to be less than 400 microns at presentation. In 5 of 7 patients with RPE tear grade <4, continuing of anti-VEGF treatment resulted to improvement of visual acuity. CONCLUSION: Critical risk factors for RPE tears are presence of PED as well as advanced age. Visual improvement appears to depend more on the extent and location of the RPE tear and less on the PED height.

Ranibizumab in choroidal neovascularisation associated with ocular sarcoidosis.

An 81-year-old Caucasian man with a history of chronic bilateral panuveitis associated with sarcoidosis presented with visual acuity 1.0 LogMAR in the right and 0.5 LogMAR in the left eye. Following fluoroscein angiogram bilateral choroidal neovascular membrane was established. Treatment was initiated with a course of 3 monthly intravitreal injections of ranibizumab 0.5 mg in 0.05 mL bilaterally; oral prednisolone 30 mg/day on tapering doses controlled the ocular inflammation prior to the treatment with intravitreal injections. An additional two intravitreal ranibizumab injections were administered in the right eye. Fibrotic tissue in the posterior pole bilaterally was present on funduscopy following ranibizumab treatment. Visual acuity was LogMAR 1.6 in the right and 1.0 LogMAR in the left eye in 1 year follow-up. This case report summarises the issues of choroidal neovascularisation as a complication secondary to panuveitis associated with sarcoidosis and highlights the treatment of this complication with antivascular endothelial growth factor agents.

Idiopathic acquired dacryocystocele treated with endonasal endoscopic dacryocystorhinostomy.

A 64-year-old woman presented with a medial canthal mass in her left eye, which was accompanied only by mild epiphora. There was no history of dacryocystitis, bloody tears, midfacial trauma or surgery. Physical examination showed a non-inflammatory, subcutaneous, immobile mass below the level of the medial canthal tendon. Lacrimal irrigation demonstrated blockage at the nasolacrimal duct. A CT revealed a non-enhancing, low density, cystic lesion in the inferomedial aspect of the left orbit without bony erosion, which was compatible with an idiopathic acquired dacryocystocele. The patient underwent endonasal endoscopic dacryocystorhinostomy (DCR) and silicone intubation. Epiphora resolved immediately after surgery. Two years after surgery, the patient has had no recurrence of either the epiphora or the orbital. Idiopathic acquired dacryocystocele associated only with epiphora without accompanying dacryocystitis although rare should be considered in the differential diagnosis of acquired non-inflammatory medial canthal masses. Endonasal endoscopic DCR represents a safe and effective treatment.

Peripheral corneal ulceration associated with rheumatoid arthritis.

PATIENT: Female, 60 FINAL DIAGNOSIS: Corneal ulceration Symptoms: Blurred vision Medication: Abatacept Clinical Procedure: - Specialty: Ophthalmology. OBJECTIVE: Management of emergency care. BACKGROUND: To report a case of a patient with rheumatoid arthritis (RA) and associated peripheral corneal ulceration. CASE REPORT: A 60-year-old woman with RA diagnosed 15 years ago, under immunosuppressive therapy (IV abatacept 250 mg/month), demonstrated blurring of vision in her RE (right eye). Visual acuity was 6/10 in the RE and 10/10 in the LE. Slit lamp examination revealed a paracentral superior corneal melt in the RE. Anterior chamber reaction was 2+. Laboratory investigations revealed positive anti-Ro and anti-La, anti-Extractable Nuclear Antigens (anti-ENA, ELISA), while anti-Sm, anti-Rnp, anti-Jo1 and anti-Scl70 were found negative. IgG and IgA serum immunoglobulins were found elevated, but IgE and IgM were within normal levels. Further evaluation for the underlying disease revealed highly elevated rheumatoid factor and C-reactive protein. The patient, who had been receiving anti-TNF during the last 6 months, underwent treatment with topical tobramycin and lubricants and oral prednisone 60 mg/day with tapering doses, to which methotrexate p.os. 15 mg/week was added. The condition improved within a few days after the initiation of prednisone treatment. Re-epithelization occurred 1 week after the onset of the immunosuppressive treatment. Only punctate fluorescein dye uptake was detected in the margins of the lesion. CONCLUSIONS: The effective control of the underlying disease and early diagnosis of the dry eye syndrome in RA patients may prevent serious corneal complications such as corneal ulceration. The initiation of treatment with steroids and immunosuppresants was found to halt the progression of keratolysis, and assisted re-epithelization.