Short-term Efficacy and Safety of Intravitreal Brolucizumab Injection for Treatment-Naive Exudate Age-related Macular Degeneration: A Multicenter Study

Purpose@#To compare short-term efficacy and safety of intravitreal brolucizumab injection with aflibercept in treatment-naive neovascular age-related macular degeneration (nAMD) patients. @*Methods@#A total of 59 eyes from 59 treatment-naive nAMD patients in three hospitals were retrospectively reviewed. Of which, 27 patients underwent intravitreal brolucizumab injections and 32 received aflibercept. After monthly consecutive three injections, best-corrected visual acuity (BCVA; in logarithm of minimal angle of resolution [logMAR]), central macular thickness (CMT), dry macula achievement rate, and intraocular inflammation (IOI) incidence were compared. @*Results@#After loading-phase treatment, BCVA was significantly increased from 0.48 ± 0.30 logMAR at baseline to 0.33 ± 0.21 logMAR at 3 months in the brolucizumab group (p = 0.002) and 0.40 ± 0.39 logMAR at baseline to 0.33 ± 0.36 logMAR at 3 months in the aflibercept group (p = 0.007). But there was no significant difference in BCVA improvement at 3 months between the two groups. CMT significantly decreased from 429.67 ± 250.59 μm at baseline to 210.67 ± 93.53 μm at 3 months in the brolucizumab group and from 346.69 ± 159.09 μm to 234.52 ± 83.42 μm in the aflibercept group (both p < 0.001). The amount of CMT reduction was significantly greater in the brolucizumab group after 3 months (p = 0.036). In typical AMD eyes, brolucizumab showed similar BCVA improvement but better CMT reduction at 3 months (p = 0.018). Dry macula achievement rate was not significantly different between the two groups. One IOI was observed in the brolucizumab group. @*Conclusions@#Intravitreal injections of brolucizumab and aflibercept showed similar anatomical and functional outcomes. But CMT reduction was greater in the brolucizumab group. One IOI was identified, which was tolerable for topical agents. These results suggest that brolucizumab could be a novel first line treatment option for treating naive nAMD patients.

Incidence and Time of Onset of Retinopathy in Premature Infants in Korea

Purpose@#This study examined the incidence and time of onset of retinopathy in premature infants in Korea. @*Methods@#The medical records of premature infants admitted to the neonatal intensive care unit from 2006 to 2018 were reviewed retrospectively. Stages 1 and 2 were classified as mild retinopathy and stages 3 and 4 were considered severe. The incidence, severity, time of diagnosis, associations between retinopathy and birth weight and also gestational age, and clinical characteristics of the treated infants were analyzed. @*Results@#The incidence of retinopathy was 10.9% with an average time of diagnosis at 34.92 weeks postmenstrual age; the frequency of severe retinopathy was 44.97%. Birth weight and gestational age were significantly lower in premature infants with retinopathy than in normal infants. In addition, birth weight was significantly lower in those with severe retinopathy than in those with mild retinopathy. For birth weight and gestational age, the incidence and severity of retinopathy tended to be higher in those with birth weights less than 1,000 g and gestational ages of less than 27 weeks. Of the infants, 4.51% underwent laser photocoagulation; the times of diagnosis, progression to type 1 retinopathy, and treatment were 33.75, 35.06, and 36.04 weeks postmenstrual age, respectively. @*Conclusions@#The incidence and severity of retinopathy of premature infants increased in those with birth weights less than 1,000 g and gestational ages less than 27 weeks. Such infants should be monitored carefully between 32 to 36 weeks of postmenstrual age, when retinopathy is mainly diagnosed.

Visual Acuity Changes with a Position Shift in a Patient with an Endocapsular Hematoma

Purpose@#To report a vitrectomy performed on a patient with an endocapsular hematoma whose visual acuity changed with her position.Case summary: A 92-year-old woman visited our hospital complaining of a visual acuity change in her left eye with good visibility while standing but poor visibility when lying. She was taking aspirin, had underlying hypertension, diabetes, and heart failure, and underwent left eye cataract surgery 15 years previously. At presentation, her best-corrected visual acuity in the left eye was 0.5, with an intraocular pressure of 23 mmHg. An endocapsular hematoma that partially covered the fundus in the left eye was found. The left eye was observed for 3 months. However, there was no change in the endocapsular hematoma and the discomfort persisted with the position shift; therefore, a vitrectomy, posterior capsulotomy, and anterior chamber irrigation were performed. One month postoperatively, the visual acuity in the left eye was 0.4 and there was no longer a change in the visual acuity with position. @*Conclusions@#A patient with an endocapsular hematoma may have changes in visual acuity with position, and a vitrectomy can be used to treat the endocapsular hematoma.

Ocular Findings in a Patient with Scheie Syndrome

Purpose@#To report ocular findings in a patient with Scheie syndrome.Case summary: A 28-year-old male who was diagnosed with Scheie syndrome ten years ago visited our ophthalmology clinic. The man was diagnosed with Scheie syndrome based on normal intelligence, a coarse face, cardiac valve problems, and reduced α-L-iduronidase, heparan sulfate and dermatan sulfate levels on urinalysis. An ophthalmic examination showed that the best-corrected visual acuities were 0.25 and 0.2, while the intraocular pressures were 11 and 12 mmHg, in the right and left eyes, respectively. An anterior segment examination was normal except for corneal clouding (grade II). Fundus examination revealed bony spicule pigmentation in the peripheral retina and vessel attenuation in both eyes. Parafoveal photoreceptor loss was revealed by optical coherence tomography. In addition, scotopic and photopic electroretinographic responses were decreased, and the visual field decreased in accordance with the photoreceptor cell loss. @*Conclusions@#Clinicians should consider a diagnosis of Scheie syndrome when examining a patient with characteristic ocular findings and general symptoms.

Fusion and Suppression in Patients with Unilateral Idiopathic Epiretinal Membrane

Purpose@#To investigate the presence of fusion and suppression in patients with unilateral idiopathic epiretinal membrane (ERM). @*Methods@#Thirty-five patients with unilateral idiopathic ERM received a full ophthalmologic exam including best corrected visual acuity (BCVA). Patients were divided into suppression and non-suppression groups according to the results of 4 Prism Dioptre Base-out Test and Worth 4 Dot test. Age, symptoms, duration of ERM, BCVA, average M-chart score, results of Titmus test and optical coherence tomography parameters were compared between the two groups. Factors associated with suppression were also evaluated. @*Results@#Eleven (31%) of 35 patients had suppression. The BCVA (0.18 ± 0.12 vs. 0.29 ± 0.12 p = 0.019) and stereopsis (2.25 ± 0.27 vs. 2.66 ± 0.62, p = 0.009) were significantly lower in the suppression group than the non-suppression group. Median age was older (63.21 ± 9.64 vs. 70.82 ± 6.80, p = 0.013) and duration of ERM (7.86 ± 3.69 vs. 18.54 ± 14.92 months, p = 0.004) was longer in the suppression group than the non-suppression group. Average M-chart score was higher in the suppression group. However, not all the patients suffered from metamorphopsia, including the suppression group when using binocular vision. @*Conclusions@#Unilateral suppression is common in unilateral idiopathic ERM and influences the patient’s stereopsis. Suppression was significantly correlated with age, duration of symptoms and metamorphopsia.

Long-term Efficacy of Vitrectomy for Macular Edema Secondary to Branch Retinal Vein Occlusion in Patients Treated with Intravitreal Injections

PURPOSE: To evaluate the long-term efficacy of pars plana vitrectomy (PPV) on refractory or recurrent macular edema due to branch retinal vein occlusion (BRVO) after intravitreal steroid or anti-vascular endothelial growth factor injections. METHODS: We retrospectively reviewed the medical records of patients with macular edema due to BRVO who underwent PPV after intravitreal triamcinolone acetonide or bevacizumab injections and followed-up for at least 12 months. The best corrected visual acuity (BCVA) and subfoveal macular thickness were measured at 1, 3, 6, 12 months postoperatively and were compared with the preoperative values. The patients received additional intravitreal injections if they had recurrence of macular edema after surgery. The frequency of intravitreal injections (per year) were compared pre- and postoperatively. RESULTS: A total of 41 eyes of 41 patients were included and the mean duration of follow up was 58.7 ± 30.0 (15 - 124) months. The BCVA (logMAR) at 1, 3, 6, 12 months postoperatively, and last follow up was 0.52 ± 0.42, 0.46 ± 0.38, 0.41 ± 0.26, 0.50 ± 0.34, and 0.49 ± 0.37, respectively, which was significantly different from the preoperative values (0.90 ± 0.47, p < 0.001). The subfoveal macular thickness at 1, 3, 6, 12 months postoperatively, and last follow up was 342.72 ± 84.10 µm, 365.02 ± 110.73 µm, 359.45 ± 119.28 µm, 360.96 ± 124.33 µm, and 329.34 ± 119.69 µm, respectively, which was also significantly different (p < 0.001) from the preoperative values (484.9 ± 112.8 µm, p < 0.001). The frequency of intravitreal injections was significantly decreased after surgery (3.58 ± 2.05 times/year vs. 0.60 ± 0.83 times/year, p < 0.001). CONCLUSIONS: Pars plana vitrectomy could improve BCVA, decrease subfoveal macular thickness, and decrease recurrence in BRVO patients with refractory or recurrent macular edema after intravitreal injection. PPV could be an effective treatment option for these patients.

A Single Isolated Cotton-Wool Spot not Associated with Systemic Diseases

PURPOSE: To present a case of a single isolated cotton-wool spot in a healthy patient. CASE SUMMARY: A 43-year-old woman with no systemic disease complained of sudden inferior field defect of the right eye. On fundoscopic examination of the right eye, a single soft white spot was observed in the superotemporal vascular arcade. An elevated hyper-reflective area in the inner retina corresponding to a white spot was observed on optical coherence tomography. Automated perimetry revealed an arcuate field defect which was wider than the cotton-wool spot. A complete workup for systemic diseases was within normal range except a positive rheumatoid factor. At the 2-week follow-up, the patient's subjective symptom improved and the white spot decreased. After 6 months, the cotton-wool spot disappeared and slit-like retinal nerve fiber layer (RNFL) defects corresponding to the location of the cotton-wool spot was noticed. One year later, disc and RNFL defect were unchanged but the previous field defect disappeared. CONCLUSIONS: Isolated cotton-wool spots can occur without serious systemic diseases in healthy patients. A single isolated cotton-wool spot in the present case disappeared spontaneously leaving permanent structural damage on the retina over time.

A Single Isolated Cotton-Wool Spot not Associated with Systemic Diseases

PURPOSE: To present a case of a single isolated cotton-wool spot in a healthy patient. CASE SUMMARY: A 43-year-old woman with no systemic disease complained of sudden inferior field defect of the right eye. On fundoscopic examination of the right eye, a single soft white spot was observed in the superotemporal vascular arcade. An elevated hyper-reflective area in the inner retina corresponding to a white spot was observed on optical coherence tomography. Automated perimetry revealed an arcuate field defect which was wider than the cotton-wool spot. A complete workup for systemic diseases was within normal range except a positive rheumatoid factor. At the 2-week follow-up, the patient's subjective symptom improved and the white spot decreased. After 6 months, the cotton-wool spot disappeared and slit-like retinal nerve fiber layer (RNFL) defects corresponding to the location of the cotton-wool spot was noticed. One year later, disc and RNFL defect were unchanged but the previous field defect disappeared. CONCLUSIONS: Isolated cotton-wool spots can occur without serious systemic diseases in healthy patients. A single isolated cotton-wool spot in the present case disappeared spontaneously leaving permanent structural damage on the retina over time.

Electroretinographic Assessment of the Retinal Function during Intravitreal Bevacizumab Injections in Central Retinal Vein Occlusion

PURPOSE: To investigate the changes of electroretinogram (ERG) at baseline and during the first 3 injections of intravitreal bevacizumab in central retinal vein occlusion (CRVO) patients. METHODS: Thirteen eyes of 13 CRVO patients who received 3 injections of intravitreal bevacizumab at 6-week intervals and who could be examined for visual acuity, optical coherence tomography and ERG at 4 weeks after each injection were included in the present study. In addition, the ERG results of the unaffected fellow eyes group at 4 weeks after each injection were compared with the CRVO eyes group. RESULTS: Amplitudes of rod b wave, a and b waves of maximal combined response and cone response, oscillatory potentials and 30-Hz flicker significantly decreased in the CRVO eyes group than the fellow eyes group at 4 weeks after each injection (p 0.05). CONCLUSIONS: After intravitreal bevacizumab injection, macular functions significantly improved and amplitudes of all ERG parameters gradually increased in CRVO patients.

Subretinal Fluid Collection in Patient With Non-Arteritic Anterior Ischemic Optic Neuropathy: A Case Report

PURPOSE: To report a patient with non-arteritic anterior ischemic optic neuropathy with submacular fluid and peripapillary swelling. CASE SUMMARY: A 53-year-old patient visited our clinic complaining of acute visual loss in the right eye which began two days previously. The patient had no clinical history of ocular pain on eye movement. A relative afferent pupillary defect was observed in the right eye. Fundoscopic examination showed optic disc edema and an elevated macular lesion (1 disc diameter). Fluorescein angiography (FAG) revealed blocking by serous detachment in the peripapillary area in the early phase and peripapillary leakage in the late phase. Spectral domain optical coherence tomography (SD-OCT) showed submacular fluid and peripapillary swelling. Intravenous steroid injection was administrated. After five days of treatment, visual acuity improved to 0.2; one month later, visual acuity was 0.5. subretinal fluid absorption was observed with remaining lipid deposits. CONCLUSIONS: In non-arteritic anterior ischemic optic neuropathy, submacular fluid accumulation can occur due to destruction of retinal glial cells. Accumulation of submacular fluid can induce sudden visual loss and may predict visual prognosis. The macular area requires careful evaluation in non-arteritic anterior ischemic optic neuropathy patients.

An experimental study on the changes of the doppler patterns in the common carotid artery after clamping of the internal carotid artery

Recently, duplex sonography has been used as a screening test for the evaluation of carotid arterial disease. If an occlusion of atherosclerosis is located at the bifurcation of the common carotid artery or the lower portion of the internal carotid artery, the luminal change may be directly visualized on high-resolution B-mode sonography or color-Doppler images. But when the lesion is located at the high cervical, petrous or cavernous protion of the internal carotid artery, it is difficult to directly visualize the lesion with the sonography. The purpose of this paper is to evaluate the indirect changes on the Doppler patterns of both common carotid arteries with clamping of an internal carotid artery. Thirty common carotid arteries in fifteen normal rabbits were examined with duplex ultrasonography using high-resolution real-time imaging and 7.5MHz pulsed-wave Doppler flow measurements with velocity waveform analysis. Systolic velocity (SV) was 45.4±8.4cm/sec, end-diastolic velocity (EDV) 15.3±4.9cm/sec and resistative index(RI) 0.66±0.08 in the common carotid artery before clamping of the internal carotid artery. SV was 26.3±7.8cm/sec, EDV 6.0±5.2cm/sec and RI 0.78±0.18 in the ipsilateral common carotid artery and SV was 56.6±13.0cm/sec, EDV 22.3±8.2cm. sec and RI 0.61±0.10 in the contralateral common carotid artery after clamping of the internal carotid artery. During clamping of the internal carotid artery, the difference between SV of bilateral common carotid arteries was 30.3±13.8cm/sec and EDV 16.3±9.2cm/sec. There was no difference of the velocity patterns of the common carotid artery between preclamping and declamping of the internal carotid artery. In conclusion, lower SV and EDV in a common carotid artery than that in contralateral side on Doppler patterns strongly suggests an occlusion of ipsilateral internal carotid artery.

Soft tissue sparganosis

Sparganosis is a rare tissue-parasitic infestation caused by a plerocercoid tapeworm larva(sparganum), genus Spirometra. The most common clinical presentation of sparganosis is a palpable subcutaneous mass or masses. Fifteen simple radiographs and 10 ultrasonograms of 17 patients with operatively verified subcutaneous sparganosis were retrospectively analyzed to find its radiologic characteristics for preoperative diagnosis of sparganosis. The locations of the subcutaneous sparganosis were lower extremity, abdominal wall, breast, inguinal region and scrotum in order of frequency. The simple radiographs showed linear or elongated calcification with or without nodular elongated shaped soft tissue mass shadows in 8 patients, soft tissue mass shadow only in 2 patients and lateral abdominal wall thickening in 1 patient. But no specific findings was noted in 4 patients with small abdominal and inguinal masses. We could classify the subcutaneous sparganosis by ultrasound into 2 types: one is long band-like hypoechoic structures, corresponding to the subcutaneous tunnel-like tracks formed by migration of sparganum larva and the other is elongated or ovoid hypoechoic nodules, representing granulomas. Long band-like hypoechoic structures within or associated with mixed echoic granulomatous masses were noted in 6 patients and elongated or ovoid hypoechoic mass or masses were noted in 4 patients. In conclusion, sparganosis should be considered when these radiologic findings-irregular linear calcifications on simple radiograph and long ban-like hypoechoic structures on ultrasonography, corresponding to the subcutaneous tunnel-like tracks formed by migration of sparganum larva-are noted in the patients who have subcutaneous palpable mass or masses. And radiologic examination especially ultrasonography is very helpful to diagnose sparganosis.